Emergency and elective surgery for small bowel Crohn's disease

Advancements in the medical treatment of Crohn's disease have reduced the need for surgery. The indications for surgery include the failure of medical management, especially the persistence or worsening of symptoms in spite of proper treatment and complications of the disease process. These complications include intestinal obstruction, intestinal perforation with fistula formation or abscess, free perforation, gastrointestinal bleeding, urologic complications, cancer, and perianal disease. In these cases, operative therapy should be directed to the specific indication for surgery, resecting only the segment of bowel involved in the complicating process while preserving as much bowel length as possible in order to prevent short-bowel syndrome. Laparoscopic surgery has been gaining acceptance as an alternative surgical approach for properly selected patients with Crohn's disease. In conclusion, identifying the need for surgery and determining the timing of operation are the cornerstones to successful surgical management of patients with Crohn's disease.     

Current treatment of rectovaginal fistula in Crohn's disease

Rectovaginal fistula (RVF) continues to be the most difficult perianal manifestation of Crohn's disease to treat. This devastating and disabling complication has a significant impact on patients' quality of life and presents unique management challenges. Current therapeutic approaches include many medical therapeutics and surgical treatments with a wide range of success rates reported. However, current evidence is lacking to support any recommendation. The choice of repair depends on various patient and disease factors and basic surgical tenets. In this article, we review the current options to consider in the treatment of Crohn's-related RVF, and try to evaluate their effects on fistulae closure and quality of life.     

Fistula treatment: The unresolved challenge

In population-based studies, up to 50% of patients with Crohn's disease suffer from fistulas. Fistulas pose a considerable morbidity including permanent sphincter and perineal tissue destruction as well as professional and personal disabilities. Treatment options have progressed in recent years and fistula closure and fibrosis of the fistula track is achieved in some patients. Depending on severity of symptoms and fistula location, different medical and surgical therapies can be chosen. Internal fistulas such as ileoileal or ileocecal fistulas are either asymptomatic and do not require intervention or they are symptomatic and need surgery alone. They always carry a risk of abscess formation. Symptomatic perianal fistulizing disease can be treated with antibiotics (i.e. metronidazole and ciprofloxacin) for three months and/or immunosuppressant therapy (6-mercaptopurine or azathioprine). More complex cases require therapy with anti-TNF agents. Only few and preliminary data exist on cyclosporine A, tacrolimus or methotrexate in fistulizing Crohn's disease. Therefore, these therapies should mainly be used as second-line therapies. Surgery is reserved for the treatment of perianal sepsis in the presence of abscesses and refractory disease or complications of fistulas, or used in combination with pharmacological approaches. The surgical interventions in perianal disease consist of surgical drainage with or without seton placement, transient ileostomy, or in severe cases, proctectomy. The classification of fistulas in patients with Crohn's disease remains poorly defined and largely investigator dependent. The unresolved challenges in fistula treatment warrant randomized controlled trials for existing and future treatment strategies as well as a better classification system to compare available studies.     

Emerging treatments for complex perianal fistula in Crohn＇s disease

Complex perianal fistulas have a negative impact on the quality of life of sufferers and should be treated. Correct diagnosis, characterization and classification of the fistulas are essential to optimize treatment. Nevertheless, in the case of patients whose fistulas are associated with Crohn＇s disease, complete closure is particularly difficult to achieve. Systemic medical treatments （antibiotics, thiopurines and other immunomodulatory agents, and, more recently, anti-tumor necrosis factor-α agents such as infliximab） have been tried with varying degrees of success. Combined medical （including infliximab） and less aggressive surgical therapy （drainage and seton placement） offer the best outcomes in complex Crohn＇s fistulas while more aggressive surgical procedures such as fistulotomy or fistulectomy may increase the risk of incontinence. This review will focus on emerging novel treatments for perianal disease in Crohn＇s patients. These include locally applied infliximab or tacrolimus, fistula plugs, instillation of fibrin glue and the use of adult expanded adipose-derived stem cell injection. More welldesigned controlled studies are required to confirm the effectiveness of these emerging treatments.     

Current treatment of rectovaginal fistula in Crohn's disease

Rectovaginal fistula(RVF) continues to be the most difficult perianal manifestation of Crohn's disease to treat.This devastating and disabling complication has a significant impact on patients' quality of life and presents unique management challenges.Current therapeutic approaches include many medical therapeutics and surgical treatments with a wide range of success rates reported.However,current evidence is lacking to support any recommendation.The choice of repair depends on various patient and disease f...     

The natural history of fistulizing Crohn's disease in Olmsted County, Minnesota

BACKGROUND & AIMS: Little is known about the cumulative incidence and natural history of fistulas in Crohn's disease in the community. METHODS: The medical records of all Olmsted County, Minnesota residents who were diagnosed with Crohn's disease from 1970 to 1993 and who developed a fistula were abstracted for clinical features and outcomes. Six patients denied research authorization. The cumulative incidence of fistula from time of diagnosis was estimated by using the Kaplan-Meier product-limit method. RESULTS: At least 1 fistula occurred in 59 patients (35%), including 33 patients (20%) who developed perianal fistulas. Twenty-six (46%) developed a fistula before or at the time of formal diagnosis. Assuming that the 9 patients with fistula before Crohn's disease diagnosis were instead simultaneous diagnoses, the cumulative risk of any fistula was 33% after 10 years and was 50% after 20 years (perianal, 21% after 10 years and 26% after 20 years). At least 1 recurrent fistula occurred in 20 patients (34%). Most fistulizing episodes (83%) required operations, most of which were minor. However, 11 perianal fistulizing episodes (23%) resulted in bowel resection. CONCLUSIONS: Fistulas in Crohn's disease were common in the community. In contrast to referral-based studies, only 34% of patients developed recurrent fistulas. Surgical treatment was frequently required.     

Evaluation of surgery for perianal Crohn's fistulas

PURPOSE: This study was designed to evaluate the operative treatments performed on patients with perianal Crohn's disease at a tertiary referral colorectal university hospital and to determine the efficacy of management by assessing patient satisfaction. METHODS: A retrospective survey included 59 patients with perianal Crohn's disease who had undergone surgery during the period of 1991 to 1993, inclusive. RESULTS: Twenty-seven patients were treated by laying the fistula open (81 percent successful), and another 27 cases were treated with a loose seton (85 percent successful). Five cases were complicated fistulas and underwent diversionary stomas as part of a primary procedure. Overall success rate, as judged by patient satisfaction, was 83 percent. CONCLUSION: Conservative surgery has a role in management of perianal Crohn's disease. Patient satisfaction can be achieved without complete healing. Better preoperative assessment may improve results further.     

Perianal Crohn’s disease： Is there something new？

Perianal lesions are common in patients with Crohn's disease, and display aggressive behavior in some cases. An accurate diagnosis is necessary for the optimal management of perianal lesions. Treatment of perianal Crohn's disease includes medical and/or surgical options. Recent discoveries in the pathogenesis of this disease have led to advances in medical and surgical therapy with good results. Perianal lesions in Crohn's disease remain a challenging aspect for both gastroenterologists and surgeons and lead to a greatly impaired quality of life for all patients affected by this disease. A multidisciplinary approach is mandatory to obtain the best results.     

Diagnostic and treatment recommendations on perianal Crohn's disease.

Treatment of perianal fistulas in Crohn's disease should be defined on an individual basis. A combined medical and surgical approach is the optimal treatment. Adequate management of perianal fistula disease is based on the presence or absence of active proctitis, anatomic location, and fistula type. Furthermore, the presence of perianal abscesses must be ruled out. This evaluation includes digital rectal examination, endoscopy, and examination under anesthesia combined with pelvic magnetic resonance imaging or anorectal endoscopy ultrasonography findings.     

Contemporary surgical management of rectovaginal fistula in Crohn's disease

Rectovaginal fistula is a disastrous complication of Crohn's disease(CD) that is exceedingly difficult to treat. It is a disabling condition that negatively impacts a women's quality of life. Successful management is possible only after accurate and complete assessment of the entire gastrointestinal tract has been performed. Current treatment algorithms range from observation to medical management to the need for surgical intervention. A wide variety of success rates have been reported for all management options. The choice of surgical repair methods depends on various fistula and patient characteristics. Before treatment is undertaken, establishing reasonable goals and expectations of therapy is essential for both the patient and surgeon. This article aims to highlight the various surgical techniques and their outcomes for repair of CD associated rectovaginal fistula.     

Imaging of perianal Crohn''s disease

Perianal fistulas and abscesses are common complications of Crohn's disease, affecting up to 50% of patients during their disease course. Accurate diagnosis and classification of perianal disease is crucial before and during treatment to plan an adequate approach for each patient and to avoid irreversible functional consequences. Although examination under anaesthesia has been considered the gold standard for diagnosis and classification of Crohn's disease perianal fistulas, taken alone it does not have perfect accuracy, stressing the need for concomitant or alternative, non-invasive, methods of evaluation. In this context, imaging modalities assessed for diagnosis, classification and monitoring of Crohn's disease perianal fistulas include pelvic magnetic resonance imaging, anorectal endoscopic ultrasonography, transcutaneous perianal ultrasound, fistulography and computed tomography. In particular, magnetic resonance imaging and endoscopic ultrasonography findings have shown the best accuracy, and the ability to influence therapeutic management of these patients. For transcutaneous perianal ultrasound too, good preliminary data have been reported. This paper reviews the available data on imaging methods for the management of perianal Crohn's disease.     

Does Infliximab Infusion Impact Results of Operative Treatment for Crohn’s Perianal Fistulas?

PURPOSE: Infliximab is an effective treatment for active intestinal Crohn's disease; however, the efficacy of infliximab in perianal Crohn's disease is controversial. This study was designed to compare patients with Crohn's disease who underwent perianal fistula surgery with or without infliximab infusion. METHODS: A retrospective chart review of 226 consecutive patients with Crohn's disease who underwent operative treatment with or without infliximab (3-6 infusions of 5 mg/kg) from March 1991 through December 2005 was completed. Patients were classified as completely healed, minimally symptomatic (seton placement with minimal drainage and/or infliximab dependence), and failure (persistent or recurrent symptomatic fistula, diverting procedure, or proctectomy). RESULTS: A total of 226 patients underwent operative treatment alone (n = 147) or in combination with infliximab infusion (n = 79). Age, gender, and preoperative history of intestinal and perianal Crohn's disease were similar between groups. Mean follow-up was 30 (range, 6-216) months. Operative treatment consisted of seton drainage (n = 112), conventional fistulotomy (n = 92), fibrin glue injection (n = 14), advancement flap (n = 5), collagen plug insertion (n = 2), and transperineal repair (n = 1). Eighty-eight patients (60 percent) healed completely with operative treatment alone, and 47 patients (59 percent) healed after operative treatment in combination with infliximab (P = not significant). CONCLUSIONS: Operative treatment of perianal fistulas in patients with Crohn's disease resulted in complete healing in approximately 60 percent of patients. Preoperative infliximab infusion did not affect overall healing rates.     

Enterovesical fistulas complicating Crohn's disease: clinicopathological features and management

Enterovesical fistula is a relatively rare condition in Crohn's disease. This study was undertaken to examine clinicopathological features and management of enterovesical fistula complicating Crohn's disease. Thirty patients with enterovesical fistula complicating Crohn's disease, treated between 1970 and 1997, were reviewed. Urological symptoms were present in 22 patients; pneumaturia in 18, urinary tract infection in 7, and haematuria in 2. In 5 patients clinical symptoms were successfully managed by conservative treatment, and they required no surgical treatment for enterovesical fistula. Twenty-five patients required surgery. All the patients were treated by resection of diseased bowel and pinching off the dome of the bladder. No patients required resection of the bladder. The Foley catheter was left in situ for an average of 2 weeks after operation. Three patients developed early postoperative complications; two bowel anastomotic leaks, and one intra-abdominal abscess. All these complications were associated with sepsis and multiple fistulas at the time of laparotomy. After a median follow-up of 13 years, 3 patients having postoperative sepsis (anastomotic leak or abscess) developed a recurrent fistula from the ileocolonic anastomosis to the bladder, which required further surgery. In the other 22 patients without postoperative complications there has been no fistula recurrence. In conclusion, the majority of patients with enterovesical fistula required surgical treatment: resection of the diseased bowel and oversewing the defect in the bladder. The fistula recurrence was uncommon, but the presence of sepsis and multiple fistulas at the time of laparotomy increased the incidence of postoperative complications and fistula recurrence.     

Surgical therapy of perianal Crohn''s disease

The surgical management of perianal Crohn's disease is complex with a wide range of operations being described. The initial emergency treatment is to drain any source of underlying sepsis. A loose seton drainage or a defunctioning stoma can then be used as a 'bridge' to definitive treatment allowing both adequate assessment of the condition and preventing further sepsis. The likelihood of success of any surgical repair must be weighed against the risk of faecal incontinence. Improved results of a local surgical repair are seen with optimal surgical and medical management of perianal Crohn's disease.     

Assessment and classification of fistula-in-ano in patients with Crohn's disease by hydrogen peroxide enhanced transanal ultrasound

Crohn's disease is well known for its perianal complications, among which fistulas-in-ano are the most common abnormalities. Fistulas-in-ano in Crohn's disease tend to be complex and have a high recurrence rate. Therefore the role of surgery is generally more conservative. Hydrogen peroxide enhanced transanal ultrasound has proven superior to physical examination, fistulography, computed tomography, and conventional ultrasound in demonstrating the fistula tract. This study examined the fistula tracks in patients with Crohn's disease. Forty-one patients with Crohn's disease and fistula-in-ano were investigated using physical examination, sondage of the fistula, proctoscopy and transanal ultrasound. Hydrogen peroxide was infused via a small catheter into the fistula. The main track and the ramification of the fistula were classified according to the anatomical Parks' classification. Only 9 (22%) patients had a single inter- or transsphincteric fistula. In 5 (12%) patients a single supra- or extrasphincteric fistula (high fistula) was found, in 14 (34%) more than one fistula track (ramified), and in 13 (32%) an anovaginal fistula. Thus 78% of patients had a surgically difficult to treat fistula. In the ramified fistula the main track follows the Parks' classification, but ramifications can have a bizarre pattern which is not in agreement with this classification. Optimal documentation by means of hydrogen peroxide enhanced transanal ultrasound is therefore mandatory before surgery or before other therapies such as anti-tumor necrosis factor treatment.     

Treatment of fistulizing Crohn's disease

The primary goals of the clinician in the treatment of fistulizing Crohn's disease (CD) include (1) defining the anatomy of the fistula, (2) draining any associated infectious material, (3) eradicating the fistulous tract through medical or surgical therapies, and (4) preventing recurrence of fistulas. Evaluation and therapeutic decisions require close collaboration between the gastroenterologist and surgeon. Appropriate evaluation should include identification of septic complications, delineation of the fistulous tract including the origin and terminus of the fistula, and determination of the extent of bowel involvement with active CD. Drainage of abscesses and control of septic complications through the placement of drains or setons is essential. Conservative therapy with avoidance of sphincter muscle-cutting procedures is the standard approach. The appropriate approach to asymptomatic patients is uncertain because there are little data to indicate if treatment alters the natural course of disease.     

Management of perianal fistulas in Crohn’s disease:An upto-date review

Perianal disease is one of the most disabling manifestations of Crohn’s disease.A multidisciplinary approach of gastroenterologist,colorectal surgeon and radiologist is necessary for its management.A correct diagnosis,based on endoscopy,magnetic resonance imaging,endoanal ultrasound and examination under anesthesia,is crucial for perianal fistula treatment.Available medical and surgical therapies are discussedin this review,including new local treatment modalities that are under investigation.     

Healing of Transsphincteric Perianal Fistulas in Crohn's Disease Using a New Technique

Objectives : Transsphincteric perianal fistulas in Crohn's disease are often refractory to medical therapy and difficult to treat surgically. Our objective was to determine whether a new method of anal fistulotomy was effective in healing these fistulas. Methods : In this new method, the internal opening of the fistula tract was displaced distally to the region of the anal mucosa in 26 patients with Crohn's disease. Results : Healing was achieved within 5 weeks of surgery in 45/49 (92%) of the fistulas and was not influenced by perioperative medication, site of preexisting Crohn's disease, or condition of the rectum. There has been no alteration of preoperative continence. Conclusions : We conclude that this method is highly effective in treating transsphincteric perianal fistulas in Crohn's disease.     

Heartburn and multiple-site foregut perforations as primary manifestation of Crohn''s disease

SUMMARY: Crohn's disease may affect any segment of the digestive tract, more commonly the distal ileum, colon and/or perianal region. There is an increasing number of reports dealing with foregut Crohn's disease. We present the case of a patient with a history of heartburn and multiple spontaneous perforations of the esophagus, duodenum and jejunum as a primary manifestation of Crohn's disease who required emergency surgical and endoscopic procedures. Early detection of Crohn's disease may decrease the incidence of acute life-threatening complications provided that appropriate medical treatment is administered and a multidisciplinary approach is offered to these patients.