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Singh JP, Aleissa M, Drelichman ER, Mittal VK, Bhullar JS. Navigating the complexities of perianal Crohn's disease: Diagnostic strategies, treatment approaches, and future perspectives. World J Gastroenterol 2024; 30:4745-4753. [PMID: 39610776 PMCID: PMC11580605 DOI: 10.3748/wjg.v30.i44.4745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2024] [Revised: 09/25/2024] [Accepted: 10/24/2024] [Indexed: 11/12/2024] Open
Abstract
This article discusses the literature review article by Pacheco et al published in July 2024; the authors provided good reviews of perianal Crohn's disease (CD), and challenges faced by clinicians in the management. CD, characterized by its chronic and relapsing nature, is an idiopathic condition that can involve any segment of the gastrointestinal tract. Perianal disease impacts up to 40% of patients with CD, with perianal fistulas constituting up to 80% of perianal lesions. Perianal CD can be highly incapacitating and profoundly diminish the overall well-being of patients. The management focuses on controlling the perianal sepsis and treating luminal CD. Biologics are crucial to the treatment approach, and results have been encouraging. The surgery focuses on controlling the sepsis, with more definitive treatments being fistula surgery, fecal diversion, and proctectomy as the last resort. This manuscript briefly describes the burden of CD, the challenges posed by perianal CD, and the role of different treatment modalities from colorectal surgeon's perspective.
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Affiliation(s)
- Jai P Singh
- Department of Surgery-Colon and Rectal Surgery, Ascension Providence Hospital, Southfield, MI 48075, United States
| | - Maryam Aleissa
- Department of Surgery-Colon and Rectal Surgery, Ascension Providence Hospital, Michigan State University College of Human Medicine, Southfield, MI 48075, United States
| | - Ernesto R Drelichman
- Department of Surgery-Colon and Rectal Surgery, Ascension Providence Hospital, Michigan State University College of Human Medicine, Southfield, MI 48075, United States
| | - Vijay K Mittal
- Department of Surgery, Ascension Providence Hospital, Michigan State University College of Human Medicine, Southfield, MI 48075, United States
| | - Jasneet S Bhullar
- Department of Surgery, Ascension Providence Hospital, Michigan State University College of Human Medicine, Southfield, MI 48075, United States
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Emoto S, Homma S, Yoshida T, Ichikawa N, Miyaoka Y, Matsui H, Takahashi R, Ishido K, Otsuka T, Mitsuhashi T, Katsurada T, Taketomi A. Transperineal total mesorectal excision for rectal cancer on the residual rectum after multiple abdominal surgeries in a patient with Crohn's disease: a case report. Surg Case Rep 2021; 7:122. [PMID: 33983535 PMCID: PMC8119543 DOI: 10.1186/s40792-021-01206-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 05/10/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The improved prognosis of Crohn's disease may increase the opportunities of surgical treatment for patients with Crohn's disease and the risk of development of colorectal cancer. We herein describe a patient with Crohn's disease and a history of multiple surgeries who developed rectal stump carcinoma that was treated laparoscopically and transperineally. CASE PRESENTATION A 51-year-old man had been diagnosed with Crohn's disease 35 years earlier and had undergone several operations for treatment of Crohn's colitis. Colonoscopic examination was performed and revealed rectal cancer at the residual rectum. The patient was then referred to our department. The tumor was diagnosed as clinical T2N0M0, Stage I. We treated the tumor by combination of laparoscopic surgery and concomitant transperineal resection of the rectum. While the intra-abdominal adhesion was dissected laparoscopically, rectal dissection in the correct plane progressed by the transperineal approach. The rectal cancer was resected without involvement of the resection margin. The duration of the operation was 3 h 48 min, the blood loss volume was 50 mL, and no intraoperative complications occurred. The pathological diagnosis of the tumor was type 5 well- and moderately differentiated adenocarcinoma, pT2N0, Stage I. No recurrence was evident 3 months after the operation, and no adjuvant chemotherapy was performed. CONCLUSION The transperineal approach might be useful in patients with Crohn's disease who develop rectal cancer after multiple abdominal surgeries.
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Affiliation(s)
- Shin Emoto
- Department of Gastroenterological Surgery I, Hokkaido University Graduate School of Medicine, Kita 15 Nishi 7, Kita-ku, Sapporo, Hokkaido, 060-8638, Japan.
| | - Shigenori Homma
- Department of Gastroenterological Surgery I, Hokkaido University Graduate School of Medicine, Kita 15 Nishi 7, Kita-ku, Sapporo, Hokkaido, 060-8638, Japan
| | - Tadashi Yoshida
- Department of Gastroenterological Surgery I, Hokkaido University Graduate School of Medicine, Kita 15 Nishi 7, Kita-ku, Sapporo, Hokkaido, 060-8638, Japan
| | - Nobuki Ichikawa
- Department of Gastroenterological Surgery I, Hokkaido University Graduate School of Medicine, Kita 15 Nishi 7, Kita-ku, Sapporo, Hokkaido, 060-8638, Japan
| | - Yoichi Miyaoka
- Department of Gastroenterological Surgery I, Hokkaido University Graduate School of Medicine, Kita 15 Nishi 7, Kita-ku, Sapporo, Hokkaido, 060-8638, Japan
| | - Hiroki Matsui
- Department of Gastroenterological Surgery I, Hokkaido University Graduate School of Medicine, Kita 15 Nishi 7, Kita-ku, Sapporo, Hokkaido, 060-8638, Japan
| | - Ryo Takahashi
- Department of Gastroenterological Surgery I, Hokkaido University Graduate School of Medicine, Kita 15 Nishi 7, Kita-ku, Sapporo, Hokkaido, 060-8638, Japan
| | - Keita Ishido
- Department of Gastroenterological Surgery I, Hokkaido University Graduate School of Medicine, Kita 15 Nishi 7, Kita-ku, Sapporo, Hokkaido, 060-8638, Japan
| | - Takuya Otsuka
- Department of Surgical Pathology, Hokkaido University Hospital, Kita 14 Nishi 5, Kita-ku, Sapporo, Hokkaido, 060-8648, Japan
| | - Tomoko Mitsuhashi
- Department of Surgical Pathology, Hokkaido University Hospital, Kita 14 Nishi 5, Kita-ku, Sapporo, Hokkaido, 060-8648, Japan
| | - Takehiko Katsurada
- Department of Gastroenterology and Hepatology, Hokkaido University Faculty of Medicine and Graduate School of Medicine, Kita 15 Nishi 7, Kita-ku, Sapporo, Hokkaido, 060-8638, Japan
| | - Akinobu Taketomi
- Department of Gastroenterological Surgery I, Hokkaido University Graduate School of Medicine, Kita 15 Nishi 7, Kita-ku, Sapporo, Hokkaido, 060-8638, Japan
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Abstract
Crohn's disease (CD) is a chronic inflammatory condition of the gastrointestinal tract resulting in progressive tissue damage, which can result in strictures, fistulae, and abscesses formation. The triggering mechanism is thought to be in the fecal stream, and diversion of this fecal stream is sometimes required to control disease when all other avenues of medical and surgical management have been exhausted. Fecal diversion can be temporary or permanent with the indications being defunctioning a high-risk anastomosis, as a result of a surgical complication, for disease control, or due to severe colonic, rectal, or perianal disease. The incidence of ostomy formation in CD has increased epidemiologically over time. The primary indication for ostomy formation is severe perianal fistulizing disease. However, while 64% of patients have an early clinical response after diversion for refractory perianal CD, restoration of bowel continuity is attempted in only 35% of patients, and is successful in only 17%. The current review discusses the indications for ostomy creation in complex CD, strategies for procedure selection, and patient outcomes.
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Affiliation(s)
- John P Burke
- Department of Colorectal Surgery, Beaumont Hospital, Dublin 9, Ireland.,Department of Surgery, Royal College of Surgeons in Ireland, Dublin 2, Ireland
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Smedh K, Sverrisson I, Chabok A, Nikberg M. Hartmann's procedure vs abdominoperineal resection with intersphincteric dissection in patients with rectal cancer: a randomized multicentre trial (HAPIrect). BMC Surg 2016; 16:43. [PMID: 27401339 PMCID: PMC4940760 DOI: 10.1186/s12893-016-0161-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2015] [Accepted: 06/21/2016] [Indexed: 02/10/2023] Open
Abstract
Background The use of Hartmann’s procedure in the old and frail and/or in patients with fecal incontinence is increasing, even though some data have reported high postoperative rates of pelvic abscesses. Abdominoperineal excision with intersphincteric dissection has been proposed as a better alternative and is performed increasingly both nationally and internationally. However, no studies have been performed to support this. The aim of this study is to randomize patients between Hartmann’s procedure and abdominoperineal excision with intersphincteric dissection and compare post-operative surgical morbidity and quality of life. The hypothesis is that intersphincteric abdominoperineal excision provides less pelvic and perineal morbidity. Methods/design In this multicentre randomized controlled study, Hartmann’s procedure will be compared with intersphincteric abdominoperineal excision in patients with rectal cancer unsuitable for an anterior resection. The patients are operated in different ways around the ano-rectum, otherwise the same procedure is performed with total mesorectal excision and all will receive a colostomy. The one-month postoperative control will focus on post-operative surgical complications, especially the perineal-pelvic, reoperations and other interventions. After one year, late complications such as pain in the perineal or pelvic area or disorders such as secretion or bleeding from the anorectal stump will be recorded and a follow-up of quality of life performed. Histological and oncological data will also be recorded, the latter up to 5 years post-operatively. Discussion The HAPIrect trial is the first randomized controlled trial comparing standard low Hartmann’s procedure with intersphincteric abdominoperineal excision in patients with rectal cancer with the aim of categorizing the post-operative surgical morbidity. Trial registration ClinicalTrials.gov Identifier: NCT01995396. Date of registration November 25, 2013.
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Affiliation(s)
- Kenneth Smedh
- Colorectal Unit, Department of Surgery and Centre for Clinical Research, Uppsala University, Västmanland's Hospital Västerås, 721 89, Västerås, Sweden.
| | - Ingvar Sverrisson
- Colorectal Unit, Department of Surgery and Centre for Clinical Research, Uppsala University, Västmanland's Hospital Västerås, 721 89, Västerås, Sweden
| | - Abbas Chabok
- Colorectal Unit, Department of Surgery and Centre for Clinical Research, Uppsala University, Västmanland's Hospital Västerås, 721 89, Västerås, Sweden
| | - Maziar Nikberg
- Colorectal Unit, Department of Surgery and Centre for Clinical Research, Uppsala University, Västmanland's Hospital Västerås, 721 89, Västerås, Sweden
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Sverrisson I, Nikberg M, Chabok A, Smedh K. Hartmann's procedure in rectal cancer: a population-based study of postoperative complications. Int J Colorectal Dis 2015; 30:181-6. [PMID: 25421100 DOI: 10.1007/s00384-014-2069-6] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/08/2014] [Indexed: 02/04/2023]
Abstract
PURPOSE Hartmann's procedure for rectal cancer patients is increasingly performed but few studies have reported the postoperative outcome. The purpose was to report postoperative complications and analyse risk factors in rectal cancer patients operated with Hartmann's procedure. To describe the selection and postoperative complication patterns, all bowel-resected rectal cancer patients were included. METHODS Population-based data were from the county of Västmanland, Sweden. All rectal cancer patients operated with an elective bowel resection between 1996 and 2012 were included. Demographics and postoperative complications were prospectively registered and data retrospectively analysed. RESULTS Of the 624 patients included, 396 (64%) were operated with an anterior resection, 159 (25%) with an abdominoperineal excision and 69 (11%) a Hartmann's procedure of which 90% were low Hartmann's. Patients operated with a Hartmann's procedure were significantly older, had higher ASA-score, poorer WHO performance score and lower serum albumin levels. Operative time for Hartmann's procedure was a median of 49 and 99 min shorter than after anterior resection and abdominoperineal excision, respectively, and entailed less bleeding. Complications related to the pelvic and perineal dissections were more common after abdominoperineal excision compared with anterior resection and Hartmann's procedure (32 vs. 9 and 13%, p < 0.001). CONCLUSIONS Few rectal cancer patients, operated with Hartmann's procedure, developed pelvic complications despite a higher age, more co-morbidities, metastases in different localities and functional inferiority when compared with the patients operated with anterior resection or abdominoperineal excision. Hartmann's procedure is a valid alternative procedure in the old and frail rectal cancer patient.
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Affiliation(s)
- Ingvar Sverrisson
- Colorectal Unit, Department of Surgery and Centre for Clinical Research of Uppsala University, Västmanland's Hospital Västerås, 72189, Västerås, Sweden,
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Sordo-Mejia R, Gaertner WB. Multidisciplinary and evidence-based management of fistulizing perianal Crohn's disease. World J Gastrointest Pathophysiol 2014; 5:239-51. [PMID: 25133026 PMCID: PMC4133523 DOI: 10.4291/wjgp.v5.i3.239] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2013] [Revised: 05/07/2014] [Accepted: 05/28/2014] [Indexed: 02/06/2023] Open
Abstract
Perianal symptoms are common in patients with Crohn's disease and cause considerable morbidity. The etiology of these symptoms include skin tags, ulcers, fissures, abscesses, fistulas or stenoses. Fistula is the most common perianal manifestation. Multiple treatment options exist although very few are evidence-based. The phases of treatment include: drainage of infection, assessment of Crohn's disease status and fistula tracts, medical therapy, and selective operative management. The impact of biological therapy on perianal Crohn's disease is uncertain given that outcomes are conflicting. Operative treatment to eradicate the fistula tract can be attempted once infection has resolved and Crohn's disease activity is controlled. The operative approach should be tailored according to the anatomy of the fistula tract. Definitive treatment is challenging with medical and operative treatment rarely leading to true healing with frequent complications and recurrence. Treatment success must be weighed against the risk of complications, specially anal sphincter injury. A full understanding of the etiology and all potential therapeutic options is critical for success. Multidisciplinary management of fistulizing perianal Crohn's disease is crucial to improve outcomes.
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Abstract
Many patients with Crohn’s disease (CD) require surgery. Indications for surgery include failure of medical treatment, bowel obstruction, fistula or abscess formation. The most common surgical procedure is resection. In jejunoileal CD, strictureplasty is an accepted surgical technique that relieves the obstructive symptoms, while preserving intestinal length and avoiding the development of short bowel syndrome. However, the role of strictureplasty in duodenal and colonic diseases remains controversial. In extensive colitis, after total colectomy with ileorectal anastomosis (IRA), the recurrence rates and functional outcomes are reasonable. For patients with extensive colitis and rectal involvement, total colectomy and end-ileostomy is safe and effective; however, a few patients can have subsequent IRA, and half of the patients will require proctectomy later. Proctocolectomy is associated with a high incidence of delayed perineal wound healing, but it carries a low recurrence rate. Patients undergoing proctocolectomy with ileal pouch-anal anastomosis had poor functional outcomes and high failure rates. Laparoscopic surgery has been introduced as a minimal invasive procedure. Patients who undergo laparoscopic surgery have a more rapid recovery of bowel function and a shorter hospital stay. The morbidity also is lower, and the rate of disease recurrence is similar compared with open procedures.
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Carlson RM, Roberts PL. Abdominal Surgery for Crohn's Disease—A Surgical Perspective. SEMINARS IN COLON AND RECTAL SURGERY 2012. [DOI: 10.1053/j.scrs.2012.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Abstract
The manifestations of perianal Crohn's disease vary from primary lesions such as skin tags and fissures, to diffuse septic destruction of tissue and sphincter muscle. These manifestations are often persistent and refractory to surgical treatment; however, a more disappointing scenario is when the treatment itself results in a chronic wound. The ideal approach for management involves basic surgical principles, careful patient selection, and realistic expectations. Choice of appropriate procedure, effective elimination of sepsis, thorough evaluation to rule out concomitant systemic disease, and appropriate use of fecal diversion are each an important principle. If proctectomy is necessary, several strategies such as intersphincteric dissection, avoidance of fecal contamination, and appropriate wound closure, are effective in diminishing the postoperative morbidity of an unhealed perineal wound. When an unhealed perineal wound develops in a patient with Crohn's disease, the initial management is conservative. When surgical treatment is necessary, success depends on careful patient selection, optimizing the patient's condition, elimination of sepsis, and choice of an effective technique for healing.
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Affiliation(s)
- Jill C Genua
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, FL 33331, USA.
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10
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Persistent perineal sinus: Incidence, pathogenesis, risk factors, and management. Surg Today 2009; 39:189-93. [DOI: 10.1007/s00595-008-3846-z] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2008] [Accepted: 07/03/2008] [Indexed: 12/20/2022]
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Persistent perineal sinus after ileoanal pouch excision in inflammatory bowel diseases: incidence, risk factors, and clinical course. Dis Colon Rectum 2008; 51:1795-9. [PMID: 18626712 DOI: 10.1007/s10350-008-9417-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2008] [Revised: 03/14/2008] [Accepted: 03/23/2008] [Indexed: 02/08/2023]
Abstract
PURPOSE This study was designed to determine the incidence of persistent perineal sinus after pouch excision in inflammatory bowel disease, risk factors, and long-term clinical course. METHODS The study included 35 consecutive patients who underwent pouch excision at St. Mark's Hospital, London, between 1996 and 2006. Incidence of persistent perineal sinus and its long-term clinical course were reported. Sixteen variables were analyzed to determine their association with persistent perineal sinus. RESULTS There were 17 men and 18 women with median age of 37 (range, 20-57) years. The final diagnosis was ulcerative colitis in 28 and Crohn's disease in 7 patients. The indications for pouch excision included pelvic or perineal sepsis in 60 percent, pouchitis in 23 percent, and poor pouch function in 17 percent. Persistent perineal sinus was diagnosed in 14 patients (40 percent). Pouch excision for fistula or abscess in the pelvis or perineum (odds ratio, 8; 95 percent confidence interval, 1.4-45.5) was an independent predictor for persistent perineal sinus. Twenty-six procedures were performed in patients with persistent perineal sinus and resulted in healing in 64 percent. Curettage was the most common procedure used. CONCLUSIONS Pouch excision for pelvic or perineal sepsis was an independent predictor for persistent perineal sinus.
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Singh B, George BD, Mortensen NJM. Surgical therapy of perianal Crohn's disease. Dig Liver Dis 2007; 39:988-92. [PMID: 17723322 DOI: 10.1016/j.dld.2007.07.157] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2007] [Accepted: 07/24/2007] [Indexed: 12/11/2022]
Abstract
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.
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Affiliation(s)
- B Singh
- Nuffield Department of Surgery, John Radcliffe Hospital, Oxford, United Kingdom.
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Keese M, Back W, Dinter D, Gladisch R, Joos A, Palma P. Case report: late perianal mucinous adenocarcinoma after Crohn's disease proctectomy: an oncological rarity. World J Surg Oncol 2005; 3:42. [PMID: 15987512 PMCID: PMC1190221 DOI: 10.1186/1477-7819-3-42] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2005] [Accepted: 06/29/2005] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND As in ulcerative colitis, there is an increased incidence of colorectal carcinoma in Crohn's disease. While carcinoma formation originating from ano-rectal fistulas is generally considered as a rare event there are different publications reporting on mucinous adenocarcinoma formation in association with a neovagina and rectovaginal fistulas. To the best of our knowledge this is the first description of a perianal mucinous adenocarcinoma arising in a patient after Crohn's disease proctocolectomy. CASE PRESENTATION We report the case of a 50-year old female with a mucinous adenocarcinoma forming in the perineum eleven years after proctocolectomy for Crohn's disease. The patient was readmitted with perineal pain, leucocytosis and a perineal mass highly suspicious of abscess formation in the MRI-Scan. Histological examination revealed a mucinous adenocarcinoma. Exenteration including vagina, uterus and ovaries together with the coccygeal-bone was performed. CONCLUSION Mucinous adenocarcinoma formation is a rare complication of Crohn's disease and so far unreported after proctocolectomy.
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Affiliation(s)
- Michael Keese
- Department of Surgery, University Hospital of Mannheim, 68135 Mannheim, Germany
| | - Walter Back
- Department of Pathology, University Hospital of Mannheim, 68135 Mannheim, Germany
| | - Dietmar Dinter
- Department of Radiology, University Hospital of Mannheim, 68135 Mannheim, Germany
| | - Rainer Gladisch
- Department of Medicine, University Hospital of Mannheim, 68135 Mannheim, Germany
| | - Andreas Joos
- Department of Surgery, University Hospital of Mannheim, 68135 Mannheim, Germany
| | - Pablo Palma
- Department of Surgery, University Hospital of Mannheim, 68135 Mannheim, Germany
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Abstract
PURPOSE An extended Hartmann's procedure is occasionally useful in rectal resections, because anastomotic, perineal, and functional problems are eliminated. This study was designed to examine the occurrence of pelvic sepsis after this procedure and identify possible risk factors. METHODS Medical records were available for 163 patients (89 females) undergoing rectal resection with colostomy and closure of the rectal remnant. Information about pelvic sepsis and possible risk factors was obtained by review of the medical records. RESULTS Pelvis sepsis developed in 31 of 163 patients (18.6 percent). When the rectum had been transected <2 cm above the pelvic floor, 24 of 73 patients (32.9 percent) developed an abscess in contrast to 7 of 90 (7.8 percent) after higher transsection (P = 0.0001). Other risk factors were male gender and missing foot pulses. Only 61 percent of pelvic abscesses healed after a median of 59 days, leaving 39 percent unhealed after an observation period of 277 (range, 20-1,643) days. CONCLUSIONS Surgical alternatives should be considered to an extended Hartmann's procedure when the level of transsection is <2 cm above the pelvic floor, particularly in males.
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Affiliation(s)
- Anders Tøttrup
- Department of Surgery L, University Hospital of Aarhus, Tage Hansensgade 2, 8000 Aarhus C, Denmark.
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15
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Abstract
BACKGROUND The management of perianal Crohn's disease is difficult. A wide variety of treatment options exist although few are evidence based. METHODS A search was conducted using the National Library of Medicine for articles on perianal Crohn's disease and its incidence, classification, assessment and management. RESULTS AND CONCLUSION Perianal Crohn's disease can manifest as skin tags, ulcers, fissures, abscesses, fistulas or stenoses. Improved radiological imaging with endoanal anal ultrasonography and magnetic resonance imaging has improved its assessment and may be used to predict outcome after surgery. Many treatment options exist. During acute complications they are generally aimed at resolving the immediate problem and limiting damage to anal and perianal tissues; this may be a 'bridge' to definitive treatment. The likelihood of success of definitive treatment must be weighed against the risk of complications, especially faecal incontinence.
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Affiliation(s)
- B Singh
- Department of Colorectal Surgery, John Radcliffe Hospital, Oxford, UK
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Affiliation(s)
- William J Sandborn
- Clinical Practice Committee, AGA National Office, c/o Membership Department, 4930 Del Ray Avenue, Bethesda, MD 20814, USA
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Cirincione E, Gorfine SR, Bauer JJ. Is Hartmann's procedure safe in Crohn's disease? Report of three cases. Dis Colon Rectum 2000; 43:544-7. [PMID: 10789755 DOI: 10.1007/bf02237203] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Crohn's disease-associated colorectal cancer may occur in an area of defunctioning bowel. Some patients with Crohn's colitis undergo subtotal colectomy, ileostomy, and low Hartmann's procedure in an effort to preserve the rectum. This procedure has also been advocated for patients with severe anorectal Crohn's disease, in whom nonhealing of the perineal wound after proctectomy occurs with alarming frequency. The authors present a review of the literature and three cases of cancer developing in the defunctioning rectal stump despite surveillance proctoscopy. METHODS Twenty-five patients underwent low Hartmann's procedure for severe anorectal Crohn's disease. Surveillance proctoscopy was performed as follow-up. Development of cancer in the rectal remnant or anus or recurrence of symptoms was managed by resection and adjuvant therapy. RESULTS One patient developed squamous-cell carcinoma of the anal canal, underwent resection and adjuvant therapy, and was disease free at the time of this study. Two patients developed adenocarcinoma of the rectum. Both underwent resection and adjuvant therapy. One patient died and the other developed a recurrence. CONCLUSIONS The authors recommend interval perineal proctectomy in all patients undergoing low Hartmann's procedure for severe anorectal Crohn's disease in whom rectal preservation is not possible. Regularly scheduled interim surveillance proctoscopy performed every two years, with biopsies of macroscopically normal-appearing and abnormal-appearing rectal mucosa and curetting of fistulous tracts, is also recommended to decrease the possibility of missing occult malignancies.
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Affiliation(s)
- E Cirincione
- Department of Surgery, The Mount Sinai Medical Center, New York, New York, USA
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Regadas FSP, Regadas SMM, Rodrigues LV. Utilização do método videolaparoscopico na reconstituição do trânsito intestinal após a operação de Hartmann. Rev Col Bras Cir 2000. [DOI: 10.1590/s0100-69912000000100003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
O objetivo é apresentar a padronização da técnica operatória e os resultados obtidos com a utilização do acesso videolaparoscópico na reconstituição do trânsito intestinal em pacientes previamente submetidos à operação de Hartmann por causas diversas. Foram analisados prospectivamente 32 pacientes, no período de dezembro de 1991 a junho de 1997, com distribuição semelhante com relação ao sexo e com idade média de 42,4 anos. Todos os pacientes foram submetidos ao mesmo preparo pré-operatório e à mesma técnica cirúrgica. Ocorreram três (9,3%) complicações transoperatórias. Uma (3,1 %) anastomose mecânica incompleta, necessitando de endossutura manual, uma (3,1 %) laceração do reto com o grampeador mecânico e uma (3,1 %) lesão da artéria epigástrica direita. Ocorreram ainda três (9,3%) conversões, sendo uma (3,1 %) devido à laceração do reto com o grampeador mecânico, outra (3.1 %) pela invasão tumoral na pelve e outra (3,1 %) pela presença de excessivas aderências intraperitoneais. O tempo operatório variou de 30 a 240 minutos, na média de 126,2 minutos (2,1 horas). A evolução clínica pós-operatória foi satisfatória. Nove (31,0%) pacientes não referiram dor, enquanto 13 (44,8%) a referiram em pequena intensidade, e apenas sete (24,0%) queixaram-se de dor com maior intensidade. A dieta líquida via oral foi instituída no período médio de 1,6 dias, e a primeira evacuação ocorreu na média de 3,2 dias de pós-operatório. O período médio de hospitalização foi de 4,7 dias. Ocorreram complicações pós-operatórias em oito (27,5%) pacientes. Duas (6,8%) infecções da ferida do estoma, dois pacientes (6,8%) com dor no ombro direito, uma (3,4%) deiscência de anastomose, um (3,4%) caso de peritonite por provável contaminação do material cirúrgico, uma coleção líquida pélvica e uma hérnia incisional. Em conclusão, a reconstituição do trânsito intestinal por videolaparoscopia apresentou-se segura e eficaz, podendo constituir-se no método cirúrgico de escolha, pois foi utilizada com sucesso em 90,6% dos pacientes.
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Abstract
PURPOSE Perianal disease is frequent in patients with Crohn's disease, and many of these patients will eventually have abscess formation. In a prospective follow-up study, we evaluated factors influencing the occurrence and recurrence of perianal abscesses. METHODS Of 126 consecutive patients with perianal Crohn's disease seen regularly in an outpatient clinic, 61 (48.4 percent) had at least one perianal abscess (mean follow-up, 32 +/- 17 months). In all, 110 episodes of an abscess with 145 anatomically distinct abscesses were documented. RESULTS The occurrence of first abscesses was dependent on the type of anal fistula (ischiorectal, 73 percent; transsphincteric, 50 percent; superficial, 25 percent; P < 0.02). Surgical therapy consisted of seton drainage (34 percent), mushroom catheter drainage (49 percent), or incision and drainage (29 percent) and led to inactivation in all patients. Cumulative two-year recurrence rates after the first and second abscess were 54 and 62 percent, respectively. Abscess recurrence was less frequent in patients with a stoma (13 vs. 60 percent in patients without stoma after two years) and in patients with superficial anal fistulas (0 vs. 55 percent/56 percent in patients with transsphincteric/ischiorectal fistulas). Only two abscesses recurred within one year after removal of seton drainage, whereas 13 abscesses recurred with the seton still in place. Neither intestinal nor rectal activity of Crohn's disease significantly influenced the occurrence of an abscess. During the study period, only two patients developed partial stool incontinence. CONCLUSION Development of perianal abscesses in Crohn's disease depends on the fecal stream and the anatomic type of anal fistula. Seton and catheter drainage are safe and highly effective in treatment. Long-term use of setons to prevent recurrent abscesses is not supported by our data.
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Affiliation(s)
- F Makowiec
- Department of Surgery, Eberhard-Karls-University, Tübingen, Germany
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Abstract
These complex anorectal conditions are difficult to diagnose because clinical features overlap. In general, an aggressive approach is reserved for hidradenitis suppurativa and necrotizing infections. Patients with Crohn's disease, hematologic disorders, or AIDS are often treated more conservatively, but the correct timing and degree of aggressiveness of surgical intervention may considerably improve the overall outcome. The increasing incidence of AIDS and the frequency with which infected patients present to surgical clinics make it imperative that all surgeons have a working knowledge of the conditions associated with this syndrome. Expertise is required not only to diagnose and treat these conditions but also to protect oneself and others from being inadvertently infected with the HIV. A high index of suspicion and constant vigilance permit the successful resolution of many of these challenging problems.
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Affiliation(s)
- R Gilliland
- Department of Colorectal Surgery, Cleveland Clinic Florida, Fort Lauderdale, USA
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Faucheron JL, Saint-Marc O, Guibert L, Parc R. Long-term seton drainage for high anal fistulas in Crohn's disease--a sphincter-saving operation? Dis Colon Rectum 1996; 39:208-11. [PMID: 8620789 DOI: 10.1007/bf02068077] [Citation(s) in RCA: 94] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
METHODS Forty-one consecutive patients with Crohn's disease who underwent long-term seton drainage for high transsphincteric, suprasphincteric, or extrasphincteric anal fistula from 1985 to 1993 were reviewed. The subsequent associated procedure was simple seton removal (18), secondary fistulotomy (7), rectal flap advancement (3), and proctectomy (2). Eleven patients still had the seton in place. RESULTS Recurrence developed in seven patients (39 percent) undergoing simple seton removal and in one patient undergoing rectal flap advancement. None of the patients treated by secondary fistulotomy developed a recurrence. At the end of follow-up, five patients (12 percent) required proctectomy mainly for severe proctitis, and five patients (12 percent) developed anal incontinence, which was severe in two. CONCLUSION Long-term seton drainage for high and fistula in Crohn's disease is efficacious in both treating sepsis and preserving anal sphincter function.
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Affiliation(s)
- J L Faucheron
- Department of Alimentary Tract Surgery, Saint-Antoine Hospital, Paris, France
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Post S, Herfarth C, Schumacher H, Golling M, Schürmann G, Timmermanns G. Experience with ileostomy and colostomy in Crohn's disease. Br J Surg 1995; 82:1629-33. [PMID: 8548223 DOI: 10.1002/bjs.1800821213] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
This study involved 746 patients with Crohn's disease treated surgically within a 13-year interval in whom 227 stomas (159 primary, 68 secondary) were created. The main indication (64 per cent) for primary stoma was severe perianal or genital fistulous disease. Revisional surgery for stomal complications was more common following colostomy than ileostomy (31 versus 5 per cent, P < 0.01). Twenty years after the first symptoms of Crohn's disease the cumulative risks of receiving any stoma or a permanent stoma were 41 and 14 per cent respectively. Four parameters were shown by proportional hazards analysis to be independently associated with the risk for any stoma as well as a permanent one; increased risk coincided with rectal inflammation, perianal fistula or abscess, and absence of small intestinal involvement. In addition, long-standing symptomatic disease before the first surgical intervention reduced the risk of a permanent stoma. The long-term chances of closure following temporary stoma were 75 per cent when used for anastomotic protection or avoidance, 79 per cent after postoperative complications, and 40 per cent for perianal or genital fistulas or for rectal inflammation or stenosis. Rectal disease and perianal fistula were the only independent predictors of a low possibility of stoma closure during follow-up.
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Affiliation(s)
- S Post
- Department of Surgery, University of Heidelberg, Germany
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Abstract
The clinical course of perianal fistulas and associated abscesses was evaluated prospectively in 90 patients with Crohn's disease. Fistula type, rectal disease, faecal diversion, and immunosuppression were examined as prognostic indicators for fistula healing and recurrence. Median follow up was 22 months. The outcome was evaluated with life table analysis. Prognostic factors were analysed by multiple regression. Inactivation was achieved in all patients. The risks of recurrent fistula activity were 48% at one year and 59% at two years. Fistulas were healed in 51% after two years but reopened in 44% within 18 months of healing. Faecal diversion and absence of rectal disease decreased recurrence rates (p = 0.019/0.04) and increased healing rates (p = 0.005/0.017). The outcome in patients with trans-sphincteric fistulas was better than that in those with ischiorectal fistulas but worse than in patients with subcutaneous fistulas (p = 0.015 for healing; p = 0.007 for recurrent fistula activity). After initial treatment about 20% of the patients were symptomatic and about 10% had painful events per six month period. Incontinence was rare and did not increase during the study period. Perianal fistulas and associated abscesses can be controlled safely by simple drainage of pus collections. Frequent reinfection and re-opening after healing of fistulas are characteristic. Fistula type, rectal disease, and stool contamination influence the clinical course. Only a few patients, however, have continuous symptoms from perianal fistulas.
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Affiliation(s)
- F Makowiec
- Department of Surgery, Eberhard-Karls-University, Tübingen, Germany
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The Evolving Role of Laparoscopic Technique in the Performance of Hartmann’s Procedure. Surg Oncol Clin N Am 1994. [DOI: 10.1016/s1055-3207(18)30487-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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