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Triantafyllakis I, Saridi M, Toska A, Albani EN, Togas C, Christodoulou DK, Katsanos KH. SURGICAL INTERVENTION IN PATIENTS WITH IDIOPATHIC INFLAMMATORY BOWEL DISEASE AND PERIANAL DISEASE. POLSKI MERKURIUSZ LEKARSKI : ORGAN POLSKIEGO TOWARZYSTWA LEKARSKIEGO 2023; 51:482-488. [PMID: 38069848 DOI: 10.36740/merkur202305106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
OBJECTIVE Aim: The aim of the study was to investigate the incidence of IBD in gastrointestinal surgery patients and record the disease's characteristics and treatment. PATIENTS AND METHODS Materials and Methods: A search was carried out in the archives of the gastroenterology clinics of the University General Hospital of Ioannina and the General Hospital of Ioannina "G. Hatzikosta" in Greece. All cases of operated patients from 1980 to 2018 were examined. The duration of the study was 4 months. Data were analyzed with the SPSS program, v.28. RESULTS Results: The total sample consisted of 1464 patients (n=1464). Most of them (915-62.5%) came from the University General Hospital of Ioannina, while the rest (549-37.5%) came from the GHI hospital "G. Hatzikosta". The mean age of the patients was 47 years (M=47.26, SD=17.34, Min=<1 month, Max=95 years). From the total sample, 58 patients (4%) suffered from IBD; most were men (42-72.41%). Their mean age was approximately 50 years (M=49.63, SD=16.48, Min=25 years, Max=77 years, range=52 years) and most belonged to the age groups of 31-40 years (11 patients- 19.6%) and 21-30 years and 61-70 years (10 patients-17.9%). The perianal disease was present in 43.1% (25 patients). The most frequent type of operation was fistula resection, ligation, curettage-biopsy (24.1%) and opening-drainage (22.4%-13 patients) and the most frequent type of anesthesia was general anesthesia (93.1%-54 patients). CONCLUSION Conclusions: This long-term study of the patients' data followed up over time showed that the possibility of surgery in patients with IBD is mitigated through systematic monitoring and multifaceted therapeutic treatment.The perianal disease which appeared more often in men shows that it can be diagnosed early and at an early stage and with the new minimally invasive techniques the patient with IBD can be treated with a better quality of life.
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Affiliation(s)
| | - Maria Saridi
- LABORATORY OF CLINICAL NURSING, DEPARTMENT OF NURSING, UNIVERSITY OF THESSALY, LARISSA, GREECE
| | - Aikaterini Toska
- LABORATORY OF CLINICAL NURSING, DEPARTMENT OF NURSING, UNIVERSITY OF THESSALY, LARISSA, GREECE
| | - Eleni N Albani
- DEPARTMENT OF NURSING, UNIVERSITY OF PATRA, PATRA, GREECE
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Xiong Z, Zhou Z, Hao L, Li Y, Hu X, Hu D, Luo Y, Wang Y, Shen Y, Li Z. The relationship between perianal fistula activity and abdominal adipose tissue in Crohn’s disease: an observational study. Insights Imaging 2022; 13:156. [PMID: 36153465 PMCID: PMC9509502 DOI: 10.1186/s13244-022-01293-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Accepted: 09/04/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Objective
The aim of this study was to analyze the relationship between abdominal adipose tissue and perianal fistula activity in patients with Crohn's disease (CD) using cross-sectional imaging.
Methods
Patients with perianal fistulizing CD who underwent pelvic magnetic resonance imaging (MRI) and abdominal computed tomography (CT) were retrospectively enrolled. We scored the fistulas in each patient's MRI images based on Van Assche's classification. The area and density of subcutaneous adipose tissue (SAT) and visceral adipose tissue (VAT) (at the third, fourth, and fifth lumbar (L3, L4, and L5) levels were measured by averaging five slices of measurements at each vertebral level in CT images, and areas were further standardized by the lumbar height2 (heightL1-5). The VAT/SAT ratio (VSR) and VAT/Total adipose tissue (VA/TA) index were calculated. Based on MRI scores, patients were divided into two groups with low and high activity, and their clinical, MRI features, and CT parameters were compared. We evaluated patients with follow-up MRI and compared the differences in clinical and radiological indicators among patients with different outcomes.
Results
Overall, 136 patients were included, 77 in the low-activity group and 59 in the high-activity group. Patients in the high activity group had lower subcutaneous adipose index (all levels, p < 0.05) and visceral adipose index (L3 level, p < 0.01), but higher SAT and VAT density (all levels, p < 0.01), VSR (L5 level, p = 0.07) and VA/TA index (L5 level, p < 0.05).
Conclusion
There were differences in adipose tissue composition among CD patients with different active perianal fistulas.
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Badak B, Pasaoglu E, Caga HT, Ihtiyar E, Sahin A, Erkasap S, Ates E, Yasar NF. Fistulized Crohn’ Disease Mimicking Sigmoid Cancer: A Case Report. GALICIAN MEDICAL JOURNAL 2020. [DOI: 10.21802/gmj.2020.4.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Crohn’s disease is an inflammatory bowel disease of unknown etiology, progressing with frequent exacerbation periods that can involve any part of the gastrointestinal tract. Although, it can manifest itself with complaints from the entire gastrointestinal tract; abdominal pain, diarrhea, nausea, weight loss and fever are the most important clinical symptoms. In this presentation, a 41-year-old male patient with known Crohn’s disease was presented to our hospital with the help of operation images.
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Haac BE, Palmateer NC, Seaton ME, VanYPeren R, Fraser CM, Bafford AC. A Distinct Gut Microbiota Exists Within Crohn's Disease-Related Perianal Fistulae. J Surg Res 2019; 242:118-128. [PMID: 31075656 DOI: 10.1016/j.jss.2019.04.032] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Revised: 03/27/2019] [Accepted: 04/09/2019] [Indexed: 12/25/2022]
Abstract
BACKGROUND Gut bacteria are strongly suspected to play a key role in the pathogenesis of Crohn's disease (CD). Studies have demonstrated alterations in the gut microbiota in this patient population. The purpose of this study was to characterize the gut microbiota of fistulizing perianal CD. MATERIALS AND METHODS Stool and fistula samples were obtained from patients undergoing surgery for CD-related anorectal fistulae. Microbial compositions of matched stool and fistula samples were characterized using 16S rRNA gene profiling. The effect of sample type, patient gender, disease classification (Montreal A/B), disease activity (Harvey Bradshaw Index), antibiotic use, and presence of active proctitis on microbial composition was assessed. RESULTS Samples were obtained from 18 patients. Bacteroides was the most abundant genera across all samples collected, followed by Streptococcus and Bifidobacterium. Bifidobacterium was present at significantly higher levels in fecal samples than fistula samples, whereas Achromobacter and Corynebacterium were present at significantly higher levels in fistula samples. Antibiotic, but not thiopurine or antitumor necrosis factor medication, exposure affected the gut microbial composition. Patient gender, disease classification, disease activity, and presence of active proctitis did not alter stool or fistula microbiota. CONCLUSIONS Our data show that the gut microbiota within CD-related anorectal fistulae is distinct from that in stool samples obtained from the same patients. We also observe a dysbiosis in patients treated with antibiotics compared with those not treated with antibiotics.
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Affiliation(s)
- Bryce E Haac
- Department of Surgery, University of Maryland, Baltimore, Maryland
| | | | - Max E Seaton
- Department of Surgery, University of Maryland, Baltimore, Maryland
| | - Ryan VanYPeren
- Institute for Genome Sciences, University of Maryland, Baltimore, Maryland
| | - Claire M Fraser
- Institute for Genome Sciences, University of Maryland, Baltimore, Maryland
| | - Andrea C Bafford
- Department of Surgery, University of Maryland, Baltimore, Maryland.
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Alegbeleye BJ. Crohn's disease in a developing African mission hospital: a case report. J Med Case Rep 2019; 13:80. [PMID: 30846003 PMCID: PMC6407268 DOI: 10.1186/s13256-019-1971-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Accepted: 01/03/2019] [Indexed: 12/31/2022] Open
Abstract
Background A case is reported of innocuous intestinal obstruction requiring surgical intervention that was confirmed to be Crohn’s disease histopathologically in a resource-constrained rural mission hospital in Cameroon. Case presentation A 70-year man of Kumbo origin from Northwest region of Cameroon with a history of crampy right lower-quadrant abdominal pain, non-bloody, non-mucoid diarrhea alternating with constipation presented to my institution. Abdominal examination of the patient revealed an ill-defined mass in the right iliac fossa and visible peristalsis. An abdominal computed tomographic scan and barium enema study confirmed a complex ascending colonic and cecal tumor. The patient underwent exploratory laparotomy. The intraoperative finding was a huge complex inflammatory mass involving the cecum, terminal ileum, and sigmoid colon. He subsequently had sigmoidectomy with end–to-end sigmoidorectal anastomosis and a cecal resection, and the proximal ascending colon was exteriorized because end mucoid fistula and terminal ileostomy were performed. The histopathological diagnosis confirmed Crohn’s disease. The patient subsequently received five courses of adjuvant chemotherapy consisting of azathioprine, methotrexate, mesalamine, and methylprednisolone. He had complete disease remission and subsequently had closure of ileostomy with satisfactory postoperative status. The most recent follow-up abdominal computed tomographic scan and colonoscopy revealed disease-free status. The patient is also currently receiving a maintenance dose of rectal mesalamine and oral omeprazole treatment. He has been followed every 2 months in the surgical outpatient clinic over the last 16 months with satisfactory clinical outcome. Conclusions Crohn’s disease is uncommon in Africa, and this entity is encountered sparingly. The signs and symptoms of Crohn’s disease overlap with many other abdominal disorders, such as tuberculosis, ulcerative colitis, irritable bowel syndrome, and others. Several publications in the literature describe that it is difficult to make an accurate diagnosis of this disease, despite the fact that many diagnostic armamentaria are available to suggest its presence. Most of the patients with Crohn’s disease are treated conservatively, and a few may require surgical intervention, especially those presenting with complications such as intestinal obstruction, perforations, and abscess as well as fistula formations, as seen in this index patient. Crohn’s disease is considered by many to be a very rare disease in Africa. It is interesting to know that Crohn’s disease, which affects mainly young adults, may debut at any age. The rarity and clinical curiosity of this entity suggested reporting of my patient’s case. Evidence-based up-to-date information on Crohn’s disease is also documented.
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Affiliation(s)
- Bamidele Johnson Alegbeleye
- Department of Surgery, St Elizabeth Catholic General Hospital, Shisong, P.O Box 8, Kumbo - Nso, Bui Division, Northwestern Region, Cameroon.
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Mak WY, Mak OS, Lee CK, Tang W, Leung WK, Wong MTL, Sze ASF, Li M, Leung CM, Lo FH, Lam BCY, Chan KH, Shan EHS, Tsang SWC, Hui AJ, Chow WH, Chan FKL, Sung JJY, Ng SC. Significant Medical and Surgical Morbidity in Perianal Crohn's Disease: Results from a Territory-Wide Study. J Crohns Colitis 2018; 12:1392-1398. [PMID: 30165543 DOI: 10.1093/ecco-jcc/jjy120] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND The presence of perianal fistulas in Crohn's disease [CD] denotes increased disease aggressiveness. We studied the epidemiology and clinical outcomes of perianal CD [PCD] using the Hong Kong territory-wide IBD Registry [HKIBDR]. METHODS Consecutive patients with PCD were identified from the HKIBDR, and disease characteristics, treatments, and outcomes were analysed. The risks for medical and surgical therapies were assessed using Kaplan-Meier analysis. RESULTS Among 981 patients with CD with 10530 patient-years of follow-up, 283 [28.8%] had perianal involvement, of which 120 [42.4%] were as first presentation. The mean age at diagnosis of PCD was 29.1 years, and 78.8% were male. The median follow-up duration was 106 months (interquartile range [IQR]: 65-161 months]. Perianal fistula [84.8%] and perianal abscess [52.7%] were the two commonest forms. Male, younger age at diagnosis of CD, and penetrating phenotypes were associated with development of PCD in multivariate analysis. Of 242 patients with fistulizing PCD, 70 [29.2%] required ≥5 courses of antibiotics, and 98 [40.5%] had ≥2 surgical procedures. Nine patients required defunctioning surgery and 4 required proctectomy. Eighty-four patients [34.7%] received biologics. Cumulative probabilities for use of biologics were 4.7%, 5.8%, and 8.6% at 12 months, 36 months, and 96 months, respectively, while the probabilities for surgery were 67.2%, 71.6%, and 77.7%, respectively. Five mortalities were recorded, including 2 cases of anal cancer, 2 CD-related complications, and one case of pneumonia. CONCLUSION Over 40% of CD patients presented with perianal disease at diagnosis. Patients with PCD had poor outcome, with young age of onset, multiple antibiotic use, and repeated surgery.
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Affiliation(s)
- Wing Yan Mak
- Department of Medicine and Therapeutics, Institute of Digestive Disease, State Key Laboratory of Digestive Disease, LKS Institute of Health Science, The Chinese University of Hong Kong, Hong Kong
| | - Oi Sze Mak
- Department of Surgery, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong
| | - Choon Kin Lee
- Department of Medicine and Therapeutics, Institute of Digestive Disease, State Key Laboratory of Digestive Disease, LKS Institute of Health Science, The Chinese University of Hong Kong, Hong Kong.,Gastroenterology Unit, Department of Medicine, Hospital Pulau Pinang, Pulau Pinang, Malaysia
| | - Whitney Tang
- Department of Medicine and Therapeutics, Institute of Digestive Disease, State Key Laboratory of Digestive Disease, LKS Institute of Health Science, The Chinese University of Hong Kong, Hong Kong
| | - Wai Keung Leung
- Department of Medicine, University of Hong Kong, Queen Mary Hospital, Hong Kong
| | - Marc T L Wong
- Department of Medicine and Geriatrics, Princess Margaret Hospital, Hong Kong
| | | | - Michael Li
- Department of Medicine and Geriatrics, Tuen Mun Hospital, Hong Kong
| | - Chi Man Leung
- Department of Medicine, Pamela Youde Nethersole Eastern Hospital, Hong Kong
| | - Fu Hang Lo
- Department of Medicine and Geriatrics, United Christian Hospital, Hong Kong
| | - Belsy C Y Lam
- Department of Medicine and Geriatrics, Kwong Wah Hospital, Hong Kong
| | - Kam Hon Chan
- Department of Medicine, North District Hospital, Hong Kong
| | | | | | - Aric J Hui
- Department of Medicine, Alice Ho Miu Ling Nethersole Hospital, Hong Kong
| | - Wai Hung Chow
- Department of Medicine, Yan Chai Hospital, Hong Kong
| | - Francis K L Chan
- Department of Medicine and Therapeutics, Institute of Digestive Disease, State Key Laboratory of Digestive Disease, LKS Institute of Health Science, The Chinese University of Hong Kong, Hong Kong
| | - Joseph J Y Sung
- Department of Medicine and Therapeutics, Institute of Digestive Disease, State Key Laboratory of Digestive Disease, LKS Institute of Health Science, The Chinese University of Hong Kong, Hong Kong
| | - Siew C Ng
- Department of Medicine and Therapeutics, Institute of Digestive Disease, State Key Laboratory of Digestive Disease, LKS Institute of Health Science, The Chinese University of Hong Kong, Hong Kong
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Adegbola SO, Pisani A, Sahnan K, Tozer P, Ellul P, Warusavitarne J. Medical and surgical management of perianal Crohn's disease. Ann Gastroenterol 2018; 31:129-139. [PMID: 29507460 PMCID: PMC5825943 DOI: 10.20524/aog.2018.0236] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Accepted: 11/24/2017] [Indexed: 12/16/2022] Open
Abstract
Crohn's disease is increasingly thought to encompass multiple possible phenotypes. Perianal manifestations account for one such phenotype and represent an independent disease modifier. In its more severe form, perianal Crohn's disease confers a higher risk of a severe and disabling disease course, relapses, hospital admissions and operations. This, in turn, imposes a considerable burden and disability on patients. Identification of the precise manifestation is important, as management is nuanced, with both medical and surgical components, and is best undertaken in a multidisciplinary setting for both diagnosis and ongoing treatment. The introduction of biologic medication has heralded a significant addition to the management of fistulizing perianal Crohn's disease in particular, albeit with modest results. It remains a very challenging condition to treat and further work is required to optimize management in this group of patients.
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Affiliation(s)
- Samuel O. Adegbola
- Department of Colorectal Surgery St. Mark’s Hospital, Harrow, United Kingdom (Samuel O. Adegbola, Kapil Sahnan, Phil Tozer, Janindra Warusavitarne)
- Department of Surgery and Cancer, Imperial College, London, United Kingdom (Samuel O. Adegbola, Kapil Sahnan, Phillip Tozer, Janindra Warusavitarne)
| | - Anthea Pisani
- Department of Gastroenterology, Mater dei Hospital, Malta (Pierre Ellul)
| | - Kapil Sahnan
- Department of Colorectal Surgery St. Mark’s Hospital, Harrow, United Kingdom (Samuel O. Adegbola, Kapil Sahnan, Phil Tozer, Janindra Warusavitarne)
- Department of Surgery and Cancer, Imperial College, London, United Kingdom (Samuel O. Adegbola, Kapil Sahnan, Phillip Tozer, Janindra Warusavitarne)
| | - Phil Tozer
- Department of Colorectal Surgery St. Mark’s Hospital, Harrow, United Kingdom (Samuel O. Adegbola, Kapil Sahnan, Phil Tozer, Janindra Warusavitarne)
- Department of Surgery and Cancer, Imperial College, London, United Kingdom (Samuel O. Adegbola, Kapil Sahnan, Phillip Tozer, Janindra Warusavitarne)
| | - Pierre Ellul
- Department of Gastroenterology, Mater dei Hospital, Malta (Pierre Ellul)
| | - Janindra Warusavitarne
- Department of Colorectal Surgery St. Mark’s Hospital, Harrow, United Kingdom (Samuel O. Adegbola, Kapil Sahnan, Phil Tozer, Janindra Warusavitarne)
- Department of Surgery and Cancer, Imperial College, London, United Kingdom (Samuel O. Adegbola, Kapil Sahnan, Phillip Tozer, Janindra Warusavitarne)
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Bafford AC, Latushko A, Hansraj N, Jambaulikar G, Ghazi LJ. The Use of Temporary Fecal Diversion in Colonic and Perianal Crohn's Disease Does Not Improve Outcomes. Dig Dis Sci 2017; 62:2079-2086. [PMID: 28550490 DOI: 10.1007/s10620-017-4618-7] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2017] [Accepted: 05/16/2017] [Indexed: 02/07/2023]
Abstract
AIMS To determine whether temporary fecal diversion for refractory colonic and/or perianal Crohn's disease can lead to clinical remission and restoration of intestinal continuity after optimization of medical therapy. METHODS We retrospectively reviewed our prospectively maintained database of patients treated at the University of Maryland for Crohn's disease between May 2004 and July 2014. Patients with colonic, perianal, or colonic and perianal Crohn's disease, who had fecal diversion for control of medically refractory and/or severe disease, were included. Outcomes, including disease activity and rate of ileostomy reversal, were evaluated up to 24 months from stoma formation. RESULTS Thirty patients were identified. Fecal diversion was performed for perianal disease in 37%, colonic disease in 33%, and both in 30% of patients. Twelve (40%) patients underwent ileostomy reversal. Twenty-five percent of patients with perianal disease had their ostomies reversed compared to 70% of patients with colonic disease alone. More patients with complex compared to simple perianal disease remained diverted (p = 0.02). Six (20%) patients required colectomy. Of these, 50% had complex perianal disease, all had received two or more biologics, and two-thirds were on combination therapy pre-diversion. CONCLUSIONS Our study found that nearly two-thirds of patients with medically refractory colonic and/or severe perianal Crohn's disease treated with fecal diversion and optimization of postoperative medical therapy remain diverted or require colectomy within two years after ileostomy formation. In patients with severe, refractory perianal disease and those treated with combination therapy and >1 biologic exposure pre-diversion, colectomy rather than temporary fecal diversion should be considered.
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Affiliation(s)
- Andrea C Bafford
- Department of Surgery, University of Maryland, 22 South Greene Street, Baltimore, MD, 21201, USA. .,Veterans Affairs, Maryland Heath Care System, Baltimore, MD, USA.
| | | | - Natasha Hansraj
- Department of Surgery, University of Maryland, 22 South Greene Street, Baltimore, MD, 21201, USA
| | | | - Leyla J Ghazi
- Division of Gastroenterology and Hepatology, University of Maryland, Baltimore, MD, USA.,Veterans Affairs, Maryland Heath Care System, Baltimore, MD, USA
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Kamiński JP, Zaghiyan K, Fleshner P. Increasing experience of ligation of the intersphincteric fistula tract for patients with Crohn's disease: what have we learned? Colorectal Dis 2017; 19:750-755. [PMID: 28371062 DOI: 10.1111/codi.13668] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Accepted: 12/20/2016] [Indexed: 12/13/2022]
Abstract
AIM Ligation of the intersphincteric fistula tract (LIFT) has been proposed as a treatment of trans-sphincteric fistula in perianal Crohn's disease (CD). The aim of this study was to look at our experience of the LIFT procedure in CD patients on long-term follow-up. Specifically, we aimed to determine the fistula healing rate after the LIFT procedure after more than 12 months follow-up and to identify any prognostic factors. METHOD Retrospective study of patients with trans-sphincteric Crohn's fistula tracts treated with the LIFT procedure between January 2011 and October 2015. Complete fistula healing as well as clinical outcomes were analysed. RESULTS Data were available for 23 patients. After a median follow-up of 23 months, LIFT site healing was 48%. Patients with healed LIFT had a median follow-up time of 10.5 months, while patients with failed LIFT had a median follow-up time of 31 months (P = 0.04). Median time to failure was 9 months for patients with follow-up > 1 year. Most patients failed within 1 year (9/12; 75%) of the procedure. In multi-site CD, the LIFT procedure was more likely to be successful in those with small bowel disease (P = 0.04) compared with colonic disease (P = 0.02). Other factors such as preoperative use of biological therapies, presence of a seton, previous repair attempts, fistula position, type or number of fistulas, multiple fistula tracts, smoking status and other associated perianal disease did not appear to influence LIFT healing rates. CONCLUSION The LIFT procedure offers reasonable long-term success in the treatment of perianal trans-sphincteric fistulas associated with CD. LIFT is more likely to fail in patients with concurrent colonic CD than in patients with small bowel CD.
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Affiliation(s)
- J P Kamiński
- Division of Colon and Rectal Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - K Zaghiyan
- Division of Colon and Rectal Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - P Fleshner
- Division of Colon and Rectal Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
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Smith RK, Carter Paulson E. Perianal fistulas in patients with inflammatory bowel disease. SEMINARS IN COLON AND RECTAL SURGERY 2014. [DOI: 10.1053/j.scrs.2014.08.011] [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
BACKGROUND Despite potent drugs and surgical techniques, the treatment of perianal fistulizing Crohn's disease (CD) remains challenging. We assessed treatment strategies for perianal fistulizing CD and their effect on remission, response, and relapse. METHODS Patients with perianal fistulizing CD visiting the Erasmus MC between January 1, 1980 and January 1, 2000 were identified. Demographics, fistula characteristics, and received treatments aimed at the outcome of these strategies were noted. RESULTS In total, 232 patients were identified (98 male; 42.2%). Median follow-up was 10.0 years (range, 0.5-37.5 yr). Complex fistulas were present in 78.0%. Medical treatment (antibiotics, steroids, immunosuppressants, and anti-tumor necrosis factor) commenced in 79.7% of the patients and in 53.2%, surgery (colectomy, fistulectomy, stoma, and rectum amputation) was performed. Simple fistulas healed more often than complex fistulas (88.2% versus 64.6%; P < 0.001). Rectum involvement was not associated with a lower remission rate, and anti-tumor necrosis factor therapy did not increase complete fistula healing rates in simple and complex fistula. Initially, healed fistulas recurred in 26.7% in case of simple fistulas and in 41.9% in case of complex fistulas (P = 0.051). Only 37.0% of the complex fistulas were in remission at the end of follow-up compared with 66.7% of the simple fistulas (P < 0.001). CONCLUSIONS Only the minority of CD complex perianal fistulas were in remission after conventional treatment strategies after a median follow-up of 10 years. Simple fistulas were more likely to heal than complex fistulas, and less of these healed fistulas relapsed. However, more than 3 quarters of the patients had complex perianal fistulas.
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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
BACKGROUND Crohn's disease (CD) often affects women during the reproductive years. Although several studies have examined the impact of pregnancy on luminal disease, limited literature exists in those with perianal CD. Decision regarding mode of delivery is a unique challenge in such patients due to concerns regarding the effect of pelvic floor trauma during delivery on preexisting perianal involvement. METHODS We performed a retrospective chart review of patients with CD with established perianal disease undergoing either vaginal delivery or caesarean section (C-section) at our institutions. We examined the occurrence of symptomatic perianal disease flares within 5 years after delivery in such women compared with nonpregnant CD controls. We also compared the occurrence of such flares between the 2 modes of delivery in women with established perianal CD. RESULTS We identified 61 pregnant patients with CD with established perianal disease (11 vaginal delivery, 50 through C-section) and 61 nonpregnant CD controls with perianal disease. One-third of the C-sections were primarily for obstetric indications. Six of the vaginal deliveries were complicated. Approximately, 36% of cases had a symptomatic perianal flare within 1 year after delivery. This was similar across both modes of delivery (P = 0.53) and similar to nonpregnant patients with CD. There was no difference in the rates of perianal surgical intervention or luminal disease flares in our population based on mode of delivery or between pregnant patients with CD and nonpregnant CD controls. CONCLUSIONS We observed no difference in risk of symptomatic perianal flares in patients with established perianal CD delivering vaginally or through C-section.
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Takano S, Boutros M, Wexner SD. Gracilis Muscle Transposition for Complex Perineal Fistulas and Sinuses: A Systematic Literature Review of Surgical Outcomes. J Am Coll Surg 2014; 219:313-23. [DOI: 10.1016/j.jamcollsurg.2014.04.006] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2013] [Accepted: 04/15/2014] [Indexed: 02/07/2023]
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Cutaneous manifestations in patients with inflammatory bowel diseases: pathophysiology, clinical features, and therapy. Inflamm Bowel Dis 2014; 20:213-27. [PMID: 24105394 DOI: 10.1097/01.mib.0000436959.62286.f9] [Citation(s) in RCA: 90] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The skin is one of the most common extraintestinal organ system affected in patients with inflammatory bowel disease (IBD), including both Crohn's disease and ulcerative colitis. The skin manifestations associated with IBD are polymorphic and can be classified into 4 categories according to their pathophysiology: (1) specific, (2) reactive, (3) associated, and (4) induced by IBD treatment. Cutaneous manifestations are regarded as specific if they share with IBD the same granulomatous histopathological pattern: perianal or metastatic Crohn's disease (commonly presenting with abscesses, fistulas or hidradenitis suppurativa-like features) is the prototype of this setting. Reactive cutaneous manifestations are different from IBD in the histopathology but have close physiopathological links: pyoderma gangrenosum, a neutrophil-mediated autoinflammatory skin disease typically manifesting as painful ulcers, is the paradigm of this group. Among the cutaneous diseases associated with IBD, the most commonly seen are erythema nodosum, a form of panniculitis most commonly involving bilateral pretibial areas, and psoriasis, a T helper 1/T helper 17-mediated erythematous squamous inflammatory disease. Finally, the number of cutaneous adverse reactions because of IBD therapies is progressively increasing. The most frequent drug-induced cutaneous manifestations are psoriasis-like, eczema-like, and lichenoid eruptions, as well as cutaneous lupus erythematosus for biologics, and nonmelanoma skin cancer, mainly basal cell and squamous cell carcinomas for thiopurines.
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Wong MTC, Seow-Choen F. Benign Disease, Fissures, Presentation and Pathophysiology. ANUS 2014:197-210. [DOI: 10.1007/978-1-84882-091-3_15] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2025]
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Surgical repair of rectovaginal fistulas in patients with Crohn's disease. Eur J Obstet Gynecol Reprod Biol 2013; 171:166-70. [PMID: 24011379 DOI: 10.1016/j.ejogrb.2013.08.011] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2013] [Revised: 07/11/2013] [Accepted: 08/05/2013] [Indexed: 12/28/2022]
Abstract
OBJECTIVES To report surgical outcomes of patients who underwent rectovaginal fistula (RVF) repair with a history of Crohn's disease utilizing several reconstructive techniques. STUDY DESIGN Retrospective case series of women (n=6) with Crohn's disease surgically treated with either vaginal or rectal advancement flaps. Demographic information and data specific to Crohn's disease at the time of surgery were collected. In addition, operative reports and postoperative follow-up visits were reviewed. RESULTS During the study period, six women with the diagnosis of Crohn's disease and RVF underwent surgical management. Five patients had a vaginal advancement flap (VAF) by Female Pelvic Medicine and Reconstructive Surgery and one patient was treated by the rectal advancement flap by Colorectal Surgery. The failure rate in our study population was 33% (2/6). Of note, two of the patients who had a successful VAF had a previous failure after RAF. In addition, four patients who had a repair via the transvaginal approach had a concomitant pedicled flap procedure (i.e. Martius or gracilis flap). The average follow-up for all our patients was 5 months (+/- 6.5 months). No patients failed if they received a VAF with a concomitant flap procedure. CONCLUSIONS This case series illustrates several techniques utilized for the repair of RVF in patients with Crohn's disease. The use of a bulbocavernosus flap during the primary repair of RVF in this patient population may be considered to bolster the rectovaginal septum.
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Antakia R, Shorthouse AJ, Robinson K, Lobo AJ. Combined modality treatment for complex fistulating perianal Crohn's disease. Colorectal Dis 2013; 15:210-6. [PMID: 22672653 DOI: 10.1111/j.1463-1318.2012.03124.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
AIM Perianal disease affects 33% (range 8-90%) of patients with Crohn's disease. Fistulae are often complex and their management is often difficult and unsatisfactory. This study was a retrospective assessment of a combination of surgical treatment with a standardized protocol of infliximab (IFX) therapy. METHOD A consecutive series of patients with complex perianal Crohn's disease, presenting between January 2003 and June 2008, were included. Acute sepsis was initially treated with antibiotics and/or surgical drainage (MRI guided when appropriate) and loose seton insertion. IFX was given at 5 mg/kg, at 0, 2 and 6 weeks. End-points were complete, partial or no response. Setons were empirically removed after the second cycle of IFX. RESULTS Forty-eight patients, average age 46 (range 24-82)years, with perianal Crohn's disease were identified. Three patients stopped IFX after the second infusion, either because of allergy (two patients) or for failure to respond (one patient). Fourteen patients were given maintenance IFX at 8-weekly intervals. Results were recorded for 48 patients, of whom 14 (29%) had a complete response, 20 (42%) had a partial response and 14 (29%) had no response to treatment. Outpatient follow-up was for a median of 20 months. CONCLUSION Combining surgical procedures with IFX resulted in complete and partial remission in 29% and 42% of patients, respectively. No serious side effects occurred. Using a combined, intensive medico-surgical approach, good initial control of perianal disease was achieved safely.
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Affiliation(s)
- R Antakia
- Department of Colorectal Surgery, Northern General Hospital, Sheffield, UK.
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Abstract
BACKGROUND Perianal Crohn's disease represents a phenotype distinct from luminal Crohn's disease and may follow a different course. To date, the only detailed classifications of perianal Crohn's disease arise from referral center cohorts that do not reflect the spectrum of disease in the population as a whole. OBJECTIVES The aim of this study was to document the rate, classification, and time course of symptomatic perianal Crohn's disease in a population-based cohort. DESIGN This is a population-based cohort study. SETTING : This study was conducted in the Canterbury region of New Zealand. PATIENTS All patients with IBD in Canterbury, New Zealand, were eligible for recruitment over a 3-year period. MAIN OUTCOME MEASURES The clinical records of all patients with Crohn's disease were reviewed, and all symptomatic perianal disease was classified according to the American Gastroenterological Society position statement. The rate of perianal involvement and timing of onset relative to Crohn's diagnosis was determined. RESULTS Ninety-one percent of IBD patients in the region were recruited. Seven hundred fifteen patients had Crohn's disease, of which 190 (26.6%) patients had symptomatic perianal disease. The median age of patients with perianal disease was 37 years (range, 4-82 years) and 58.4% were female. Median follow-up was 9 years (range, 2 months to 45 years) from Crohn's disease diagnosis. Onset of perianal disease ranged from 18 years pre-Crohn's diagnosis to 33 years post-Crohn's diagnosis. Fistulas were the most common lesion (50% of patients), followed by perianal abscesses (42.1%), fissures (32.6%), skin tags (11.1%), strictures (7.4%), and hemorrhoids (1.6%). The cumulative probability at 20 years of any perianal Crohn's disease was 42.7% and of a perianal fistula 28.3%. LIMITATIONS This study assumed all noted perianal lesions were related to Crohn's disease and the retrospective classification may have been inaccurate in some cases. CONCLUSIONS This study provides the first detailed classification of perianal Crohn's disease in a population-based cohort.
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Gupta M, Goyal S, Goyal R. Crohn's disease presenting as acute abdomen: Report of two cases. NORTH AMERICAN JOURNAL OF MEDICAL SCIENCES 2012; 3:209-11. [PMID: 22540094 PMCID: PMC3336915 DOI: 10.4297/najms.2011.3209] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Context: Crohn's Disease may involve any part of GI tract leading to inflammation of all the layers of the affected bowel. The symptoms may mimc other intestinal pathologies and at times diagnosis remains a dilemma. Mostly medical therapy remains the mainstay of treatment. However surgical intervention is warranted in cases presenting with acute abdomen.
Case Report: We present two such cases of acute abdomen admitted in our hospital and diagnosed as case of intestinal obstruction. Exploratory laparotomy was performed in both cases and diseased resected segments were confirmed as Crohn's Disease on histopathology. Conclusion: Crohn's Disease should be kept as a differential diagnosis in patients presenting with acute abdomen especially with a long history of vague abdominal complaints.
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Affiliation(s)
- Mahesh Gupta
- Department of Surgery, M.M. Institute Of Medical Sciences And Research, Mullana, (Distt - Ambala), Haryana, India
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Clinical and genetic risk factors for perianal Crohn's disease in a population-based cohort. Am J Gastroenterol 2012; 107:589-96. [PMID: 22158027 DOI: 10.1038/ajg.2011.437] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Perianal Crohn's disease (CD) affects around one-quarter of CD patients and represents a distinct disease phenotype. The objective of this study was to investigate a large population-based cohort of inflammatory bowel disease (IBD) patients to identify clinical and genetic risk factors for perianal CD. METHODS Data were collected in the Canterbury IBD database, estimated to include 91% of all patients with IBD in Canterbury, New Zealand. Genotyping was performed for selected loci previously demonstrated to be associated with CD. Patients with perianal disease were then compared with both CD patients without perianal disease and healthy controls to assess the presence of potential phenotypic, environmental, and genetic risk factors. RESULTS Of the 715 CD patients in the database, 190 (26.5%) had perianal disease. In all, 507 patients with genotype data available were analyzed. Perianal disease was associated with younger age at diagnosis (P < 0.0001), complicated intestinal disease (P < 0.0001), and ileal disease location (P = 0.002). There was no association with gender, ethnicity, smoking, or breast feeding. Genotype analysis revealed an association with the neutrophil cytosolic factor 4 (NCF4) gene compared with both non-perianal CD patients (odds ratio (OR): 1.47; 95% confidence interval (CI): 1.08-1.99) and healthy controls (OR: 1.47; 95% CI: 1.10-1.95). There was no association identified with other genes, including IBD5 (OR: 0.91; 95% CI: 0.69-1.20), tumor necrosis factor α (OR: 1.04; 95% CI: 0.56-1.85), and IRGM (immunity-related guanosine triphosphatase protein type M) (OR: 1.21; 95% CI: 0.80-1.82). CONCLUSIONS This study suggests that younger age at diagnosis, complicated disease behavior, and ileal disease location are risk factors for perianal CD. In addition, this paper represents the first report of an association of the NCF4 gene with perianal disease.
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de la Poza G, López-Sanroman A, Taxonera C, Marín-Jimenez I, Gisbert JP, Bermejo F, Opio V, Muriel A. Genital fistulas in female Crohn's disease patients.: clinical characteristics and response to therapy. J Crohns Colitis 2012; 6:276-80. [PMID: 22405162 DOI: 10.1016/j.crohns.2011.08.015] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2011] [Revised: 08/16/2011] [Accepted: 08/17/2011] [Indexed: 12/13/2022]
Abstract
BACKGROUND Genital fistulas (GF) can arise in the course of Crohn's disease (CD), are difficult to manage and determine a significant alteration of the quality of life. AIMS To review the joint experience of the Inflammatory Bowel Disease Units in six University Hospitals in the management of GF in Crohn's disease on female patients. RESULTS A total of 47 patients with GF were identified, affecting 3.8% of women with CD treated in our centers. A 47.5% of patients were smokers. The median of time from the diagnosis of CD reached 102 months. According to anatomical type, GF were classified as rectovaginal (74.5%), anovaginal/anovulvar (21.3%) and enterovaginal (4.3%). Main symptoms were vaginal discharge of fecal material (55.3%), vaginal passage of gas (40.4%), or both. Fistulas were treated with antibiotics in 59.6% of patients, without any lasting success. Thiopurines were used in 80.9% of cases, with 13.2% of complete and 23.7% of partial responses. Anti TNF-alpha therapy was applied in 63.8%, with a 16.7% of complete and a 30% of partial responses (all responding patients received infliximab). Surgery was indicated in 38.3% of patients, with a 22% of complete responses after a first operation and 38.8% after reintervention. In all, definitive closure after one or more of these therapies was achieved in only 31.9% of cases. CONCLUSION Genital fistulas are a significant problem in female Crohn's disease patients. Therapy is not well defined and only partially effective (one in three cases). Surgical therapy stands out as the most effective treatment.
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Hong MKH, Craig Lynch A, Bell S, Woods RJ, Keck JO, Johnston MJ, Heriot AG. Faecal diversion in the management of perianal Crohn's disease. Colorectal Dis 2011; 13:171-6. [PMID: 19863597 DOI: 10.1111/j.1463-1318.2009.02092.x] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
AIM Severe perianal Crohn's disease remains an uncommon but important indication for faecal diversion (FD). The advent of biological therapy such as infliximab for Crohn's disease is considered to have improved the outcome for these patients. The aim of this study was to assess the outcome of patients undergoing FD for perianal Crohn's disease and the impact of biological therapy (infliximab). METHOD Retrospective chart review was undertaken of patients who underwent FD for management of perianal Crohn's disease at two tertiary centres between 1990 and 2007. Patient demographics, disease extent and use of biological therapy were recorded. Subsequent surgery was assessed. The impact of infliximab on rates of proctocolectomy and restoration of intestinal continuity was assessed. RESULTS Twenty-one patients (one male, 20 female), median age 34 years (range 21-67 years), underwent FD for perianal Crohn's disease. At a median follow-up time of 22 months (range 4-121 months), four patients had undergone stoma closure, 11 had had proctocolectomy and six had a stoma in situ. The effects of the procedure on severity of perianal disease were no effect in four (19%), temporary improvement in six (29%), initial improvement with later plateau in seven (33%) and healing in four patients (19%). Eleven patients (52%) received infliximab. In this group, four underwent proctocolectomy and two had intestinal continuity restored. This was not significantly different from the noninfliximab group. CONCLUSION Patients undergoing FD for perianal Crohn's disease have <20% likelihood of restoration of intestinal continuity. This is not improved with biological therapy.
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Affiliation(s)
- M K H Hong
- Department of Colorectal Surgery, St Vincent's Hospital, Melbourne, Victoria, Australia
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Ruffolo C, Scarpa M, Bassi N, Angriman I. A systematic review on advancement flaps for rectovaginal fistula in Crohn's disease: transrectal vs transvaginal approach. Colorectal Dis 2010; 12:1183-91. [PMID: 19674019 DOI: 10.1111/j.1463-1318.2009.02029.x] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
AIM Despite advances in the treatment of Crohn's disease (CD), the treatment of rectovaginal (RV) fistula remains challenging. Transrectal (RAF) and transvaginal advancement flaps (VAF) represent two possible alternative surgical approaches to this problem. The study aims to review and compare the results of these approaches for RV fistula in CD. METHOD Medical databases from January 1983 to August 2008 were consulted for potentially relevant publications. All studies dealing with the RV fistula repair in CD with RAF or VAF were included. Two researchers worked independently on the study selection, quality assessment, data extraction and analysis phases of the study. Analyses were performed with Review Manager 2.0 software. RESULTS Eleven observational studies were included with a total of 219 flap procedures for RV fistula. The primary fistula closure pooled rate was 54.2% (range 33.3-100%) after RAF and 69.4% (range 0-92.9%) after VAF (P = 0.13). Four studies were eligible for direct comparison between the two procedures. No clearly significant difference between RAF compared with VAF in terms of primary fistula closure rate, nor in terms of overall fistula closure rate, was apparent. The risk of recurrence after RAF compared with VAF seemed similar; in this case, only two studies were taken into consideration. CONCLUSIONS Although limited by a small number of studies of low clinical evidence level, this systematic review suggests that there is no significant difference in terms of outcome between RAF and VAF for RV fistula in CD.
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Affiliation(s)
- C Ruffolo
- Regional Hospital Cà Foncello, Treviso, Italy.
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Eglinton T, Reilly M, Chang C, Barclay M, Frizelle F, Gearry R. Ileal disease is associated with surgery for perianal disease in a population-based Crohn's disease cohort. Br J Surg 2010; 97:1103-9. [PMID: 20632279 DOI: 10.1002/bjs.7031] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND The aim of this study was describe the frequency and characteristics of perianal surgical intervention (PSI) for Crohn's disease in a population-based cohort of patients with inflammatory bowel disease (IBD). METHODS A total of 1421 patients with IBD were recruited, representing approximately 91 per cent of people with IBD in Canterbury, New Zealand. The clinical notes were screened to confirm the diagnosis and extract clinical data, including details of PSIs. RESULTS Some 649 patients with Crohn's disease were included in the analysis, of whom 119 (18.3 per cent) had at least one PSI. Of these, 61 (51.3 per cent) required further procedures. Operations for perianal abscess and fistula accounted for 72.4 per cent of interventions. PSI rates did not differ between the sexes (P = 0.218). Age less than 17 years (adjusted odds ratio (OR) 1.89 (95 per cent confidence interval 1.08 to 3.28)) and ileal disease (OR 1.76 (1.06 to 2.92)) were identified as predictors of PSI. As disease duration increased, so did the proportion of patients with complicated intestinal disease among those who had undergone PSI. The median time to first PSI from diagnosis of Crohn's disease was 28 (interquartile range 7-82) months. Sex, age at diagnosis and disease location did not influence the time to first PSI. CONCLUSION PSIs are frequent in patients with Crohn's disease, particularly those with ileal disease and those diagnosed at a young age.
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Affiliation(s)
- T Eglinton
- Department of Surgery, Christchurch Hospital, Christchurch, New Zealand.
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Abstract
Anal fissure is a common disorder that is effectively treated and prevented with conservative measures in its acute form, whereas chronic fissures may require medical or surgical therapy. This article discusses the nonoperative and operative management strategies, reviews the current literature on expected outcomes, and provides guidance on dealing with fissures in special situations, such as patients with inflammatory bowel disease or hypotonic sphincters.
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Affiliation(s)
- Daniel O Herzig
- Department of Surgery, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Mail Code L-223A, Portland, OR 97239, USA.
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Ruffolo C, Penninckx F, Van Assche G, Vermeire S, Rutgeerts P, Coremans G, D'Hoore A. Outcome of surgery for rectovaginal fistula due to Crohn's disease. Br J Surg 2009; 96:1190-5. [PMID: 19688772 DOI: 10.1002/bjs.6661] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND This study examined the outcome of surgery for symptomatic Crohn's rectovaginal fistula (RVF) and assessed the effect of therapy with antibody against tumour necrosis factor (TNF) on healing. METHODS Fifty-six patients with Crohn's disease underwent surgery for a RVF between January 1993 and December 2006. Outcome analysis was performed in February 2008 in relation to the surgical procedures used and the effect of anti-TNF treatment. RESULTS Four patients with a healed fistula still had a stoma at final follow-up for other reasons and were excluded from the analysis. Fistula closure was achieved in 81 per cent of the remaining 52 patients. Primary and secondary surgical success rates were 56 and 57 per cent respectively. The primary healing rate was similar in patients who received anti-TNF treatment before the first operation (12 of 18 patients) and those who did not (19 of 34). In univariable analysis, duration of Crohn's disease (P = 0.037) and previous extended colonic resection (P < 0.001) were significantly related to failure of primary surgery, but only the latter remained significant in multivariable analysis (P < 0.001). Late recurrence developed in four patients. CONCLUSION Fistula closure was achieved in most patients, but more than one operation was often required.
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Affiliation(s)
- C Ruffolo
- Department of Abdominal Surgery, University Hospital Gasthuisberg, Leuven, Belgium
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Craniofacial Surgical Management of a Patient With Systematic Juvenile Idiopathic Arthritis and Crohn's disease. J Craniofac Surg 2009; 20:948-50. [DOI: 10.1097/scs.0b013e3181a14bb4] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Graham DB, Tishon JR, Borum ML. An evaluation of vaginal symptoms in women with Crohn's disease. Dig Dis Sci 2008; 53:765-6. [PMID: 17764029 DOI: 10.1007/s10620-007-9921-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2006] [Accepted: 07/04/2007] [Indexed: 12/09/2022]
Abstract
There are limited data available that address the prevalence of vaginal complaints in women with Crohn's disease. This study assessed the frequency of vaginal involvement and types of vaginal symptoms in women with Crohn's disease managed at a university inflammatory bowel disease program. The charts of 50 women with Crohn's disease seen consecutively during a three-month period were reviewed for the presence of vaginal involvement. The intestinal distribution of Crohn's disease [colonic, small bowel (SB), colonic/SB] was determined, and the presence of vaginal symptoms and types of complaints were assessed. Eleven of the 50 women (22%) described vaginal symptoms. Vaginal complaints included ten patients with labial swelling and one patient with passage of stool through the vagina. Nine of the 11 women with vaginal complaints also had concurrent intestinal symptoms and perineal manifestations (P < 0.001). This study suggests that vaginal involvement in Crohn's disease may be a more frequent phenomenon than previously reported.
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Affiliation(s)
- Deborah B Graham
- Division of Gastroenterology and Liver Diseases, The George Washington University Hospital, Washington, DC 20037, USA.
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Colon, Rectum, and Anus. Surgery 2008. [DOI: 10.1007/978-0-387-68113-9_52] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Williams JG, Farrands PA, Williams AB, Taylor BA, Lunniss PJ, Sagar PM, Varma JS, George BD. The treatment of anal fistula: ACPGBI position statement. Colorectal Dis 2007; 9 Suppl 4:18-50. [PMID: 17880382 DOI: 10.1111/j.1463-1318.2007.01372.x] [Citation(s) in RCA: 131] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- J G Williams
- McHale Centre, New Cross Hospital, Wolverhampton, UK.
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Ingle SB, Loftus EV. The natural history of perianal Crohn's disease. Dig Liver Dis 2007; 39:963-9. [PMID: 17720635 DOI: 10.1016/j.dld.2007.07.154] [Citation(s) in RCA: 76] [Impact Index Per Article: 4.2] [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
Perianal lesions are exceedingly common in Crohn's disease and many patients have more than one type of lesion. Skin tags, fissures and haemorrhoids may persist over time and are usually managed expectantly or with topical therapy. Perianal and rectovaginal fistulas and associated abscesses often require both local and systemic therapy, and recurrence is common. In general, the clinical course of Crohn's disease is more aggressive in patients with perianal involvement. Established risk factors for perianal disease include colonic disease and young age at disease onset. Classification schema now recognize perianal fistulas as distinct from other forms of penetrating Crohn's disease. Genetic susceptibility factors for perianal disease may exist, but they remain incompletely delineated at present. There is hope that immunosuppressive and biotechnology medications will influence the natural history of perianal disease by preventing invasive surgeries, disease complications and recurrence, but this needs to be confirmed. Cancer, a rare complication of perianal disease, must be suspected when lesions persist despite therapy.
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Affiliation(s)
- S B Ingle
- Miles and Shirley Fiterman Center for Digestive Diseases, Mayo Clinic College of Medicine, Rochester, MN 55905, USA
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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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Abstract
The treatment of fistulizing CD has evolved greatly in the last 15 years, largely caused by improvements in medical therapy. Tables 2 and 3 summarize all published controlled and uncontrolled trials of immunomodulator and biologic therapy for the treatment of Crohn's fistulae. The advent of immunomodulators and anti-TNF-alpha agents has transformed the treatment of Crohn's fistulae from almost exclusively surgical to placing a much larger emphasis on medical therapy, either as initial therapy alone, with surgery reserved for refractory cases, or in combination with surgery from the start. For this reason, surgeons and gastroenterologists must work in concert to provide the best care for each patient. Proper fistula management also relies heavily on accurate diagnosis, especially defining the anatomy of the fistula, ascertaining whether abscess formation is present, and determining the location and extent of intestinal inflammation.
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Affiliation(s)
- Mark T Osterman
- Division of Gastroenterology, Department of Medicine, Penn Presbyterian Medical Center, University of Pennsylvania School of Medicine, 218 Wright Saunders Building, 39th and Market Streets, Philadelphia, PA 19104, USA
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Abstract
Fistula in ano is a common condition that often recurs despite seemingly adequate surgery, usually because of infection that was missed at surgery. It is now increasingly recognized that preoperative imaging can help identify infection that would have otherwise gone unidentified. In particular, magnetic resonance (MR) imaging findings have been shown to influence surgery and markedly diminish the chance of recurrence; thus, preoperative imaging will become increasingly routine in the future. In this article, the authors describe the pathogenesis, classification, and imaging of fistula in ano, with an emphasis on MR imaging. Most important, the authors describe how the radiologist is well placed to answer the surgical riddles that must be solved for treatment to be effective.
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Affiliation(s)
- Steve Halligan
- Department of Specialist Radiology, University College Hospital, Level 2, Podium, 235 Euston Road, London NW1 2BU, England
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Stringer EE, Nicholson TJ, Armstrong D. Efficacy of topical metronidazole (10 percent) in the treatment of anorectal Crohn's disease. Dis Colon Rectum 2005; 48:970-4. [PMID: 15785894 DOI: 10.1007/s10350-004-0873-8] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE The aim of this study was to investigate the efficacy of 10 percent topical metronidazole in the treatment of symptomatic anorectal Crohn's disease. METHODS Patients with symptomatic anorectal Crohn's disease were studied in a prospective, nonblinded, nonrandomized study to evaluate the efficacy of topical 10 percent metronidazole. Perianal Crohn's Disease Activity Index and each component (pain, discharge, induration, sexual dysfunction, and type of pathology) were recorded before treatment and at four weeks. Visual analog pain score (0-10) was recorded before treatment and at weekly intervals for up to four weeks. RESULTS Fourteen patients were studied prospectively for four weeks. Mean Perianal Crohn's Disease Activity Index decreased from 8.8 +/- 0.9 before treatment to 4.1 +/- 0.7 after four weeks' treatment (P < 0.0001). Visual analog pain scores decreased from 5.4 +/- 0.7 before treatment to 2.4 +/- 0.5 at one week (P < 0.001) and to 1.0 +/- 0.4 after four weeks' treatment (P < 0.0001). Of the Perianal Crohn's Disease Activity Index components, significant decreases were noted in pain and discharge (P < 0.0001) and induration (P < 0.001). CONCLUSION For patients with perianal Crohn's disease, topical 10 percent metronidazole decreases the Perianal Crohn's Disease Activity Index and anorectal pain.
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Talbot C, Sagar PM, Johnston MJ, Finan PJ, Burke D. Infliximab in the surgical management of complex fistulating anal Crohn's disease. Colorectal Dis 2005; 7:164-8. [PMID: 15720356 DOI: 10.1111/j.1463-1318.2004.00749.x] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVES To assess prospectively the efficacy and safety of treatment of perianal Crohn's disease by means of a combination of surgical management and a standardized protocol for the intravenous infusion of infliximab. METHODS A consecutive series of patients who presented with complex perianal Crohn's fistulae between November 1999 and March 2003 were included in the study. Perianal sepsis was eradicated with drainage of collections and insertion of setons. Infliximab was infused at 5 mg/kg at 0, 2, and 6 weeks. Setons were removed after the second infliximab infusion. Endpoints were defined as either complete, partial or no response as noted at subsequent outpatient follow up. Adverse reactions were recorded. RESULTS Twenty-one patients had a median of three fistulae per patient (range 1-9). All patients tolerated the initial protocol, receiving a median of five infusions of infliximab (range 3-19); median follow up 20 months (range 12-52). Eleven patients (53%) were continued on maintenance therapy with 12 weekly infusions of infliximab for either a perceived clinical need for treatment or after a relapse of their symptoms. Ten (47%) patients experienced a complete response to treatment and the remaining 11 (53%) experienced a partial response. No patient failed to respond to treatment. Four adverse reactions were noted (2 mild allergies, 1 rash and 1 patient experienced joint pains). All adverse reactions settled with cessation of the drug infusion. CONCLUSIONS The combination of seton drainage and infusion of infliximab completely healed the perineum of 47% patients with complex fistulating perianal Crohn's disease. Partial response was seen in the remainder of patients. No serious adverse reactions reported.
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Affiliation(s)
- C Talbot
- Division of Colon and Rectal Surgery, The General Infirmary at Leeds, United Kingdom
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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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Affiliation(s)
- S B Hanauer
- University of Chicago Pritzker School of Medicine, Illinois 60637, USA
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Abstract
The surgical treatment of Crohn's disease of the colon is distinct from that used in treating ulcerative colitis. Crohn's disease often involves the small bowel and is not "cured" by colorectal resection. The popular ileo-anal pouch procedures used in the management of ulcerative colitis generally are not used for the treatment of Crohn's colitis, because of higher complication rates. Commonly performed operations include ileostomy, segmental colon resection, subtotal colectomy, and proctocolectomy. The general surgeon, therefore, is provided with many options when faced with complications of Crohn's colitis. This article examines the attributes of and results reported for each of these options.
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Affiliation(s)
- T S Guy
- Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, USA
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Abstract
Anorectal disease affects many patients with Crohn's disease. Clinical manifestations vary from asymptomatic skin tags to severe, debilitating perineal destruction and sepsis. Surgical management needs to be conservative and must focus on draining septic sites, preserving sphincter function, and palliating symptoms. Medical management has had some success in improving symptoms, but as yet, it has not been able to ameliorate most perianal complaints quickly and enduringly. Many new and exciting treatment modalities are being investigated with the hope that more effective approaches to these complex and difficult problems can be realized.
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Affiliation(s)
- S J McClane
- Department of Colorectal Surgery, Cleveland Clinic Foundation, Ohio, USA
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Petros JG. Crohn's disease update. Abstracts & commentary. CURRENT SURGERY 2000; 57:95-103. [PMID: 16093037 DOI: 10.1016/s0149-7944(00)00181-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Affiliation(s)
- J G Petros
- St. Elizabeth's Medical Center of Boston, Boston, Massachusetts, USA
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Abstract
The management of perirectal disease in association with IBD requires an individual approach to the patient with combined medical and surgical therapy where appropriate. No matter what therapy is used, the main goal is to alleviate symptoms and cure the problem where possible. Before undertaking management it is crucial to delineate the extent not only of the local disease but the total extent of the problem in the gastrointestinal tract. This will obviously influence the way in which the local disease is managed. What has been presented is a practical, common-sense approach to the management of what is often an extremely difficult problem.
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Affiliation(s)
- Z Cohen
- University of Toronto, Canada
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