Anorectal Crohn's Disease Research Articles

Fecal diversion in complex anal fistulas: Is there a way to avoid it?

Temporary fecal diversion by a diverting colostomy or ileostomy is occasionally performed for serious complex fistulas. The main indications are highly complex and extensive cryptoglandular anal fistula, anal fistula associated with severe anorectal Crohn’s disease, recurrent rectovaginal fistula, radiation-induced fistula and anal fistula with associated necrotizing fasciitis. The purpose of stoma formation is to divert the fecal stream away from the anorectum and the perianal region so as to control the infective process and prevent trauma to the operated repaired tissues. Once the fistula has healed, the diverting stoma is closed. However, two questions are relevant. First, is it certain that the same disease would not relapse (or the fistula would not recur) once the colostomy is closed? Second, is there a non-surgical method which can obviate the need for a diverting colostomy? An attempt is made to answer both these questions in this review.

Colonic disease recurrence following proctectomy with end colostomy for anorectal Crohn’s disease

In patients with anorectal Crohn's disease, it remains uncertain whether a total proctocolectomy with end ileostomy or proctectomy with end colostomy should be recommended due to the unknown rate of disease recurrence in the remaining colon. A retrospective review of all patients with a known diagnosis of Crohn's disease who underwent a proctectomy with end colostomy for distal Crohn's disease between January 1, 2010 and January 1, 2019 at two IBD referral centres was conducted. Data collected included patient demographics, surgical variables at the time of proctectomy, and postoperative clinical, endoscopic and surgical recurrence rates. A total of 63 patients were included; mean age was 47years (SD 15years) and 32 (50.8%) were female. The majority of patients underwent a proctectomy with end colostomy (n=56; 88.9%) while the remaining seven patients (11.1%) underwent a proctectomy with end colostomy and concurrent ileocectomy. A total of 55 patients (87.3%) had proctitis, 51 (81%) had perianal fistulating disease, and 34 (54%) had anal canal stenosis or ulceration. Most patients had medically refractory disease (n=54; 85.7%) versus neoplasia (n=9; 14.3%). The median length of long-term follow-up was 17.7months (IQR: 4.72, 38.7months). During that time, 14 (22.2%) experienced clinical recurrence, 10 of 34 evaluated (29.4%) had endoscopic recurrence, and 3 (4.76%) required a completion total abdominal colectomy for recurrent medically refractory disease in the colon. Colonic recurrence remains low following proctectomy and descending colostomy suggesting this operative management strategy is reasonable in Crohn's patients with distal disease.

P687 Fate of the rectum in anorectal Crohn's disease

P687 Fate of the rectum in anorectal Crohn's disease

Intersphincteric proctectomy with end-colostomy for anorectal Crohn's disease results in early and severe proximal colonic recurrence

BackgroundPerianal Crohn's disease (CD) represents a more aggressive phenotype of inflammatory bowel disease and often coincides with proctocolitis. This study aims to assess the outcome of patients undergoing proctectomy with end-colostomy. MethodsA retrospective outcome analysis of 10 consecutive patients who underwent intersphincteric proctectomy with end-colostomy between February 2007 and May 2011 was performed. All patients suffered from refractory distal and perianal CD. The proximal colon was normal at endoscopy. All data were extracted from a prospectively maintained database. The main outcome parameter was disease recurrence and need for completion colectomy. ResultsSevere and early endoscopic recurrence in the proximal colon occurred in 9/10 patients at a median time interval of 9.5months (range: 1.9–23.6months). Despite protracted medical treatment, completion colectomy was necessary in 5 patients. One patient, who underwent a second segmental colectomy with a new end-colostomy, showed again endoscopic recurrence and is currently treated with anti-TNF agents. ConclusionsIntersphincteric proctectomy with colostomy seems to be an ineffective surgery for perianal CD with coexisting proctitis and results in a high risk of recurrence of the disease in the remaining colon. Therefore, despite a normal appearance of the proximal colon, a proctocolectomy with end-ileostomy seems to be the surgical approach of choice in these patients.

Efficacy of Topical Metronidazole (10 Percent) in the Treatment of Anorectal Crohn's Disease

Efficacy of Topical Metronidazole (10 Percent) in the Treatment of Anorectal Crohn's Disease

Results of external sphincter repair in Crohn's disease.

The results of anal sphincter repair in a group of six patients with anorectal Crohn's disease are reported. All patients had previously undergone anal surgery which was followed by faecal incontinence in five. The sixth patient became incontinent following obstetric injury. Of the six patients, five are completely continent and one has a permanent stoma (follow-up from 18 months to 16 years, mean 7.8 years). Anal sphincter repair in this highly selected group of patients with Crohn's disease has not been complicated by wound breakdown or fistula formation, and has given good results.

Efficacy of Topical Metronidazole (10 Percent) in the Treatment of Anorectal Crohn's Disease

The aim of this study was to investigate the efficacy of 10 percent topical metronidazole in the treatment of symptomatic anorectal Crohn's disease. 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. 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). For patients with perianal Crohn's disease, topical 10 percent metronidazole decreases the Perianal Crohn's Disease Activity Index and anorectal pain.

Combined seton placement, infliximab infusion, and maintenance immunosuppressives improve healing rate in fistulizing anorectal Crohn's disease: a single center experience.

Infliximab (anti-TNF alpha) has been used for the treatment of fistulizing Crohn's disease with variable efficacy. The aim of this study was to evaluate the efficacy of infliximab combined with selective seton drainage in the healing of fistulizing anorectal Crohn's disease. This was a retrospective chart review of all patients with fistulizing Crohn's disease treated with infliximab between March 2000 and February 2002. Twenty-nine patients (12 male; mean age, 31 years) received a mean of 3 (range, 1-5) doses of infliximab 5 mg/kg. Twenty-one patients had perianal fistulas; eight had rectovaginal fistulas, four with combined rectovaginal/perianal fistula. Fourteen of 21 patients (67 percent) with perianal fistula had a complete response (mean follow-up, 9 months), 4 of the 14 relapsed (mean, 6 months), but all had a complete response to retreatment (mean, 9 months). A partial response occurred in four patients (19 percent), defined by decreased drainage (2 patients) or infliximab dependence (2 patients) requiring repeated dosing every six to eight weeks. Three patients (14 percent) had no response. Seton drainage was used before infusion in 13 perianal patients for perianal infection and 17 were treated with maintenance azathioprine or methotrexate. Of eight patients with rectovaginal fistula, complete response occurred in one, partial response in five, and no response in two. Two partial responders became infliximab dependent. A complete response was observed in one patient with isolated rectovaginal fistula, a partial response in five. No patient with a combined rectovaginal/perianal fistula had a complete response. Five rectovaginal fistula patients were taking maintenance immunosuppressive agents and two had seton drainage before infusion. Selective seton placement combined with infliximab infusion and maintenance immunosuppressives resulted in complete healing in 67 percent of Crohn's patients with perianal fistula and partial healing in 19 percent. Relapse was successfully treated with repeat infusion. Concomitant rectovaginal fistula was a poor prognostic indicator for successful infliximab therapy.

Anorectal Crohn's Disease

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.

LAPAROSCOPIC COLECTOMY IN DIVERTICULAR AND CROHN'S DISEASE

Laparoscopy is still controversial when applied for the attempted cure of colorectal cancer. Although some advantages may be possible, some disadvantages also have been postulated. Laparoscopic treatment of benign disease is far less controversial. Three of the best procedures and indications, respectively, are laparoscopic sigmoid colectomy for diverticulitis, laparoscopic-assisted ileocolic resection for terminal ileal Crohn's disease, and laparoscopic stoma creation for perianal Crohn's disease. Other potentially advantageous surgeries and indications include laparoscopic-assisted total abdominal colectomy for colonic Crohn's disease, laparoscopic total proctocolectomy for colonic and anorectal Crohn's disease, and laparoscopic secondary ileoproctostomy or coloproctostomy as Hartmann reversal procedures. Significant benefits can be expected with these procedures relative to decreased pain; ileus; length of hospital stay; disability, and, possibly, adhesion formation and subsequent bowel obstruction, and improved cosmesis.

Anorectal Crohn??s Disease

In some patients with Crohn's disease the anorectal complications are the major cause of symptoms and morbidity. Anorectal Crohn's disease may be present in patients with intestinal Crohn's disease, may be the initial manifestation of the disease, or rarely occurs without involvement of Crohn's disease elsewhere in the intestinal tract. The pathogenesis of these anorectal complications remains to be clarified. The anorectal examination is very important in the assessment of patients with suspected or documented inflammatory bowel disease. Meticulous physical examination, examination under anaesthesia and radiological imaging modalities may be utilised to specifically identify the location of abscesses and fistulae. Treatment strategy should be directed toward symptomatic relief; the most important symptom is pain. In most patients this pain will be attributable to an incompletely drained rectal abscess. Simple incision and drainage procedures are often all that is required as initial treatment of anorectal abscesses. Treatment of the anorectal fistulae that occur secondary to Crohn's disease requires combined medical and surgical therapy. Drug therapy is more often initiated for Crohn's disease that involves other areas of the gastrointestinal tract. The anorectal manifestations often respond to these same medications. Lay-open procedures (fistulotomies) are often all that is required surgically for simple (low) anorectal fistulae. High (complex) fistulae that involve large portions of the anorectal muscular ring are more difficult to treat. Patients with these fistulae must be treated on an individual basis, usually local surgical therapy combined with a medical regimen. Many surgical procedures are performed and many classes of medications are utilised on patients with these complex anorectal fistulae. Choosing the appropriate surgical and medical interventions is often quite difficult. Although sulfasalazine, mesalazine and corticosteroids have no lasting or maintenance value for fistulae, the immunosuppressive agents mercaptopurine, azathioprine and cyclosporin, the antibacterial metronidazole and the anti-tumour necrosis factor-alpha monoclonal antibody infliximab have varying degrees of effect. The goal of the combined regimen is to cure the fistula, or at least make it minimally symptomatic, without altering the patient's continence.

New aspects of surgical therapy of recurrent Crohn's disease.

Crohn's disease can neither be cured by surgery nor by medical therapy. Surgical therapy of recurrent Crohn's disease requires special precautions. The recurrence rate is 60% after 15 years. There are no certain data of the risk factors influencing the recurrence rate. The only clear facts are that wide resection out of the resection margins and smoking negatively influence recurrence. Hence, the major principles of therapy is a minimally-resected surgery. This mainly concerns strictures and stenosis. Strictures should be treated by stricturoplasty and stenosis by limited resection with Crohn-free resection margins. Just in case of interenteric and enterocutanous with a concomitant short bowel syndrome, in blind-ending fistulas with an abscess or in enterovesical fistulas, we recommend immediate operation. The therapy of recurrent anorectal Crohn's disease underlies the same rules as primary therapy. If necessary, proctectomy remains the last option. Also, emergency surgery in recurrent Crohn's disease follows the same rules as in elective surgery.

Two cases of anorectal Crohn's disease with characteristic appearances of anus.

Two cases of anorectal Crohn's disease with characteristic appearances of anus.

169 対向型骨盤用表面コイルを用いた直腸・肛門周囲クローン病の評価

169 対向型骨盤用表面コイルを用いた直腸・肛門周囲クローン病の評価

Melkersson-Rosenthal Syndrome and Crohnʼs Disease

In 1985, a 19-year-old woman had clinical features suggesting anorectal Crohn's disease. Two years later, swelling of the vulva associated with perianal swelling developed. The clinical manifestations responded to oral prednisone until 1989, when she returned with a swelling of the upper lip, a polypoid lesion of the oral buccal mucosa, and swelling of the anus and vulva. The lip biopsy demonstrated granulomas. The illness failed to respond to systemic immunosuppressive therapy, wider consultation was made, and the diagnosis of the Melkersson-Rosenthal syndrome was made. Such an appearance of this rare condition is unusual. We describe her case and discuss the literature, raising the possibility that the Melkersson-Rosenthal syndrome and Crohn's disease are the same condition with different initial clinical appearances.

Role of the seton in the management of anorectal fistulas

To identify the incidence of major fecal incontinence and recurrence after staged fistulotomy using a seton. A five-year retrospective chart review of 116 patients (70 males and 46 females) ranging in age from 18 to 81 years (mean, 42 years), in whom setons were placed as part of a surgical procedure for anorectal fistulas, was carried out. Follow-up ranged from 2 to 61 months (mean, 23 months). Setons were employed to identify and promote fibrosis around a complex anorectal fistula as part of a staged fistulotomy in 65 patients (56 percent). Other indications for seton placement included 24 women with anteriorly situated high transsphincteric fistulas (21 percent) and three patients with massive anorectal sepsis (floating, freestanding anus) (2.5 percent). In addition, setons were used to preclude premature skin closure and promote controlled long-term fistula drainage in 21 patients with severe anorectal Crohn's disease (18 percent) and in three patients with AIDS (2.5 percent). Major fecal incontinence (requiring the use of a perineal pad) occurred in five patients (5 percent), and recurrent fistulas were noted in three (3 percent). Staged fistulotomy using a seton is a safe and effective method of treating high or complicated anorectal fistulas.

Low Hartmann's procedure for severe anorectal Crohn's disease.

Perineal wounds often fail to heal following proctectomy for Crohn's disease. Twenty-five patients with severe anorectal Crohn's disease and perineal fistulas, necessitating excisional surgery, underwent a low Hartmann's procedure in lieu of a standard proctectomy. Fifteen of the 25 (60 percent) patients had a completely healed perineum and required no further surgical therapy. Although perineal disease persisted in the other 10 patients, their perinea were much improved compared with the initial presentation. Following a low Hartmann's procedure, the rectal stump becomes atrophic and anoperineal disease regresses, thereby permitting subsequent perineal proctectomy in less inflamed tissues. Since only a 3-cm to 5-cm cuff of rectum was retained from the initial surgery, a perineal intersphincteric approach could be employed and no abdominal dissection was necessary. Of the 10 patients who subsequently underwent perineal proctectomies, three patients still have an unhealed perineum. Twenty-two of the 25 (88 percent) patients have a completely healed perineum (mean follow-up period, 69.1 months). No attempt was made to establish intestinal continuity in any of the 25 patients. We conclude that the problem of the unhealed perineal wound can be averted with this approach, thereby reducing the long-term morbidity to the patient.

Perirectal abscess in Crohn's disease

The role of surgical intervention in the treatment of patients with anorectal Crohn's disease is controversial. To clarify the success of aggressive drainage and the subsequent clinical course of patients with Crohn's disease and perirectal abscesses, the authors reviewed the records of 38 patients who presented with this condition during an eight-year period. Twenty-two male and 16 female patients (median age, 32 years; range, 17 to 61 years) with clinically or pathologically confirmed Crohn's disease of the bowel underwent operation for perirectal abscesses. Thirty-two percent of patients had no previous history of anorectal Crohn's disease. Thirty simple abscesses and 8 complex horseshoe abscesses were treated. At operation, 53 percent of patients underwent incision and drainage whereas 26 percent received loop indwelling drains and 21 percent had mushroom catheters placed. After resolution of the index abscess, recurrent abscesses occurred in 45 percent of the patients who underwent catheter drainage and 56 percent of the patients who underwent incision and drainage. More importantly, 44 percent of the incision and drainage group and only 31 percent of the catheter drainage group required subsequent proctectomy to control perineal sepsis. The healing time of the perineal wound was longer than six months in 83 percent of patients requiring rectal excision. We concluded that long-term catheter drainage may offer substantial benefit in the overall outcome of the treatment of patients with Crohn's disease and perirectal abscess.

Anorectal Crohn's disease. A long-term perspective.

A group of 86 patients with anorectal Crohn's disease were followed up from ten to 40 years to determine the course of the disease and the number of patients who later required proctectomy. The overall cumulative probability of avoiding proctectomy was 91.6 percent at ten years and 82.5 percent at 20 years. Resection of all proximal Crohn's disease did not ameliorate the anorectal disease, except in patients who had all proximal disease removed and had no recurrence.

Anorectal crohn's disease: Definitive surgery for fistulas and recurrent abscesses

Twenty patients with anorectal Crohn's disease manifested by anal fistulas or recurrent perirectal abscesses underwent attempted definitive surgical eradication of that pathologic process. The role of Parks' partial internal anal sphincterectomy is discussed. The results are presented and correlated with the activity of the underlying Crohn's disease. The excellent results recommend this approach for re-current perirectal abscess and intersphincteric abscess, even when occurring for the first time.