Severe Perianal Crohn's Disease Research Articles

Biallelic TLR4 deficiency in humans

Toll-like receptors (TLRs) mediate functions for host defense and inflammatory responses. TLR4 recognizes LPS, a component of gram-negative bacteria as well as host-derived endogenous ligands such as S100A8 and S100A9 proteins. We sought to report phenotype and cellular function of individuals with complete TLR4 deficiency. We performed genome sequencing and investigated exome and genome sequencing databases. Cellular responses were studied on primary monocytes, macrophages, and neutrophils, as well as cell lines using flow cytometry, reporter, and cytokine assays. We identified 2 individuals in a family of Qatari origin carrying a homozygous stop codon variant p.Q188X in TLR4 presenting with a variable phenotype (asymptomatic and inflammatory bowel disease consistent with severe perianal Crohn disease). Athird individual with homozygous p.Y794X was identified in a population database. In contrast to hypomorphic polymorphisms p.D299G and p.T399I, the variants p.Q188X and p.Y794X completely abrogated LPS-induced cytokine responses whereas TLR2 response was normal. TLR4 deficiency causes a neutrophil CD62L shedding defect, whereas antimicrobial activity toward intracellular Salmonella was intact. Biallelic TLR4 deficiency in humans causes an inborn error of immunity in responding to LPS. This complements the spectrum of known primary immunodeficiencies, in particular myeloid differentiation primary response 88 (MYD88) or the IL-1 receptor-associated kinase 4 (IRAK4) deficiency that are downstream of TLR4 and TLR2 signaling.

Diverting Ostomy: For Whom, When, What, Where, and Why.

Fecal diversion is an important tool in the surgical armamentarium. There is much controversy regarding which clinical scenarios warrant diversion. Throughout this article, we have analyzed the most recent literature and discussed the most common applications for the use of a diverting stoma. These include construction of diverting ileostomy or colostomy, ostomy for low colorectal/coloanal anastomosis, inflammatory bowel disease, diverticular disease, and obstructing colorectal cancer. We conclude the following: diverting loop ileostomy is preferred to loop colostomy, an ostomy should be used for a pelvic anastomosis < 5 to 6 cm including coloanal anastomosis and ileo-anal-pouch anastomosis, severe perianal Crohn's disease frequently requires diversion, a primary anastomosis with diverting ileostomy in the setting of diverticular perforation is safe, and a diverting stoma can be used as a bridge to primary resection in the setting of an obstructing malignancy.

Hyperbaric oxygen therapy is an effective adjunctive treatment for severe perianal Crohn's disease

Hyperbaric oxygen therapy is an effective adjunctive treatment for severe perianal Crohn's disease

Sa1887 Use of Diverting Ileostomy As Induction Strategy for Severe Perianal Crohn's Disease

Sa1887 Use of Diverting Ileostomy As Induction Strategy for Severe Perianal Crohn's Disease

Factors affecting the fate of faecal diversion in patients with perianal Crohn's disease.

A study was carried out with the aim of identifying potential factors which might influence the fate of patients undergoing faecal diversion by stoma in perianal Crohn's disease. Patients with severe perianal Crohn's disease undergoing faecal diversion between 1994 and 2012 were identified and the factors associated with stoma closure were assessed using univariate and multivariate analysis. Of 138 diverted patients, 30 (22%) achieved stoma closure, 45 (33%) had a stoma with the rectum left in situ and 63 (45%) underwent proctectomy with permanent stoma formation after a mean follow-up of 5.7 years. Univariate analysis demonstrated that synchronous colonic (P = 0.004) or rectal (P = 0.021) disease involvement and an increased frequency of loose seton placement (P = 0.001) adversely affected successful stoma closure rates. Multivariate analysis indicated a significant association between the inability to achieve stoma closure and persisting rectal involvement (OR 7.5, 95% CI 2.4-33.4), one or two placements of a loose seton (OR 3.3, 95% CI 1.4-8.8) and more than two placements (OR 6.9, 95% CI 1.2-132.5). No specific medical management was associated with an improved stoma closure rate, including biological agents when these were available (P = 0.25). The fate of temporary faecal diversion in patients with perianal Crohn's disease is adversely affected by aggressive disease characteristics. No particular treatment, including biological therapy, was associated with an improved outcome.

Natural history of perianal Crohn's disease after fecal diversion.

Temporary fecal diversion has been used to allow severe perianal Crohn's disease (CD) to heal. Most data on intestinal reconnection rates precede the biological era with limited patient follow-up after reconnection. We, therefore, sought to evaluate the natural history of perianal CD after fecal diversion. We identified 49 patients with CD and perianal involvement who underwent fecal diversion between 1991 and 2011 at a tertiary referral care center. Demographics, medication use, onset and extent of disease, and surgical interventions were abstracted. We determined the percentage of patients who were able to restore intestinal continuity and assessed the sustainability of this reversal. Time to intestinal reconnection and subsequent procedures were determined. We also examined temporal trends in the proportion of patients with perianal CD undergoing diversion or management with seton/EUA/fistulotomy between 2000 and 2011. Fifteen of 49 patients (31%) reestablished intestinal continuity during the study follow-up period. Ten of 15 patients (67%) who had reestablished intestinal continuity required an additional procedure to divert the fecal stream. Of the 5 patients who remained reconnected, 3 patients required further procedures to control sepsis. The proportion of patients with CD requiring perianal surgical interventions declined between 2000 and 2011. Severe perianal CD remains a challenging problem. In patients with CD with perianal disease requiring fecal diversion, the likelihood of sustained intestinal continuity remains low, despite greater biological use. However, there has been a temporal decline in the rate of surgical interventions required for perianal CD from 2000 to 2011.

Anorectal stricture in 102 patients with Crohn's disease: natural history in the era of biologics.

The natural history of nonfistulising perianal Crohn's disease (PCD) remains unknown. To assess the long-term outcome of anorectal strictures. All outcomes of PCD patients with anorectal stricture followed in a single unit from 2005 to 2013 were reviewed, as well as subsequent therapeutic management. Cumulative incidence of stricture healing (disappearance of the anal stricture) was estimated using a Kaplan-Meier method and factor associated with an unfavourable course (persistent stricture S2, persistent stoma or proctectomy) with nonparametric test. A total of 102 patients (M/F: 37/65) were included. The duration of CD at diagnosis was 8.9 years. After a median follow-up period of 2.8 years, 52 of the 88 followed patients (59%) achieved anorectal stricture healing. Two patients (2%) developed anal adenocarcinoma. Female gender [HR 2.05 (1.1-4.03), P = 0.0221], disease duration of CD of less than 10 years [HR 1.94 (1.01-3.63), P = 0.0271], and anal fistula at stricture diagnosis [HR 2.36 (1.21-5.05), P = 0.0106) were significantly associated with anorectal stricture healing in a multivariate analysis model. Twenty-eight patients (32%) had an unfavourable course at the end of follow-up. Gender and introduction or optimisation of TNFα antagonist treatment decreased the risk of unfavourable course in multivariate analysis. Conversely, the Luminal B2 phenotype at CD diagnosis was the only factor associated with unfavourable course. Anorectal stricture does not imply a nonreversible and complicated condition related to severe perianal Crohn's disease. However, both the diagnosis of cancer and sepsis drainage remain challenging in this situation.

Su1743 Exome Sequencing Identify Novel Variants in African-Americans With Severe Perianal and Colonic Crohn's Disease

Background Mesenchymal stem cells (MSCs) have been candidate as therapeutic treatment for several immune diseases including inflammatory bowel disease (IBD). Although most of beneficial effects are explained by MSC engrafting at the site of tissue injury with modulation of inflammatory reactions, the mechanisms by which MSCs exert their activities need to be clarified. Aim of this study was to investigate the mechanisms underlying the therapeutic efficacy of MSCs in experimental model of colitis. Methods Colitis was induced in C57BL6 mice by 3% DSS treatment for 10 days. MSCs were isolated from bone marrow of wild type (WT) and GFP-transgenic C57BL6 mice, cultured for 4 weeks and then sorted for Sca-1+, CD31-, cocktail lineagesurface markers. At day 5 of colitic induction the mice were treated intraperitoneally with a single injection of 3x106 GFP-MSC free or encapsulated MSC cells, or in alternative with 5 daily injections of recombinant TNF α-stimulating gene protein 6 (rTSG-6) each of 4 μg. Body weight and disease activity index (DAI) were monitored daily and the damage of murine colonic mucosa was evaluated by endoscopic and histological scores. To follow the migratory activity of the MSCs, GFP-MSCs were injected intraperitoneally in healthy or colitic mice at day 5 and their presence was assessed by flow cytometry after 24 and 48 hours in the colon and mesenteric lymph nodes. Levels of TSG-6, IL-6 and IFN-γ were measured in serum and in mucosal extracts by ELISA, while MMP activities were quantified by WB. Results We found that one injected, MSCs remain into the peritoneal cavity, where they aggregate along with macrophages and lymphocytes, generating organized structures. Only a small fraction (, 1%) of cells reached the inflamed colon. Furthermore, encapsulated MSCs and implanted into peritoneal cavity displayed comparable therapeutic efficacy with free MSCs suggesting that the gut homing was not relevant for their efficacy. In vitro and in vivo assays have demonstrated that MSCs secrete a multipotent anti-inflammatory protein TSG-6 able to reduce the damage to the colon. In fact, rTSG-6 treatment improved survival rate and DSS-induced colitis by reducing both systemic and mucosal levels of IL6, IFN-γ, neutrophil infiltration, and MMP activities. Conclusions Overall, these data indicate that the MSC gut-homing is not relevant for exerting their immunomodulatory effects, but MSCs dampen the mucosal inflammatory response at distance by releasing the potent antiinflammatory protein TSG6.

Retrospective Review of Infliximab Use in Patients Less Than Six Years of Age

The REACH study helped determine the efficacy and safety of infliximab in patients 6-17 years of age. The dosing, including induction, was found to be similar to adult dosing. This study also demonstrated an incidence of serious infections at 5.7%. The most prevalent adverse events were respiratory infections. In 2012, deBie et al. reviewed the literature on the use of anti-TNF medications in pediatric IBD and found adjustments in dosing between 27-49% of the time. The median time to dose adjustment was 6-9 months. After initiation of infliximab, intestinal surgery was performed in 25-35% of patients with Crohn's disease. There are no reports on the use of infliximab in patients less than 6 years of age. This was a descriptive, retrospective chart review of patients with IBD receiving infliximab as standard care for treatment of IBD from June 2002- July 2012. Since 2002, our institution has diagnosed 790 patients with IBD; 50 patients (6%) were under 6 years of age at the time of diagnosis. 13 (26%) of these patients with IBD received infliximab when they were less than 6 years of age; 8 diagnosed with Crohn's disease, 3 with UC, and 2 with indeterminant colitis. The age at diagnosis ranged from 11 months to 66 months with a mean of 37 months. 12 patients presented with bloody diarrhea. The age infliximab was initiated ranged from 15 months to 69 months with a mean of 46 months. 7 patients received monotherapy. Prior to 2008, infliximab was given in combination with mercaptopurine in one patient and azathioprine in 3 patients. Since 2008, methotrexate was given in combination with infliximab in two patients. The number of doses of infliximab given ranged from 2 to 38 with dosage ranges of 4.7 mg/kg to 13 mg/kg. The doses were adjusted in 6 patients, 4 with success. Two patients still on infliximab have not had dose adjustments due to high initial doses (9.3 mg/kg and 12.5 mg/kg). Seven patients had colectomies; two diagnosed with UC, two indeterminant colitis, two diagnosed with Crohn's after an initial diagnosis of UC, and one patient with severe perianal Crohn's disease. Six of the patients requiring colectomy were prior to 2008; only one out of 7 patients in the past 4 years required a colectomy. Two patients developed hives after 6-7 doses and one had an acute infusion reaction with facial swelling and desaturation. Other potential complications were limited to one patient with mycoplasma pneumonia, one with recurrent UTIs, and one with recurrent Clostridium difficile. The patient with severe perianal disease has since been diagnosed with IL10RA. Infliximab was used successfully in 6 out of 7 patients with IBD in the past 4 years. All six patients who received infliximab prior to 2008 went on to colectomy.

Racial Differences in Fistulizing Perianal Crohnʼs Disease

Purpose: Perianal disease is noted in up to one-third of patients with Crohn's disease (CD). In 2005, the Montreal Classification recognized that fistulizing perianal disease (FPD) represents a distinct phenotype from enteric fistulization. A growing body of literature suggests that there might be racial variations in the phenotypic manifestations of CD but different studies have reached conflicting conclusions and few if any have specifically focused on perianal disease in adults with pre-specified criteria of severity. The goal of our study was therefore to explore racial differences in the prevalence of severe fistulizing perianal Crohn's disease. Methods: We conducted a cross-sectional study of all adult patients with Crohn's disease treated with Remicade® at The Mount Sinai Hospital between May 1 and December 31, 2011. We retrieved the electronic and/or paper charts of all 363 CD patients who had received Remicade® at our institution. Each chart was reviewed to confirm the diagnosis and features of CD based on gastroenterologists' notes and colonoscopy and pathology reports. Variables recorded included age, sex, self-reported race, and presence or absence of notation of FPD. Proportions of patients with FPD noted among AA vs. others, and among Caucasians vs. others were compared using Pearson chi square analysis. P-value <0.05 was considered statistically significant. Results: Among all 333 evaluable CD patients on Remicade®, 73.6% were Caucasian, 11.4% AA, 13.2% Hispanic, and 1.8% Asian. Of these 333 patients, 88 had FPD. 48 of the FPD group (54.5%) were Caucasian, 18 (20.5%) were AA, 20 (22.7%) were Hispanic, and 2 (2.3%) were Asian. Thus, AA were more likely to have FPD than others (RR =1.87, 95% CI =1.18-2.65, p=0.004), while Caucasians were correspondingly less likely to have FPD than non-whites (RR =0.49, 95% CI= 0.35-0.70, p <0.0001). Conclusion: In agreement with some prior suggestions (e.g., J Pediatric Gastroenterol Nutr 1995;21:149-53 and Am J Gastroenterol 2009;104:2100-9) but not with others (e.g., Inflamm Bowel Dis 2006;12:192-8 and Inflamm Bowel Dis 2008;14:960-7), African-Americans with Crohn's disease are significantly more likely than others, and Caucasians significantly less likely, to have severe fistulizing perianal disease.

Infliximab Aids Recovery of Anal Continence in a Patient with Perianal Crohnʼs Disease

Perianal complications occur in approximately 33% of patients with Crohn's disease, and may be the most prominent or even the presenting complaint suggestive of a diagnosis of Crohn's disease. A case is reported of severe perianal Crohn's disease with anal destruction and incontinence that developed after perianal surgery. Healing of perianal lesions and recovery of anal function was achieved with infliximab therapy.

Fistula-associated anal adenocarcinoma in Crohnʼs disease

Adenocarcinoma arising from perianal fistulae in patients with Crohn's disease (CD) is rare. The literature consists mainly of case reports and small series making characterization of this clinical entity difficult. We present 6 patients with CD and fistula-associated anal adenocarcinoma (FAAA) and a systematic review of published series. Retrospective charts were reviewed of 6 consecutive patients with FAAA in CD treated from 1992 through 2007. All available variables of our patients and of all available published cases were included for statistical analysis. All patients treated at our institution had severe perianal CD at presentation. The average age at time of diagnosis was 45.5 years. All patients underwent abdominoperineal resection (APR) and 4 received chemoradiation. Four patients died with metastatic disease, 1 is alive with pelvic recurrence at 55 months, and 1 is alive without evidence of disease at 19 months follow-up. A total of 23 publications including 65 patients (37 female, mean age 53 years) with FAAA were reviewed in our systematic review. The average fistula duration was 14 years. Mean delay of cancer diagnosis was 11 months. APR was performed in 56 patients with an overall 3-year survival rate of 54%. Thirteen of 15 patients with node-positive tumors died with recurrent disease following surgery. Adenocarcinoma arising from long-standing perianal CD fistulae is being increasingly reported. The outcome is poor following operative treatment, especially if perirectal lymph nodes are involved. Periodical cancer surveillance should be performed in all patients with long-standing perianal CD fistulae.

Long-Term Quality of Life in Patients with Crohn's Disease and Perianal Fistulas: Influence of Fecal Diversion

Symptomatic perianal fistulas impair quality of life in patients with Crohn's disease. Fecal diversion improves symptoms but may impair quality of life. This study was designed to compare long-term quality of life in patients with Crohn's disease with symptomatic perianal fistulas who were treated with or without fecal diversion. From 1996 to 2002, perianal fistulas were treated in 116 patients with Crohn's disease. A questionnaire, including four quality of life instruments, was mailed to each patient (Short-Form General Health Survey, Gastrointestinal Quality of Life Index, Cleveland Global Quality of Life Score, Short Inflammatory Bowel Disease Questionnaire). Questionnaires were returned by 77 of 116 patients (66 percent). Thirty-four of these patients had undergone fecal diversion, whereas 43 had not. Median follow-up was 49 (range, 18-97) months in diverted and 44 (range, 14-98) months in undiverted patients (not significant). In the diverted group, 44 percent complained of Crohn's disease-related symptoms, which was less compared with 79 percent in undiverted patients (P < 0.05). Diverted patients achieved 68 +/- 1 percent of the maximum possible score on the Gastrointestinal Quality of Life Index compared with 60 +/- 2 percent in undiverted patients (mean +/- standard error of the mean; P < 0.001); diverted patients scored better on the subscale "gastrointestinal symptoms" of the Gastrointestinal Quality of Life Index (81 +/- 1 percent vs. 67 +/- 2 percent; P < 0.001). There was no difference in the Short Inflammatory Bowel Disease Questionnaire between diverted and undiverted patients except for the subscale "bowel function" (91 +/- 2 percent vs. 76 +/- 2 percent; P < 0.0001). No difference in quality of life was detected by the Short-Form General Health Survey and Cleveland Global Quality of Life Score. In the investigated population of patients with Crohn's disease, quality of life seems to be similar or potentially superior in diverted patients suffering from perianal fistulas compared with undiverted patients. A diverting stoma, therefore, may improve quality of life in patients with severe perianal Crohn's disease.

The effect of split ileostomy on perianal Crohn's disease.

The effect of 32 split ileostomies on 29 patients with severe symptomatic perianal Crohn's disease is reported. The perianal disease improved or healed after 23 (72 per cent) split ileostomies, although it relapsed in 2 patients while diverted and in 6 after closure of split ileostomy. Seven of 12 rectovaginal fistulas healed initially but only remained healed in those patients without rectal involvement with disease. At the time of review 6 patients have normal bowel continuity, 8 have had proctocolectomies and 15 are still defunctioned. Split ileostomy should be considered as an initial step in the management of intractable perianal disease.

Advancement sleeve flaps for treatment of severe perianal Crohn's disease.

Traditionally proctectomy has been the treatment for severe, complex fistula in ano from Crohn's disease. However, based on the success of rectal advancement flaps in Crohn's disease, circumferential transanal sleeve advancement flaps (TSAFs) were proposed for this subgroup of patients with severe fistula. From 1991 to 1995, 13 patients (12 women) with severe perianal Crohn's disease and multiple fistula tracts underwent a TSAF procedure. Data were collected retrospectively using a standard data sheet. There were no postoperative deaths or major morbidity. One year after surgery, the fistula had healed in eight of 13 patients (with three requiring additional surgery before healing). Of patients in whom the procedure failed, three underwent proctectomy for progression of disease and the other two had recurrence of a rectovaginal fistula 6 and 8 months after surgery. Of six variables evaluated (previous procedure, steroid use, steroid dosage, associated Crohn's disease, associated procedures and diverting stoma), only associated procedures were significantly related to a successful outcome (P=0.008). Some patients with severe perianal Crohn's fistula and a relatively normal rectum can be offered TSAFs. Even with successful outcome in eight of 13 patients, this may still be a viable option if the only alternative would be total proctocolectomy and a permanent stoma.

Crohn's disease: bowel resection to protect the proctium in severe perianal disease?

Patients with anal Crohn's disease generally have a bad prognosis. Up to 50% end up with an anus praeter or proctectomy. Many of these young people develop psychological and social problems causing them to become invalids. Local surgery and conservative therapy in such aggressive cases of Crohn's disease presenting with recurring perianal fistulae and abscesses are often unsuccessful; the destruction of the proctium continues. The purpose of our study was to look at the outcome of our patients with regard to these aspects. We included all 56 patients suffering from Crohn's disease treated at our clinic from 1984 until 1991 in a retrospective study and focused on the 13 patients with anal manifestation. The mean follow-up was 15.8 years (3-28 years). Often there was no improvement of perianal disease without resection of the involved bowel, especially in cases where both the colon and the rectum were affected. Anal destruction went on. Seven of the 13 patients suffering from anal complications finally received an anus praeter. An previous bowel-resection or the construction of a temporary anus praeter seem to be necessary to protect the proctium irrespective of abdominal symptoms in patients with recurrent severe perianal Crohn's disease.

Laparoscopic surgery in the management of inflammatory bowel disease

The role of laparoscopic surgery in the treatment of various upper and lower gastrointestinal disorders is still under investigation. However, a variety of laparoscopic procedures may be applied in the treatment of inflammatory bowel disease (IBD). We present our initial results of laparoscopic and laparoscopic-assisted management of IBD in 72 consecutive patients (37 women and 35 men; mean age 36 years, range 20 to 79). The indications for surgery included: terminal ileitis in 29 patients, mucosal ulcerative colitis in 23 patients, Crohn's colitis in 11 patients, severe perianal Crohn's disease in 4 patients, duodenal Crohn's disease in 3 patients, Crohn's rectovaginal fistula in 1 patient, and rectourethral fistula in 1 patient. The procedures performed included: total abdominal colectomy (TAC) in 30 patients (22 with total proctocolectomy with ileoanal reservoir, 6 with TAC with ileorectal anastomosis, and 2 with TAC with end ileostomy), ileocolic resection in 30 patients, diverting loop ileostomy in 6 patients, closure of an end ileostomy as an ileorectal anastomosis in 3 patients who already underwent a TAC with end ileostomy, and duodenal bypass gastrojejunostomy in 3 patients. There were 16 complications in 13 (18%) patients: 3 enterotomies, 4 episodes of bleeding, 3 pelvic abscesses, 2 intestinal obstructions, 2 prolonged ileus, 1 anastomotic leak, and 1 efferent loop obstruction after gastrojejunostomy. However, only 3 patients required laparotomy for morbidity, and there was no mortality. In 7 (10%) patients, the laparoscopic procedure was converted to a laparotomy due to a large inflammatory mass with fistula in 4 patients, bleeding in 2 patients, and an enterotomy in 1 patient. The mean operating time was 2.9 hours (range 0.7 to 6) and the mean length of hospital stay was 6.5 days (range 3 to 19). When compared with ileocolic resection, total colectomy was associated with higher morbidity (30% versus 10%, P < 0.05) and longer hospitalization (8.7 days [range 4 to 19] versus 5.2 days [range 3 to 7], respectively; P < 0.05). According to this initial experience, laparoscopic surgery is a versatile and effective modality in the surgical management of inflammatory bowel disease in selected patients. However, laparoscopic total colectomy is associated with higher morbidity when compared with ileocolic resection.

Combination of Ciprofloxacin and Metronidazole in Severe Perianal Crohn’s Disease

MJ SOLOMON, RS MCLEOD, Bl O'CONNOR, AH STEINHART, GR GREENBERG, Z COHEN. Combination ciprofloxacin and metronidazole in severe perianal Crohn's disease. Can J Gastroenterol 1993;7(7):571-573. Severe perianal involvement in Crohn's disease often is refractory to both medical and surgical treatment. The object of this study was to review retrospectively the response of patients with severe perianal Crohn's disease to a combination of ciprofloxacin and metronidazole. Fourteen patients (seven males, seven females, mean age 34.8 years) were treated consecutively with a combination of ciprofloxacin (1000 to 1500 mg/day) and metronidazole (500 to 1500 mg/day). All had 4uiescent bowel disease. Perianal disease had been present for a mean of 28.4 months. Six patients were on metronidazole at presentation and seven had had previous perianal surgery (mean of three operations per patient). All patients were symptomatic. Nine patients had complex fistula, six had anal canal ulceration, one had a rectovaginal fistula and five had discharging abscesses. Seven patients had multiple perianal lesions. Physician assessment at a mean of 12 weeks after commencing therapy revealed three patients healed, nine improved, one unchanged and one worsened, requiring a defunctioning stoma. Thus, 12 of 14 (85%) showed benefit from combination therapy. Patients have been followed a mean of 6.4 months since commencing therapy. Five patients had therapy stopped at 12 weeks and have not required further treatment, six patients required continuous low dose therapy (ciprofloxacin 500 to 1000 mg/day plus metronidazole 500 to 750 mg/day), three patients stopped therapy at 12 weeks hut subsequently restarted therapy because of relapse. Thus, nine of 14 patients (64%) required continuous or repeat therapy. At present, seven patients have quiescent, six have mild, and one has moderate perianal disease. These results suggest that ctprofloxacin plus metronidazole may be effective in severe pcrianal Crohn's disease. (Pour resume , voir page 572)

Abdominoperineal resection for severe perianal Crohn's disease

Despite the high incidence of involvement of the perianal region in Crohn's disease, excisional surgery seldom is required for perianal disease alone. Nine patients are presented who had severe perianal Crohn's disease, which eventually required abdominoperineal excision of the anorectum. In all nine patients, it was secondary manifestations of anal Crohn's disease that precipitated proctectomy, such as high fistulas, strictures, and rectovaginal fistulas. These secondary phenomena, especially fistulas caused by cavitating ulceration, become self-perpetuating by the mechanical effect of feces being forced into the tract. During the same period, 17 patients required rectal excision by abdominoperineal resection, where perianal disease was incidental to severe colorectal disease. There is a tendency for excessive delay before advising surgery for severe perianal disease. An attempt should be made to identify patients with a poor prognosis to avoid unnecessarily prolonged morbidity. Assessment of the exact nature of the anal lesion and assessment of Crohn's disease activity are important in making this decision.