Malcolm C. Veidenheimer

Anal complications in Crohn's disease.

Anal fissures, fistulas, and abscesses occurred as complications in 22 per cent of our population of 1,098 patients with Crohns disease. Crohns colitis was much more frequently associated with an anal lesion than Crohns disease of the small bowel (52 per cent vs. 14 per cent). When an anal lesion is the manifesting sign, Crohns disease will soon develop elsewhere in the intestine. Since these lesions frequently herald the onset of intestinal Crohns disease, the physician must always be aware of the possibility of inflammatory bowel disease when dealing with suspicions anal lesions.

Indeterminate colitis predisposes to perineal complications after ileal pouch-anal anastomosis.

This study retrospectively evaluated 288 patients who had undergone ileal pouch-anal anastomosis to determine the incidence of perineal complications and to relate these findings to the pathologic diagnosis, with the goal of specifically clarifying the appropriate surgical management of patients with indeterminate colitis. Of these 288 patients, 235 patients (82 percent) had a diagnosis of chronic ulcerative colitis, 18 patients (6 percent) had indeterminate colitis, 6 patients (2 percent) had Crohns disease, and 29 patients (10 percent) had familial polyposis. All complications occurred at least 6 months after closure of the stoma and required operative therapy. Of 18 patients with indeterminate colitis, 9 patients experienced complications (50 percent)vs.8 of 235 patients with chronic ulcerative colitis (3 percent), a highly significant difference (P<0.001). Furthermore, the risk of eventual ileostomy because of perineal complications was 0.4 percent in patients with chronic ulcerative colitisvs.28 percent in patients with indeterminate colitis (P<0.001). We conclude that a diagnosis of indeterminate colitis predisposes the patient undergoing ileal pouchanal anastomosis to perineal complications, with a resultant high chance of reservoir loss. Ileal pouch-anal anastomosis should be considered with caution in the patient with a diagnosis of indeterminate colitis.

Surgical management of Crohn's disease involving the duodenum

The experience with 25 patients who required operation for Crohns disease involving the duodenum is reviewed. Two distinct patterns of duodenal involvement are apparent. Intrinsic duodenal Crohns disease has a characteristic clinical presentation that is distinct from the symptoms seen in patients with involvement of other portions of the gastrointestinal tract. Among 70 patients with duodenal Crohns disease seen over a 30 year period, 22 required surgical intervention at the Lahey Clinic. Although hemorrhage and intractable pain were associated problems in several of these patients, unrelenting duodenal obstruction remained the primary indication for operation. Of patients who underwent operative bypass, 78 percent had a good result with a median follow-up period of 12.3 years. The presence of associated gastric Crohns disease did not influence long-term results. A third of the patients required reoperation for duodenal disease. Marginal ulceration and recurrent gastroduodenal obstruction have been the primary reasons for reoperation. Although the addition of vagotomy to operative bypass has not helped to protect against subsequent marginal ulceration, the absence of appreciable morbidity associated with vagotomy in our series and the high incidence of marginal ulcers reported with gastroenterostomy in other clinical settings lead us to recommend gastroenterostomy with vagotomy as the procedure of choice for duodenal Crohns disease. Proceeding with vagotomy in persons who have had previous ileocecal or extensive small bowel resection should not be undertaken without careful consideration. Similar caution should also be used in patients who are already troubled with poorly controlled diarrhea. The duodenum may also be involved by duodenoenteric fistulas which represent a complication of Crohns disease involving other portions of the gastrointestinal tract. Most frequently this occurs in patients with Crohns colitis who have no evidence of intrinsic duodenal disease. Management of the internal fistula requires resection of the involved colon and closure of the duodenal defect. Three patients with duodenocolic fistula have been so treated.

Surgical management of complicated diverticulitis

One hundred forty patients who had complicated diverticular disease were identified in a retrospective review at the Lahey Clinic between 1967 and 1982. Of these patients, 86 underwent resection with primary anastomosis with a 1 percent mortality rate and an 18 percent morbidity rate; 13 had resection with anastomosis and creation of a proximal colostomy with no death and a 22 percent morbidity rate; 19 had the Hartmann operation or colostomy with mucous fistula with a 16 percent mortality rate and a 23 percent morbidity rate; and 22 underwent a traditional three-stage operation with 14 percent mortality and 24 percent morbidity rates. The average duration of hospitalization was 21 days for patients who underwent the one-stage operation, and 52 days for patients who underwent the three-stage procedure. Primary resection for complicated disease is associated with acceptable morbidity and mortality rates under appropriate circumstances.

Anal fissure in Crohn's disease : a plea for aggressive management

PURPOSE: This study was undertaken to identify clinical characteristics, natural history, and results of medical and surgical treatment of anal fissures in Crohns disease. METHODS: This is a retrospective review of patients with Crohns disease and anal fissure. RESULTS: Of the 56 study patients, 49 (84 percent) had symptomatic fissures. Fissures were most commonly (66 percent) located in the posterior midline, and 18 patients (32 percent) had multiple fissures. Fissures healed in one-half of patients treated medically. Factors predictive of successful medical treatment included male gender, painless fissure, and acute fissure. Of 15 patients, 10 (67 percent) treated surgically healed. Fissures in seven of eight patients (88 percent) who underwent anorectal procedures healed compared with fissures in only three of seven patients (43 percent) who underwent proximal intestinal resection. In the group of 50 patients with complete follow-up studies, an anal abscess or fistula from the base of an unhealed fissure developed in 13 patients (26 percent). More fissures healed after anorectal surgery (88 percent) than after medical treatment alone (49 percent;P=0.05) or after abdominal surgery (29 percent;P=0.03). CONCLUSION: This series documents that unhealed fissures frequently progress to more ominous anal pathologic disease. Judicious use of internal sphincterotomy appears to be safe for fissures unresponsive to medical treatment.

Evolutionary Changes in the Pathologic Diagnosis After the Ileoanal Pouch Procedure

PURPOSE: Inadequate initial differentiation between ulcerative colitis and Crohns disease may lead to a diagnosis of indeterminate colitis. Construction of an ileoanal pouch in these patients may result in significant morbidity and pouch failure when the ultimate diagnosis is Crohns disease. METHOD: We prospectively studied 543 patients with idiopathic inflammatory bowel disease to determine whether a patients pathologic diagnosis changed with time and how it affected outcome. RESULTS: Preoperative diagnosis was ulcerative colitis in 499 patients, indeterminate colitis in 42 patients, and Crohns disease in 2 patients. Prior colectomy was performed in 58 percent of patients with ulcerative colitis and in all patients with indeterminate colitis and Crohns disease. Postoperatively, the diagnosis changed in 20 patients with ulcerative colitis (13 to indeterminate colitis, 7 to Crohns disease). Another two patients with indeterminate colitis showed evidence of Crohns disease in the resected rectal specimen. As patients were followed up, an additional 13 patients were found to have Crohns disease (5 indeterminate colitis, 8 ulcerative colitis). With the current diagnosis, perineal complications and pouch failure occurred, respectively, in 23 and in 2 percent of patients with ulcerative colitis, in 44 and in 12 percent of patients with indeterminate colitis, and in 63 and in 37 percent of patients with Crohns disease. Pathologic diagnosis was altered in 35 patients (6 percent) overall, with a 12-fold increase in the diagnosis of Crohns disease. Only 3 percent of patients with ulcerative colitis compared with 13 percent of patients with indeterminate colitis had a change in diagnosis to Crohns disease (P=0.006; Fishers exact test). CONCLUSION: Pouch-related complications, eventual pouch failure, and discovery of underlying Crohns disease occurred in a significant number of patients with a diagnosis of indeterminate colitis. Until more accurate diagnostic differentiation is available, caution is advised in recommending the ileoanal pouch procedure to patients with indeterminate colitis.

Rediversion after ileal pouch-anal anastomosis

PURPOSE: The aim of this study was to understand better the cause and predictability of pouch failure requiring rediversion after ileal pouch-anal anastomosis and to assess the ultimate outcome of patients in a large ileal pouch series who required rediversion. METHODS: Data from 460 patients completing ileal pouch-anal anastomosis at one institution were recorded from both a prospectively accumulated ileal pouch registry and patient medical records. RESULTS: Of 460 patients, 21 (4.6 percent) who underwent ileal pouch-anal anastomosis required rediversion. Five of these patients subsequently had successful restoration of pouch continuity, leaving a permanent failure rate of 16 of 460 patients (3.5 percent). The most common reasons for rediversion were pouch fistula formation (12) and poor functional results (5). Preoperative factors, including age, previous colectomy, and indication for colectomy, did not predict eventual need for rediversion. Patients requiring rediversion had significantly higher rates of postoperative complications (95vs.43 percent;P<0.001). Specifically, this group had a higher rate of postoperative pouch fistula (57vs.3.4 percent;P<0.001). Additionally, a final diagnosis of Crohns disease significantly predicted the need for rediversion. Permanent pouch failure occurred in 36.8 percent of patients with a final diagnosis of Crohns disease compared with 1.4 percent of patients with a final diagnosis of ulcerative colitis (P<0.001). All five salvaged patients had fistula formation in the absence of Crohns disease. CONCLUSIONS: The overall rate of permanent pouch failure is low. The majority of failures were related to fistula formation associated with Crohns disease or poor functional results. Pouches complicated by fistulas not associated with Crohns disease can be salvaged with temporary rediversion.

Biofeedback training is useful in fecal incontinence but disappointing in constipation

BACKGROUND: Successful biofeedback therapy has been reported in the treatment of fecal incontinence and constipation. It is uncertain which groups of incontinent patients benefit from biofeedback, and our impression has been that biofeedback is more successful for incontinence than for constipation. PURPOSE: This study was designed to review the results of biofeedback therapy at the Lahey Clinic. METHODS: Biofeedback was performed using an eightchannel, water-perfused manometry system. Patients saw anal canal pressures as a color bar graph on a computer screen. Assessment after biofeedback was by manometry and by telephone interview with an independent researcher. RESULTS: Fifteen patients (13 women and 2 men) with incontinence underwent a mean of three (range, 1–7) biofeedback sessions. The cause was obstetric (four patients), postsurgical (five patients), and idiopathic (six patients). Complete resolution of symptoms was reported in four patients, considerable improvement in four patients, and some improvement in three patients. Manometry showed a mean increase of 15.3 (range, −3–30) mmHg in resting pressure and 35.7 (range, 13–57) mmHg in squeezing pressure after biofeedback. A successful outcome could not be predicted on the basis of cause, severity of incontinence, or initial manometry. Twelve patients (10 women and 2 men) with constipation underwent a mean of three (range, 1–14) biofeedback sessions. Each had manometric evidence of paradoxic nonrelaxing external sphincter or puborectalis muscle confirmed by defography or electromyography. All patients could be taught to relax their sphincter in response to bearing down. Despite this, only one patient reported resolution of symptoms, three patients had reduced straining, and three patients had some gain in insight. CONCLUSIONS: Biofeedback helped 73 percent of patients with fecal incontinence, and its use should be considered regardless of the cause or severity of incontinence or of results on initial manometry. In contrast, biofeedback directed at correcting paradoxic external sphincter contraction has been disappointing.

Perianal hidradenitis suppurativa

Perianal hidradenitis suppurativa, a chronic recurrent inflammatory disease of apocrine glands, adjacent anal canal skin, and soft tissues, is characteristically ignored and misdiagnosed. A retrospective analysis of 43 patients with perianal hidradenitis suppurativa was performed; 40 patients (93 percent) were male and 3 (7 percent) were female, with a median age at presentation of 29 years. Symptoms, including pain, swelling, purulent discharge, and pruritus, had been present for a median of six years. Diagnoses at the time of presentation included pilonidal disease (28 percent), anal fistula (37 percent), and perirectal abscess (16 percent). Associated medical conditions included diabetes (12 percent) and obesity (12 percent), and 70 percent of the patients were smokers. Once the correct diagnosis was established, 72 percent of patients had wide local excision with healing by secondary intention, and 28 percent of patients had incision and drainage or limited local excision. Although 67 percent of the patients had recurrence of disease after initial treatment, wide excision was more successful in preventing recurrence. Skin grafting failed uniformly, and colostomy was rarely necessary. Despite its relatively common occurrence, perianal hidradenitis suppurativa is infrequently diagnosed correctly and recurs in many patients despite appropriate surgical treatment, making the disease a source of frustration for surgeon and patient alike.

Fertility and sexual and gynecologic function after heal pouch-anal anastomosis

PURPOSE: This study was designed to determine the incidence of infertility, gynecologic problems, and sexual dysfunction after ileal pouch-anal anastomosis (IPAA). METHODS: A questionnaire was sent to 206 females who underwent pouch surgery at a single institution from 1980 through 1991. Response rate was 53 percent (110/206). The computerized registry of the 206 females undergoing IPAA at this institution was reviewed to add additional data. RESULTS: Mean age at pouch construction was 32 (range, 14–61) years. Mean time from pouch surgery to survey was 49 (range, 1–132) months. Fifty-seven females had 119 children before pouch surgery, and 23 children were born to 19 females after IPAA (5 vaginal deliveries, 18 Cesarean sections). Eighteen females experienced infertility after IPAA. Thirty patients had persistent dyspareunia. Pelvic cysts developed in 15 patients; 11 patients required surgery. CONCLUSIONS: Although childbirth appears safe, gynecologic problems, such as dyspareunia and formation of pelvic cysts, may be underestimated after IPAA. The effects of IPAA on fertility are still unknown.