Michael R. B. Keighley

Natural history of perianal Crohn's disease: Ten year follow-up: A plea for conservatism

A 10 year follow-up of 109 patients with histologic Crohns disease and anal lesions is reported. Fourteen patients (13 percent) have died, 7 from unrelated disorders. Ten required excision of the rectum, but only 5 for perianal disease (4.5 percent). Of the remaining 85 patients, 61 have been followed up to proctoscopy and rectal biopsy. Anal skin tags were still evident in 25 of 37 patients (68 percent), but new tags have appeared in only 2 patients. Ten of 53 fissures (19 percent) were still present at 10 years, and there were no new fissures. Seven of 21 patients (33 percent) still had fistulas but were asymptomatic; the remainder of the fistulas had healed spontaneously (8) or after operation (6). New fistulas have appeared in five patients. None of the patients have been in continent. These results indicate that perianal manifestations of Crohns disease pursue a relatively benign course and are rarely an indication for proctectomy.

Current status and influence of operation on perianal Crohn's disease.

Two hundred and two patients with Crohns disease have been examined during the year 1984 to assess the frequency of perianal disease. One hundred and ten have had evidence of perianal complications (54%). In 30% of patients with perianal disease, the anal manifestations preceded any evidence of intestinal disease. Perianal disease was associated with pain in only 39%. Operations for perianal disease rarely achieved healing and were frequently associated with complications. Attempts to lay open a fistula-in-ano caused healing in only one of 12 cases and 6 developed incontinence. A high proportion of patients with Crohns ulcers and strictures required proctectomy (87%). Proctectomy was performed in 27 patients with perianal disease of whom only 8 (30%) had primary healing of the proctectomy wound compared with complete healing in all 9 patients having a proctectomy without perianal disease (p < 0.01). These results imply that patients with perianal Crohns disease should be treated conservatively and that proctectomy, particularly in patients with rectal strictures, is associated with very high incidence of persistent perineal sinus.

Wide-lumen stapled anastomosisvs. conventional end-to-end anastomosis in the treatment of Crohn's disease

PURPOSE: Preanastomotic recurrence and stricturing after surgery for ileocolic Crohns disease is a frequent, unexplained phenomena that may lead to prompt reoperation. The aim of this study was to determine whether a wide-lumen stapled anastomosis (side-to-side, functional end-to-end) provides better outcome than a conventional sutured end-to-end anastomosis METHOD: A case-control comparative analysis of patients with Crohns disease from two inflammatory bowel disease centers treated with wide-lumen stapled anastomosis and a matched (age and gender) group treated with conventional sutured end-to-end anastomosis was performed. RESULTS: A total of 138 patients with Crohns disease were treated, 69 with wide-lumen stapled anastomosis and 69 with conventional sutured end-to-end anastomosis. Preoperative therapy, number of previous resections, indication for operation, and length of bowel resected were similar in both groups. Fewer complications occurred after wide-lumen stapled anastomosis (P=0.048). A total of 55 patients developed recurrent Crohns disease symptoms, 39 (57 percent) in the conventional sutured end-to-end anastomosis and 16 (24 percent) in the wide-lumen stapled anastomosis group. Median follow-up was 70 and 46 months, respectively. After conventional sutured end-to-end anastomosis 18 reoperations were required, 15 for anastomotic stricture and 3 for fistulization. After wide-lumen stapled anastomosis three reoperations were necessary, two for stricture and one for fistulization. The cumulative reoperation rate for anastomotic recurrence was significantly lower (P=0.017; log-rank test) for the wide-lumen stapled anastomosis group. CONCLUSION: Wide-lumen stapled anastomosis is as safe as conventional sutured end-to-end anastomosis and results in a lower incidence of symptomatic recurrent Crohns disease and need for reoperation. Further prospective study of the wide-lumen stapled anastomosis technique is necessary to define the precise role of this operation in patients with Crohns disease.

Effect of fecal diversion alone on perianal Crohn's disease.

Abstract. The role of fecal diversion alone for perianal Crohns disease remains unclear. This study was undertaken to assess its role in perianal Crohns disease and to examine predictive factors for outcome. Thirty-one patients who underwent fecal diversion alone for perianal Crohns disease between 1970 and 1997 were reviewed. The principal indications for fecal diversion were severe perianal sepsis in 13 patients, recurrent deep anal ulcer in 3, complex anorectal fistula in 9, and rectovaginal fistula in 6. Twenty-five patients (81%) went into early remission, and six (19%) failed to respond. Of the 25 early responders, 17 relapsed at a median duration of 23 months after fecal diversion. By contrast, 8 patients (26%) went into complete remission and required no further surgery at a median duration of 81 months after the diversion. Altogether, 22 patients required surgery at a median duration of 20 months after fecal diversion: proctectomy in 21 and repeated drainage of anal sepsis in 1. At present, intestinal continuity has been restored in only three patients (10%). The following parameters were compared in patients with and without complete remission after fecal diversion: age, gender, duration of disease, steroid use, smoking, coexisting Crohns disease, preoperative blood indices, and Crohns disease activity index. None of these parameters affected the outcome. In conclusion, fecal diversion alone is effective in selected patients with perianal disease, but the prospect of restoring intestinal continuity is low. There were no parameters to identify those in whom a successful outcome is likely.

Persistent perineal sinus after proctocolectomy for Crohn's disease

PURPOSE: Persistent perineal sinus is a source of morbidity after proctocolectomy for Crohns disease. This study examined the factors responsible for persistent sinus after proctocolectomy for Crohns disease. We also assessed the outcome of surgical treatment for persistent perineal sinus. METHODS: The records of 145 patients who underwent proctocolectomy for Crohns disease between 1970 and 1997 were reviewed. RESULTS: Persistent sinus occurred in 33 (23 percent) patients after proctocolectomy. Factors associated with a significantly greater risk of perineal sinus were younger age (P=0.006), rectal involvement (P=0.02), perianal sepsis (P=0.0005), high fistulas (P=0.04), extrasphincteric excision (P=0.0004), and fecal contamination at operation (P=0.0003). Multivariate analyses showed that age (P=0.0001), rectal involvement (P=0.007), and fecal contamination (P=0.009) were significant independent predictive factors for perineal sinus. Fifty-six operations, including 24 radical excisions, two rectus abdominis flaps, four gracilis transpositions, and two omentoplasties were performed in 24 patients with persistent sinus, but only 9 achieved healing. Long sinuses (>10 cm) and sinuses presenting late (>12 weeks after proctocolectomy) were seldom cured by surgical treatment. CONCLUSION: Persistent perineal sinus is more likely to occur if an extrasphincteric dissection is needed because of extensive anorectal disease or if fecal contamination occurs at operation. Attempted surgical eradication of perineal sinus is often ineffective.

Sphincter repair for fecal incontinence

Twenty-seven patients who had sphincter repair by one surgeon over the last ten years were reviewed. Previous surgery, childbirth, and perineal trauma were the most common causes. Twelve patients had been treated previously using an anal continence device (N=6), postanal repair (N=5), and rectopexy (N=1). A covering colostomy was used in ten patients. At the initial operation only 7 patients were rendered completely continent, 13 others were improved, but results were poor in the other 7. Four of the 7 patients were rendered completely continent after secondary operations. Maximum anal pressure and maximum squeeze pressure did not change significantly after surgery; however, preoperative maximum squeeze pressure in patients who achieved complete continence was significantly greter than in those that did not Poor results usually were associated with severe obstetric trauma

An audit of strictureplasty for small-bowel Crohn's disease

PURPOSE: The aim of this study was to review the long-term outcome of strictureplasty for small-bowel Crohns disease. METHODS: We reviewed 111 patients who underwent 285 primary strictureplasties (Heineke-Mikulicz, 236; Finney, 49) between 1980 and 1997. RESULTS: Eighty-seven patients (78 percent) had had previous bowel resections. Forty-six patients (41 percent) required synchronous resection for perforating disease (abscess or fistula) or long strictures (>20 cm). The mean number of strictureplasties was three (range, 1–11). There were no operative deaths. Septic complications (fistula or intra-abdominal abscess) related to strictureplasty developed in eight patients (7 percent), of whom two required a proximal ileostomy. Abdominal symptoms were relieved in 95 percent of patients. The majority (95 percent) of patients with preoperative weight loss gained weight (median gain, +2 kg; range, −6 to +22.3 kg). After a median follow-up of 107 months, symptomatic recurrence occurred in 60 patients (54 percent). In 11 patients symptomatic recurrence was successfully managed by medical treatment. Forty-nine patients (44 percent) required reoperation for recurrence: strictureplasty alone in 22 patients, resection alone in 19 patients, strictureplasty and resection in 6 patients, and ileostomy alone in 2 patients. Eighteen patients (16 percent) required a third operation. One patient died from a small-bowel carcinoma which developed in the vicinity of a previous stricture-plasty. Two of 19 patients with diffuse jejunoileal disease developed short-bowel syndrome, and were receiving long-term parenteral nutrition. Two other patients were taking corticosteroids for recurrent symptoms. All other patients were asymptomatic, receiving neither medical treatment nor nutritional support. CONCLUSIONS: Strictureplasty is a safe and efficacious procedure for small-bowel Crohns disease in the long-term.

Factors affecting the incidence of postoperative septic complications and recurrence after strictureplasty for jejunoileal Crohn's disease.

BACKGROUND This retrospective study was undertaken to examine the long-term outcome of strictureplasty for Crohns disease and factors affecting the incidence of postoperative septic complications and recurrence. METHODS Eighty-seven patients who underwent 245 primary jejunoileal strictureplasties for jejunoileal Crohns disease between 1980 and 1997 were reviewed. RESULTS Septic complications (fistula/abscess) occurred in 7 patients (all at strictureplasty site). Only intra-abdominal sepsis with peritoneal contamination at laparotomy was significantly associated with these complications. After a median follow-up of 104 months, 49 patients (56%) developed symptomatic recurrence. In 11 patients, symptomatic recurrence was successfully managed by medical treatment. Thirty-eight patients (44%) required further surgery for recurrence. Only young age (< or = 37 years) was associated with high incidence of reoperation for recurrence. Preoperative steroid use, nutritional status, synchronous bowel resection, and number, site, or length of strictureplasties did not affect the incidence of septic complications and recurrence requiring reoperation. CONCLUSIONS Intra-abdominal sepsis with peritoneal contamination increased the incidence of septic complications. Only young age was associated with the increased risk of recurrence requiring reoperation.

Comparison of three methods of whole bowel irrigation

Sixty-two patients undergoing colorectal surgery or colonoscopy were prepared by three methods of whole bowel irrigation: nasogastric saline solution alone, nasogastric saline irrigation with oral mannitol, and oral mannitol solution without saline. The additional of mannitol to saline irrigation reduced the risk of sodium and water retention, which was eliminated by oral mannitol alone. The best mechanical preparation was achieved by adding mannitol to saline irrigation, but oral mannitol alone was judged more acceptable by the patients and less demanding by the nursing staff and was the preparation of choice for colonoscopy.

Prospective randomised comparison of photocoagulation and rubber band ligation in treatment of haemorrhoids

Two hundred and sixty eight patients with haemorrhoids were allocated at random to treatment by either photocoagulation (group 1, n=141) or rubber band ligation (group 2, n=127) and followed up for one year. There was no significant difference in the symptomatic outcome of treatment between the two groups at one, four, or 12 months, irrespective of whether first or second degree haemorrhoids were treated. Side effects of treatment (bleeding or severe pain) were significantly more common after rubber band ligation (n=11) than after photocoagulation (n=2; p less than 0.01). Further outpatient treatment, however, was required significantly more often after photocoagulation (n=23) than rubber band ligation (n=6) (p greater than 0.02), and 19 patients (14 in group 1 and five in group 2; NS) subsequently had a haemorrhoidectomy. At one year 26 of 103 patients were dissatisfied after photocoagulation compared with 20 of 88 after rubber band ligation. Photocoagulation is a safe and comfortable treatment which gives long term results that are as good as those of rubber band ligation. Complications are more common after rubber band ligation, but further treatment is required more commonly after photocoagulation.