Robert N. Allan

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.

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.

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.

Carcinoma in a rectovaginal fistula in a patient with Crohn's disease.

A patient with Crohns disease underwent resection for internal fistulas. Later a rectovaginal fistula developed that persisted with minimal symptoms for 10 years before causing pain and induration in the posterior vaginal wall, due to carcinoma developing within the fistula.

Perforating ileocecal Crohn's disease does not carry a high risk of recurrence but usually re-presents as perforating disease.

PURPOSE: The aim of this study was to study the natural history of perforating and nonperforating ileocecal Crohns disease. METHODS: One hundred sixty-five cases of primary ileocecal Crohns disease operated on between 1975 and 1995 were reviewed. Perforating disease was defined as acute free perforation, subacute perforation with an abscess, or chronic perforation with an internal or external fistula. RESULTS: Perforating disease was identified in 72 patients (44 percent); 11 with acute free perforation, 18 with abscess formation, and 43 with fistulas. Postoperative complications occurred in 29 percent of perforating and in 23 percent of nonperforating disease (not a significant difference). There was no significant difference in the cumulative reoperation-free rate for recurrence at the ileocolonic anastomosis (perforating, 78 percentvs. nonperforating, 73 percent at 5 years and perforating, 61 percentvs. nonperforating, 55 percent at 10 years), or in the median time interval from the primary to the secondary operation (perforating, 49vs. nonperforating, 37 months). Seventy percent of perforating disease re-presented with perforating recurrence. Likewise, 83 percent of nonperforating disease re-presented with nonperforating (P<0.0001) recurrence. Re-reoperation rate for re-recurrence at the ileocolonic anastomosis and median duration from the second operation to the third operation did not differ between perforating and nonperforating disease. Seventy-nine percent of perforating disease re-presented again with perforating disease, and 87 percent of nonperforating disease re-presented again with nonperforating disease as before (P=0.001). CONCLUSIONS: These data suggest that perforating ileocecal disease usually re-presents in the way it did originally but does not represent a high-risk group for recurrence.

How does pouch construction for a final diagnosis of Crohn's disease compare with ileoproctostomy for established Crohn's proctocolitis?

PURPOSE: There is a difference of opinion concerning the role of ileal pouch-anal anastomosis in Crohns disease, even in the absence of small-bowel or perianal disease. One view is that ileal pouch-anal anastomosis should never be entertained, the other is that ileal pouch-anal anastomosis, like ileoproctostomy, can be justified sometimes, because it allows young people a period of stoma-free life. The aim of this study was to examine the outcome of ileal pouch-anal anastomosis and to contrast it with ileoproctostomy in patients with Crohns disease without small-bowel or perianal disease. METHODS: Ileal pouch-anal anastomosis was performed in 23 patients with Crohns disease (12 of whom had evidence of Crohns disease at the time of operation and 11 who were eventually found to have Crohns disease as a result of complications) and ileoproctostomy in 35. Patients were matched for age, gender, follow-up, and medication, but all ileoproctostomy cases had relative rectal sparing. Thus, the groups were not comparable and the reasons for ileal pouch-anal anastomosis and ileoproctostomy were therefore quite different. RESULTS: The outcome in ileal pouch-anal anastomosis at a mean follow-up of 10.2 years was pouch excision, 11 (47.8 percent); proximal stoma, 1 (4.3 percent; patient preference); average small-bowel resection, 65 cm; persistent perineal sinus, 8 of 11 having pouch excision (73 percent); and mean time in hospital, 37 (range, 8–108) days. Of those in circuit having ileal pouch-anal anastomosis (n=12), 24-hour bowel frequency was 6, with no incontinence or urgency, but 6 (50 percent) were on medication. When ileal pouch-anal anastomosis was done for Crohns disease in the resection specimen, only 4 of 12 (33 percent) were excised compared with 7 of 11 (64 percent) in whom the diagnosis was made as a result of complications. The outcome in ileoproctostomy at a mean follow-up of 10.9 years was rectal excision in 3 (8 percent), proximal stoma in 1 (3 percent), average small-bowel resection was 15 cm, persistent perineal sinus in 1 (3 percent), and time in hospital was 21 (range, 8–36) days. Of those in circuit (n=32), 24-hour bowel frequency was 5, 2 had incontinence, 3 had urgency, and 12 (36 percent) were taking medication. CONCLUSIONS: These results indicate that the overall outcome of ileal pouch-anal anastomosis is inferior to that of ileoproctostomy, especially if Crohns disease was diagnosed as a result of complications. Nevertheless, the functional results of those with a successful outcome are comparable.

Fecal diversion in the management of Crohn's disease of the colon

The clinical course of 44 patients undergoing elective proximal fecal diversion for Crohns disease of the colon is reported. Sustained disease remission was obtained in 31 patients (70 percent). Diversion was associated with a significant reduction in steroid requirements (P<0.01) and a significant improvement in hemoglobin (P<0.001), erythrocyte sedimentation rate (P<0.001), and albumin (P<0.05). Sixteen patients (36.4 percent) have required a proctocolectomy, 19 patients (43.2 percent) remain defunctioned, and four patients (9 percent) have died. Five patients have had intestinal continuity restored, which has remained intact in four patients for a mean follow-up of 99 (range 21–153) months. Fecal diversion for Crohns disease of the colon produces a high incidence of sustained disease remission, but for the majority of patients the prospect of future restoration of intestinal continuity is limited.

Entero-enteric fistula complicating Crohn's disease.

We have reviewed our experience with, and management of, entero-enteric fistula in Crohns disease between 1970 and 1980 (inclusive). Thirty-three patients (20 of them female) came to our unit with entero-enteric fistulas, representing one-third of all Crohns fistulas seen during those years. Entero-enteric fistulas gave few symptoms and their precise identification was not important in clinical management. The presence of the fistula itself is not an indication for operation and treatment should be directed towards the active or stenotic disease and not to the entero-enteric fistula. Therefore, radiological examination is important only to identify the extent of underlying disease.