Tomas M. Heimann

Relationship of postoperative septic complications and blood transfusions in patients with Crohn's disease.

We prospectively studied 169 patients with Crohns disease to determine if postoperative infectious complications could be related to perioperative blood transfusions. Postoperative septic complications developed in 18 of the 69 patients who received more than 1 unit of blood (26 percent) compared with 8 of the 100 patients (8 percent) who received 1 unit of blood or no blood (p = 0.0014). Previous operation, low body weight, and having an ostomy were also related to septic complications. Patients receiving more than 1 unit of blood were significantly more likely to have low preoperative serum albumin levels, to have undergone abdominoperineal or small bowel resection, and to have an ostomy. Postoperative septic complications were significantly related to perioperative blood transfusions after controlling for these potential confounding factors independently by subgrouping and simultaneously by using multiple logistic regression. Blood transfusion may be a more significant factor in postoperative immune suppression and susceptibility to infection than previously recognized.

Spontaneous free perforation and perforated abscess in 30 patients with Crohn's disease.

Spontaneous free perforation is an uncommon event in the natural history of Crohns disease. It occurred in 21 of 1415 patients (1.5%) admitted with Crohns disease to The Mount Sinai Hospital between 1960 and 1983. The mean duration from onset of Crohns disease to occurrence of perforation was 3.3 years. Ten patients had small bowel perforation, ten patients had large bowel perforation, and one patient had simultaneous perforation of both ileum and cecum. The incidence of perforation in disease segments of small bowel was 1.0% (jejunum 6.0%, ileum 0.7%), and in the colon, 1.3%. Besides the 21 patients with spontaneous free perforation, an additional nine patients had spontaneous free rupture of an abscess into the peritoneal cavity. The mean duration from onset of Crohns disease to rupture of abscess was 8.5 years. All 30 patients had surgery within 24 hours of perforation or rupture. All 21 patients with spontaneous free perforations survived, as did all but one of the nine patients with perforated abscess. The cornerstone of the treatment of ileocolonic lesions perforating into the general peritoneal cavity is proximal diversion with delayed reconstruction of intestinal continuity whenever possible. With perforation of the small bowel, primary reanastomosis is possible in selected patients.

Early complications following surgical treatment for Crohn's disease.

One hundred thirty patients with Crohns disease operated at the Mount Sinai Hospital were studied to determine the incidence of early postoperative complications. Thirty per cent of patients developed postoperative complications, while eight per cent had major complications requiring readmission to the hospital, reoperation, or suture of a bleeding vessel. Patients with a low preoperative serum albumin concentration had a significantly higher incidence of nonseptic and multiple complications. Septic complications were more common in patients having extensive resections and in those with multiple previous operations. There was also a significantly higher complication rate in patients requiring permanent or temporary ileostomy as opposed to those having intestinal anastomosis. The majority of complications in the patients with ileostomy were nonseptic in nature. There were no mortalities in this series.

Comparison of primary and reoperative surgery in patients with Crohns disease

OBJECTIVE This study was performed to determine the clinical results of patients with Crohns disease who require surgical resection. The outcome of patients undergoing initial surgery was compared with those having reoperation. METHODS One hundred sixty-four patients undergoing intestinal resection for Crohns disease at The Mount Sinai Hospital from 1976 to 1989 were studied prospectively. The mean duration of follow-up was 72 months. RESULTS Ninety patients (55%) underwent initial intestinal resection whereas 74 patients (45%) underwent reoperation for recurrent disease. Patients undergoing reoperation were older (33.4 vs. 38.7 years), had longer durations of disease (8.7 vs. 15.2 years), had shorter resections (60 vs. 46 cm), and were more likely to require ileostomy. Forty-seven percent of the patients with multiple previous resections required an ileostomy. This group also received a mean of 2.3 U blood in the perioperative period and showed a trend to increased symptomatic recurrence (49% vs. 71% at 5 years). CONCLUSIONS Patients with Crohns disease undergoing first and second reoperation have outcomes similar to those in patients undergoing primary resection. Patients requiring multiple reoperations are more likely to require blood transfusions and permanent ileostomy and to show a greater trend to early symptomatic recurrence.

A comparison of multiple synchronous colorectal cancer in ulcerative colitis, familial polyposis coli, and de novo cancer.

Multiple synchronous colorectal cancer (MSCC) among 1537 patients (69 with familial polyposis coli (FPC), 780 with ulcerative colitis (UC), and 685 with de novo colorectal (DNC) cancers) admitted to The Mount Sinai Hospital between 1945 and 1981 was tabulated. MSCC occurred in five of 24 cancer patients with FPC (21%), in 12 of 65 cancer patients with UC (18%), but in only 17 of 685 DNC patients (2.5%). The proportions of MSCC cases with more than two synchronous tumors were also much greater in the former two groups (UC 6/12 = 50%, FPC 3/5 = 60%) than in DNC (0/17 = 0%). Multiplicity of cancers is thus a distinguishing feature of UC and FPC. MSCC differed from solitary cancers by association with older age and more advanced stage at diagnosis in patients with FPC and by a rightward shift in anatomic distribution in all patients, especially those with FPC and UC.

Prediction of early symptomatic recurrence after intestinal resection in Crohn's disease.

OBJECTIVE This study was performed to identify clinical criteria that may help recognize patients with Crohns disease who are at high risk for early symptomatic postoperative recurrence. SUMMARY BACKGROUND DATA Currently, no reliable criteria are available to help recognize patients who are prone to experience early symptomatic recurrence. METHODS One hundred sixty-four patients undergoing intestinal resection for Crohns disease at the Mount Sinai Hospital between 1976 and 1989 were studied prospectively. Patients with symptomatic recurrent disease within 36 months were defined as having an early recurrence. RESULTS Multivariate analysis revealed that the number of anastomoses was the most important prognostic indicator (p = 0.001), followed by inflammation at the resection margins (p < 0.05). Patients requiring an ileostomy had a significantly lower early recurrence rate than those having single or multiple anastomoses. There was no significant correlation between inflammation at the margins and early recurrence in patients requiring an ileostomy (n = 38), or a single anastomosis (n = 98). When the margins were examined in the 28 patients with 2 or more anastomoses, 10 of 11 patients (91%) with inflammation at either margin experienced early recurrence. Patients having multiple anastomoses with normal margins had the same recurrence rate as patients with single anastomosis (42%). CONCLUSIONS Patients with extensive Crohns disease requiring multiple resections with anastomosis, especially when microscopic inflammation is present at the margins, are at very high risk for symptomatic early recurrence. Ileostomy seems to be associated with a significantly lower early recurrence potential than anastomosis. Further study is needed to determine whether avoidance of multiple anastomosis and adjuvant medical treatment can alter the course of the disease after intestinal resection in patients at high risk for early symptomatic recurrence.

Course of enterovesical fistulas in Crohn's disease

Enterovesical fistulas occurred in 38 of 683 patients (5.6 percent) with Crohns disease admitted to The Mount Sinai Hospital between 1960 and 1977. There were 22 ileovesical fistulas, 8 colovesical fistulas, and 8 fistulas of combined ileal and colonic origin. These cases fell into three different pathophysiologic categories: 16 patients presented with sepsis after a mean duration of 7 years of Crohns disease, 19 presented without sepsis after a mean of 10 years of disease, and 3 elderly cancer patients presented with an average 25 years disease duration. Sepsis was usually due to deep pelvic or lower quadrant abscess with spontaneous rupture into the bladder. Nonseptic fistulization was a later, more gradual process, reflecting slow penetration into the bladder from a site of chronic cicatrizing bowel disease. Cancer was a very late complication, arising in each patient from an excluded loop. Although medical treatment was successful in delaying surgery in 6 patients and obviated surgery altogether in 2 patients, 36 of 38 patients (95 percent) eventually required operation. Postoperative mortality in this series was limited to two patients (5 percent) with preoperative intraabdominal abscess and sepsis. Five other deaths, unrelated to urinary complications, were caused by intestinal cancer in three patients and by intestinal complications of recurrent Crohns disease in two patients. The urologic course of patients with enterovesical fistula was completely benign. All operated patients were cured of their enterovesical fistulas, and no urologic sequelae developed. Subsequent reoperations that were required in 45 percent of these patients were all for recurrent bowel disease and not for fistula or other urologic problems.

Survival with colorectal cancer in ulcerative colitis. A study of 102 cases.

ObjectiveThis study was undertaken to correlate postoperative survival of patients with ulcerative colitis-associated colorectal cancer with the stage, configuration, size, and mucin content of the tumor. Summary Background DataThe factors influencing prognosis in colorectal cancer in the general population are well accepted, but less is known about their influence in cases of colorectal cancer associated with ulcerative colitis. MethodsThe authors reviewed the records of 102 patients with ulcerative colitis-associated colorectal cancer admitted to The Mount Sinai Hospital between 1959 and 1988. Tumors were classified on independent pathologic review according to histologic stage, configuration, size, and mucin content. Comparisons among survival curves were tested by the generalized Wilcoxon test. Cox regression models were used to examine the joint effects of selected clinicopathologic features on postoperative survival rates. ResultsComplete follow-up was obtained for 93 patients (92%). Overall 5-year actuarial survival was 52%. When factors were analyzed one at a time, survival was significantly poorer among patients with advanced cancer stage, larger tumor size, infiltrating and ulcerating configuration, and high mucin concentration. On multivariate analysis by the Cox regression model, however, only cancer stage emerged as a factor independently predicting survival. ConclusionsFor colitis-associated colorectal cancers, as for noncolitic cancers, histologic stage is the most important variable determining postoperative survival. The distribution of stages in our series and the survival rates within each stage did not differ appreciably from the distributions and survival rates reported for noncolitic colorectal cancers.

Adenocarcinoma following ileal pouch–anal anastomosis for ulcerative colitis: Review of 26 cases

&NA; The occurrence of adenocarcinoma following ileal pouch–anal anastomosis (IPAA) for ulcerative colitis (UC) is an infrequent and but potentially lethal complication. We have seen 1 such case among 520 IPAAs performed in our group practice between 1978 and February 2008. We have added this case to a review of 25 previously reported cases of adenocarcinoma of the pouch or outflow tract following IPAA for UC. Our conclusions are 1) that post‐IPAA cancer can occur following either mucosectomy or stapled anastomosis; 2) that this malignancy can occur after IPAA performed for UC either with or without neoplasia; and 3) that this complication is seen whether or not the initial cancer or dysplasia had involved the rectum.

Superior Mesenteric Vein Thrombosis After Colectomy for Inflammatory Bowel Disease

AbstractPURPOSE: Thromboembolism is a significant cause of morbidity and mortality in inflammatory bowel disease. Several prothrombotic conditions have been investigated in inflammatory bowel disease. The aim of this study was to evaluate the incidence of symptomatic postoperative superior mesenteric vein thrombosis in inflammatory bowel disease patients undergoing colonic resections and to identify and characterize their clinical presentation. METHODS: Between January 1999 and December 2001, 83 consecutive patients undergoing total colectomy for inflammatory bowel disease were studied retrospectively. Patients who developed new-onset postoperative acute abdominal pain were evaluated by CT scan of the abdomen. A complete coagulation profile, including thrombin time, platelet count, protein C, protein S, antithrombin III, homocysteine level, factor V Leiden mutation, plasminogen, and prothrombin G20210A mutation, was obtained in patients diagnosed with superior mesenteric vein thrombosis. RESULTS: Four patients (4.8 percent; 3 females; 3 patients with ulcerative colitis and 1 with Crohn’s colitis) developed symptomatic postoperative superior mesenteric vein thrombosis. Two of these patients had extension of the clot into the portal vein. Their presenting symptom was abdominal pain, with a median interval of ten days from the index surgery. The hematologic workup was negative in three patients, with one heterozygous for prothrombin G20210A mutation. All patients were treated with systemic anticoagulation for at least six months. One ulcerative colitis patient was diagnosed after abdominal colectomy and underwent an uneventful ileal pouch-anal anastomosis after systemic anticoagulation. CONCLUSION: Postoperative superior mesenteric vein thrombosis is a more frequent occurrence than previously reported in patients with inflammatory bowel disease. Direct surgical trauma to the middle colic veins, with resulting thrombosis, is likely to be the precipitating factor in a borderline intrinsically hypercoagulable environment. All patients became asymptomatic after systemic anticoagulation and recovered uneventfully.