Conventional proctectomy for inflammatory bowel disease is followed by delayed perineal wound healing in 20% to 63% of patients and sexual dysfunction in. If you are a member, please log in to view this content. If you are not currently a member, please consider joining ASCRS. Member benefits include resources. Abstract. Background: Perianal Crohn’s disease (CD) represents a more aggressive phenotype of inflammatory bowel disease and often coincides with.
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Anthony de Buck van Overstraeten, Albert M. Perianal Intersphoncteric disease CD represents a more aggressive phenotype of inflammatory bowel disease and often coincides with proctocolitis. This study aims to assess the outcome of patients undergoing proctectomy with end-colostomy.
A retrospective outcome analysis of 10 consecutive patients who underwent intersphincteric proctectomy with end-colostomy between February and May was performed. All patients suffered from refractory distal and perianal CD. The proximal colon was normal at endoscopy. All data were proctecomy from a prospectively maintained database. The main outcome parameter was disease recurrence and need for completion colectomy. Despite protracted medical treatment, completion colectomy was necessary in 5 patients.
One patient, who underwent a second segmental colectomy with a new end-colostomy, showed again endoscopic recurrence and is currently treated with anti-TNF agents. Intersphincteric proctectomy with colostomy seems to be an ineffective surgery for perianal CD with coexisting proctitis and results in a high risk of recurrence of the disease in the remaining colon. Therefore, despite a normal appearance of the proximal colon, a proctocolectomy with end-ileostomy seems to be the surgical approach of choice in these patients.
St Mark’s Online DVDS – Intersphincteric Proctectomy
Perianal disease significantly jeopardizes the quality of life as the relapsing and penetrating nature of the disease may result in persistent perianal drainage, pain, dyspareunia, dyschezia and progressive destruction of the anal canal and sphincters causing intractable anal incontinence.
Surgery for small bowel or ileocolic disease is well established and includes segmental resection and strictureplasty. In patients with large bowel Crohn’s disease and rectal sparing a segmental or sub total colectomy can be performed.
In intersphincgeric with anorectal involvement proctocolectomy with definitive ileostomy has been the surgical approach of choice. In a recent meta-analysis comparing segmental vs.
This study aims to assess untersphincteric outcome of patients undergoing proctectomy with end-colostomy for intractable perianal Crohn’s disease. All patients had disabling rectoperineal disease despite optimized local surgery and protracted medical therapy with immunomodulators and anti-tumor necrosis factor anti-TNF.
The anal function of all patients was impaired, due to penetrating disease and multiple surgical interventions. For all patients the indication for intersphincteric proctectomy was decided by an IBD multidisciplinary team.
Patient data were retrieved from a prospectively maintained database. The study was approved by the medical ethical committee. The following data were analyzed: Recurrence was assessed clinically, with blood analysis CRP, leukocytosis… and confirmed by colonoscopy.
None of the patients received prophylactic medical treatment after primary surgery. Therapy was started only after objective evidence of recurrence.
All data are represented as median and range. Patients were followed on a regular basis at the outpatient’s clinic. A intersphincteriic colonoscopy was performed one year postoperatively unless an earlier assessment was necessary because of clinical concerns.
Between February and May10 consecutive CD patients underwent a proctectomy with end-colostomy.
The median age at surgery intersphnicteric 40 years 22—61 with median disease duration of 15 years 6— Five patients never had documented proximal colonic and or ileal disease before. Four patients had at least one flare of terminal ileitis, resulting in ileocecal resection in two patients.
One patient had a history of pancolitis, however at the time of surgery, endoscopic assessment of the colon could intersphincgeric withhold any inflammation proximal from the rectum. All patients, except one, were taking immunosuppressant drugs and or Interrsphincteric before primary surgery.
Two patients were active smokers. Nine out of ten patients had a flexible ileocolonoscopy at a median interval of 3. In one patient endoscopic evaluation of the proximal colon was not possible because of rectal stricture. This patient had no evidence of previous proximal colonic involvement.
Ileocolonoscopy showed a median proximal extent of the disease of 35 cm 15—50 with only 2 patients showing mild inflammation higher up. The first one had loss of haustration of the transverse colon, but without any ulceration, the second patient showed little ulceration more proximal in the colon.
All patients consented to undergo proctectomy with end-colostomy. All data are summarized in Table 1. An intersphincteric proctectomy with end-descendostomy was performed in 9 cases; a transversostomy was used intersphincterc one patient. The kntersphincteric colon had a normal macroscopic appearance in all patients.
Microscopic analysis of the specimens showed negative section margins in 5 specimens. In the other 5 patients there was microscopic evidence of inflammation at the proximal section margin.
Median length of stay was 9.
Perineal wound complications are very frequent after proctectomies for CD, however in our patients wound problems were superficial, secondary to the limited intersphincteric resection, avoiding tension on the wound. There was no mortality. No patients received medical therapy after primary surgery.
In all but one patient anti-TNF treatment or immunomodulators were restarted. At a median follow-up of 26 months 2—486 patients needed further surgery. Completion colectomy with end-ileostomy was performed in 5 patients and a segmental colectomy with terminal transversostomy was performed in 1 patient.
However, despite anti-TNF treatment this patient developed again endoscopic recurrence requiring surgery.
The median interval between primary and re-resection was The median length of stay was 10 days 9—29without any mortality but with increased morbidity. Two patients developed respiratory distress and two patients developed abdominal sepsis.
One of them needed an explorative laparotomy.
Interzphincteric patients have continued medical therapy but no mucosal healing could be obtained. Follow-up data are summarized in Table 2. This outcome assessment heralds an important clinical observation about the high rate of recurrence after proctectomy with end-colostomy for patients with anorectal CD.
Temporary fecal diversion can lead to remission in the defunctioned bowel segment in some patients.
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In this series the anal function of all patients was completely affected and no conservative surgery, even fecal diversion, could be proposed. Therefore all patients underwent a definitive proctectomy. Restorative proctectomy with coloanal anastomosis has been proposed as an ultimate alternative for proctectomy and definitive ostomy in selected patients.
Clinical relapse proxtectomy a constant pattern: This mimics the recurrence pattern of ulcerative colitis when a subtotal colectomy is performed, as described in some older case series.
There is no unequivocal explanation for the ulcerative colitis like behavior of the distal colonic part in CD patients. It remains to be determined whether resections for Crohn’s colitis could be segmental or have to be more extensive.
In our center a more restrictive surgical approach has been in use for Crohn’s colitis, performing a segmental colectomy for localized disease, even in the presence of anal involvement. The incentives to retain a part of the colon and to perform a colostomy instead of an ileostomy are a significant reduced stoma output and the related problem of dehydration, a reduced risk for peristomal skin problems and a presumed better quality of life. We must emphasize that this meta-analysis is based on a rather small series, gathering patients from to In contrast, Kiran et al.
Segmental colectomy was not an independent risk factor for recurrence. They suggest, however, to perform a proctocolectomy with Brooke ileostomy in patients with severe perianal disease, even if perianal disease was not retained as risk factor in their multivariate analysis. They conclude that only a well-localized colonic disease is an indication for segmental resection. It seems that the site of initial disease plays a role in the recurrence pattern. Therefore in all patients with colo-proctitis and anal disease, proctocolectomy with intersphincterjc ileostomy seems to be the surgery of choice.
An increased relative risk for surgical recurrence has also been described when anal disease was present before surgery. Anal disease seems indeed to be an independent risk factor intersphoncteric development of recurrent disease, in series comparing several different types of colonic resections.
In patients with anorectal CD proctectomy with end-colostomy is ineffective surgery resulting in early severe recurrence in the proximal colon and disabling peristomal cutaneous lesions. Most patients will require completion colectomy with end ileostomy.
It is therefore concluded that patients with anorectal CD who need proctectomy should undergo proctocolectomy with end ileostomy despite the absence of proximal colonic involvement. Oxford University Press is a department of the University of Oxford.
It furthers the University’s objective of excellence in research, scholarship, and education by publishing worldwide. Sign In or Create an Account. Close mobile search navigation Article navigation. Intersphincteric proctectomy with end-colostomy for anorectal Intersohincteric disease results in early and severe proximal colonic recurrence Anthony de Buck van Overstraeten.
Crohn’s diseaseProctectomyRecurrenceAnorectal involvementProctocolectomy. Classification of surgical complications: Effect of resection margins on the recurrence of Crohn’s disease in the iintersphincteric bowel.
A randomized controlled trial. Surgical treatment of anoperineal Crohn’s disease: The place of isolated rectal excision in the treatment of ulcerative colitis. Failure of right-sided coloanal anastomosis for treatment of left-sided ulcerative colitis. Report of a case. Is ileostomy always necessary in the surgical treatment of segmental ulcerative colitis?