Discussion

This systematic review has highlighted some very important differences in outcome between restorative proctocolectomy and IRA for the patient with FAP. The results on functional outcome suggest a favourable outcome towards the IRA procedure with regards to stool frequency over a 24-h period, need for defecation at night, incontinence (both over a 24-h period and at night) and pad usage. These finding are perhaps expected in a patient with a retained, functioning rectum. Interestingly, IPAA was...

Surgical Treatment

Accurate diagnosis of UC and CD has major implications on the choice of surgical treatment and long-term prognosis. The controversial issue of IC has become fundamental in the so-called pouch era. The need to obtain a differential diagnosis rises from the data widely accepted that ileoanal anastomosis should be contraindicated in patients with Crohn's colitis. Panis et al. 27 reported a 10 rate of pouch failure in highly selected patients with confirmed preoperative diagnosis of CD. It has to...

Rectal Cancer Risk

IRA carries a definite cancer risk in FAP due to the remaining rectal stump 3,4 , with a long-term rectal cancer risk reported to increase from 4 at 5 years to 25 at 20 years post-operatively 5 . More recently it has been suggested that absolute patient age is the determinant factor for cancer development rather than the length of post-operative follow-up 6 . This has led some to suggest that IRA should be converted to IPAA before the age of 50 7 . Several factors are thought to increase the...

Treatment

Many patients with anorectal Crohn's disease present other intestinal locations of the disease, requiring an evaluation of the colon and small bowel. The presence of proximal disease poses a therapeutic dilemma early reports suggest that perianal conditions persist in the presence of proximal disease and improve only if proximal disease is resected 10,11 however, other reports refute these findings and show no improvement in perianal disease after treatment of proximal disease 12 . Thus, the...

Introduction

Patients with inflammatory bowel disease (IBD) are at an increased risk for colorectal cancer (CRC) 1-4 , but the quantisation of the risk of CRC in this specific population varies widely in different studies. However, CRC complicating ulcerative colitis (UC) and Crohn's disease (CD) only accounts for 1-2 of all cases of CRC in the general population. Most cases of CRC are either sporadic (65-85 ) or familial (10-30 Fig. 1) 3-4 . CRC is considered a serious complication of the disease and...

Incontinence

Faecal incontinence in patients with perianal Crohn's disease is common, occurring in 39 of patients 32 . Management of this condition is challenging because the cause is often multifactorial. The incontinence may be secondary to severe perineal Crohn's disease associated with chronic fibrosis and scarring of the anorectum resulting in loss of reservoir function. In this situation, faecal diversion or proctectomy is indicated. If the patient suffers from severe Crohn's-related muscle...

Ankylosing Spondylitis

This chronic inflammatory disease is characterised by a progressive ligament calcification with hardening of the spine that reduces the function of the spine and therefore causes disability 13 . Although at present there are few clinical trials to confirm the benefits of therapeutic exercise in treating ankylosing spondylitis 14 , it is firmly believed that a rehabilitative program for patients with IBD should include 2. Achieving and maintaining correct posture. 3. Maintaining correct...

HRQL after RPC in FAP Patients

The latest treatment of choice in FAP in the past two decades, has been RCP with IPAA, which preserves the sphincters as well as sexual and bladder function while nevertheless completely removing colorectal mucosa 19, 21 . However, increasing experience with long-term postoperative care of FAP patients has raised doubts as to whether - apart from its well-known elevated rate of complications 22, 23 - IPAA really offers as much comfort as was initially thought. Indeed, ileorectal anastomosis...

Results

Up until March 31, 2005, a total of 1292 intestinal transplants in 1210 patients have been reported at 65 centers to the International Intestinal Registry 570 were isolated small-bowel transplants, 490 combined liver-small-bowel transplants and 232 were multivis-ceral transplants. Of the 1292, 772 intestinal transplants were performed in 721 pediatric recipients. For transplants carried out between 2003 and 2005, graft survival at 1 year was calculated to be around 80 with a patient survival...

References

Langholz E, Munkholm P, Davidsen M et al (1994) Course of ulcerative colitis analysis of changes in disease activity over years. Gastroenterology 107 3-11 2. Becker JM (1999) Surgical therapy for ulcerative colitis and Crohn' disease. Gastroenterol Clin North Am 28 371 3. Truelove SC, Witts LJ (1955) Cortisone in ulcerative colitis final report on a therapeutical trial. Br Med J 2 1041-1081 4. Hanauer SB (1966) Inflammatory bowel disease. N Eng J Med 334 841-848 5. Strong SA (2002) Fulminant...

Upper Gastrointestinal Polyps and Cancer

After the colon and rectum, the duodenum is the second most commonly affected site of polyp development in FAP 2,3 . Duodenal adenomas can be found in 30-70 of patients 2-4 and the lifetime risk of Table 1. Extra-colonic manifestations of familial polyposis Stomach fundic gland polyps, adenomatous polyps, cancer Duodenum and small bowel duodenal adenomas, periampullary cancer, small-bowel adenomas, cancer, lymphoid polyps of ileum Gallbladder, bile duct, pancreas adenomas, cancer Desmoid tumors...

Perianal and Colonic Crohns Disease

When isolated perianal Crohn's disease is present, loop ileostomy is often offered to patients as a temporary or definitive solution. Laparoscopic ileostomy construction is easily performed 20 and at the same time it gives the possibility of performing a complete abdominal exploration in order to detect additional sites of disease. Bowel obstruction due to bowel twisting is a possible complication and therefore particular care has to be taken to mark the bowel in order to exteriorise it in the...

Depression How Crohns Disease Patients Defend Themselves

Depression itself is a mechanism of defence in a person whose quality of life is severely affected by Crohn's colitis. The more the patient interacts with people, deals with his her job, enjoys - or tries to enjoy - social life, the more he she gets frustrated and suffers, as routine daily activities are prevented by anal soiling, frequent diarrhoea or abdominal pain Therefore, depression, i.e. refusal to participate actively in life, introversion and self-confinement to a comfortable jail...

Elective Procedures in Crohns Disease of the Colon

Throughout their lifespan, 70-80 of patients suffering form CD require surgical intervention. In 10-15 years from the first surgery, approximately 40-50 of patients require the next operation due to recurrence 20, 21 . Elective surgical strategy for Crohn's disease of the colon is somehow different from the strategy for CD of the small intestine. Due to the role of the small intestine, surgical procedures must aim to minimise the risk of short bowel syndrome. The large bowel is mainly...

Other Agents under Trial

Other agents under investigation in colorectal chemoprevention include difluoromethylornithine (DFMO), which irreversibly inhibits ornithine decarboxylase and blocks cell proliferation. Ursodeoxy-cholic acid reduces the concentration of the secondary bile acid deoxycholic acid in the colon and affects arachidonic acid metabolism 9-11 . 3-hydroxy-3-methylglutaryl Coenzyme A reductase inhibitors are usually used in the setting of lowering cholesterol but also have antioxidant anti-inflammatory...

Ulcerative Colitis Pouch Surgery

Measurement of quality of life, especially in pouch patients is fraught by methodological problems 1 . Quality of life varies on a daily basis and depends on mood, expectations and anal function. The instruments of measurements are usually based on questionnaires which attempt to quantify abstract issues 2 . Even though pouch surgery is generally successful, there is always a fear of incontinence, which would require a permanent stoma. High bowel frequency, which is not uncommon following pouch...

Restorative Total Proctocolectomy

The ileoanal pull-through procedure, also referred as restorative proctocolectomy, is rarely performed in urgent cases. This procedure can be potentially offered to patients in good clinical condition, namely, young patients with normal anal sphincter function and or rectal adenocarcinoma or uncontrollable hemorrhage (Figs. 7, 8). The real advantages of the IPAA are avoidance of permanent stoma and maintenance of the anal route of evacuation, along with the inherent eradication of the disease...

Dietary Restriction Social and Sexual Dysfunction

The studies reporting on dietary restriction, social restriction, and sexual dysfunction are shown in Table 4. The results from meta-analysis of these outcomes are shown in the Forrest plot in Figs. 3 and 4. The incidence of social restrictions following 58 IPAA and 85 IRA procedures (33, 35), was found to be significantly lower at 3.5 following IRA as compared to 13.8 following IPAA (OR 6.04, CI 1.53-23.78). There was no significant difference between IPAA and IRA in terms of need for dietary...

Nutritional Care in Children with Crohns Disease

Between 15 to 40 of children with Crohn's disease suffer from malnutrition and growth failure, puberty retardation and development of secondary sexual characteristics retardation 4 . The slowing down of height velocity has been also observed 4, 5 . What is clinically relevant is that malnutrition may affect as many as 25 of children even before the apparent onset of the disease 5 . Some factors are involved such as the catabolic state during the acute and or persistent active phase, anorexia...

MR Enteroclisis Findings

Early lesions of Crohn's disease such as blunting, flattening, thickening, distortion and straightening of the valvulae conniventes and tiny aphthae were clearly shown at conventional enteroclysis, but they were not consistently depicted with MR enteroclysis due to its inadequate spatial resolution. The valvulae conniventes were shown to their best advantage and distortion of the mucosal folds was easily detected with MR enteroclysis. The characteristic discrete longitudinal or transverse...

Division of Either the Ileocolic or Superior Mesenteric Blood Vessels

If the above maneuvers are still insufficient for providing adequate mesenteric length, some of the blood vessels supplying the terminal ileum can be divided. If the colectomy is performed at the same time as the ileal J-pouch anal anastomosis, it is important to pre Fig. 2a-c. Peritoneal windowing to gain additional mesenteric length. a A hemostat is inserted underneath the peritoneum to lift it away from the underlying mesenteric blood vessels. b Electrocautery is then used to divide the...

Animal in Vivo and in Vitro Studies

As already described, the mechanisms of altered motility in IBD are unclear but may reflect changes in the axon smooth muscle cell relationship and data suggest that the enteric nervous system (ENS) has an important role in the motility defects 68 . A limitation in understanding the etiology of IBD is that few animals spontaneously develop colitis and several animal models, particularly the hapten 2,4,6-trini-trobenzenesulfonic acid (TNBS) in ethanol have been used to produce an acute...

Management Outcome and Complications

The management of a conventional Brooke ileostomy is quite easy, both for the surgeon and the patient. As soon as possible, the patient is allowed to drink to easily achieve a correct balance of fluid intake. Beginning in the early post-operative period, a stoma care nurse should instruct the patient and his partner to empty and change the bag and to apply the flange. Although the rehabilitation mainly depends on patient motivation, the availability of a stoma care unit greatly helps the...

Nephrotoxicity from Medical Treatment

Renal toxicity is unusual with the drugs commonly utilised to treat IBD 91-95 , buthappens more frequently during treatment with cyclosporine, with reported incidence of up to 19 96-98 . However, the risk of irreversible damage is very low if cyclosporine dosage does not exceed 5 mg kg day and if the creatinine level does not increase over 30 of the normal level 99 . Results from a review showed that a > 30 increase in serum creatinine was present in 6 of patients treated with oral or...

Cancer Screening and Colonoscopy Surveillance

In the past, the indication for prophylactic colectomy for patients with longstanding ulcerative colitis was mainly based on the disease history and the clinical risk factors mentioned above. Today, with the availability of colonoscopy and the recognition of the dys-plasia-precancer-cancer sequence, surveillance colonoscopy with serial colonoscopic examinations and mucosal biopsies is thought to allow for a more adequate individual assessment of the cancer risk and firm recommendation for...

Screening and Treatment Options of Patients with Dysplasia Associated IBD

The evidence of the association of dysplasia with cancer in patients with IBD has been noticed since the first publication of Crohn and Rosenberg early in the 1900s 41-43 . The fact that dysplasia is commonly seen near areas of invasive carcinoma in up to 74 of resection specimens from IBD patients, has lead to the conclusion that this is a precursor to the invasive lesion 44 . The diagnosis of dysplasia in patients with IBD is a crucial step because in some centres it will leave the patient...

Induction of Remission

Sutherland et al. 5, 6 , in a meta-analysis of controlled trials, observed that 5-ASA was superior to placebo in active colitis (OR for maintaining remission 2). The same Authors, in an update of the aforementioned meta-analysis, confirmed that 5-ASA was superior to placebo for all outcome variables (global clinical remission, global clinical improvement, endoscopic remission or improvement). When 5-ASA was compared to sulfasalazine, there Table 1. Expectations expressed by members of the...

Perforation

Crohn stated in a 1957 paper Free perforation of ileitis into the peritoneal cavity never occurs or at least I have not seen it 47 . In 1965 however, he reported seven cases of free perforation 48 . Free perforation occurs in approximately 2 of patients with ulcerative colitis and is usually associated with toxic colitis or megacolon 28 . Its occurrence without megacolon is rare 49 . The diagnosis may be delayed, as high-dose steroids may mask the signs of peritonitis. In Crohn's disease, free...

Hman In Vb Studies

Studies on colonic motility in IBD patients date back decades and provide conflicting results. The discrep ancies reflect differences of study design, pressure sensors and patients selection 5 . Diarrhea may partly be explained by changes in mucosal secretory and absorptive functions, but some authors also suggest that alterations in colonic motility may also contribute to increased urgency and frequency of defecation in patients with ulcerative colitis. The cause of diarrhea could be...

Sexual Dysfunction Related to the Disease

Sexual desire may be reduced by generalised debility or by the presence of perianal or cutaneous fistulas which alter the acceptance of his her own body image and thus make the patient uncomfortable and embarrassed with his or her partner. More often, the constant presence of symptoms like abdominal pain and diarrhoea are the cause of reduced relational and sexual activity 9 . Besides these psychological aspects, many women suffer from dyspareunia. This can be secondary to perineal disease,...

Capsule Endoscopy in Crohns Disease

Video capsule endoscopy (VCE) is a new, noninva-sive imaging technique for the complete small bowel. The video capsule is a small device with a diameter of 11 mm and a length of 26 mm, which can be swallowed. It contains six light-emitting diodes, a lens, a colour camera chip and two batteries. The video capsule obtains two images per second. Video images are transmitted by means of radiotelemetry to the sensor array attached to the body with a belt. Images from a period of time as long as 8 h...

Cytotoxic Chemotherapy

Systemic chemotherapy has been administered to patients with DTs continually growing despite treatment with NSAIDs or anti-oestrogens or rapidly increasing in size thus leading to life-threatening complications. However, chemotherapy is rarely employed because of its toxicity. The published reports regard single cases or small numbers of patients. All treated patients were affected with large tumours, had severe symptoms or major complications. The DTs continued to grow even if medically...

Crohns Disease

Results with probiotics in Crohn's disease are conflicting. In a small pilot study, treatment with capsules containing E. coli Nissle 1917 was compared to the administration of placebo in maintenance of steroid-induced remission of colonic CD. Twelve patients were treated with E. coli Nissle 1917 and 11 with placebo at the end of the treatment period (12 weeks) relapse rates were 33 in the E. coli group and 63 in the placebo group, but unfortunately, because of the very small number of patients...

Uric Acid Stones

Crohn Disease Skin

Generally, uric acid renal stones are likely to form in the following circumstances (1) increased excretion Fig. 1. Bilaterally dilated renal calices, renal and ureteral calculi (white arrows) and calcifications (black arrow) in a patient with longstanding CD Fig. 1. Bilaterally dilated renal calices, renal and ureteral calculi (white arrows) and calcifications (black arrow) in a patient with longstanding CD of uric acid in the urine, (2) persistently concentrated urine, (3) persistently low...

HRQL after RPC in Crohns Disease Patients

IPAA has come to represent the procedure of choice for patients requiring surgery for mucosal UC 36 . In contrast, a proven diagnosis of Crohn's disease is generally held to preclude IPAA. However, patients with IPAA for apparent mucosal UC who are subsequently found to have Crohn's disease have a variable course. In fact, up to 15 of cases of UC are mistakenly diagnosedin patients with Crohn's disease because of overlap in the clinical, endoscopic and histologic findings 52-54 . Even the...

Clinical Studies on Artificial Nutrition in Crohns Disease

Artificial nutrition (enteral and parenteral) represents a widespread approach to many gastrointestinal disorders such as intestinal failure and chronic intestinal pseudo-obstruction, inflammatory bowel disease (IBD), severe exocrine pancreatic insufficiency due to cystic fibrosis, enteric and pancreatic fistulas, swallowing disorders, and other conditions secondary to other severe gastrointestinal disease or major digestive surgery leading to malnutrition. The availability of different enteral...

Macroscopic Features of IBD

Pseudo Polyp Image

In IBD, the gross appearance of the colon depends on the stage of the disease and the clinical severity 54 . In UC, the mucosa of the distal colon in early phases is red, friable, mucoid, with petechial haemorrhages. With the progression of the disease, broad-based ulceration of the mucosa develops, separating isolated islands of mucosa which could be inflamed or show features of regeneration. They may be seen to be protruding into the lumen to create the so-called pseudo-polyps commonly seen...

Hpv And Crohns Disease

Crohn's disease, a chronic inflammatory condition, may involve the entire alimentary tract from the mouth to the anus. The three major locations of the disease are 1. Ileocolic 41-55 of cases . Perianal or anorectal Crohn's disease affects the patient as a primary feature with a prevalence of 8-90 . Approximately one in three patients are afflicted 2-5 and it is rarely the only site of disease. The prevalence of perianal disease has been found to be greater in blacks than in whites 2 . More...

Crohns Disease Fissure

If a midline fissure appears abnormal or fails to heal with conventional therapy, Crohn's disease should be suspected 26 . Spontaneous healing is observed in 80 of patients with Crohn's fissures followed for 10 years 12 . For this reason, the majority of the fissures may be treated medically. The Lahey Clinic found that only 15 of 56 patients with fissures required surgical treatment, despite 88 presenting with symptoms 27 . A painful fissure is generally associated with an underlying abscess...

Pathophysiology

Healing is a complex process not yet completely understood. Soon after tissue damage, the inflammation phase takes place with subsequent migration and proliferation of macrophages, lymphocytes and fibroblasts thereafter, neoangiogenesis and fibro-plasias lead to wound closure, and finally, contraction of the scar tissue and remodelling complete the healing process. This organised sequence of events can be retarded by many endogenous factors such as ischaemia or poor blood supply, and...

Hepatobiliary Complications

Complications Crohn Disease

The incidence of hepatobiliary complications ranges from 5 to 15 in IBD patients. These complications include steatosis, cholelithiasis and PSC. An Italian study reported an overall prevalence of hepatobiliary alterations, e.g. steatosis and altered liver function test results, in 12 of IBD patients. A recent study by Bargiggia et al. reported gallstones, liver steatosis and liver enlargement in about 55 of 511 IBD patients undergoing abdominal ultrasound Fig. 3 . Cholelithiasis is reportedly...

Anti Inflammatory Medications

Several studies demonstrated that sulphasalazine and mesalazine are efficacious at high dose 3 g or more for CD, but there is no evidence that these drugs are effective in fistula healing. Also corticosteroids have no proven efficacy in the treatment of fistulizing Crohn's disease. In most of the studies on steroid efficacy, patients were not randomized for fistulae 9 . A recent review 10 has associated in patients with fistulizing CD, the use of corticos-teroids with deleterious outcome,...

Intestinal Strictures are a Commonly Encountered Problem in Patients with Crohns Disease

Intestinal strictures are a commonly encountered problem in patients with Crohn's disease, resulting in bowel obstruction and eventually in repeated bowel resection and short bowel disease. Over one third of patients with Crohn's disease have a clear stenosing disease phenotype, often in the absence of luminal inflammatory symptoms 39 . At the foundation, as in other organs and tissues, there is transformation and activation of fibroblasts and smooth muscle cells that underlie fibrogenesis in...

Mesenteric Fibromatosis

Mesenteric Fibromatosis

The term desmoid was first used by Muller 1 to describe the tendon-like aspect and the hard consistency of this type of proliferation desmos in Greek means band . Desmoid tumours DTs are classified as extra- or intra-abdominal. The extra-abdominal DTs arise from fascial or musculoaponeurotic structures predominantly of the abdominal wall Fig. 1a, b, c and occasionally of the shoulder girdle, chest wall, inguinal region and extremities. They present as a firm, smooth, painless, progressively...

Endosonographic Anatomy of the Anal Canal

Endosonography Rectal Crohn

Knowledge of the anal canal and pelvic floor anatomy is required in order to better understand how Fig. 8. Normal ultrasonographic six-layer structure of the mid anal canal in a male. Axial image a , schematic representation b perianal sepsis develops and to more accurately classify fistulae and abscesses. On ultrasound, six hypoe-choic and hyperechoic layers can be seen in the normal anal canal 14 . The ultrasonographer must have a clear understanding of what each of these six lines represent...

Postoperative Complications

Hepatic artery thrombosis HAT with an incidence of 1-5 following adult Ltx is a feared complication frequently leading to graft loss and retransplantation. The reason for the increased incidence of hepatic artery thrombosis in PSC patients is unclear 17 . New immunosuppressive regimens have significantly reduced rejection episodes in liver allograft recipients. Patients with PSC, PBC or autoimmune hepatitis seem to experience more acute rejections compared with patients with alcoholic cirrhosis...

Surgical Indications in Crohns Disease and Preoperative Preparation

Table 1 summarises indications for surgical treatment in Crohn's disease 4, 12, 13 . Surgery may be either scheduled or urgent. The subdivision into absolute and relative indications is partly arbitrary. Regardless of CD, intestinal perforation is considered to require urgent surgical treatment, but determining Table 1. Indication for surgical therapy Intestinal obstruction especially terminal ileum Intestinal perforation Complication of the disease process Intestinal bleeding Recalcitrant...

Calcium Oxalate Stones

Calcium oxalate is the most common type of kidney calculi not only in IBD patients but also in the general population. However, in the latter, urinary oxalate concentration is often normal and the formation of stones is mainly secondary to the abnormalities in its solubility. In contrast, the pathogenesis in IBD patients appears to be related to hyperoxaluria combined with fluid depletion. It has been shown that hyperox-aluria is present in two thirds of patients with ileal disease, or those...

Recurrence of Crohns Disease

Crohn's disease is considered to be an autoimmune disorder. Therefore, the possibility of recurrence within the graft is an important issue. So far, only two well-documented cases of recurrent disease have been reported. The first case was a 33-year-old female, who underwent small-bowel transplantation in December 1994. After induction with donor bone marrow infusion and with OKT3, immunosuppres-sion consisted of tacrolimus and methylpred-nisolone. Only 7 months post-transplant did the Fig. 4....

Risk of Cancer and Endoscopic Surveillance

The first description of a cancer of the colon complicating regional enteritis was described in 1948 79 . After this, published works abounded with reports of colorectal cancer in series of patients with Crohn's disease 80 . In a recent population-based study 81 , Bernstein et al. determined the incidence of cancer by linking records from the IBD and non-IBD cohort with the Comprehensive Cancer Care Manitoba Registry. IBD patients were matched 1 10 to randomly selected members of the population...

Abdominal MRI

The diagnosis of Crohn's disease should include assessment of the presence, severity, and extent of disease, inflammatory lesion activity, and the presence of extra-intestinal complications to aid in treatment planning, which largely depends on imaging findings, particularly those of cross-sectional imaging. Endoscopy and barium studies are the principal tools for diagnosis and evaluation of Crohn's disease however, they are limited in their capability to demonstrate the transmural or...

Irritable Pouch Syndrome IPS

IPS is a functional disorder diagnosed in symptomatic patients who suffer mainly from increased bowel frequency, urgency and abdominal pain without endoscopic or histologic evidence of rectal cuff or pouch inflammation 75 . Clinical features overlap with those of pouchitis and resemble those of irritable bowel syndrome. The aetiology is unclear, and is probably multifactorial in nature. Brain-gut factors may play a role in the pathophysiology of IPS. It is currently a diagnosis of exclusion. A...

Use of Stoma Rods

If there is excessive tension, a stoma rod may be used. I prefer short plastic ileostomy rods Marlen . These have the advantage that they are relatively small, being only several centimeters in length, so that they do not interfere with the stoma appliance, as can larger rods that are meant for use with colostomies. Such rods should be left in place for 5 days after surgery in order to assure adherence of the bowel to the abdominal wall and subcutaneous tissue before removal. In a patient in...

Abscess

Ischiorectal Abscess

Infection may spread and seek the path of least resistance Fig. 1 . It may extend downwards into the intersphincteric space resulting in a perianal abscess A , upwards inside the longitudinal muscle layer within the gut wall causing an intermuscular abscess, or upwards outside the gut wall resulting in a supral-evator abscess E . It may spread across the external sphincter B at any level resulting in an ischiorectal abscess which may also extend upwards or downwards C . Furthermore,...

One Stage Fistulotomy and Fistulectomy

Fistulotomy involves the deroofing or the laying open of a fistulous tract along a probe. Fistulectomy means excision of all the fistulous tract, granulation, and dense fibrous tissue, creating larger wounds and a greater separation of the ends of the sphincter, which results in a longer healing time and increased risk of incontinence. Fistulectomy and fistulotomy are easy to perform in cases of perineal, intersphinc-teric and low trans-sphincteric fistulae. If the fistu-lous tract crosses the...

Hand Assisted Technique with Personal Adjustments

Kock Pouch

When we began using HAL, the type of hand-port we chose was a Lap-Disc Ethicon Endosurgery, USA Fig. 4 . This system is made of rubber rings and a double circle which allows its rotation and closure as a diaphragm around the hand, while at the bottom, the rubber ring models its form, which is generally opened in the hypogastrium site, on the abdominal wall 7-cm incision according to Pfannenstiel . The patient is adjusted as for a cholecystectomy with parted legs and the operator in between, and...

Sexual Dysfunction Secondary to Surgical Treatment

Sexual dysfunction following rectal surgery for IBD has been reported in 1-27 of cases but dysfunction is often partial and transient 119, 128, 132, 133, 142-148 . This is usually due to damage of neurological structures during pelvic dissection, although psychogenic or vasculogenic factors may contribute 149 . Normal sexual function in males is under the control of both the sympathetic and parasympathetic system erection is mainly mediated by parasympa-thetic fibres, while sympathetic fibres...

Cause or Just Association Psychiatric Illness and IBD

Some confusion has occurred in the past decades on the psychosomatic aetiology or pathogenesis of IBD. There is enough evidence that depression or any psychiatric diagnosis is statistically more often associated with Crohn's disease than with diabetes, hyper tension or cardiac diseases 29 and that emotional distress may cause exacerbation of IBD, as reported at the beginning of this chapter with the sad story of Angela F. Psychiatric illness may precede the onset of Crohn's disease, but no...

One or Two Stage Operation the Value of Seton Drainage

After the abscess is incised and drained as previously described, the fistulous tract should be drained using a seton drainage 21 . Two or three 4-0 or 5-0 non-absorbable monofilament sutures are placed from the incision of the abscess along the tract to the primary orifice Fig. 2 . They are then tied separately and loosely without tension to avoid pain and skin damage. The seton will allow drainage and promote fibrosis around the fistulous tract. In cases of Crohn's disease, setons can be used...

Fistulae Management

Currently, there are no data supporting the role of endoscopy as primary treatment of fistulising Crohn's disease. Nevertheless, aside from guiding medical and surgical therapy of a fistula, endoscopy may indirectly and directly impact the treatment of fistulising Crohn's disease 58 . Indirectly, endoscopy may allow for dilation of obstructing strictures that prevent the closure of the fistula. Directly, may treat the fistula via an injection of fibrin-based sealants or anticytokine therapy. A...

Indications

The choice of the ideal surgical procedure for treating these patients is based upon the following considerations - the need of definitive treatment with a one-stage procedure that allows a complete removal of the diseased tissue and avoids the risk of cancer. - The possibility of restoring the anatomy as well as the bowel function and the faecal continence. - The outcome and the complications of different surgical procedures. - The patient's skills in managing the new condition and coping with...

Restorative Proctocolectomy

Laparoscopic Restorative Proctocolectomy

After placement of trocars and survey of the abdomen, complete mobilisation of the intraabdominal colon and terminal ileum up to the inferior border of the duodenum is accomplished. The distal ileum and mesenteric vessels are divided intracor-poreally. With the patient in Trendelenburg position, the rectum is circumferentially dissected down to the pelvic floor and transected with an articulate linear stapler at a level confirmed by digital examination. Fig. 12. Laparoscopic total colectomy...

Bone Disease in IBD

Reduced bone mineral density BMD is frequently associated with Crohn's disease CD . Early studies have described a high prevalence of osteopenia a T-score of -1 or lower and osteoporosis a T-score of -2.5 or lower in inflammatory bowel disease IBD . Uncontrolled studies gave a prevalence of severe demineralisation determined by dual-energy absorp-tiometry Z-score of lower than -2 or T-score of lower than -2.5 that ranged from 18 to 42 , while larger studies with a healthy control group showed...

Stapled Ileal Pouch Anal Anastomosis

Ileal Pouch Anvil

Performing stapled ileal J-pouch anal anastomosis is by far the easiest method with respect to mesenteric length, because in this situation, the transanally placed stapler pushes the perineum towards the abdomen and small-bowel mesentery, reducing the length needed by several centimeters compared to hand-sewn techniques. Purse string sutures are not reliable and frequently are placed incorrectly. Because of this, incomplete doughnuts are common. I prefer to use a triple-staple approach, in...

Nnsteroidal Ati Inflammatory gents for Colon Cancer Prevention

Colon cancer prevention has now focused on novel targeted therapies, such as non-steroidal anti-inflammatory agents NSAIDs . Aspirin, an inhibitor of COX-1 and -2, has been studied in several large randomised studies, but the effect on colorectal cancer prevention is unclear. The US Physician's Health Study, which enrolled 22 071 physicians as participants, reported that aspirin had no effect on the incidence of polyps or colon cancer 3 . However, Baron et al. conducted the Aspirin Folate Polyp...

Anal Skin Tags and Haemorrhoids

Skin Tags After Hemorrhoids

Anal skin tags are typically asymptomatic and present problems only when they interfere with perianal hygiene Fig. 5 . They are more prominent with active intestinal disease. Approximately 25 resolve spontaneously, generally after remission of concomitant bowel disease. These tags should not be removed Fig. 5. Anal tags with ulceration and tissue inflammation Fig. 5. Anal tags with ulceration and tissue inflammation because that may result in an unhealed wound, a chronic ulcer or perianal...

Hull T.l.1996 Work On Ileostomy

Schraut WH, Medich DS 1997 Crohn's disease. In Greenfield LJ, Mulholland M, Oldham KT et al eds Surgery scientific principles and practice, 2nd edn. Lippincott, Philadelphia 2. Kodner IJ 1997 Perianal Crohn's disease. In Allan RN, Rhodes JM, Hanauer SB et al eds Inflammatory bowel diseases, 3rd edn. Churchill Livingstone, New York, p 863 3. Platell C, Mackay J, Collopy B et al 1996 Anal pathology in patients with Crohn's disease. Aust N Z J Surg 66 5-7 4. Solomon MJ 1996 Fistulae and...

Peculiar Aspects of Gastroenteric Extra Colonic Manifestations of FAP

Among the possible extra-colonic manifestations are upper gastroenteric lesions, stomach polyps 25-60 of the patients and duodenal polyps 24-73 19-21 . Hyperplastic polyps are commonly observed at a gastric level, whereas at a duodenal level and in the Vater's ampulla we mostly have real adenomas which are also subject to the rule of adenoma-carcinoma progression. Therefore, periodic endoscopic surveillance of the upper gastroenteric tract with possible removal of duodenal adenomas is...

Ultrasonographic Assessment of Perianal Crohns Disease

Eas Defect Ultrasound

Accurate identification of all loculate purulent areas and definition of the anatomy of the primary fistulous tract, secondary extensions and internal opening is crucial for the treatment plan. EAUS has been demonstrated to be a very helpful diagnostic tool in accurately assessing all fistula or abscess characteristics 8-11, 16, 17 . Ultrasound examination with the 2050 transducer is generally started using 13 MHz, changing to 12 MHz or 9 MHz to optimise visualisation of the deeper structures...

Flogistic and Fistulous Disease

Flogistic mass is a frequent finding in Crohn's patients, in particular in recurrent disease. Large palpable mass per se, especially if associated with complex fistulous disease or with a frozen abdomen, are often considered to be a contraindication to laparoscopy 4, 7, 9 10 , whereas a mininvasive approach is considered possible even after previous multiple surgeries 11, 12 . When a flogistic mass is present with thickened mesentery, the size of the minilaparotomy depends on the size of the...

NSAIDs and Desmoid Tumours

Several reviews 51-53 have summarized the intriguing and accumulating evidence that nonsteroidal anti-inflammatory drugs NSAIDs have potential as anti-cancer drugs. NSAIDs have been shown experimentally to stimulate apoptosis and to inhibit angiogenesis, two mechanisms that help to suppress malignant transformation and tumour growth. The mechanism of action common to NSAIDs is the inhibition of cyclooxygenase COX enzymatic conversion of the polyunsaturated fatty acid arachi-donic acid produced...

Ureteral Obstruction

Retroperitoneal Fibrosis Ultrasopund

This event is not rare and in most cases is not secondary to renal calculi. Although some signs of unilateral renal stasis have been demonstrated in almost 50 of IBD patients, who for various reasons have an intravenous pyelogram 83 , the reported incidence of ureteral obstruction with associated hydronephrosis is 3.1-14.3 in patients with CD 1, 3, 6, 84-86 and 6.8 in those with UC 84 . However, these percentages might be underestimated, considering that this condition is often asymptomatic or...

Anal Fistulae

Anal Fistula Drainage

Corman observed that, More surgeons' reputations have been impugned because of problems with fistula operations than from any other operative procedure 47 . In general, anal fistulae present symp-tomatically Fig. 6 . In Crohn's disease, they have the reputation of being difficult to treat with a high rate of recurrence. Patients are more concerned with postoperative incontinence, even if minor. Many authors advise the most cautious attitude in regards to surgical treatment 12, 18, 22, 47 ....

Accuracy

Horseshoe Fistula Ischioanal

Imaging with EAUS has been shown to be a useful method accuracy ranging from 63 to 100 for evaluation of perianal abscesses and fistulae in CD 7-11,13,18 . Van Outryve et al. 8 reported that the routine proctological examination showed Crohn's lesions in 30 of patients and EAUS performed with a linear probe detected anorectal anomalies in 75 of patients. Moreover, EAUS was superior to CT scan in the study of pararectal and para-anal abscesses and fistulae. Schratter-Sehn et al. 19 demonstrated...

Recto Vaginal Fistula

Fistula Perianal

The development of fistulae is a common complication of Crohn's disease CD . The lifetime risk of fistula development in patients with CD has typically been reported to range from 20 to 40 . The reported incidence of fistulizing CD from referral-based case series ranged from 17 to as much as 85 1-3 . The probability of internal fistulae was particularly high in patients with perianal disease who presented a relative risk of 3.4 compared to patients with different localizations 4 . Over time,...

Perianal Abscess

Intersphincteric Fistula

Perianal disease is an important and distinguishing feature of Crohn's disease CD . The incidence of perianal disease in patients with CD varies from 3.8 to 81 in different series 1, 2 . While perianal lesions occur more often in patients with colonic disease than in patients with small intestinal disease 2 , 5 of patients with anorectal CD do not have proximal disease. Clinical features include hypertrophic skin tags, ulceration Fig. 1 , perianal abscesses and fistulae Figs. 2 and 3 ,...

The Voluminous Mass was a Desmoid Tumour

Desmoid from the Greek desmos, which means tendon like tumours are begnin tumours arising from the muscle-aponeurotic structures 25 . They are usually well differentiated but with an aggressive behaviour. Even if they have no metastatic potential, they can locally infiltrate the adjacent structures, leading to morbility mortality because of the deformity resulting from the pressure or obstruction of vital structures organs 26-28 . They represent 0.03 of all neoplasies 29 but this incidence...

Conclusion

Treatment of inflammatory bowel disease is a challenge. Many surgeons are not enthusiastic about treatment of patients with Crohn's disease or ulcerative colitis. During recent decades, specialised centres have been created where a team of skilled surgeons, gastroenterologists, radiologists, pathologists, and psychologists guarantee an optimal management of patients with IBD. This opportunity should be offered to IBD patients whenever possible. However, in case of emergencies such as toxic...

Stricturoplasties Notes on Surgical Technique

Stricturoplastie Finney

The first description of the use of stricturoplasty dates back to 1977 when Katariya, an Indian surgeon, published its use for the treatment of multiple tubercular stenoses in a series of nine patients 35 . In 1982, Lee and Papaioannou published the first results about the use of the strictureplasty technique in nine patients with CD 36 . Since then, many techniques were proposed on how to perform stricturoplasties. Surgical technique for this kind of operation must be very strict. After...

Fissure or Ulcers

Fissure Disease

Anal fissures in perineal Crohn's disease are classically deep, indolent, relatively painless and eccentrically located Fig. 4 but most Crohn's related fissures are in the midline. Fig. 3. Abscess in perineal Crohn's disease Fig. 3. Abscess in perineal Crohn's disease Fig. 4. Ulceration located at 1 o'clock lithotomy position with granulation tissue Fig. 4. Ulceration located at 1 o'clock lithotomy position with granulation tissue

Desmoid Tumors

Desmoid tumors DTs are benign fibrous growths which do not metastasize, but tend to invade locally. Although rare in the general population, DTs are not rare in FAP. They may arise in musculoaponeurotic structures throughout the body, but are most common in the abdomen. Desmoid tumors DTs affect between 4 and 20 of FAP patients. Within 10 years after colectomy, the cumulative risk of developing DTs is 16 61 , and the cumulative lifetime risk is 21 62 . The peak incidence is between 28 and 31...

Rectus Abdominis Myocutaneous Flap

Gracilis Myocutaneous Flaps

This technique was described by Taylor et al. in 1983 35 . It is an excellent method for closing a large perineal defect. Based on the inferior epigastric artery and vein, it may be passed into the pelvis to close the pelvic floor and fill the dead space. It is best employed pro-phylactically in high risk patients at the time of proc-tectomy when potential perineal wound problems are anticipated 17 , or at the time of abdominoperineal excision for a large neoplasm 34 when extensive perineal...

Gluteus Maximus Muscle and Musculocutaneous Flap

Gluteus Maximus Flap

The gluteus maximus muscle is one of the largest muscles in the body. Its principle actions are to extend the thigh and assist in its lateral rotation, steady the thigh and assist in raising the trunk from the flexed position. It has a dual blood supply from the superior and inferior gluteal vessels. The inferior gluteal artery and posterior cutaneous nerve of the thigh supply the inferior portion of gluteus maximus and the skin of the posterior thigh. Excision of the lower aspect of the...

Fulminant Colitis

Ulcerative Colitis With Necrotic

Fulminant colitis represents transmural extension of inflammation to the serosa and is manifested by abdominal tenderness in addition to systemic toxicity. Fulminant colitis with acute abdomen occurs in approximately 10 of patients with ulcerative colitis 5 . A definition of fulminant colitis is not equally accepted and lacks uniformity. To date, severity of the disease is based upon a composite of clinical and endoscopic criteria but no single system has been accepted. Truelove and Witts 6...

Gracilis Muscle Flap

Skeletal Muscle Blood Supply

Bartholdson and Hulten described the gracilis muscle flap for perineal reconstruction in 1975 29 . This fusiform muscle lies along the medial side of the thigh and knee and serves to adduct the thigh, and to flex and medially rotate the leg. It attaches proximal-ly at the body and inferior ramus of the pubic bone and distally to the superior part of the medial surface of the tibia. The dominant vascular pedicle of this flap is the medial femoral circumflex artery and vein that branches off the...

Conventional and Videolaparoscopic Treatment

When IPAA is performed for UC some technical questions are still debated, especially about the type of ileoanal anastomosis hand-sewn after mucosectomy or stapled without mucosectomy and the number of surgical stages one, two or three total colectomy, restorative proctectomy with IPAA, removal of protection ileostomy . In patients affected with FAP, total colectomy and IRA are performed in a single operation without any protection ileostomy, whereas IPAA is usually a two-stage technique with a...

Familial Adenomatous Polyposis

Stomach Polyps

In these patients, the disease begins at the age of 8-10 years with a small number of colonic polyps, increasing progressively until the colon becomes studded with adenomas. Endoscopy mainly plays a diagnostic role Fig. 2 since colorectal cancer should be considered an inevitable consequence in the natural history of FAP, appearing approximately 15 years after the onset of the polyps. For this reason prophylactic proctocolectomy is the procedure of choice for this condition. After the...

Entero Urinary Fistula EUF

Entero Vaginal Fistula

It is well known that about one third of patients with CD have enteroenteric or enterocutaneous fistulas which are secondary to the characteristic transmural inflammation 58 . Fistulisation within the urinary system is also possible but it is much less common, occurring in 1-8 of cases 1, 3, 6,19, 59-62 . The majority of fistulas result from direct contact between inflamed terminal ileum and the bladder dome ileovesical fistula . Sometimes an intervening abscess is present and in this case it...