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Atlas of
Surgical Treatment
of Inflammatory
Bowel Disease
Tomas M. Heimann
Editor
Atlas of Surgical Treatment
of Inammatory Bowel Disease
Tomas M. Heimann
Editor
Atlas of Surgical Treatment
of Inammatory Bowel
Disease
Editor
Tomas M. Heimann
Department of Surgery
Icahn School of Medicine at Mount Sinai
New York, USA
ISBN 978-3-031-62430-8 ISBN 978-3-031-62431-5 (eBook)
https://doi.org/10.1007/978-3-031-62431-5
© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland
AG 2024
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If disposing of this product, please recycle the paper.
The authors would like to dedicate this Atlas
to Dr. Arthur H.Aufses, Jr., MD.Dr. Aufses,
an excellent teacher and master surgeon,
was the chairman of the Department of
Surgery at the Mount Sinai Medical Center
for most of our surgical residency and the
following 20years. Mount Sinai is regarded
as a world-renowned center for the treatment
of Inammatory Bowel Disease and Dr.
Aufses, an outstanding IBD surgeon, was
instrumental in maintaining this reputation.
One of his greatest achievements was the
creation of an outstanding department of
surgery which is now named after him.
Without his foresight and guidance, this Atlas
would not have been possible.
Foreword
Basic science and the contribution on the possibility of an infectious cause, causes
of Inammatory Bowel disease at the Mt Sinai hospital and its afliates.
When the rst report of what is now known as Crohn’s disease was communicated from the Mt Sinai Hospital in 1932 [1], the authors commented on its similarity to intestinal tuberculosis and made diligent efforts to identify a possible infectious
association. They were unable to do so. In a preceding report from Scotland in 1913
[2], the surgeon reported on identical cases to the Mt Sinai ones, once again commenting on the similarity to intestinal tuberculosis. There was a diligent attempt to
identify a known infectious cause. It too was unsuccessful. Interestingly, Dalziel
commented on the pathological similarity to a disease in cattle [3] caused by
Mycobacterium avium subspecies paratuberculosis (MAP). This is now referred to
as Johne’s disease.
Over the ensuing decades, multiple attempts have been made to identify a possible infectious etiology of Inammatory Bowel Disease, of which Crohn’s is a
major component. The results are, at best, equivocal [4].
The Veterans Affairs Medical Center in Bronx, an academic afliate of The Mt
Sinai Hospital, housed the laboratory of Roslyn S.Yalow. In 1977, she became the
second woman to win the Nobel Prize in Medicine, for the development of the technique of Radio-Immuno assay. She welcomed young investigators into her laboratory and encouraged “non-directed” research. Following a surgical residency at Mt
Sinai Hospital, I joined the Surgical Department at the VA and, with the encouragement of Dr Yalow, in 1982 I established a basic science laboratory at the VA.
My brother Adrian was an Inammatory Bowel Disease surgeon at Mt Sinai. On
clinical grounds, he had suggested that there might be two forms of Crohn’s disease,
which he called “perforating” and “non-perforating” [5]. A Dutch medical student
came to do an elective with my brother. He had no agenda. I suggested that he
attempt to replicate a study showing the different cytokine responses in the two
forms of leprosy: tuberculoid and lepromatous [6]. Using surgical specimens provided by Adrian, we showed a different cytokine expression in the two forms of
Crohn’s disease [7]. Subsequently, we identied the RNA of MAP in all Crohn’s
samples as well as patients with Ulcerative Colitis [8]. From this the hypothesis
evolved that all of IBD was a disparate manifestation of an MAP infectious spectrum of gut pathology [9].
vii
viii
Foreword
Anti-MAP antibiotic studies in Crohn’s disease have been inconclusive [4]. We
suggest that the etiological role of MAP in IBD has been missed because, unrecognized, MAP is being treated with “anti-inammatory” and “immune-modulating”
pharmaceutical agents [10, 11], whose actual primary mechanism of action are as
anti-MAP antibiotics [12–14]. Others subsequently conrmed our observations
[15–17].
Hence, until appropriate anti-MAP antibiotic studies are performed in CD, the
possible zoonotic MAP/CD enigma will remain unresolved.
References
1. Crohn BB, Ginzberg L, Oppenheimer GD.Regional Ileitis. J Amer Med Assoc.
1932;99:1323–8.
2. Dalziel TK.Chronic intestinal enteritis. Br Med J. 1913;ii:1068–70.
3. Johne HA, Frothingham L.Ein eigenthumlicher fall von tuberculose beim rind
(A particular case of tuberculosis in a cow). Dtsch Zeitschr Tiermed, Vergl
Pathol. 1895;21:438–54.
4. Peyrin-Biroulet L, Neut C, Colombel JF.Antimycobacterial therapy in Crohn’s
disease: game over? Gastroenterology. 2007;132:2594–8.
5. Greenstein AJ, Lachman P, Sachar DB, etal. Perforating and non-perforating
indications for repeated operations in Crohn’s disease: evidence for two clinical
forms. Gut. 1988;29:588–92.
6. Yamamura M, Uyemura K, Deans RJ, etal. Dening protective responses to
pathogens: cytokine proles in leprosy lesions. Science. 1991;254:277–9.
7. Gilberts EC, Greenstein AJ, Katsel P, Harpaz N, Greenstein RJ.Molecular evi-
dence for two forms of Crohn disease. Proc Natl Acad Sci U S A. 1994;91:12721–4.
8. Mishina D, Katsel P, Brown ST, Gilberts EC, Greenstein RJ.On the etiology of
Crohn disease. Proc Natl Acad Sci U S A. 1996;93:9816–20.
9. Greenstein RJ. Is Crohn’s disease caused by a mycobacterium? Comparisons
with leprosy, tuberculosis, and Johne’s disease. Lancet Infect Dis.
2003;3:507–14.
10. Greenstein RJ, Cameron DW, Brown ST. “Add-on” is scientically more accu-
rate than “Placebo control” in multiple Inammatory Bowel Disease (IBD) trials. J Crohn’s Colitis. 2014;8:1334–5.
11. Greenstein RJ, Cameron DW, Brown ST. Yet another awed “placebo con-
trolled” study in Crohn’s disease? Foodborne Pathog Dis. 2015;12:812.
12. Greenstein RJ, Su L, Haroutunian V, Shahidi A, Brown ST. On the action of
methotrexate and 6-mercaptopurine on M. avium subspecies paratuberculosis.
PLoS One. 2007;2:e161.
13. Greenstein RJ, Su L, Juste RA, Brown ST.On the action of cyclosporine A,
rapamycin and tacrolimus on M. avium including subspecies paratuberculosis.
PLoS One. 2008;3:e2496.
14. Greenstein RJ, Su L, Shahidi A, Brown ST.On the action of 5-amino-salicylic
acid and sulfapyridine on M. avium including subspecies paratuberculosis.
PLoS One. 2007;2:e516.
Foreword
ix
15. Shin SJ, Collins MT. Thiopurine drugs azathioprine and 6-mercaptopurine
inhibit Mycobacterium paratuberculosis growth in vitro. Antimicrob Agents
Chemother. 2008;52:418–26.
16. Krishnan MY, Manning EJ, Collins MT.Effects of interactions of antibacterial
drugs with each other and with 6-mercaptopurine on in vitro growth of
Mycobacterium avium subspecies paratuberculosis. J Antimicrob Chemother.
2009;64:1018–23.
17. Zhang S, Fu J, Dogan B, Scherl EJ, Simpson KW. 5-Aminosalicylic acid down-
regulates the growth and virulence of Escherichia coli associated with IBD and
colorectal cancer, and upregulates host anti-inammatory activity. J Antibiot
(Tokyo). 2018;71(11):950–61.
Department of Surgery RobertJ.Greenstein
James J.Peters Veterans
Administration Hospital,
Bronx, NY, USA
Contents
Part I Crohn’s Disease
1 IBD Surgery at Mount Sinai . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Tomas M. Heimann and Robert J. Kurtz
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
2 Jejunoileitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Tomas M. Heimann and Robert J. Kurtz
2.1 Ileitis, Obstruction, and Mesenteric Phlegmon . . . . . . . . . . . . . . . . . 12
2.2 Ileitis with Ileosigmoid Fistula . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
2.3 Ileitis with Ileosigmoid Fistula . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
2.4 Ileitis with Abscess and Ileocolic Fistula . . . . . . . . . . . . . . . . . . . . . . 20
2.5 Ileitis with Ileocolic Fistula . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
2.6 Ileitis with Retroperitoneal Abscess . . . . . . . . . . . . . . . . . . . . . . . . . . 25
2.7 Jejunoileitis with Mesenteric Abscess . . . . . . . . . . . . . . . . . . . . . . . . 28
Further Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
3 Jejunoileitis with Obstruction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Tomas M. Heimann and Robert J. Kurtz
3.1 Ileitis with Obstruction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
3.2 Ileitis with Obstruction and Fistula . . . . . . . . . . . . . . . . . . . . . . . . . . 36
3.3 Ileitis with Bleeding and Stricture . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
3.4 Ileitis, Chronic Obstruction, and Fistula . . . . . . . . . . . . . . . . . . . . . . 43
3.5 Ileitis, Chronic Obstruction, and Fistula . . . . . . . . . . . . . . . . . . . . . . 46
3.6 Ileitis with Obstruction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
3.7 Extensive Jejunoileitis with Obstruction . . . . . . . . . . . . . . . . . . . . . . 51
3.8 Severe Ileitis with Obstruction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
3.9 Extensive Jejunoileitis with Obstruction . . . . . . . . . . . . . . . . . . . . . . 56
Further Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
4 Ileocolitis with Fistula . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
Tomas M. Heimann and Robert J. Kurtz
4.1 Ileocolitis with Retroperitoneal Fistula . . . . . . . . . . . . . . . . . . . . . . . 62
4.2 Ileocolitis and Retroperitoneal Phlegmon . . . . . . . . . . . . . . . . . . . . . 64
4.3 Ileocolitis with Pelvic Abscess . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
xi
xii
Contents
4.4 Ileocolitis with Pelvic Abscess . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
4.5 Ileocolitis with Fistula and Stricture . . . . . . . . . . . . . . . . . . . . . . . . . 72
4.6 Ileocolitis with Recto-Vaginal Fistula . . . . . . . . . . . . . . . . . . . . . . . . 75
Further Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
5 Ileocolitis, Obstruction, and Perianal Disease . . . . . . . . . . . . . . . . . . . . 79
Tomas M. Heimann and Robert J. Kurtz
5.1 Ileocolitis with Stricture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
5.2 Ileocolitis with Obstruction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82
5.3 Ileocolitis with Chronic Stricture . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85
5.4 Ileocolitis with Obstruction and Fistula . . . . . . . . . . . . . . . . . . . . . . . 87
5.5 Ileocolitis with Severe Perianal Disease . . . . . . . . . . . . . . . . . . . . . . 89
5.6 Ileocolitis with Severe Perianal Disease . . . . . . . . . . . . . . . . . . . . . . 93
5.7 Ileocolitis, Fistula, and Perianal Disease . . . . . . . . . . . . . . . . . . . . . . 95
5.8 Ileocolitis Presenting as Ulcerative Colitis . . . . . . . . . . . . . . . . . . . . 99
5.9 Ileocolitis Presenting as Ulcerative Colitis . . . . . . . . . . . . . . . . . . . . 101
Further Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103
6 Granulomatous Colitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105
Tomas M. Heimann and Robert J. Kurtz
6.1 Segmental Granulomatous Colitis . . . . . . . . . . . . . . . . . . . . . . . . . . . 105
6.2 Recurrent Segmental Colitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108
6.3 Segmental Colitis with Fistula . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110
6.4 Extensive Segmental Crohn’s Colitis . . . . . . . . . . . . . . . . . . . . . . . . . 112
6.5 Granulomatous Colitis with Rectal Sparing . . . . . . . . . . . . . . . . . . . 115
6.6 Granulomatous Proctitis with Stricture . . . . . . . . . . . . . . . . . . . . . . . 117
Further Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120
7 Extensive Granulomatous Colitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121
Tomas M. Heimann and Robert J. Kurtz
7.1 Crohn’s Presenting as Ulcerative Colitis . . . . . . . . . . . . . . . . . . . . . . 121
7.2 Crohn’s Colitis with Gastrocolic Fistula . . . . . . . . . . . . . . . . . . . . . . 125
7.3 Crohn’s Colitis with Bleeding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127
7.4 Severe Crohn’s Colitis with Stricture . . . . . . . . . . . . . . . . . . . . . . . . . 130
7.5 Severe Crohn’s Colitis with Stricture . . . . . . . . . . . . . . . . . . . . . . . . . 132
7.6 Severe Perianal Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134
7.7 Crohn’s Colitis with Perianal Disease . . . . . . . . . . . . . . . . . . . . . . . . 136
Further Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139
8 Recurrent Ileitis with Obstruction and Stricture . . . . . . . . . . . . . . . . . . 141
Tomas M. Heimann and Robert J. Kurtz
8.1 Recurrent Ileitis with Obstruction . . . . . . . . . . . . . . . . . . . . . . . . . . . 141
8.2 Recurrent Ileitis with Stricture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145
8.3 Recurrent Ileitis with Stricture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148
8.4 Recurrent Ileitis with Stricture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150
8.5 Recurrent Ileitis with Stricture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152
8.6 Recurrent Ileitis with Stricture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155
8.7 Recurrent Ileitis with Stricture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158