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COLON
211
va
ginal wall, the skin paddle may be used for reconstruction. e
gracilis ap is oen used to ll the distal pelvic cavity because this
area is most prone to infection, leading to a UPW.
e VRAM ap is based on the inferior epigastric artery and
brings healthy, nonradiated skin, subcutaneous fat, and muscle to the
perineum. is ap has the potential to aect stoma siting at the initial operation and in the future should problems arise (e.g., a signicant stomal hernia and prolapse). A VRAM ap with its larger bulk
may be preferable to a primary gracilis ap in men, who don’t have
the posterior vaginal wall to ll some of the pelvis.
GNOSIS/WORKUP
DIA
hronic UPWs are generally lined by granulation tissue (Fig.
C
41-3). Our proposed algorithm for their management is shown
in Figure 41-4.
e algorithm begins with a careful evaluation of the unhealed
wound, which may include an examination with use of an anesthetic.
A plastic surgery consultation for possible ap closure should be
considered. e size of the defect, quality of the surrounding tissues,
proximity to the urethra and vagina, presence of any foreign body,
and presence of any ongoing infection need to be determined. Malignant degeneration of chronic, unhealed wounds has been reported,
and thus any suspicious lesions should be biopsied. In patients who
have undergone radiation, it is helpful to nd the tattoos marking the
extent of the radiated eld. Infection should be eradicated prior to
denitive treatment.
In patients who have very deep wounds or provide a history
that is suspicious for a fistula, further diagnostic testing is often
necessary. Cross-sectional imaging such as magnetic resonance
imaging or a computed tomography scan can define persistent
pelvic fluid collections and provide a useful road map by outlining
the anatomy. The addition of enteric contrast material is helpful
to delineate a fistula, if one is suspected. Fistulography performed
with fluoroscopy during an examination of an anesthetized patient
can also be useful.
NONOPERA
nitial nonoperative treatment requires patience, attention to
I
TIVE TREATMENT
hygiene, gentle outpatient debridement of necrotic tissue, and
drainage of any associated infection. e use of negative-pressure
vacuum dressings has been described. In a recent series, Ip and
co
lleagues reported that 23% of their patients’ proctectomy wounds
r
emained unhealed at 12 months; many wounds that were unhealed
at 6 months had closed by 1 year. However, some wounds do not
heal and evolve into a low-output, minimally symptomatic, manageable chronic sinus. ese patients do not necessarily require any
active treatment.
FIGURE 41-3
tissue
.
An unhealed perineal w
Unhealed perineal
wound >6 months
after proctectomy
ound with excessive granulation
Asymptomatic
or improving
Symptomatic,
not improving
Workup:
Exam under anesthesia
± CT/MRI
± Fistolography
OPERA
S
mall, supercial sinus tracts or wounds may respond to serial
TIVE MANAGEMENT
unroong and curettage; the wound tends to get progressively
smaller, and adequate symptomatic relief may be achieved, even
if complete healing does not occur. Excision and saucerization
to change the shape of the defect from a deep, narrow sinus to a
broader wound with a atter surface may also help. Skin graing
of the resulting wound can be performed simultaneously or at a
future time. Healing rates of 55% to 77% have been reported with
this technique.
Observe/local
treatment
Superficial
Deep
Excision/curettage
(± skin graft)
Excision/curettage
of cavity and muscle
flap (e.g., gracilis)
FIGURE 41-4 A pr
Computed tomography; MRI, magnetic resonance imaging.
oposed algorithm for treatment of patients with an unhealed perineal wound. CT,
212
Unhealed
Perineal Wo
Und
tructures. e coccyx oen must be excised and the lower two seg-
s
ments of the sacrum can be safely resected if necessary to provide a
tension-free closure of nonbrotic tissue. In wounds that require a
bulkier ap, an omental pedicle ap or VRAM may be preferable. e
VRAM ap has a success rate between 50% and 100%.
FIGURE 41-5
left leg r
eep, large cavities will likely require transposition of healthy,
D
A perineal w
eady to be positioned. (Photo courtesy Robert Nesbit, MD.)
ound with a gracilis flap harvested from the
well-vascularized tissue aps to ll the space. Tissue aps generally
can be divided into those that do and do not require a laparotomy.
A laparotomy is necessary to create omental pedicle aps or rectus
abdominis myocutaneous aps. A laparotomy carries the risk of
inadvertent enterotomy, repeat pelvic dissection, and an increased
risk of hernia. e rectus abdominis ap may have an impact on subsequent stoma siting if the need for revision arises. For most of the
deep wounds extending into the pelvis, we favor the gracilis ap (Fig.
41-5). e morbidity of a gracilis muscle harvest is low, and the eect
on ambulation or extremity function is minimal. Gracilis aps have a
success rate of 20% to 75%. e gracilis is harvested initially with the
patient in the lithotomy position, with the muscle insertion division
distally. e muscle is then tunneled to the perineal wound and the
patient is placed in the prone jackknife position. e perineal wound
is carefully inspected and debrided with care to avoid injuring other
SUMMAR
phincter-saving techniques have diminished the number of
S
roctectomies being performed both for IBD and malignancy.
p
onetheless, an unhealed perineal wound remains a problem, with
N
nicant morbidity and impact on quality of life.
sig
Y
Proper preoperative management prior to proctectomy and good
surgical technique provide the best chance of avoiding a UPW.
When a UPW develops, it may respond to patient, nonoperative
therapy. Deep, chronically brotic pelvic cavities require debridement and the use of a muscle ap such as the gracilis.
g g e
S
u
C
ollie MH, Potter MA, Bartolo DC. Myocutaneous aps promote perineal
healing in inammatory bowel disease. Br J Surg. 2005;92(6):740–741.
Genua JC, Vivas DA. Management of nonhealing perineal wounds. Clin Colon
Rectal Surg. 2007;20(4):322–328.
Ip B, Jones M, Bassett P, Phillips R. Factors aecting the healing of the
p
erineum following surgery. Ann R Coll Surg Engl. 2013;95(4):252–257.
Menon A, Clark MA, Shatari T, et al. Pedicled aps in the treatment of
n
onhealing perineal wounds. Colorectal Dis. 2005;7(5):441–444.
Pemberton JH. How to treat the persistent perineal sinus aer rectal excision.
Colorectal Dis. 2003;5(5):486–489.
Shibata D, Hyland W, Busse P
w
a
nd intraoperative radiation therapy for recurrent carcinoma of the
r
ectum. Ann Surg Oncol. 1999;6(1):33–37.
e d
S t
ound with gracilis muscle aps following abdominoperineal resection
e
R
a d i n g
, et
al. Immediate reconstruction of the perineal
M
M
C D
Edith
Y. Ho, Jeffry A. Katz, and Fabio Cominelli
INTR
ODUCTION
Cr
ohn disease (CD) is a chronic, relapsing, idiopathic inammatory
condition that primarily aects the gastrointestinal tract. e severity
and location of CD are variable. CD, a transmural inammation of
the bowel characterized by skip lesions that may involve any section
of the gastrointestinal tract, is sometimes complicated by strictures
and stula formation. In about 50% of cases, CD aects the terminal
ileum and colon; in 20% of cases, it aects the colon only; and in
30% of cases, it aects the small bowel only. Perianal complications
develop in about 20% of persons with CD.
Treatment paradigms for CD are rapidly evolving as newer agents
become available. Treatment with 5-aminosalicylates (5-ASA) is no
longer recommended, and anti–tumor necrosis factor (TNF) therapies are initiated earlier in the course of disease to induce mucosal
healing. e primary treatment goal is induction and maintenance
of steroid-free remission while minimizing drug toxicity. is target
has been associated with a better quality of life and a lower likelihood
of requiring hospitalizations or surgery. “Deep remission,” dened as
both clinical and endoscopic remission, might become the ultimate
therapeutic goal in the future.
MEDIC
ultiple options exist for the medical treatment of CD. e choice
M
of therapy is guided by the ecacy of any given agent in inducing
and/or maintaining remission, as well as by the severity and extent
of the disease. Serious adverse eects of medical treatment are rare,
but risks and benets should be carefully weighed in selecting the
appropriate treatment strategy.
5-Aminosalicylates
SA drugs, such as mesalamine and sulfasalazine, are no lon-
5-A
ger recommended for the treatment of CD. Sulfasalazine alone has
shown moderate benet in treating active disease, but it has not been
shown to be eective in maintaining remission. Nevertheless, many
physicians prescribe ASA drugs for mild CD because of their low toxicity, low cost, and familiarity. In particular, mesalamine (Pentasa), a
controlled-release formulation of 5-ASA, is a favorite drug for CD
involving the small bowel and colon because it releases approximately
50% of 5-ASA in the small intestine and the remaining 50% in the
colon. Mesalamine suppositories and enemas are also used for distal
le-sided disease. 5-ASA agents have a relatively safe toxicity prole. Kidney function may be checked annually because of a low risk
of renal insuciency. Interstitial nephritis is considered an idiosyncratic reaction and is not dose dependent. Rarely, a hypersensitivity reaction can occur, causing worsening abdominal pain, diarrhea,
AL THERAPIES
or hematochezia, which should prompt discontinuation of the drug.
Although many physicians and patients still elect to use 5-ASA, it has
not been proved that these agents aect the course of CD.
Antibiotics
o strong evidence exists to support the use of antibiotics in persons
N
with active CD. However, antibiotics may be benecial in treating
suppurative disease, perianal complications, or hospitalized patients
who have signs of infection. A common practice is to prescribe a
2-week course of ciprooxacin, 500 mg by mouth twice a day, and
metronidazole, 500 mg by mouth twice a day.
ticosteroids
Cor
orticosteroids are highly potent antiinammatory medications
C
used to achieve clinical remission in patients with active CD. ey
should not be used as long-term therapy because of their adverse
eects. Short-term adverse eects include mood disturbances, uid
retention, hypertension, and weight gain. Long-term consequences
include thinning of skin, poor wound healing, cataracts, diabetes,
osteoporosis, adrenal insuciency, and increased risk of infections.
Corticosteroids can be administered parenterally, orally, or topically.
Severely ill, hospitalized patients with CD benet from intravenous
corticosteroids, such as hydrocortisone, 300 mg per day, or methylprednisolone, 40 to 60 mg per day. Prednisone is the most commonly
used oral corticosteroid, starting at 40 to 60 mg per day, and tapering
by 5 to 10 mg every 5 to 7 days once remission is achieved. Entericcoated budesonide, an analog of conventional corticosteroids, is an
excellent and eective alternative for ileal and right-sided colonic
CD. Because of its high rst-pass metabolism in the liver, only 10%
to 15% of budesonide is systemically bioavailable, thus conferring
less toxicity than conventional steroids. Studies have shown that
budesonide is eective in inducing remission or delaying relapse
for up to 9 months, but evidence for its use in maintaining remission is lacking. e optimal dose to induce remission is 9 mg per
day, followed by a 3 mg taper every 4 weeks. Physicians and patients
should develop a management plan that aims to maintain steroid-free
remission on a long-term basis, which typically includes the use of an
immunomodulator or a biologic agent.
unomodulators
Imm
io
purines (e.g., azathioprine and 6-mercaptopurine [6-MP]) are
the most common immunomodulators in the treatment of moderate
to severe CD disease and are primarily used for the maintenance of
remission. Because of their slow onset of action (up to several weeks),
213
214
Medic
al Manage
Ment of cr
ohn
disease
imm
unomodulators are not eective in inducing remission. erefore, in patients with active disease, immunomodulators with a more
rapid onset of action such as corticosteroids are typically prescribed.
e standard dose of azathioprine is 2 to 2.5 mg/kg/day, whereas
the dose of 6-MP is 1 to 1.5 mg/kg/day. Azathioprine is a prodrug
that is converted to 6-MP, which is then metabolized into an active
metabolite, 6-thioguanine nucleotide (6-TGN). Excess production
of the 6-TGN metabolite can cause myelotoxicity and increased
risk of infection. Excess production of the 6-methylmercaptopurine
(6-MMP) metabolite can lead to hepatotoxicity. erefore, before
starting therapy, thiopurine methyltransferase (TPMT) enzymatic
activity should be checked to assess potential risk for drug sensitivity and toxicity. iopurine is not recommended for patients with a
low or undetectable TPMT level. In patients with low to intermediate
TPMT activity, the dosage should be reduced, usually by 50%.
No standard method exists for monitoring blood tests. We recommend weekly complete blood cell count and liver function tests
for the rst month, then every other week for 1 month, then every 3
months. If the white blood cell count is less than 3000 per mm
3
or if
transaminases are greater than three times the upper limits of normal, the dosage should be reduced or the drug should be discontinued. One key drug interaction is allopurinol, an inhibitor of xanthine
oxidase, which interferes with the metabolism of azathioprine and
6-MP. is drug-drug interaction can elevate plasma levels of 6-TGN,
which can suppress bone marrow function. erapeutic drug monitoring for 6-TGN and 6-MMP are now commercially available. ese
tests are particularly useful in patients who did not respond to thiopurine treatment despite an adequate duration and dose of immunomodulator therapy. 6-TGN levels of greater than 235 pmol/8 × 10
r
ed blood cells correlate with a higher likelihood of response, whereas
6-MMP levels of greater than 5700 pmol/8 × 108 red blood cells correlate with a higher likelihood of hepatoxicity.
Before initiating immunosuppressive therapy, patients are
screened for latent tuberculosis and chronic hepatitis B. Age-appropriate vaccinations may be considered prior to initiating immunomodulators, especially live vaccines, given the risk of reactivation
or dissemination in an immunocompromised host. ere is also an
increased risk of nonmelanoma skin cancers and a four- to vefold
increased risk of non-Hodgkin lymphoma. erefore, annual skin
surveillance is oen recommended along with routine blood work.
Methotrexate, another immunomodulator, is oen used in
conjunction with a biologic agent to reduce antibody formation.
Although less commonly used as monotherapy for CD, a reasonable
amount of placebo-controlled data shows that methotrexate is eective for the induction and maintenance of remission. e dose is 25
mg once weekly administered subcutaneously, which is then lowered
to 15 mg aer 8 to 12 weeks if the patient improves. Because methotrexate is a folate antagonist, it is usually taken with folic acid, at a
dose of 1 mg daily. e risk of infection and malignancy is slightly
increased. Complete blood cell count and liver function tests are
checked regularly. Methotrexate is classied as a category X drug in
pregnancy because it has been associated with miscarriage and birth
defects. Patients are counseled to use contraception while undergoing
therapy and are advised to discontinue the drug for 6 months before
planning for conception.
therapy is the treatment of choice for perianal stulas. Currently,
three anti-TNF medications have been approved for the treatment of
CD in the United States: iniximab, adalimumab, and certolizumab
pegol. Iniximab and adalimumab are approved for the induction
and maintenance of remission, but certolizumab has a higher failure
rate in inducing remission. Iniximab is administered via intravenous infusion, whereas adalimumab and certolizumab are injected
subcutaneously. ese agents dier by their chemical structure but
share similar adverse eects. e most common include infusion
reaction or injection site reactions, which can be addressed easily.
Most serious adverse eects include an increased risk of infection
and non-Hodgkin lymphoma, especially with exposure to thiopurines concurrently or in the past. Anti-TNF monotherapy does not
appear to be associated with an increased risk of lymphoma, but it is
associated with melanoma. Latent tuberculosis, active hepatitis B, or
fungal infections should be ruled out before starting biologic agents.
Age-appropriate vaccinations and live vaccines may be initiated prior
to starting biologic agents because of the potential risk of reactivation. Patients may be monitored with routine blood work every 3 to
6 months and with annual skin examinations. Commercially available tests to detect therapeutic levels and the presence of antibody
toward iniximab and adalimumab can be helpful in persons with a
poor response to anti-TNF therapy to determine the optimal dosage,
interval of administration, or need to consider an alternative biologic
agent.
Another therapeutic option is natalizumab, a humanized mono-
clonal antibody directed against cell adhesion molecule α
α
in
tegrins, which prevents T-lymphocyte adhesion to vascular
4β7
8
cell adhesion molecule–1 and mucosal addressin–cell adhesion molecule–1 (MAdCAM-1), thus downregulating inammation. Natalizumab was rst shown to be eective in the treatment of multiple
sclerosis but has since been shown to be eective in inducing and
maintaining remission of moderate to severe CD. Use of this drug
has been limited by the risk of progressive multifocal leukoencephalopathy (PML), and thus the U.S. Food and Drug Administration has
restricted it to patients who have not responded to anti-TNF drugs.
Before treatment with natalizumab is initiated, patients must be
tested for the JC virus antibody to assess their risk of the development of PML.
Vedolizumab, a humanized monoclonal immunoglobulin G
antibody, specically binds to integrin α
α
4β1
or α
e agent inhibits adhesion of a gut-specic subset
Eβ7.
but does not inhibit
4β7
of T lymphocytes to MAdCAM-1 but not to vascular cell adhesion
molecule–1. Because MAdCAM-1 resides almost exclusively in the
gastrointestinal tract, vedolizumab does not aect systemic immune
response or aect T-cell migration to the central nervous system
and therefore may be the rst gut-specic CD treatment. It does
not appear to be associated with risk of PML, which is a signicant
advantage compared with natalizumab. e pivotal GEMINI 2 study
demonstrated the ecacy and safety of vedolizumab in treating CD,
which led to approval by the U.S. Food and Drug Administration in
2014. Many new agents, including ustekinumab and etrolizumab, are
in development, and ongoing research continues to expand our repertoire of therapies for CD.
4β1
an
d
1
Biologic Agents
e introduction of biologic agents has substantially improved the
care of patients with CD by eectively inducing and maintaining
remission and reducing the need for hospitalization and surgery.
Monoclonal anti–tumor necrosis factor (anti-TNF) antibodies are
designed to bind to human TNF-α, thereby impairing binding to
TNF-α receptor sites and resulting in downregulation of the cytokine-driven inammatory response. Multiple studies have shown
that anti-TNF agents are eective in inducing and maintaining remission in persons with moderate to severe CD. Additionally, anti-TNF
Combination Thera
e Study of Biologic and Immunomodulator Naïve Patients in
py
Crohn’s disease (SONIC), a single randomized controlled trial, demonstrated that combination therapy of immunomodulators and antiTNF was superior to monotherapy in persons with moderate to severe
CD. In this trial, combination therapy of azathioprine and iniximab
was more eective than iniximab monotherapy, which, in turn, was
more eective than azathioprine alone at maintaining clinical and
endoscopic remission at 26 and 54 weeks. It is not clear whether azathioprine compounds antiinammatory eects, but it does appear
to enhance the response to iniximab by decreasing anti-iniximab
COLON
215
a
ntibodies and increasing iniximab levels. Combination therapy
was not associated with a higher risk of serious infections during
the trial, and evidence in subsequent studies was insucient to conclude whether combination therapy increases the risk of opportunistic infections or malignancies. Furthermore, the risks and benets
beyond 1 year are not known. Expert opinion states that results from
SONIC can be extrapolated to adalimumab. Controversy exists about
duration of combination therapy and whether combination therapy
provides benet for persons who have failed to respond to immunomodulator therapy. Some patients might elect monotherapy because
of a higher value of avoiding any potential risk of serious complications or malignancies compared with an increased chance of inducing and maintaining remission.
PERIANAL
AND FISTULIZING CROHN
DISEASE
P
erianal/perirectal abscess and acute suppuration are indications for
surgical drainage with or without placement of setons. Patients with
nonsuppurative perianal complications, such as recurrent stulization
Assess disease severity
Mild to
moderate
Moderate to
severe
o
r ssuring, can rst try metronidazole alone or in combination with
ciprooxacin, followed by immunosuppressive agents upon resolution of infection. In patients with stulizing disease that is refractory
to antibiotics, corticosteroids, or immunomodulators, a series of 5
mg/kg iniximab infusions at 0, 2, and 6 weeks can enhance closure
of CD stulae. Continuation of 5 mg/kg iniximab at 8-week intervals showed durable benet.
APPR
OACH TO MANAGEMENT OF
CROHN DISEASE
reatment recommendations depend on disease severity, the extent
T
of involvement, and the complexity of the disease. e therapeutic
goal is to induce and then maintain clinical remission. is approach
is outlined in Figure 42-1. To assess disease severity, two systems
commonly used in clinical trials are suitable, including the Crohn’s
Disease Activity Index (CDAI) and the Harvey-Bradshaw Index,
which is a simplied version of the CDAI. A drop in the CDAI of
100 points corresponds to a drop in the Harvey-Bradshaw Index by 3
points. In general, patients with mild to moderate CD disease (CDAI
Severe to fulminant/
refractory
Budesonide
±5-ASA (PO/PR)
Induction of remissionMaintenance of remission
Response?
Yes
±5-ASA
No
Thiopurine or
methotrexate
Oral
steroids
Response?
Yes
No
Anti-TNF
± thiopurine
Response?
Yes
No
OR OR
Oral steroids
+ Anti-TNF
± Thiopurine
Response?
Yes
Anti-TNF ± Thiopurine
No
IV steroids
Response?
Yes
Oral steroids
+ Anti-TNF
± Thiopurine
No
Surgery
Post-operative
prophylaxis
5-ASA or
thiopurine or
anti-TNF
FIGURE 42-1 Appr
rectum; TNF, tumor necrosis factor.
oach to management of Crohn disease by disease severity.
5-ASA, 5-Aminosal
ycilic acid; I V, intravenous; P O, by mouth; PR, per
216
Medic
al Manage
Ment of cr
ohn
disease
50-200)
are ambulatory and able to maintain adequate nutrition
without signicant symptoms. Patients with moderate to severe CD
disease (CDAI 200-450) have failed to respond to treatment for mild
to moderate disease and are dependent on systemic corticosteroids
for symptom control. ey present with fever, weight loss, nausea or
vomiting, abdominal tenderness, and/or anemia. Severe to fulminant
disease (CDAI >450) refers to patients who present with alarming
symptoms such as high fevers, persistent vomiting, peritonitis, bowel
obstruction, or abscess formation. ey are refractory to conventional glucocorticoids or biologic agents.
SURGER
ost patients with CD require surgery over the course of their dis-
M
Y
ease, and a subset may require multiple surgeries. Except for total
colectomy and ileostomy for CD limited to the colon, surgery is rarely
curative because CD recurs in most patients within 5 years. e most
common indications for surgery are refractory disease that is not
responsive to medical therapy or intolerability of the adverse eects
of medications. Surgery is also indicated for penetrating and stricturing CD causing perforation or bowel obstruction, abscesses not amenable to percutaneous drainage, complex perianal or internal stulas,
uncontrolled hemorrhage, high-grade dysplasia, or malignancy.
POST
R
ecurrence of CD disease aer surgery occurs in most patients. Post-
OPERATIVE RECURRENCE
operative recurrence can be dened by endoscopy, symptoms, or the
need for another surgery. Because endoscopic recurrence generally
precedes clinical symptoms, it is recommended that an endoscopic
assessment be performed 6 to 12 months aer surgery to identify
recurrence and assess risk. Disease patterns (e.g., jejunal or extensive ileal-colonic disease, stulization, and perianal involvement) and
patient-specic variables (e.g., a shorter preoperative disease duration or initial presentation requiring surgery, prior surgeries, age
younger than 30 years, failure of medical management, and current
history of smoking) appear to increase risk. Patients with high-risk
features might benet from aggressive and early prophylaxis within
30 days of surgery and continue to receive lifelong therapy. To date,
no consensus exists regarding optimal medical strategies for preventing recurrence. Treatment options include 5-ASA, imidazole antibiotics, azathioprine, 6-MP, and anti-TNF biologic agents.
SMOKING
CD is more likely to develop in past and current smokers than in
persons who have never smoked. Smoking also increases the risk of
exacerbations, stulizing and stricturing disease, reduced response
to medical therapy, and postoperative recurrence. Persons with CD
therefore should stop smoking.
NUTRITION
Nutritional therapy alone has not been a reliably eective treatment
for CD. In general, patients experiencing a CD are can follow a lowresidue diet divided into small, frequent meals. Nonabsorbable bers
s
uch as raw vegetables can exacerbate symptoms. Patients in clinical
remission can follow a healthy diet that is low in saturated fat and
red meat but high in sh and vegetables. Patients with more than 100
cm of diseased or resected ileum experience bile salt malabsorption
but not depletion. e large amount of unabsorbed bile salts entering the colon causes choleraic diarrhea, which can be symptomatically controlled by bile salt sequestrants such as cholestyramine. In
patients with more than 100 cm of terminal ileum that is diseased
or resected, the liver is unable to compensate for bile salt losses, and
fat malabsorption ensues. In these cases, a low-fat diet supplemented
with medium-chain triglycerides (medium-chain triglyceride oil) is
recommended. ese patients also may require parenteral replacement of vitamin B12. Fat-soluble vitamins (A, D, and E) should be
checked and supplemented. Vitamin K status can be assessed by
international normalized ratio. In prolonged and severe cases of
CD, zinc, chromium, and selenium deciency also may develop, and
parental or enteral nutrition may be needed to correct these nutritional deciencies.
S
u
g g e
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Seow CH, B enchimol EI, Griths AM, etal. Budesonide for induction of remis-
sion in Crohn’s disease. Cochrane Database Syst Rev. 2008;(3):CD000296.
Toruner M, Lous EV, Harmsen WS, etal. Risk factors for opportunistic in-
fections in patients with inammatory bowel disease. Gastroenterology.
2008;134(4):929–936.
S t
e d
e
R
a d i n g
C
M
C
r
ohn disease can aect any segment of the intestinal tract, and the
C
colon will be involved in approximately half of aicted patients.
Crohn disease of the colon can entail disease of the large bowel alone
or of the large bowel plus the terminal ileum. e behavior of the disease varies and can be categorized as predominantly inammatory,
stricturing, or penetrating. Furthermore, disease of the anal canal
or perineum can complicate any of these behavior patterns. Under-
creation of an individualized treatment plan that usually begins with
medical therapy but ultimately includes surgery in many patients.
MEDIC
e appropriate treatment of a patient with Crohn disease of the colon
or ileocolon generally begins with individual or combination medical therapy in the form of antibiotics, 5-aminosalicylic acid (5-ASA)
compounds, glucocorticoids, immunomodulators, or biologic agents.
e 5-ASA compounds and glucocorticoids can be orally or topically
delivered, depending on the disease location. e medications are
conventionally prescribed in an escalating or “bottom-up” fashion in
which the next level of medication is implemented when the disease
shows itself to be unresponsive to the current therapy. However, more
recent studies suggest that early aggressive or “top-down” treatment
might be more eective with quicker and greater control of mucosal inammation and disease symptoms. Regardless of the medical
treatment, surgery is ultimately required in many patients with large
bowel disease. e incidence of surgery, however, is lower than that
for terminal ileal or small bowel Crohn disease.
OPERA
e indications for surgery in a patient with Crohn disease are gen-
erally categorized as failed medical therapy or disease-associated
complications. Medication failure can be dened as the persistence
of symptoms despite appropriate medical therapy, failure as a result
of poor compliance, intolerance of medications, debilitating adverse
eects, or concern for potential risks/complications. Disease complications can be classied as acute (e.g., abscess, free perforation,
hemorrhage, and severe colitis) or chronic (e.g., growth retardation,
neoplasia, and obstruction).
PREOPERA
A
ny patient requiring surgery for large bowel disease requires routine
laboratory studies to exclude anemia and electrolyte abnormalities.
Assessment of nutrition-related proteins (e.g., albumin, transferrin,
and prealbumin) is reserved for a patient with recent poor caloric
AL MANAGEMENT
TIVE INDICATIONS
TIVE CONSIDERATIONS
Scott A.
in
take or substantial weight loss (>10% of the patient’s weight when
well). Simple decits such as hemoglobin less than 7. 0 g/dL, hypokalemia, and hypomagnesemia should be corrected. Malnutrition
secondary to systemic inammatory mediators will not improve with
hyperalimentation, but 7 to 10 days of parenteral nutrition should be
considered in elective situations if the cause of malnutrition is poor
caloric intake. Smoking cessation should be strongly encouraged
and supported when appropriate because of the negative impact of
smoking on operative morbidity and disease recurrence. Regardless
of the setting, a patient who may or will require fecal diversion should
undergo marking in at least one abdominal quadrant in an area that
is easily visible and remote from bony structures, scars, and creases
despite the patient’s position (e.g., lying, sitting, and standing). A
patient with anorectal sepsis in whom a proctectomy is planned will
usually benet from preliminary drainage of the sepsis.
A patient scheduled for elective surgery should generally undergo
endoscopy and selective imaging if these investigative studies have
not been performed recently. Colonoscopy is warranted to determine
the distribution of disease, but upper endoscopy is usually not necessary. Magnetic resonance imaging or computed tomography (CT)
enterography is performed to evaluate small bowel involvement in
a patient with suggestive symptoms. Rectal compliance and anal
sphincter function should be assessed if preservation of the rectum
and anal canal is considered. e compliance and sphincter strength
can be objectively measured using anorectal physiology testing and
subjectively assessed by observing distensibility of the rectum with
insuation during endoscopy and digital examination. A patient
who can retain a 150-mL saline enema for at least 5 minutes should
experience minimal problems with urgency or seepage aer an operation that spares the rectum and anal canal.
e colon is responsible for absorption of water and salt from
stool, and the majority of this activity occurs in the midgut portion
of the large bowel. is physiologic role helps protect patients against
dehydration and electrolyte imbalances. Although the large bowel is
dispensable and patients undergoing a colectomy have a normal life
expectancy, attempts at preservation of the colon are justied.
OPERA
aboratory, endoscopic, and imaging studies are used to plan the oper-
L
ation so that unanticipated ndings are rare. However, patients with
large bowel disease must be emotionally prepared for the possibility
of a permanent stoma during their lifetime. e incurable nature of
the disease causes physicians and surgeons to redirect eorts toward
safely restoring a normal quality of life, and many patients equate
this goal with avoidance of a permanent stoma. Patient education or
experience with a temporary ileostomy oen helps alter a patient’s
outlook and enables her or him to appreciate that a permanent stoma
does not negatively aect quality of life for most ostomates.
TIVE APPROACH
Strong
217
218
FIGURE 43-1 Retroileal passage of the short colonic limb ensures a
tension-fr
Clinic Center for Medical Art & Photography. Copyright 1998-2016. All Rights
Reserved.)
ee colorectal anastomosis. (Reprinted with permission, Cleveland
ManageMent of Cr
ohn Colitis
Disease aecting the ascending colon and transverse colon is
also managed with limited resection, but a tension-free anastomosis
is best assured by rotating the midgut mesentery counterclockwise
to bring the terminal ileum into close proximity of the descending
colon. e small bowel will accordingly lie medial to the hindgut
mesentery and occupy the right side of the abdomen.
Disease of the transverse colon, descending colon, and sigmoid
colon can be treated by either segmental resection with creation of a
colorectal anastomosis or a total colectomy with construction of an
ileorectal anastomosis. e latter approach is generally preferred, but
a more limited resection is favored if the patient is older (>50 years)
or has undergone signicant (>50 cm) small bowel resection. In both
scenarios, preservation of the ascending colon may signicantly
improve the patient’s function because absorptive colonic mucosa is
retained. Problems with reach of the colonic segment associated with
a limited resection can be overcome by passing the colon through a
window created between the superior mesenteric and ileocolic vessels in the midgut mesentery (Fig. 43-1).
Disease of the entire colon is best managed with a total colectomy
and construction of an ileorectal anastomosis. e anastomosis is
created using sutures or stapling instruments in any manner of conguration (e.g., end-to-end or side-to-end), but an anastomosis to the
side of rectum is usually avoided. A hand-sewn end-to-end anastomosis can be challenging if a marked discrepancy exists between the
diameters of the two lumens. A Cheatle slit along the antimesenteric
margin of the terminal ileum can be used to reduce the size dierence
(Fig. 43-2), or a side-to-end anastomosis can be created. e method
used to construct and congure the anastomosis does not seem to
signicantly aect the risk for early complications or later recurrence.
aparoscopic approach to large bowel Crohn disease is associated
A l
with an acceptable conversion rate and is generally favored in the elective setting for a patient undergoing a rst-time operation for uncomplicated disease. Compared with a conventional open procedure, this
laparoscopic approach is associated with reduced postoperative pain,
lessened operative morbidity, better cosmesis, and decreased length of
stay without an increased risk for disease recurrence.
OPERA
e surgical options that are used for large bowel Crohn disease include
resection with or without fecal diversion. Diversion (i.e., an ileostomy
or colostomy) can be temporary or permanent. A temporary ileostomy
is used to avoid or protect an anastomosis in a patient with coagulopathy, debilitating comorbid conditions, high-dose glucocorticoid usage,
or severe malnutrition, as well as someone requiring an operation
associated with undrained sepsis, purulent or feculent peritonitis, or
excessive blood loss. Unlike in persons with small bowel Crohn disease, strictureplasty is not generally advocated for large bowel strictures
because approximately 7% of colonic strictures harbor a malignancy
and colonic strictureplasty does not provide better postoperative function or quality of life compared with resection.
Disease of the Colon
C
olonic disease can be managed by segmental resection with creation
of a primary anastomosis or by a total colectomy with construction of
an ileorectal anastomosis.
Disease that is limited to the ascending colon with or without terminal ileum involvement is best treated by resection, but the resultant
anastomosis can abut against the second portion of the duodenum
and expose the patient to risk of a complex stula involving the duodenum or retroperitoneum if disease recurs at the ileocolic anastomosis. Accordingly, omentum is interposed between the anastomosis
and duodenum or the distal resection margin is moved into the mid
transverse colon to create separation from the duodenum.
TIVE OPTIONS
Alone
Disease of the Rectum
Di
sease limited to the rectum that requires surgery is usually managed with resection of the entire large bowel and creation of an end
ileostomy. However, proctectomy alone with construction of a colostomy has been advocated by some centers with acceptable recurrence
rates. is option is attractive in a patient who would benet from
retained water and salt absorption, such as someone who is older
(>50 years) or has undergone signicant (>50 cm) small bowel resection. In a highly selected young patient with no history of anoperineal
disease, a coloanal anastomosis can be safely performed to avoid a
stoma in the short term. However, the patient is at signicant risk for
recurrent disease that would necessitate complex reoperative pelvic
surgery and creation of a permanent ileostomy.
Alone
Disease of the Colon and Rectum
Di
sease aecting at least portions of the colon and the entire rectum
is typically treated by resection of the entire large bowel and creation
of an end ileostomy. e proctectomy is usually performed in an
endoanal fashion with excision of the internal sphincter and preservation of the external sphincter and muscles of the pelvic oor. ese
structures are closed in a layered manner (Fig. 43-3), with the skin
le to heal by secondary intention if an anorectal abscess or stula
is present. Regardless of the closure technique used, normal healing
of the perineal wound occurs in only half of patients, and approximately 25% will demonstrate a persistent wound aer 6 months of
follow-up. Supercial wounds will eventually close, as opposed to
sinus tracts that extend into the pelvis, which oen require a repeat
operation with debridement and use of omental pedicle or muscle
aps to achieve healing.
For young patients aicted with proctocolitis who do not have
any history or evidence of small bowel or anoperineal disease, a
restorative procedure such as a proctocolectomy with creation of an
ileal pouch–anal anastomosis is an option. e procedure is usually
performed in two or three stages depending on the clinical scenario.
COLON
219
FIGURE 43-2
for Medical Art & Photography. Copyright 1998-2016. All Rights Reserved.)
I
f the disease aects portions of the colon and upper rectum, selected
A Cheatle slit of the terminal ileum facilitates construction of an ileor
patients without signicant small bowel or anoperineal disease can be
managed with resection of the colon and upper rectum and creation
of an ileal pouch–rectal anastomosis. e ileal pouch measures 10 cm
in length, is congured in a J shape, and is joined to the remaining
normal rectum near the peritoneal reection. Although the likelihood of disease recurrence is relatively high with this procedure, the
function is acceptable and the patient can oen avoid a permanent
ileostomy during her or his early adult years.
SPECIAL SITUATIONS
Medications
H
igh-dose glucocorticoid usage has been linked to an increased risk
for postoperative complications (e.g., infection and poor healing), and
a patient requiring high-dose prednisone (>20 mg daily) should be
counseled about the possible need for temporary fecal diversion. e
impact of biologic agents on the risk for infectious complications has
been argued, but the risk is likely linked to serum levels of the drug
that is metabolized at varying patient-dependent rates. Regardless, it
is likely advisable to schedule an elective procedure when the patient
is due for her or his next scheduled infusion or injection of the agent.
Abscess
ntra-abdominal abscesses associated with penetrating disease usu-
I
ally arise from the le colon. ese abscesses are best managed by
parenteral antibiotics plus CT-guided drainage if the abscess measures greater than 3 cm or by aspiration if the abscess is 3 cm or
smaller and the patient has been treated with glucocorticoids. Reimaging is recommended if the patient’s condition worsens or does not
improve within 3 to 5 days of treatment onset. A sinogram through
the existing drain should be performed every few weeks, followed by
ectal anastomosis.
FIGURE 43-3
endoanal proctectomy. (Reprinted with permission, Cleveland Clinic Center
for Medical Art & Photography. Copyright 1998-2016. All Rights Reserved.)
La
(Reprinted with permission,
yered closure of the perineal wound following
Cleveland Clinic Center
repeat CT imaging in all patients at 6 weeks to ensure resolution of
the abscess. Whether the patient’s condition is subsequently managed
with long-term medical therapy or surgery is the topic of debate and
depends on the interplay of multiple factors.
vere Colitis
Se
A
ny patient with severe colitis should be resuscitated and evaluated
for peritonitis with physical examination and for perforation with
abdominal imaging (Fig. 43-4). Aer stool studies for Clostridium
dicile, lower endoscopy is conducted with minimal insuation.
220
ManageMent of Cr
ohn Colitis
Severe colitis
No
Peritonitis or
perforation
Yes
No
Operation Discharge on medical therapy
FIGURE 43-4
e severity of mucosal inammation is assessed and biopsy speci-
Infliximab Glucocorticoids
Response by day 7 Response by day 3
T
reatment algorithm for severe colitis.
mens are obtained to exclude cytomegalovirus infection. High-dose
glucocorticoids are typically started, and the patient is frequently
assessed with abdominal examinations and daily abdominal
roentgenograms. If the patient shows signs of deterioration or no
improvement aer 3 days of therapy, rescue therapy or surgery is
recommended. Iniximab is the agent most commonly used for
rescue therapy, and the patient should experience improvement
within 5 to 7 days. An operation is indicated if rescue therapy
fails to resolve disease-related symptoms and signs. In patients
with “severe” endoscopic inammation, iniximab is oen used as
rst-line therapy instead of glucocorticoids. Regardless the setting,
iniximab is not prescribed in a patient in whom severe disease
developed while he or she was being treated with immunomodulators or biologic agents.
If an operation is warranted, the procedure of choice is a laparoscopic colectomy with creation of an end ileostomy. e distal transected bowel can be managed in a variety of ways. Intraperitoneal
closure of a rectal stump is complicated by dehiscence and an intraabdominal abscess in approximately 10% of cases. is complication
can be avoided by leaving a longer stump that is closed and implanted
above the fascia level in the lower abdomen. Dehiscence of the stump
with this approach occurs in one quarter of the cases but results in a
mucous stula that can be easily managed. Rarely, the stump cannot be
closed because the tissue is too fragile. In this instance, a short (5-cm)
segment of the transected sigmoid colon is exteriorized. e short segment is amputated and a mucous stula is created aer 7 to 10 days.
A denitive operation is planned 6 months later when the patient has
recovered and has usually discontinued all medical therapy.
Severe endoscopic findings
Yes
No
r
equired because the stula is oen symptomatic or at risk for associ-
No
YesYes
ated complications. e diseased large bowel is resected, and the edges
of the stomach are excised to healthy tissue and primarily closed.
Neoplasia
ysplasia and adenocarcinoma can develop in any segment of
D
chronically inamed large bowel, and the risk for malignancy is
generally estimated at 0.5% per year aer 8 to 10 years of disease
symptoms. e risk is greatest in patients with extensive disease,
severe disease, or sclerosing cholangitis. Patients in whom at least
one-third of the large bowel is aected by disease are surveyed every
1 to 2 years with a colonoscopy that includes targeted biopsies of
any suspicious lesions or masses, as well as four-quadrant random
biopsies obtained every 10 cm. Strictures should be extensively
biopsied, and cytologic brushing should be considered. If the entire
bowel at risk cannot be surveyed because of a stricture or atrophy
associated with out-of-circuit rectum, prophylactic resection is
usually advised if adequate surveillance has not been performed for
more than 5 years.
Oncologic resection of the diseased bowel and its lymphatic drainage basin is recommended for any nding of dysplasia that cannot be
endoscopically resected or adenocarcinoma. Continued surveillance
is generally suggested for patients with indenite dysplasia and adenoma-like dysplasia but is debated for unifocal dysplasia arising in at
mucosa found during surveillance. Colonic dysplasia or carcinoma in
a patient with rectal sparing is usually managed with a colectomy and
construction of an ileorectal anastomosis. If the rectum is the site of
neoplasia or is inamed, a total proctocolectomy is warranted.
owth Retardation
Gr
rowth retardation is a disease- or medication-related complication
G
seen in prepubescent children aicted with Crohn disease of the
large bowel. Surgery can return growth velocity to normal, but catchup growth is oen incomplete. In some aected children, delayed
puberty may compensate for poor growth experienced earlier in life,
and signicant growth can still occur. Surgery may have a favorable
impact on growth in the short term, but nal height oen remains
less than predicted.
Fistula
Fi
stulas complicating Crohn disease of the large bowel most oen arise
from the transverse colon and target the stomach. Surgery is usually
OUTCOME
A s
egmental colectomy and total colectomy are associated with
comparable 30-day operative morbidity rates of approximately
14%. The overall 30-day mortality rate is approximately 0.4%
for elective procedures but higher for emergency operations.
Although the surgical recurrence rates are similar for the two
procedures, patients undergoing a segmental resection exhibit
recurrence an average of 4.4 years earlier than those who undergo
a total colectomy. Moreover, patients with at least two colonic
segments involved by disease tend to do better if they undergo
a total colectomy with construction of an ileorectal anastomosis.
Fortunately, permanent fecal diversion is required in only a small
number (18%) of patients, but the presence of anoperineal disease
portends a greater risk.