Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1515_Библиотеки_им_академика_М_И_Перельмана
.pdf
Introduction
The most common complications of inflammatory
bowel disease (IBD) requiring emergency treatment
are toxic colitis, perforation, toxic megacolon, bleed-
ing, sepsis and intestinal occlusion [1]. Admittedly,
our experience with these situations is limited. Our
gastroenterologist treats about 50 patients with IBD
and an incidence rate of 5–6 newly detected patients
per year per 70 000 habitants in our area, which cor-
responds to the nationwide population-based study
in Italy (Table 1) [2]. Whereas most of these patients
are amenable to medical treatment, some of them
sooner or later present with intestinal emergencies.
Furthermore, septic, hemorrhagic or perforative
complications may be the first clinical manifestations
of IBD. A transfer of these patients to specialized cen-
tres may be hazardous. This contribution gives true
insight into the surgical management of IBD emer-
gencies in a peripheral hospital based on 7 years of
experience.
Patients and Methods
In a 7-year period, from 1997 to 2004, 13 patients
were referred to our surgical department for man-
agement of IBD emergencies (Table 2). Most of them
had to be operated on more than once. Patients with
ulcerative colitis (UC) or Crohn’s disease (CD)
admitted for elective surgical procedures as well as
those suitable for an ileal pouch-anal anastomosis
are not included. The mean age of women (n=6) was
32.5 years, while the mean age of men (n=7) was
46.3 years. Ten patients had CD-associated emergen-
cies, only three had ulcerative colitis. Abscess and fis-
tula formation, associated with sepsis (n=7), were the
most frequent emergencies regarding our IBD
patients. We emphasise that these patients had to be
operated on under general anaesthesia and that those
with superficial lesions treated in local anaesthesia
and in an ambulatory setting are not included in this
group. As a rare occurrence, one patient presented
with ulcerative colitis and a giant subhepatic abscess,
which could be successfully drained by a transcuta-
neous echoguided approach. Another patient pre-
sented with a right multiloculated psoas abscess.
After successful drainage of the abscess, diagnosis of
Crohn’s disease of terminal ileum was established.
Despite adequate medical therapy, the patient devel-
oped another psoas abscess. Therefore, besides
abscess drainage, an ileocecal resection was per-
formed. Since then, the patient is doing well. Four
patients with CD underwent urgent ileocecal resec-
tion for intestinal obstruction. In three of them the
obstruction was associated with the abscess forma-
tion; in one it was associated with an enteroenteric fis-
tula. In a patient with a descendent colon obstruction
due to CD, only a cecostomy was carried out; after
1 year of medical treatment the obstruction resolved
and the cecostomy could be closed. Two patients with
ileal CD underwent appendectomy without complica-
tions. The patient with toxic megacolon underwent
colectomy and an ileal pouch-anal anastomosis in
another hospital where he was known as an UC
patient. Some months later, when the specimen was
re-examined by a famous pathologist, the diagnosis of
UC was changed to CD. The patient, indeed, devel-
oped severe complications caused by the ileal pouch
such as diarrhoea, incontinence and perianal fistula.
Surgical Management of IBD Emergencies:
the Approach in a Peripheral Hospital
Walter Thaler, Hansjörg Marsoner, Gianluca Colucci, Barbara Mahlknecht, Umberto Pandini,
Anke Gutweniger, Monika Niederkofler, Emanuela Dapunt, Alex Wiegele, Hans Dejaco,
Siegfried Jesacher
Table 1. Incidence of inflammatory bowel disease in Italy
[39]
UC CD
Age adjusted incidence 5.22.3
rates per 100 000 per year
Rates computed after correcting 6.82.8
underestimation
Sex ratio M/F 1.71.0
Highest age specific 30-39 20-29
incidence rates years years
456 W. Thaler, H. Marsoner, G. Colucci et al.
Table 2. Emergencies in IBD: our experience
Gender Age of patient Diagnosis Treatment Results
Male 60
Female 29
Female 38
Male 36
Female 25
Female 32
Male 30
Female 43
Female 44
Male 63
Male 73
Male 65
Male 52
1990: intestinal bleeding
(UC)
1993: toxic megacolon
Histological diagnosis revis-
ited: Crohn’s disease
Increasing perianal problems
1998: diagnosis of CD
2000: acute appendicitis
1989: diagnosis of CD
1997: fulminant colitis
1999: development of a rec-
tovaginal fistula. Severe
perianal CD
2001: duodenal CD
1990: diagnosis of CD
1998: perianal fistula
1995: diagnosis of CD of the
small bowel
2000: bowel obstruction
1998: diagnosis of CD
1999: acute appendicitis
1997: diagnosis of CD
2002: anorectal fistula
2004: abscess with bowel ob-
struction
1989: diagnosis of CD
1998: abscess, enteroenteric
fistula and bowel obstruction
2002: psoas abscess (diagno-
sis of CD)
2002: bowel obstruction
2005: psoas abscess
1999: diagnosis of Crohn’s
colitis
2003: colonic obstruction
1987: diagnosis of UC
1998: acute colitis
2003: free sigmoid colon
perforation
1987 diagnosis of UC
2004: subhepatic abscess
2004: cecal perforation in
ileocecal CD and cecal carci-
noma
Colectomy, end-ileostomy
and mucous fistula.
Some months later ileo-
anal-pouch
Several operations for peri-
anal- and abdominal-wall
fistula
2000: end-ileostomy
Laparoscopic appendecto-
my
Subtotal colectomy, ileo-
rectal anastomosis
2001: end-ileostomy
Fistulectomy
Ileal resection and end-to-
anastomosis
Appendectomy
Ileocecal resection, abscess
drainage relaparotomy for
multiple intraperitoneal ab-
scesses 7 days later
1998: ileocecal resection
Drainage, ileocecal resec-
tion, re-resection of termi-
nal ileum, abscess drainage
Cecostomy, medical treat-
ment
2004: closure of cecostomy
Left hemicolectomy, end
transversostomy, closure of
the rectum
Percutaneous drainage
Laparoscopic closure of the
perforation and biopsy,
which revealed carcinoma
Has mild symptoms of peri-
anal CD and lastly a low out-
put enterocutaneous fistula
has developed.
General state of health is
good
Histologically severe inflamed
appendix without specific
signs of CD
No further surgical treat-
ment until now
Azothioprin-induced pan-
creatitis
Improvement of perineal
CD, no evidence for recto-
vaginal fistula and duodenal
CD today
No recurrence of perianal
CD
No further surgical therapy
No further surgical therapy
Enterocutaneous fistula for
5 months. Actually on med-
ical treatment without com-
plaints
Good state of health without
medical treatment, 2 child-
births
Actually on medical therapy
without complaints
Actually on medical therapy
without complaints
No evidence for IBD in the
right colon and in the rec-
tum
Abdominal wall rupture,
stomal problems, rectal
stump failure, sepsis, death
after two months of inten-
sive care
Actually on medical therapy
without complaints
Died after right hemicolec-
tomy in his reference hospi-
tal
Surgical Management of IBD Emergencies: the Approach in a Peripheral Hospital 457
These symptoms could be successfully managed by an
ileostomy. Another patient underwent subtotal colec-
tomy and ileo-rectal anastomosis for Crohn’s disease.
One year later, severe anal CD developed postopera-
tively with perianal und rectovaginal fistula forma-
tion. Additionally, an azathioprine associated pancre-
atitis and a duodenal manifestation of Crohn’s disease
impaired the state of health of this young woman.
Four years after colectomy, an end-ileostomy was
performed and since that time the patient is doing
well: she has regained her normal body weight, she is
on medical treatment without evidence of duodenal
CD and the disastrous perianal situation has
improved dramatically showing a disappearance of
the rectovaginal fistula. Two patients had free intes-
tinal perforation. The first, a 73-year-old man with
UC for 16 years, was referred to our department with
free sigmoid colon perforation. The patient was on
medical treatment for acute colitis at the medical
department of our hospital when he developed multi-
organ failure. Interestingly, there was no evidence of
toxic megacolon, and free air evidenced on the
abdominal plain X-ray was not associated with a clas-
sical appearance of acute abdominal pain. The patient
was immediately referred to the operating theatre
where a large perforation of the sigmoid colon with
advanced signs of general peritonitis was found. The
right colon, however, and the rectum were free of dis-
ease. Therefore, a modified Hartmann’s procedure
was carried out with resection of the sigmoid colon,
closure of the rectal stump and construction of an
end-transverse colostomy. After an uneventful post-
operative phase of 5 days, a rectal stump insufficiency
and an abdominal wall dehiscence had to be repaired
twice. Finally, the patient died after 2 months of
intensive care treatment. The other patient, a 56-year-
old man with CD for more than 10 years, was referred
for acute abdomen. This patient also had a long histo-
ry of duodenal ulcer disease and therefore he under-
went laparoscopic exploration. A small perforation of
the cecum was found, biopsied, and, because of the
absence of typical signs of peritonitis, closed by direct
suture. A drain was placed near to the perforation and
the postoperative phase was uneventful. Histologic
examination of biopsies revealed a carcinoma. The
patient underwent a right hemicolectomy some weeks
later in his reference hospital, and he died due to
anastomotic leakage.
Discussion
Perianal Abscesses and Fistulae
Perianal abscesses and fistulae were the most fre-
quent complications of IBD of patients who required
emergency treatment in our series. Many of them
underwent more than one operation for fistulae.
When cases of Crohn’s disease are described as “fis-
tulising”, one has to distinguish between perianal
and intestinal fistulation. The question, however,
remains open as to whether or not there is truly an
association between perianal fistulisation and intra-
abdominal intestinal fistulisation in CD. There is a
statistically significant association between perianal
CD and intestinal fistulisation, which is much
stronger and more consistent in cases of Crohn’s
colitis than in cases limited to the small bowel [3].
The management of perianal CD continues to be
challenging. Roughly half of patients require perma-
nent faecal diversion, which is even more frequently
true for patients with colonic CD and anal stenosis.
Recognising these tendencies will assist both patients
and surgeons in planning optimal treatment [4]. If it
is indeed a superficial fistula, the correct course of
action for most patients would be a fistulotomy and
perhaps a short course of antibiotics. Failing this,
most patients would receive a non-cutting seton [5].
Long-term indwelling seton is an effective manage-
ment modality for complex perianal Crohn’s fistulas
which do not negatively impact faecal continence [6].
Endoanal ultrasound has been suggested for the
evaluation of rectal abscesses and fistulas [7]. The
insertion of rectal probes can, however, still be
painful. The use of a rigid endoanal ultrasound probe
can even be impossible in patients with inflammatory
perianal disease due to anal stenosis. This limitation
is obviated by the use of perineal ultrasonography,
which is a simple, painless, feasible, real-time method
that can be performed without specific patient prepa-
ration and which is comparable in its sensitivity to
pelvic MRI in the detection of perianal fistulae and/or
abscesses [8]. The combination of MRI and endoanal
ultrasound is capable of detecting perianal fistulae
with a sensitivity of 100% [9]. We have little experi-
ence with perineal ultrasonography. In our opinion,
transrectal ultrasonography is an excellent method in
cases of newly diagnosed perianal disease, but it is less
exact in cases of recurrent fistulae.
Rectovaginal fistulae are a well-recognized com-
plication of Crohn’s disease, occurring in 5–10% of
women [10]. The management of rectovaginal fistu-
lae complicating Crohn’s disease is often unsatisfac-
tory. Faecal diversion has been used to achieve
remission in colonic Crohn’s disease [11]. Most
patients with rectovaginal fistulae secondary to rectal
disease, even if it is quiescent, eventually require a
proctectomy due to progressive rectal disease or
unmanageable incontinence [12, 13]. The role of fae-
cal diversion applied on its own in perianal Crohn’s
disease remains unclear. Many perianal lesions, par-
ticularly ulcers and fistulae, heal completely without
458 W. Thaler, H. Marsoner, G. Colucci et al.
any specific therapy [14]. The advantage of fecal
diversion is that it is a relatively minor procedure,
and it may promote healing of an anal ulcer and
some fistulae. It would be helpful if we could predict
which patients with perianal disease might respond
to faecal diversion. No predictive factors could be
found by Yamamoto et al. [15]. Patients have to be
warned that the ileostomy is closed in only a few
cases, but that the severe sepsis or anal pain is usual-
ly alleviated. Our two patients who underwent
ileostomy for intractable perianal CD didn’t ask for a
closure of ileostomy until now.
Infliximab is an efficacious treatment for fistulae
in patients with Crohn’s disease [16]. The perianal
disease process should first be fully delineated with
endoscopy and either MRI or EUS before treatment
is begun. Although the initial response to infliximab
is dramatic, the median duration of fistula closure is
approximately 3 months, and repeated infusions are
required [16]. Patients with fistulising CD treated
with infliximab are more likely to maintain fistula
closure if the treatment is preceded by an evaluation
under anaesthesia and seton placement [17]. Com-
plex fistulae first require surgical intervention prior
to medical treatment. A combination of antibiotics,
immunosuppressive therapy and infliximab are then
initiated to facilitate fistula healing [18]. Two of our
patients have been treated with infliximab; both of
them, finally, required an ileostomy for permanent
improvement of their perianal disease.
Intra-Abdominal Abscesses
Intra-abdominal abscesses can be successfully
drained by an echoguided mini-invasive access like
that described in regards to our patient with ulcera-
tive colitis and a subhepatic abscess. In many cases,
however, fistula formation and intestinal obstruction
is associated with intra-abdominal abscesses, and
abscess drainage does not improve the situation in
the long term. More than 25% of patients undergoing
surgery for Crohn’s disease will have either an intra-
abdominal mass or abscess. Of these masses, 40%
will have an associated fistula [19, 20]. Traditionally,
the majority of abscesses associated with Crohn’s
disease have been approached with operative
drainage; however, improved interventional radio-
logical techniques have resulted in an increased use
of percutaneous drainage. Doing so will facilitate an
improvement in the patients general condition prior
to definitive surgical repair [20]. Non-operative ther-
apy prevented subsequent surgery in half of the
patients and may be a reasonable treatment option
[21]. In cases with no associated abscess primary
reconstruction can be proposed.
Psoas Abscesses
As for psoas abscesses, Crohn’s disease is today the
most common cause of this entity. Nevertheless, it is
a rare event as it develops in less than 1% of patients
with CD [22]. An occasional patient will require mul-
tiple operations [23].
Acute Appendicitis
Acute appendicitis and appendectomy in patients
with CD is a matter of debate. Crohn’s disease con-
fined to the appendix is rare but has been well
described in the literature [24]. Crohn’s disease of the
appendix can mimic acute appendicitis, although
often with a more indolent course. It has been sug-
gested that appendectomy in patients with CD may
be complicated by fistula formation. Interestingly, in
patients with abdominal pain for less than 1 week,
appendectomy was followed by minimal problems,
whereas in those with pain for longer than a week,
incidental appendectomy was followed by an 83%
incidence of fistulae, arising not from the appen-
diceal stump but from the terminal ileum [25]. The
disease may be treated successfully by laparoscopic
appendectomy with good long-term results [26]. A
laparoscopic approach may be advantageous since
the trocars are inserted far away from the diseased
ileocecal region and scar formation is reduced in
comparison with an open access.
Toxic Colitis
Toxic colitis, with or without megacolon, is an emer-
gent life-threatening complication of inflammatory
bowel disease. Its overall incidence in patients with
ulcerative colitis is about 10% [27]. Although in the
past, toxic colitis was thought to be a rare complica-
tion of Crohn’s disease compared with ulcerative
colitis, recent studies have shown that Crohn’s colitis
is the etiology in approximately 50% of the cases [28].
The overall incidence of complicated Crohn’s disease
is about 6%, with an increasing number occurring in
Crohn’s colitis [29]. The presentation of toxic “fulmi-
nant” colitis includes fever, an abrupt onset of
bloody diarrhoea, abdominal tenderness, colicky
pain, and anorexia [30]. Toxic megacolon is present
if, in addition to toxic colitis, either total or segmen-
tal dilatation of the colon occurs [31, 32]. Once the
diagnosis of toxic colitis is suspected, aggressive
medical therapy is initiated. A team approach is
required involving both gastroenterologists and sur-
geons. Prompt surgery is indicated for patients with
Surgical Management of IBD Emergencies: the Approach in a Peripheral Hospital 459
toxic colitis or megacolon if there is evidence of free
perforation, peritonitis, or massive haemorrhage.
Surgery may also be indicated to avoid perforation if
no clinical improvement occurs with aggressive med-
ical management within 48–72 h. A persistently dilat-
ed colon on plain films is also often an indication for
operative intervention. The optimal operation
involves subtotal colectomy with end ileostomy. This
allows removal of the majority of the bowel and
avoids an anastomosis in a critically ill patient [30].
Total colectomy was at one time the procedure of
choice, but has fallen out of favour due to increased
morbidity and mortality. An endoscopic decompres-
sion by sigmoido- or colonoscopy can be achieved
[33, 34], but it cannot be recommended unless used
in a non-surgical candidate. Computed tomography
scans should be performed on all patients for whom
the diagnosis of toxic megacolon is suspected, as sev-
eral complications can be identified before clinical or
plain film findings. Diffuse colonic wall thickening,
submucosal edema and pericolic stranding are all
indicative of severe colitis [35]. Timing of surgery
regarding toxic megacolon may be crucial, and delay
in surgical management can result in perforation and
the poor prognosis that accompanies it. The long-
term prognosis of medically managed, ulcerative
colitis-related toxic megacolon is poor [36].
Intestinal Obstruction
Intestinal obstruction most commonly occurs in
patients with Crohn’s disease. Small bowel obstruc-
tion is the most common complication requiring sur-
gical correction in Crohn’s disease and affects
35–54% of patients [37, 38]. It is important to rule
out a malignancy whenever a stricture, especially
colonic, is present. The initial management of intes-
tinal obstruction in Crohn’s disease is medical thera-
py. Obstruction that is unresponsive to medical treat-
ment requires resection or possible strictureplasty
[39]. Septic problems or phlegmon, a stricture close
to a planned resection and extensive ulceration or
bleeding are contraindications for strictureplasty.
Ileocecal resection is a very satisfactory procedure
since most patients enjoy longstanding good health
after this procedure. “Don’t operate until a patient
gets a complication from Crohn’s disease; but don’t
wait for a complication to become further complicat-
ed” [40]. Extended resection margins confer no
advantage to patients in reducing cumulative recur-
rence rates. The presence of residual microscopic
Crohn’s disease at resection margins does not
increase recurrence rates vs. normal margins. Resec-
tion margins of 2 or 12 cm after a median follow-up
of 56 months had the same recurrence rate [41].
Haemorrhage
Although we had no patients with massive bleeding
in our hospital in the last 7 years to treat, this issue is
worth mentioning. Severe bleeding occurs in 0–6% of
patients with inflammatory bowel disease with most
series quoting a 2–3% incidence [42–44]. As com-
pared with ulcerative colitis, where bleeding may dif-
fuse from large areas of ulcerated mucosa, in Crohn’s
disease the bleeding is often from a localised source.
It is important to rule out a gastroduodenal source
prior to bowel resection. Robert et al. [43] found that
nearly 30% of patients with Crohn’s disease treated
for significant gastrointestinal bleeding had a bleed-
ing duodenal ulcer as its source. In Crohn’s disease,
it is important to localise the source of bleeding pre-
operatively. If gastroscopy and colonoscopy are not
successful, the use of angiography may be consid-
ered, but only if patient stability is obtained. Other
methods include the use of a nuclear medicine
known as red cell scan.
Life-threatening haemorrhage and exsanguination
from Crohn’s disease in four patients were described
in 1995, when 34 cases similar to the medical litera-
ture were reviewed [45]. Five patients died, in 30
(90%) surgery was necessary to cease haemorrhage
and ileocolectomy was the most frequently per-
formed procedure. Mesenteric arteriography was
positive in 17 patients, providing precise preopera-
tive localisation, resulting in no mortality in this
group [45]. A retrospective study of 34 patients with
acute lower gastrointestinal bleeding in Crohn’s dis-
ease, the largest to date, shows a more favourable
result [46]. Acute haemorrhage was defined as acute
rectal bleeding originating in diseased bowel, requir-
ing a transfusion of at least 2 units of red blood cells
within 24 h. Upper gastrointestinal tract haemor-
rhage or anal lesions and postoperative bleeding
were excluded. Recently, several promising studies
have been published that describe transcatheter
embolization for the treatment of massive lower gas-
trointestinal bleeding in cases of bleeding colonic
diverticular disease and angiodysplasia. This
approach may be useful for bleeding in Crohn’s dis-
ease as well.
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
460 W. Thaler, H. Marsoner, G. Colucci et al.
toxic colitis or megacolon [28]. Its occurrence with-
out megacolon is rare [49]. The diagnosis may be
delayed, as high-dose steroids may mask the signs of
peritonitis. In Crohn’s disease, free perforation is a
rare but severe complication occurring in 1–3% of
cases [50, 51]. Holzheimer et al. [52] reported an inci-
dence of 13% in 1995. Such different incidence rates
are due to the fact that in some reports, abscess for-
mation is included and in others it is not. A large
series of free perforation in Crohn’s disease has been
published by Greenstein et al. [53] in 1985 and by
Ikeuchi et al. [54] in 2003; it seems that the incidence
of free perforation in Japan is higher than in Western
countries. The procedure of choice for a patient with
ulcerative colitis and free perforation is a subtotal
colectomy and end ileostomy. Gastroduodenal perfo-
rations in Crohn’s patients are best managed with
debridement and primary repair. Perforated Crohn’s
colitis, which is often in the setting of toxic colitis,
requires subtotal colectomy with rectal preservation
and end ileostomy [51]. If the perforation occurs in a
diseased small-bowel segment, this segment along
with the perforation is resected. In a recent study,
Nissan et al. [55], who advocated a more liberal
approach to surgical treatment, found free perfora-
tion in only 3.8% of their study group. Intensive
medical treatment resulted in a 6.2-year delay from
diagnosis until surgery, in contrast to 3.3 years in the
study by Greenstein et al. [56]. It is possible that a
serious complication such as free perforation result-
ed from a conservative medical approach. Perforative
Crohn’s disease is accompanied by more postopera-
tive complications, anastomotic healing is poor, and
recurrent disease is more frequent in the short-term
(up to 5 years) follow-up than in obstructive Crohn’s
disease [57]. Based on the results of many authors
[55, 56, 58], early surgery in Crohn’s disease patients
depending on the clinical presentation, intensity and
duration of medical treatment, and life quality
impairment, is recommended. It is generally accept-
ed that 1–3 % of patients with CD will present with a
free perforation—initially or eventually in the course
of their disease [53, 58, 59]. Operative mortality in
case of perforation is 20–40% [31, 60], whereas it is
4% in patients with toxic megacolon operated on
before perforation has taken place. In half of
patients, perforation is not associated with toxic
megacolon. Free perforation of the bowel due to can-
cer in Crohn’s disease is very rare [61].
Perforated Cancer in IBD
People with ulcerative colitis and Crohn’s disease are
at greater risk for colon cancer than the general pop-
ulation. Four patients with bowel perforation
because of carcinoma in Crohn’s disease are
described in the literature [61, 62]. In case of a con-
servative procedure such as suture of perforated
intestine or drainage only or strictureplasty, stenting,
biopsies of the perforated area are recommended.
Prognosis of carcinoma in IBD, according to Fraschi-
ni [61], is good. His patient underwent a right hemi-
colectomy and was alive without recurrence or
metastases at the 31-months follow-up. Prognosis of
carcinoma in IBD, according to Greenstein [62], is
bad. Two of his patients died because of operative
complications. Our patient, who underwent laparo-
scopic closure of the cecal perforation, was dis-
charged 6 days postoperatively, but, as mentioned
above, he died after a planned right hemicolectomy
in his reference hospital.
Laparoscopy
The final role of laparoscopic surgery for the man-
agement of inflammatory bowel disease is still under
evaluation, but it is attractive. Since it is well known
that development of laparoscopic techniques is not
reserved for university centres or high volume hospi-
tals, minimal invasive procedures can also be applied
in peripheral hospitals. Certainly, laparoscopy is not
the first choice approach in the emergency treatment
of our patients with inflammatory bowel disease, but
we do not hesitate to perform a diagnostic
laparoscopy in patients with known inflammatory
bowel disease which present with unclear acute
abdominal complaints. In this way, we managed a
cecal perforation in a patient with Crohn’s disease
and cecal carcinoma by direct closure of the perfora-
tion and peritoneal lavage and drainage. Laparoscop-
ic ileocolic resection is a feasible procedure for
skilled surgeons. When compared with an open
approach, laparoscopic ileocolic resection led to
lower 5-year small-bowel obstruction rates in select-
ed patients with ileocecal Crohn’s disease, whereas
the 5-year recurrence rates did not differ [63].
Conclusion
Treatment of inflammatory bowel disease is a chal-
lenge. Many surgeons are not enthusiastic about
treatment of patients with Crohn’s disease or ulcera-
tive colitis. During recent decades, specialised cen-
tres have been created where a team of skilled sur-
geons, 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 megacolon,
Surgical Management of IBD Emergencies: the Approach in a Peripheral Hospital 461
bowel perforation, bleeding, and intestinal obstruc-
tion, treatment In Loco is unavoidable. Transfer to a
specialised centre, which doesn’t always mean the
next closest hospital, may be very dangerous for
patients with IBD emergencies. An immediate surgi-
cal intervention is required, and the surgeon has to
know what to do. This is expecially true for patients
presenting with acute abdominal pain as a first man-
ifestation of IBD, a rare event nowadays.
Since ulcerative colitis and Crohn’s disease are not
extremely rare, doctors in peripheral hospitals are
familiar with them. Surgical management of patients
with IBD is not extremely difficult from the technical
point of view. The question is when and how to
choose the right approach. Decisions made in emer-
gency situations, or better, before these develop, are
made in an interdisciplinary way. For instance, every
patient with IBD should be evaluated by the gas-
troenterologist and the surgeon together at the time
of the initial hospital admission and at every read-
mission thereafter.
Histologic examination of biopsies may be haz-
ardous. A proven diagnosis of Crohn’s disease is gen-
erally seen as precluding ileal pouch-anal anastomo-
sis. This problem exists in peripheral hospitals as
well as in big institutions.
In a peripheral hospital such as ours, there is a
surgeon, a gastroenterologist and endoscopist, a
radiologist, a blood bank, an intensive care unit, and
a CT-scan available. Using these resources, we have
treated patients with IBD emergencies with the
results reported above (Table 2). If we have to resolve
emergency situations regarding IBD patients, some
planned operations should also be done. Treatment
of IBD patients in our department is performed in
accordance and in synchronisation with our gas-
troenterologist and specialised centres. We do not
carry out ileal pouch-anal anastomoses because of
the low number of patients requiring this operation
at our hospital.
References
1. Cheung OR (2003) Inflammatory bowel disease emer-
gencies. Gastroenterol Clin North Am 32:1269–1288
2. Tragnone A, Corrao G, Miglio F et al (1997) Incidence of
inflammatory bowel disease in Italy: a nationwide pop-
ulation-based study. Gruppo Italiano per lo Studio del
Colon e del Retto (GISC). Int J Epidemiol 26:904–906
3. Sachar DB, Bodian CA, Goldstein ES et al (2005) Is
perianal Crohn’s disease associated with intestinal fis-
tulization? Am J Gastroenterol 100:1547–1549
4. Galandiuk S, Kimberling J, Al Mishlab T et al (2005)
Perianal Crohn’s disease: predictors of need for per-
manent diversion. Ann Surg 241:796–802
5. Sangwan YP, Schoetz DJ Jr, Murray JJ et al (1996) Peri-
anal Crohn’s disease. results of local surgical treat-
ment. Dis Colon Rectum 39:529–535
6. Thornton M, Solomon MJ (2005) Long-term
indwelling seton for complex anal fistulas in Crohn’s
disease. Dis Colon Rectum 48:459–463
7. Cataldo PA, Senagore A, Luchtefeld MA (1993)
Intrarectal ultrasound in the evaluation of perirectal
abscesses. Dis Colon Rectum 36:554–558
8. Wedemeyer J, Kirchhoff T, Sellge G et al (2004) Tran-
scutaneous perianal sonography: a sensitive method
for the detection of perianal inflammatory lesions in
Crohn’s disease. World J Gastroenterol 10:2859–2863
9. Schwartz DA, Wiersema DJ, Dudiak KM et al (2001) A
comparison of endoscopic ultrasound, magnetic reso-
nance imaging, and exam under anethesia for evalua-
tion of Crohn’s perianal fistulas. Gastroenterology
121:1064–1072
10. Radcliffe AG, Ritchie JK, Hawley PR et al (1988)
Anovaginal and rectovaginal fistulas in Crohn’s dis-
ease. Dis Colon Rectum 31:94
11. Winslet MC, Andrews H, Allan RN et al (1993
) Fecal
diversion in the management of Crohn’s disease of the
colon. Dis Colon Rectum 36:757
12. Heyen F, Winslet MC, Andrews H et al (1989) Vaginal
fistulas in Crohn’s disease. Dis Colon Rectum 32:379
13. Person B, Wexner SD (2005) Management of perianal
Crohn’s disease. Curr Treat Options Gastroenterol
8:197–209
14. Keighley MRB, Allan RN (1986) Current status and
influence of operation on perianal Crohn’s disease. Int
J Colorectal Dis 1:104
15. Yamamoto T, Allan R, Keighley MRB (2000) Effect of
fecal diversion alone on perianal Crohn’s disease.
World J Surg 24:1258–1263
16. Present DH, Ruutgerts P, Targan S et al (1999) Inflix-
imab for the treatment of fistulas in patients with
Crohn’s disease. N Engl J Med 340:1398–1405
17. Regueiro M, Mardini H (2003) Treatment of perianal
fistulizing Crohn’s disease with infliximab alone or as
an adjunct to exam under anesthesia with seton place-
ment. Inflamm Bowel Dis 9:98–103
18. Schwartz DA, Herdman CR (2004) The medical treat-
ment of Crohn’s perianal fistulas. Aliment Pharmacol
Ther 19:953–967
19. Nagler SM, Poticha SM (1979) Intraabdominal abscess
in regional enteritis. Am J Surg 137:350–354
20. Nichols RJ (1999) Intraabdominal mass and/or
abscess. In: Michelassi F, Milsom JW (eds) Operative
strategies in inflammatory bowel disease. Springer,
Berlin Heidelberg New York, pp 360–368
21. Garcia JC, Persky SE, Bonis PAL et al (2001) Abscesses
in Crohn’s disease: outcome of medical versus surgical
treatment. J Clin Gastroenterol 32:409–412
22. Agha FP, Woolsey EJ, Amendola MA (1985
) Psoas
abscess in inflammatory bowel disease. Am J Gas-
troenterol 80:924–928
23. Procaccio JA, Lavery IC, Fazio VW et al (1991) Psoas
abscess: difficulties encountered. Dis Colon Rectum
34:784–789
24. Roth T, Zimmer G, Tschanz P (2000) Crohn’s disease
of the appendix. Ann Chir 7:665–667
25. Simonowitz DA, Rusch VW, Stevenson JK (1982) Nat-
ural history of incidental appendectomy in patients
462 W. Thaler, H. Marsoner, G. Colucci et al.
with Crohn’s disease who required subsequent bowel
resection. Am J Surg 143:171–173
26. Zager JS, Gusani NJ, Derubertis BG et al (2001)
Laparoscopic appendectomy for Crohn’s disease of
the appendix presenting as acute appendicitis. J
Laparoendosc Adv Surg Tech A 4:255–258
27. Marion JF, Present DH (1997) The modern medical
management of acute, severe ulcerative colitis. Eur J
Gastroenterol Hepatol 9:831–835
28. Keighley MRB (1993) Acute fulminating colitis and
emergency colectomy In: Keighley MRB, Williams NS
(eds) Surgery of the anus, rectum and colon. Saunders,
London, pp 1379–1397
29. Reddy SB, Jeejeebhoy KN (1988) Acute complications
of Crohn’s disease. Crit Care Med 16:557–561
30. Tjandra JJ (1999) Toxic colitis and perforation. In:
Michelassi F, Milsom JW (eds) Operative strategies in
inflammatory bowel disease. Springer, Berlin Heidel-
berg New York, pp 234–245
31. Sheth SG, LaMont JT (1998) Toxic megacolon. Lancet
351:509–512
32. Present DH (1993) Toxic megacolon. Med Clin North
Am 77:1129–1148
33. Banez AV, Yamanishi F, Crans CA (1987) Endoscopic
colonic decompression of toxic megacolon, placement
of colonic tube, and steroid colonclysis. Am J Gas-
troenterol 82:692–694
34. Riedler L, Wohlgenannt D, Thaler W et al (1989)
Endoscopic decompression in “toxic megacolon”.
Surg Endosc 3:51–53
35. Imbriaco M, Balthazar EJ (2001) Toxic megacolon:
role of CT in evaluation and detection of complica-
tions. Clin Imaging 25:349
–354
36. Gan SI, Beck PL (2003) A new look at toxic megacolon:
an update and review of incidence, etiology, pathogene-
sis, and management. Am J Gastroenterol 98:2363–2371
37. Stone W, Veidenheimer MC, Corman ML et al (1977)
The dilemma of Crohn’s disease: long term follow-up
of Crohn’s disease of the small intestine. Dis Colon
Rectum 20:372–376
38. Platell C, Mackay J, Collopy B et al (1995) Crohn’s dis-
ease: a colon and rectal department experience. Aust
NZ J Surg 65:570–575
39. Yamamoto T, Bain IM, Allan RN et al (1999) An audit
of stricturoplasty for small bowel Crohn’s disease. Dis
Colon Rectum 42:797–803
40. Kumar D, JA Williams (1993) Crohn’s disease und
ulcerative colitis: surgical management. Springer,
Berlin Heidelberg New York, pp 188
41. Fazio VW, Marchetti F, Church J et al (1996) Effect of
resection margins on the recurrence of Crohn’s dis-
ease in the small bowel: a randomized controlled trial.
Ann Surg 224:563–573
42. Park R, Roger V, Penna C (1999) Management of hem-
orrhage. In: Michelassi F, Milsom JW (eds) Operative
strategies in inflammatory bowel disease. Springer,
Berlin Heidelberg New York, pp 229–233
43. Robert JR, Sachar DB, Greenstein AJ (1991) Severe
gastrointestinal hemorrhage in Crohn’s disease. Ann
Surg 213:207–211
44. Robert JH, Sachar DB, Aufses AH et al (1990) Manage-
ment of severe hemorrhage in ulcerative colitis. Am J
Surg 159:550–555
45. Cirocco WC, Reilly JC, Rusin LC (1995) Life-threaten-
ing hemorrhage and exsanguinations from Crohn’s
disease: report of four cases. Dis Colon Rectum
38:85–95
46. Belaiche J, Louis E, D’Haens G et al (1999) Acute lower
gastrointestinal bleeding in Crohn’s disease: charac-
teristics of a unique series of 34 patients. Am J Gas-
troenterol 94:2178–2181
47. Crohn BB (1957) Indication for surgical intervention
in regional enteritis. Arch Surg 74:305–311
48. Crohn BB (1965) Acute regional enteritis: clinical
aspects and follow-up studies. NY State J Med
65:641–644
49. Greenstein AJ, Barth JA, Sachar DB et al (1986) Free
colonic perforation without dilatation in ulcerative
colitis. Am J Surg 152:272–275
50. Bundred NJ, Dixon JM, Lumsden AB et al (1985) Free
perforation in Crohn’s colitis: a ten year review. Dis
Colon Rectum 28:35–37
51. Nordlinger B, Saint–Marc O (1999) Free perforation.
In: Michelassi F, Milsom JW (eds) Operative strategies
in inflammatory bowel disease. Springer, Berlin Hei-
delberg New York, pp 369–373
52. Holzheimer RG, Molloy RG, Wittmann DH (1995)
Postoperative complications predict recurrence of
Crohn’s disease. Eur J Surg 161:129–135
53. Greenstein AJ, Mann D, Sachar B et al (1985) Free per-
foration in Crohn’s disease: a survey of 99 cases. Am J
Gastroenterol 80:682–689
54. Ikeuchi H, Yamamura T (2002) Free perforation in
Crohn’s disease: review of the Japanese literature. J
Gastroenterol 37:1020–1027
55. Nissan A, Zamir O, Spira M et al (1997) A more liber-
al approach to the surgical treatment of Crohn’s dis-
ease. Am J Surg 174:339–341
56. Greenstein AJ, Sachar D, Mann D et al (
1986) Sponta-
neous free perforation and perforated abscess in 30
patients with Crohn’s disease. Ann Surg 205:72–76
57. Werbin N, Haddad R, Greenberg R et al (2003) Free
perforation in Crohn’s disease. Is Med Assoc J
5:175–177
58. Voeller G, Britt L (1990) Surgical management of per-
forated Crohn’s disease. Am Surg 56:100–103
59. Katz S, Schulman N, Levin L (1986) Free perforation in
Crohn’s disease: a report of 33 cases and review of lit-
erature. Am J Gastroenterol 81:38–43
60. Nicholls RJ (2002) Ulcerative colitis: surgical indica-
tions and treatment. Aliment Pharmacol Ther 4 [Suppl
16]:25–28
61. Fraschini A, Sella D, Gullotta R et al (1989) Free perfo-
ration due to colonic adenocarcinoma in Crohn’s dis-
ease. Ital J Surg Sci 19:85–88
62. Greenstein AJ, Gennuso R, Sachar DB et al (1987) Free
perforation due to cancer in Crohn’s disease. Int J Col-
orectal Dis 2:201–202
63. Bergamaschi R, Pessaux P, Arnaud JP (2003) Compari-
son of conventional and laparoscopic ileocolic resection
for Crohn’s disease. Dis Colon Rectum 46:1129–1133
Introduction
Since the introduction of the abdominoperineal
resection of the rectum (APR) for cancer or IBD [1],
an increasing number of perineal complications have
been reported. Delayed wound healing and local
infection are in fact common complications. Healing
depends on the patient’s general and nutritional sta-
tus, the nature of the underlying disease, the tech-
nique used for perineal reconstruction (primary clo-
sure or healing by secondary intention) and the
development of perineal infection. Simple primary
skin closure has been used in the past with poor
results, mainly from insufficient control of local
infection [2]. For some decades, frequent dressing of
the perineal wound with swabs has been considered
the treatment of choice, although healing by second-
ary intention involves prolonged hospital stay and
persistent wound drainage, usually requiring fre-
quent dressings and occasionally the development of
a persistent perineal sinus (PPS). In the seventies, the
introduction of closed suction drainage brought new
interest to primary perineal closure techniques.
McLeod et al. [3] evaluated the results of primary clo-
sure and suction drainage on 57 APRs (40 ulcerative
colitis, 4 Crohn’s disease, 10 carcinoma of the rec-
tum, 2 had carcinoma of the anus and 1 had anal
incontinence), reporting an overall 72% closure rate
and concluding that primary healing can be achieved
in a large proportion of patients operated on for can-
cer or IBD. More recently, the introduction of neoad-
juvant radiotherapy seems to have greatly increased
the risk of perineal wound complication after APR
with direct primary closure.
Common experience shows that when the per-
ineum is left open, healing by secondary intention is
accompanied by a significant morbidity, prolonged
hospitalisation, discomfort, protracted postoperative
drainage and higher risk of PPS. The patient usually
requires daily care of the perineum for 2–12 months.
The wound heals more slowly in patients with
inflammatory disease of the colon.
The presence of a persistent perineal sinus is cer-
tainly a disabling complication for the patient as it is
usually accompanied by foul secretions, perineal
pain, chronic pelvic pain, local dermatitis, infections
and dyspareunia. It represents the most frequent late
complication of APR and it is a challenging condition
for the surgeon. According to Eftaiha and Abcarian
[4], after a 4-month period from APR, the perineal
wound completely healed in 78% of patients. For this
reason it is important to monitor the perineal wound
at 4 months. If the repair process has failed, it is
important to differentiate unhealed perineal wound
(UPW), those wounds still open at 6 months from
initial surgery, from persistent perineal sinus (PPS),
those steady fibrous wounds still present 1 year after
surgery and probably unable to heal by themselves.
According to some authors, a small shallow UPW can
be successfully treated with curettage and local treat-
ments, while long and complex UPW as well as PPS
usually require a more extended surgical approach
[5–7]. As reported by Opelka, after 6 months from
radical proctectomy, the perineum heals in 58% of
the patients with IBD and 70% of the patients with
carcinoma. After 1 year, the wound is completely
closed in 98% of the patients [8]. In all cases, espe-
cially when cancer is involved, an evaluation under
anaesthesia with multiple-site biopsies is mandatory.
The anatomical limits of a perineal sinus largely
depend upon the operation performed. When the
rectum and the anal canal are removed, the anterior
aspect of the sinus is usually formed in the female by
the posterior aspect of the uterus and the posterior
vaginal wall, and by the bladder, the seminal vesicles
and the prostate gland in the male. These organs are
rather fix, but they can nevertheless slide down to
some extent with the loops of the small bowel, con-
tributing to the closure of the pelvic defect. The later-
al and the posterior aspect of the small pelvis are
formed by the pelvic sidewalls and by the anterior
aspect of the sacrum and coccyx covered by the pre-
sacral fascia. These structures do not take part in the
process that finally leads to the closure of the pelvic
wound. When APR is performed, the levator ani
muscle is partially removed with the specimen so that
Management of the Unhealed Perineal Wound
Diego Segre, Herbert M. Dal Corso, Marino Landra, Maria C. Giuffrida
464 D. Segre, H.M. Dal Corso, M. Londra, M.C. Giuffrida
its margins are very seldom useful for primary clo-
sure. Lubbers et al. [9] have reported a reduced num-
ber of perineal wound dehiscence and PPS after
intersphincteric or perimuscular dissection of the
rectum compared to wide APR.
Pathophysiology
Healing is a complex process not yet completely
understood. Soon after tissue damage, the inflamma-
tion phase takes place with subsequent migration
and proliferation of macrophages, lymphocytes and
fibroblasts; thereafter, neoangiogenesis and fibro-
plasias lead to wound closure, and finally, contrac-
tion 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 nutritional defi-
ciencies (common in IBD patients) as well as exoge-
nous ones such as infection, trauma and the use of
anti-inflammatory drugs.
Inadequate perfusion or low haemoglobin level,
metabolic diseases (e.g. diabetes mellitus) and con-
nective tissue disorders are all systemic factors that
contribute to alterations in the healing process.
Before focusing on local treatment of an unhealed
perineal wound, the surgeon has to correct possible
nutritional and circulatory deficiencies, maintain
blood glucose within the normal range and control
high blood pressure. Radiotherapy, usually per-
formed preoperatively in patients with rectal or anal
cancer, represent a further factor that may delay
healing and lead to PPS. Microangiosclerosis related
to ionising radiation may alter the perfusion at the
wound margins, while oedema and subsequent fibro-
sis of the pelvic tissues prevent an adequate closure
of the pelvic dead space.
Patients with IBD have shown more complications
in healing perineal wounds in respect to patients
undergoing proctectomy for cancer. In fact, as shown
by Manjoney et al. [10] in their report, at 6 weeks 39%
of patients in the IBD group had completely healed in
comparison to 64% in the cancer group. Patients
affected by Crohn’s disease are at higher risk for PPS
compared to those with ulcerative rectocolitis. The
frequent involvement of the small bowel in Crohn’s
disease and the constant hypovitaminosis with mal-
absorption of ascorbate and zinc, both key elements
in enzyme activation, involved in the healing process
are possible explanations. Furthermore, the inflamed
small bowel usually becomes rigid and does not
descend to occupy the empty pelvis, leading to a per-
sistent pelvic dead space. The risk of pelvic infection
is then very much increased and fistulisation of the
remaining bowel is always of great concern. Finally,
at the time of operation, the rectal wall, hardened by
chronic inflammation, may easily tear with spillage
of content into the pelvis. Under these circumstances
infection is very likely to occur [11].
Yamamoto et al. [12] reviewed the records of 145
patients who underwent proctocolectomy for
Crohn’s disease between 1970 and 1997 and found
that PPS was present in 33 (23%) of the cases. The
factors indicated by the authors as contributing to
the significantly increased risk included the younger
age, the presence of rectal inflammation, perianal
sepsis, high fistulous tracts, extra-sphincteric exci-
sion of the rectum and fecal contamination of the
pelvis. In their experience, the surgical eradication of
the perineal sinus gave such poor results as to make
them question the usefulness of any aggressive surgi-
cal approach for perineal sinus after proctocolecto-
my for Crohn’s disease. In any case, patients should
be thoroughly informed about the possibility that
perineal complication may frequently occur [13].
Whitlow et al. [14] evaluated a series of 195 patients
all undergoing proctectomy at the Ochsner Clinic in
New Orleans from 1980 to 1996. They reported minor
wound complications in 45 (23%) patients and major
complications in 13 (7%). Diagnosis of Crohn’s dis-
ease, neoadjuvant full course radiotherapy, the pres-
ence of perineal fistulae or abscesses preoperatively
and the direct closure of the peritoneum were all fac-
tors that significantly increased the risk of wound
complication.
A persistent perineal sinus was the most common
late complication in a series of 67 patients who
underwent pouch removal after failed restorative
proctocolectomy at St. Mark’s Hospital between 1977
and 2002 [15]. After 6 months from pouch excision,
40 patients had completely healed while 27 had a PPS
that required at least another operation; at 1 year 7
patients were still unhealed.
In order to reduce the risk of perineal wound
infection and finally PPS, it is mandatory to avoid
any contamination of the pelvis during surgery. Nev-
ertheless, should any spillage of bowel content occur,
a generous washing of the pelvic cavity is not a reli-
able remedy, in this case the perineal wound should
be better dressed open. During APR, the laceration of
the rectum is more frequent when two surgical teams
are operating at the same time; for this reason Keigh-
ley [16] recommends performing the abdominal part
of the operation first, and then, while the assistant
completes the colostomy, the same surgeon carries
out the perineal dissection. The control of haemor-
rhage is essential as a careful haemostasis prevents
the formation of a pelvic haematoma and subsequent
infections. Blood pressure needs to be checked
throughout the procedure as bleeding or oozing can
be difficult to detect if the patient’s blood pressure is
Соседние файлы в папке Библиотека им академика М.И. Перельмана