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317
22 Perianal Crohn’s Disease
In the end, all of the decisions made after perianal Crohn’s sepsis control with a
seton require a careful discussion about the pros and cons of each choice (Box 22.7 ).
22.6 Finally: Three Didactic Points on the Failed Bottom
22.6.1 Recognition
Pain, pads, and incontinence defi ne the failed or failing bottom. It is clearly a diffi -
cult conclusion for a patient to reach – but it is has to be the patient’s prerogative
(and not the surgeon’s) to recognize when this point has been reached.
22.6.2 Diversions Are (Usually) Forever
Diversion in a patient with severe symptomatic perianal Crohn’s fi stulation is associ-
ated with a signifi cant improvement in the quality of life for the patient [ 26 ] . But it is
important for the patient offered diversion to realize that it is very likely that the divert-
ing stoma is for good – barely 10% of patients return to intestinal continuity [ 27 ] . In the
large majority of perianal Crohn’s disease patients in whom faecal diversion is required
for symptoms, the diverting stoma is very often a stepping stone to proctectomy.
22.6.3 Proctectomy for Severe PCD: Perineal Reconstruction
Proctectomy in the setting of severe perianal Crohn’s disease is associated with very
poor perineal healing in 35–40% of patients [ 28 ] . While in some patients, the end
result is simply an occasional perineal discharge, in others the nonhealing perineal
wound can reestablish considerable discharge and sepsis. Reconstruction with a
Box 22.7: Long-Term Seton or Infl iximab in Perianal Crohn’s
Pro Con
Seton forever Safe for continence Palliative
Keeps abscess free Discharge and discomfort
Embarrassment potential
Seton out – fl ap Offers cure with
continence
Only for selected patients
Nearly 60% fail
Seton out – mainte-
nance infl iximab
Not an operation,
continence safe
Palliative
Infusion
Rare but devastating morbidity
Cost
318
N. Scott
vertical rectus myocutaneous fl ap [ 29 ] or gracilis myocutaneous fl ap should be con-
sidered in cases of bad PCD at the time of proctectomy. Because of this eventuality,
transverse abdominal incisions in the young Crohn’s disease patients, as they com-
promise future rectus muscle fl ap use, should be avoided.
Key Points
Scenario Options
Minimal disease/minimal
symptoms
Minimal intervention
? Long-term antibiotics
Warn of metronidazole peripheral
neuropathy
Severely painful disease but
no abscess
• Anal ulcer Depo-Medrone local injection
• Highly destructive perianal
Crohn’s disease
Azathioprine/infl iximab
Defunction (proctectomy/
reconstruct)
Symptomatic fi stulae with sepsis
• Initial management Drain collection
Draining seton, not fi stulotomy, in
most cases
• Seton control established Take it out – 80% will recur
Long-term seton – safe if inconvenient
? Glue/plug/fl ap – uncertain
outcomes
Remove and maintenance infl iximab
Cost, uncertain morbidity? helps 50%
• Sepsis control poor Defunction (proctectomy/reconstruct)
Failing/failed bottom Recognize with patient
Defunction – improves QoL, rarely
reversed
Proctectomy – if done for severe
PCD often needs reconstruction
Case Scenario Answers
(a) False
(b) True
(c) False
(d) False
(e) False
319
22 Perianal Crohn’s Disease
References
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in Crohn’s disease. World J Gastroenterol. 2009;15(34):4263–72.
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come following loose-seton technique for external sphincter preservation in complex anal fi s-
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12. Thornton M, Solomon MJ. Long-term indwelling seton for complex anal fi stulas in Crohn’s
disease. Dis Colon Rectum. 2005;48:459–63.
13. Schwandner O, Stadler F, Dietl O, Wirsching RP, Fuerst A. Initial experience on effi cacy in
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ized, controlled trial of fi brin glue vs. conventional treatment for anal fi stula. Dis Colon
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Korzenik JR, Lashner BA, Onken JE, Rachmilewitz D, Rutgeerts P, Wild G, Wolf DC, Marsters
PA, Travers SB, Blank MA, van Deventer SJ. Infl iximab maintenance therapy for fi stulizing
Crohn’s disease. N Engl J Med. 2004;350(9):876–85.
17. Present DH, Rutgeerts P, Targan S, Hanauer SB, Mayer L, van Hogezand RA, Podolsky DK,
Sands BE, Braakman T, DeWoody KL, Schaible TF, van Deventer SJ. Infl iximab for the treat-
ment of fi stulas in patients with Crohn’s disease. N Engl J Med. 1999;340(18):1398–405.
18. van Bodegraven AA, Sloots CEJ, Felt-Bersma RJF, Meuwissen SGM. Endosonographic evi-
dence of persistence of Crohn’s disease-associated fi stulas after infl iximab treatment, irrespec-
tive of clinical response. Dis Colon Rectum. 2002;45:39–46.
19. Van Assche G, Vanbeckevoort D, Bielen D, Coremans G, Aerden I, Noman M, D’Hoore A,
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of infl iximab on perianal fi stulizing Crohn’s disease. Am J Gastroenterol. 2003;98(2):332–9.
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22. Regueiro M, Mardini H. Treatment of perianal fi stulizing Crohn’s disease with infl iximab
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2003;9(2):98–103.
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Does infl iximab infusion impact results of operative treatment for Crohn’s perianal fi stulas?
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of complex fi stulating anal Crohn’s disease. Colorectal Dis. 2004;7(2):164–8.
26. Kasparek MS, Glatzle J, Temeltcheva T, Mueller MH, Koenigsrainer A, Kreis ME. Long-term
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27. Yamamoto T, Allan RN, Keighley MR. Effect of fecal diversion alone on perianal Crohn’s
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disease: postoperative complications and recurrence. Dis Colon Rectum. 2000;43:249–56.
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321
S.R. Brown et al. (eds.), Contemporary Coloproctology,
DOI 10.1007/978-0-85729-889-8_23, © Springer-Verlag London Limited 2012
Nutritional status is an important independent variable infl uencing outcome from
surgery. Malnourished patients do less well after surgery. They have higher mortal-
ity rates, more complications, longer lengths of stay, and cost more to treat. A large
number of studies have shown a relationship between nutritional status and clinical
outcome following surgery. As long ago as 1936, a tenfold difference in mortality
after gastrectomy was demonstrated when severely malnourished and more nor-
mally nourished patients were compared [ 1 ] . Many more recent studies have shown
marked increases in postoperative morbidity and mortality after gastrointestinal sur-
gery in severely malnourished patients and moreover that they stay in hospital sig-
nifi cantly longer at substantial extra cost. These fi ndings have been reproduced
consistently across surgical specialties and are particularly relevant in colorectal
surgery (Box 23.1 ).
C. J. Walsh , M.Ch., FRSCI
Department of Surgery ,
Wirral NHS Trust, Arrowe Park Hospital ,
Arrowe Park Road, Upton ,
Wirral , UK
e-mail: ciaran.walsh@nhs.net
Chapter 23
Surgical Nutrition
Ciaran J. Walsh
Box 23.1: Effect of Malnutrition on Surgical Outcome
Increased mortality
Increased postoperative septic complications
Prolonged hospital stay
Increased cost of hospitalization
322
C.J. Walsh
Nutritional support of surgical patients is a fundamental component of surgical
management. Surgeons need to understand the effect of suboptimal nutritional sta-
tus on surgical outcomes. They also need to know how to manipulate the nutritional
intake of their patients to optimize their outcome. It is established that correcting
nutritional defi cits leads to improved outcomes [
2 ] . Moreover, it is also now estab-
lished that normally nourished patients can have their surgical outcome improved
by manipulating their nutritional intake immediately before surgery if carried out in
conjunction with the other principles of an enhanced recovery protocol. Surgery is
by defi nition a craft specialty, and many surgeons still channel most, or all, of their
energy into the craft of surgery in an attempt to get best outcomes for their patients
without fully appreciating that this alone will not achieve the fi rst-class results they
want and expect.
Malnutrition, even when not accompanied by disease, tends to cause apathy,
depression, self-neglect, and impaired mental, physical, and immune function with
deterioration in social interactions. When combined with the catabolic effects of
illness and surgery as well as the impaired wound healing, reduced muscle strength,
and impaired thermoregulation often seen in the elderly, the scene is set for an
increased incidence of postoperative complications and poorer surgical outcomes in
many of our colorectal patients (Box
23.2 ) .
23.1 Incidence and Prevalence of Malnutrition
Malnutrition is common among hospitalized patients. Up to 40% of consecutive
adult admissions to a British teaching hospital were malnourished (body mass index
<20) in a 1994 study [ 4 ] . Some 8% of these were seriously malnourished. There is
no reason to think things are different today with the notable exception of the tidal
wave of morbid obesity. This can make identifi cation of malnutrition more com-
plex, and it needs to be remembered that morbidly obese patients may become
acutely undernourished.
In 1995, Giner et al. found 44% of surgical patients to be malnourished [ 5 ] , and
in 2002, Fettes et al. suggested 9% of patients admitted for GI surgery were mal-
nourished [ 6 ] .
Signifi cant weight loss is not the norm in most colorectal cancer patients with
early-stage disease undergoing elective surgery. While this may be true, this should
not defl ect one from the fact that weight loss has been shown to be associated with
less good outcomes in colorectal cancer surgery, and a recent study from Manchester
Box 23.2: Enhanced Recovery After Surgery
In spite of a large evidence base for perioperative care aiming to alleviate post-
operative catabolism and organ dysfunction, surgical patients remain exposed
to unnecessary starvation , suboptimal stress reduction and fl uid overload [ 3 ] .
323
23 Surgical Nutrition
demonstrated malnutrition (defi ned as loss of 10% or more of normal body weight)
in 20% of their study cohort of colorectal cancer patients [ 7 ] . Rectal cancer patients
having long-course neoadjuvant chemoradiotherapy are also at risk of weight loss.
Furthermore, 20–25% of colorectal cancer patients present as an emergency, and
they are highly likely to have signifi cant nutritional problems. Retrospective epide-
miological data suggest malnutrition occurs in up to 40% of patients with advanced
colorectal cancer [
8 ] . Clinically relevant malnutrition is clearly not just in the
domain of colorectal cancer. In Crohn’s disease, 60–80% of patients have weight
loss, and even in the absence of active disease, 20% of patients are more than 10%
below their ideal body weight (Box 23.3 ).
We are dealing with an increasingly elderly population, and it is absolutely com-
monplace to perform major colorectal resections for malignancy in octogenarians.
Malnutrition is much more common in the elderly, particularly the institutionalized
elderly. In the USA, it is estimated that malnutrition is prevalent in 5–12% of US
elderly in the community, 55% of hospitalized US elderly, and 52–85% of institu-
tionalized elderly. In the UK, it has been shown that octogenarians are much more
likely to be malnourished than younger patients [ 9 ] (Box 23.4 ).
It is readily apparent from these data that a signifi cant minority of the colorectal
patients we operate on are malnourished and will have poorer than expected out-
comes as a result.
It is therefore imperative that nutritional assessment and correction should be an
integral part of the care of all colorectal patients and elderly patients in particular.
Box 23.3: Malnutrition in Surgical Patients
27% of general surgical admissions were malnourished. Two-thirds were
moderately or severely malnourished. BMJ 1994
44% of surgical patients were malnourished. Nutrition 1996
9% of patients admitted for GI surgery were malnourished. Clin Nutr 2002
20% of colorectal cancer patients were malnourished. J Hum Nutr Diet 2010
Up to 40% of patients with advanced colorectal cancer were malnourished. J
Clin Epidemiol 2006
Box 23.4: Malnutrition in the Elderly
Patients over the age of 80 years admitted to hospital have a fi ve times
higher prevalence of malnutrition than those under 50 years of age.
BAPEN 2003, Age Concern 2006
324
C.J. Walsh
23.2 Recognizing Malnutrition
The fi rst step is recognizing the malnourished patient. In the fi rst instance, this is a
corporate responsibility. There should be formal nutrition screening of all admis-
sions using a validated nutrition screening tool such as MUST (malnutrition univer-
sal screening tool) or similar. Core systems need to be in place within the hospital,
ideally with a nutrition steering group, an adequately funded dietetic department,
and a nutrition support team, all of which will enable the detection and management
of malnourished patients. It is tempting for surgeons to opt out of the responsibility
of ensuring that these core services are established, but ultimately their patient out-
comes are their responsibility, and they need to commit some of their energy to
ensuring that appropriate services are in place for their patients (Box
23.5 ).
Within this formal nutritional care framework of a hospital, an individual sur-
geon needs to be able to recognize patients who are undernourished or at risk of
undernutrition. They then need to involve the relevant nutritional support service, be
that the outpatient or ward dietician or the hospital nutrition support team. NICE
have defi ned malnutrition as a state in which a defi ciency of nutrients such as energy,
protein, vitamins, and minerals causes measurable adverse effects on body compo-
sition, function, or clinical outcome [ 2 ] . There is no simple standardized defi nition
of malnutrition that works in clinical practice, and as a result, a lot of different sur-
rogate markers and defi nitions have been used (Box 23.6 ).
Box 23.6: Identifying Malnutrition
Weight loss
Body mass index
Triceps skin fold thickness
Handgrip strength
Immune competence
Serum proteins
Nutrition risk index
Subjective global assessment
Box 23.5: Identifying Malnutrition: Corporate Responsibilities
Trust nutrition steering group
Appropriately funded dietetic department
Validated nutrition screening tool
Nutrition support team
Ongoing education and training
CG032 NICE Guideline Feb 2006
325
23 Surgical Nutrition
In busy clinical practice, there are a number of simple ways of recognizing clini-
cally relevant malnutrition without resorting to time-consuming assessments or
anthropometric measurements. A history of weight loss of 10% or more of body
weight in the preceding 3 months and/or body mass index less than 18.5 are com-
monly used. Less obvious but equally simple is handgrip strength whether assessed
informally or formally using a dynamometer. It has been shown that handgrip
strength of preoperative patients (a measure of protein at work) can accurately pre-
dict postoperative complications [
10, 11 ] (Box 23.7 ).
Of course, serum protein levels such as albumin or prealbumin may theoretically be
associated with nutritional status, but in day to day colorectal surgical practice serum,
albumin should be regarded as a negative acute-phase protein and not a marker of nutri-
tional status. An increase in serum levels of C-reactive protein (CRP) is a general marker
for infl ammation. CRP is an acute-phase protein synthesized by hepatocytes and is a
component of the innate immune response to trauma, infections, burns, tissue infarction,
infl ammatory processes, and tumors brought about by cytokines. A perfectly well-nour-
ished patient with a normal preoperative CRP and serum albumin has an uncomplicated
elective open anterior resection in the confi nes of an enhanced recovery program. They
are tolerating diet on day one post-op, and on day two post-op, they are very well clini-
cally, but their CRP is 130 and albumin is now 30. They have not become acutely mal-
nourished! Albumin is a negative acute-phase protein. Think of it as 1/CRP.
On the other hand, a patient with nearly terminal anorexia nervosa may have a
normal serum albumin. Interestingly, much of the well-documented association
between hypoalbuminemia and poor surgical outcomes, including an increased inci-
dence of anastomotic leaks in colorectal surgery [ 12, 13 ] , previously attributed to
malnutrition, may actually be a refl ection of surgery performed on a patient who has
already mounted an acute-phase response. There is a well-documented association
between high preoperative serum CRP levels and poor outcome from colorectal can-
cer surgery. Nonetheless, weight loss is also independently associated with an
increased incidence of anastomotic leakage in colorectal surgery. It is therefore dif-
fi cult to tease out what the true interpretation of hypoalbuminemia is in this context.
23.3 Micronutrient Defi ciency
The term malnutrition is often thought of in the context of macronutrients and pro-
tein calorie malnutrition and does not take into account the impact of micronutrient
defi ciency. Micronutrients such as vitamins, minerals, and trace elements are critical
Box 23.7: Detection of Clinically Relevant Malnutrition
Handgrip strength below the normal for age and sex accurately predicts post-
operative complications.
326
C.J. Walsh
cofactors in many biochemical pathways and, as a result, are critical for normal
metabolism and organ function [ 14 ] . A patient may not have lost weight or have a
reduced BMI yet, due to a very poor quality diet, may have signifi cant micronutrient
defi ciencies. Vitamin C, for example, is essential for wound healing as a result of its
role in hydroxylation of proline residues in collagen. Vitamin C defi ciency is very
common in the elderly and prevalent in up to 40% of the institutionalized elderly.
Older age and poor diet are not the only factors as intestinal disease per se, with or
without previous surgery, that may lead to various different micronutrient defi cien-
cies. This is typically seen in Crohn’s disease where micronutrient defi ciency is all
too common (Box
23.8 ) .
23.4 Correcting Malnutrition
It has been well demonstrated that improving the nutritional status of a malnour-
ished patient preoperatively can improve outcome [ 15 ] . Arguably, most important
of all is the fact that it has been demonstrated that optimizing a malnourished
patient’s nutrition postoperatively will also lead to an improved outcome. This was
very nicely shown by tube feeding malnourished patients postoperatively following
emergency surgery for fractured neck of femur and fi nding that they did signifi -
cantly better than malnourished patients who had not been fed in this way and that
outcomes approximated those seen in well-nourished patients [ 16 ] . While this is an
old study in orthopedic patients, these data are fundamentally important because
they demonstrate that manipulating a patient’s nutritional intake after the insult can
alter outcome in the patient’s favor. Other studies have shown that nutritional sup-
port leads to improved wound healing, improved immune response, reduced septic
complications, and improvement in skeletal, respiratory, and cardiac muscle
strength. In essence therefore, one can improve outcome for undernourished patients
by improving their nutritional status both before and after surgical intervention.
This is clearly important as not all colorectal patients undergo elective surgery, and
potential improvements in outcome due to nutritional therapy are not restricted to
this elective group. Interestingly, while severe malnutrition is associated with
increased mortality from surgery, and there is evidence that correcting malnutrition
reduces morbidity, there are no convincing data that correcting nutritional defi cits
reduces mortality.
Box 23.8: Micronutrient Status in Crohn’s Disease
Iron defi ciency in 20–40%
Folate defi ciency 30%
Zinc defi ciency in 40% after ileal resection
B
12
defi ciency after terminal ileal resection
Selenium defi ciency
Reduced fat-soluble vitamins and bile salt pool
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