Therapy of complicated Crohn's disease during pregnancy--an interdisciplinary challenge.

BACKGROUND: Severe courses of Crohn's disease (CD) during pregnancy are rare. However, if occurring, the risk of miscarriage and low birth weight is increased. At present, only limited data is available on the treatment of CD during pregnancy. In particular, there are no standard guidelines for surgical therapy. Nevertheless, surgery is often unavoidable if complications during the course of the disease arise. PURPOSE: This study provides a critical overview of conventional and interventional treatment options for CD complications during pregnancy and analyses the surgical experience gained thus far. For illustrative purposes, clinical cases of three young women with a severe clinical course during pregnancy are presented. METHODS: After treatment-refractory for conservative and interventional measures, surgery remained as the only treatment option. In all cases, a split stoma was created after resection to avoid anastomotic leaks that would endanger the lives of mother and child. The postoperative course of all three patients was uneventful, and pregnancy remained intact until delivery. No further CD specific medication was required before birth. CONCLUSIONS: The management of CD patients during pregnancy requires close interdisciplinary co-operation between gastroenterologists, obstetricians, anaesthetists and visceral surgeons. For the protection of mother and child treatment should thus be delivered in a specialised centre. This article demonstrates the advantages of surgical therapy by focusing on alleviating CD complaints and preventing postoperative complications.

Predictors of permanent ileostomy after restorative proctocolectomy.

BACKGROUND: Proctocolectomy with ileal pouch-anal anastomosis (IPAA) is a surgical approach for ulcerative colitis and familial adenomatous polyposis. This study evaluated predictors of the need for a permanent ileostomy to identify patients at high risk of IPAA failure. METHODS: This was a retrospective analysis of patients who underwent proctocolectomy and IPAA between 1997 and 2008. A logistic regression model was used for multivariable analysis of potential risk factors. RESULTS: Proctocolectomy was combined with IPAA in 185 patients, of whom 169 had a loop ileostomy formed. IPAA and ileostomy closure were successful in 162 patients (87.6 per cent). Reasons for not closing the ileostomy included pouch failure (16 patients), patient choice (5) and death (2). Thus one in eight patients had a permanent ileostomy after planned IPAA. Age was the major predictor of the need for a permanent ileostomy in multivariable analysis (P = 0.002) with a probability of more than 25 per cent in patients aged over 60 years. However, advancing age was associated with colitis, co-morbidity, obesity and corticosteroid use. CONCLUSION: The probability of the need for a permanent ileostomy after IPAA increases with age.

Abdominal resection rectopexy with an absorbable polyglactin mesh: prospective evaluation of morphological and functional changes with consecutive improvement of patient's symptoms.

BACKGROUND: The pathophysiology of rectal prolapse and intussusception has not yet been clarified. This is reflected in the multiplicity of surgical procedures. The aim of this prospective study was to measure morphological and functional changes of the pelvic floor and the rectum before and after resection rectopexy. METHODS: A total of 21 patients (mean age 60 years; 2 men, 19 women) with manifest rectal prolapse and rectoanal intussusception underwent sigmoidectomy and rectopexy with an absorbable polyglactin mesh graft. The following analyses were performed preoperatively and, on average, 15 months (range 6-21 month) postoperatively: radiologic defecography, rectal volumetry, sphincter manometry, and evaluation of clinical symptoms. RESULTS: Postoperatively there was no patient with rectal prolapse, and only one with an intussusception. Rectal compliance increased from 6.4 to 10.2 ml/mmHg. Rectal volumetry showed a decrease of the thresholds for the sensation of "desire to defecate" and "maximal tolerated volume" (100-75 ml, 175-150 ml). Postoperatively, there was a higher level of the pelvic floor during contraction. The anorectal angle, vector volume, radial asymmetry, sphincter length, and resting and squeezing pressures were unchanged. Surgery improved rectal evacuation (p = 0.03), continence (p = 0.01), stool consistency (p = 0.03), and warning period (p = 0.01). Patients' personal assessment showed an improved overall satisfaction. CONCLUSIONS: Resection rectopexy is a reliable method for treating rectal prolapse and rectoanal intussusception with clear improvement of the patient's clinical symptoms. The restored anorectal function can be attributed to improved rectal compliance, a lower sensory threshold, an elevation of the pelvic floor during squeezing, and an improved rectal evacuation.

Comparative analysis of mononuclear cells isolated from mucosal lymphoid follicles of the human ileum and colon.

Studies of human mucosal lymphoid follicles are rare and have been limited to children's Peyer's patches, which are visible at endoscopy. We investigated lymphoid follicles in ileum biopsies of 87 patients and surgical colon specimens from 66 cancer patients, and examined phenotype and function of isolated follicular immune cells. Two (0-10) and 12 (0-117) follicles per patient were found in ileum and colon samples respectively (P < 0.001). The number of lymphoid follicles mononuclear cells (LFMC) that could be isolated per patient was higher from colon compared with ileum specimens [725 000 (0-23 Mio) versus 100 000 (0-1.3 Mio), P < 0.001]. T cells were predominant in both LFMC and lamina propria mononuclear cells (LPMC), but B cells were more and plasma cells less frequent in LFMC. T cells from mucosal follicles were more frequently CD4-positive and CD62L-positive, but less frequently CD8-positive, CD103-positive and CD69-positive than lamina propria T cells. LFMC from ileum compared with colon showed no differences in mononuclear cell composition. Anti-CD3/CD28 stimulation induced similar proliferation of LFMC and LPMC from ileum and colon, as well as secretion of high levels of interferon-gamma, tumour necrosis factor-alpha and interleukin (IL)-2, but lower levels of IL-4, IL-6 and IL-10. LFMC from colon secreted more IL-2 than those from ileum. Our study shows that mucosal lymphoid follicles can be identified clearly in adult human colon and yield viable immune cells sufficient for phenotypical and functional analysis. The cellular composition of LFMC from ileum and colon is similar, and both secrete predominantly T helper type 1 cytokines.

[Surgical strategy to save ileoanal pouch reconstruction]. / Chirurgische Strategien zur "Pouch-Rettung".

Restorative proctocolectomy under formation of an ileoanal/ileorectal J­pouch has become the procedure of choice in the therapy of ulcerative colitis. Although patients experience a dramatic improvement of their quality of life, surgery is not successful in about 5-10% of all treated patients. The reasons for failure are chronic pouchitis, incontinence, delayed diagnosis of Crohn's disease, fistula, surgical complications, too long remnant rectal stump, chronic abscess, and surgical technical errors. Some of the reasons do not always prevent the loss of a well-functioning ileoanal pouch. In many cases, correction, closure of fistulas or even a complete reconstruction of the ileoanal pouch are possible. Based on a review of the literature and our own experience, we show in 887 patients a success rate of 75% with acceptable pouch function. Indications, technics, and results are presented.

[Special surgical complications in chronic inflammatory bowel diseases]. / Spezielle chirurgische Komplikationen bei chronisch entzündlichen Darmerkrankungen.

After colorectal and anorectal interventions for chronic inflammatory bowel diseases, specific complications can occur.In Crohn's disease these complications mainly occur after proctocolectomy. Pelvic sepsis can be prevented by omentoplasty with fixation inside the pelvis. A persisting sepsis of the sacral cavity can be treated primarily by dissection of the anal sphincter which ensures better drainage. In cases of chronic sacral sepsis, transposition of the gracilis muscle is a further effective option. Early recurrence of a transsphincteric anal fistula should be treated by reinsertion of a silicon seton drainage.Complications after restorative proctocolectomy are frequent and manifold (35%). The main acute complications are anastomotic leakage and pelvic sepsis. Therapy consists of transperineal drainage of the abscess with simultaneous transanal drainage. Late complications due to technical and septic reasons are still a relevant problem even 36 years after introduction of this operative technique. A consistent approach with detailed diagnostic and surgical therapy results in a 75% rescue rate of ileoanal pouches.

New aspects of surgical therapy of recurrent Crohn's disease.

Crohn's disease can neither be cured by surgery nor by medical therapy. Surgical therapy of recurrent Crohn's disease requires special precautions. The recurrence rate is 60% after 15 years. There are no certain data of the risk factors influencing the recurrence rate. The only clear facts are that wide resection out of the resection margins and smoking negatively influence recurrence. Hence, the major principles of therapy is a minimally-resected surgery. This mainly concerns strictures and stenosis. Strictures should be treated by stricturoplasty and stenosis by limited resection with Crohn-free resection margins. Just in case of interenteric and enterocutanous with a concomitant short bowel syndrome, in blind-ending fistulas with an abscess or in enterovesical fistulas, we recommend immediate operation. The therapy of recurrent anorectal Crohn's disease underlies the same rules as primary therapy. If necessary, proctectomy remains the last option. Also, emergency surgery in recurrent Crohn's disease follows the same rules as in elective surgery.

[The importance of diagnostics in faecal incontinence. Endosonography]. / Rolle der Bildgebung bei Analinkontinenz. Endosonographie.

Endoanal sonography is a well established method for the morphological diagnosis of anal sphincter damage. The best images are obtained using a 7-10 MHz rotating rigid endoprobe. The internal anal sphincter and the external anal sphincter, as well as the other pelvic floor structures, can be clearly visualised with this technique. Endosonography has shown physiological differences in sphincter anatomy and brought new insights into the pathogenesis of anorectal disorders. Apart of anal fistulas, faecal incontinence represents the main indication for the use of this method. In addition, rectal evacuation disorders are an indication for which endosonography allows a first step towards a diagnosis. Anal ultrasound is a technique friendly to both the physician and the patient, and belongs in every coloproctological unit for the assessment of faecal incontinence. Accuracy, specificity and sensitivity for the detection of anal sphincter defects range between 83 and 100% in almost all studies. Additional methods are vaginal endosonography, three dimensional endosonography and perineal sonography.

[Biofeedback in faecal incontinence]. / Biofeedback bei Analinkontinenz.

Biofeedback training is a well established method for the treatment of faecal incontinence. Prior to any biofeedback training program, a definitive diagnostic study is essential. Idiopathic faecal incontinence is the main indication for biofeedback training. Additional indications are a menacing faecal incontinence after deep anterior rectal excision with restoration of the rectal reservoir by an ileoanal pouch, anal sphincter reconstruction, rectopexy and rectocele repair. Only four studies provide evidence-based medical criteria. These, as well as numerous uncontrolled studies, show the effectiveness of biofeedback training for the treatment of faecal incontinence. Electrical stimulation of the anal sphincter is only shown to be effective in one controlled study in which it was combined with biofeedback training.

[Typical complications and their control after restorative proctocolectomy]. / Typische Komplikationen und ihre Beherrschung nach restorativer Proktocolektomie.

The overall rate of complications after ileal pouch-anal anastomosis is 60%. This rate, however, includes complications such as bowel-obstruction and hernias. Pouch-related complications occur after ileal pouch-anal anastomosis with a frequency of 15-25%. In an analysis of the recent literature the main risk factors are: tension of the ileal pouch-anal anastomosis, anastomotic leakage, lack of protective ileostomy, preoperatively undiagnosed Crohn's disease and the experience of the surgeon. We classified pouch related-complications into (1) surgical complications (leakage, bleeding, pelvic sepsis, fistulas); (2) technical problems (long S-pouch spout, rectal cuff stenosis, etc.); (3) functional problems (anal sphincter insufficiency, night incontinence, hypermotility, evacuation disorders); (4) pouchitis; (5) pouch neoplasias. Pathogenesis, diagnostic features, and medical and surgical therapy are discussed in detail. In our own series of 11 pouch-redo operations we had 6 pouch fistulas (3 related to Crohn's disease, 3 postoperative fistulas), 3 wrongly constructed pouches, 1 chronic pouchitis and 1 long S-pouch spout. In 3 cases the pouch had to be excised completely. Two patients remained with a permanent ileostomy. In 6 patients the pouch could be preserved on long term. Due to the technical complexity, the need to understand pathophysiology and the need for a differentiated diagnostic procedure, this operation should be performed only in specialised centers.

[Surgical therapy of recurrent Crohn disease]. / Chirurgische Therapie beim Rezidiv des Morbus Crohn.

The surgical therapy of recurrent Crohn's disease requires due to a recurrence rate of 60% after 15 years special precautions. The major principle of therapy is a minimal resecting surgery. This concerns mainly strictures and stenosis. Strictures should be treated by stricturoplasty and stenosis by limited resection. Recurrent fistulas should be treated conservatively. Just in case of interenteric and enterocutaneous fistula with a concomitant short bowel syndrome, in blind ending fistulas with an abscess or in enterovesical fistulas we recommend immediate operation. The therapy of recurrent anorectal Crohn's disease underlies the same rules as the primary therapy. If necessary, proctectomy remains an important option. Also emergency surgery in recurrent Crohn's disease follows the same rules as in elective surgery.

[Incontinence after ileo-anal pouch anastomosis--diagnostic criteria and therapeutic sequelae]. / Kontinenzstörungen nach ileoanaler Pouchanlage--diagnostische Kriterien und therapeutische Folgerungen.

After ileo-pouch-anal anastomosis (IPAA) there is an increased risk of incontinence due to intraoperative damage of the anal sphincter. We present a new concept to identify a potential incontinence prior to the closure of ileostomy by clinical and anal manometrical examinations. In 11 of 121 (9.1%) patients we diagnosed a potential incontinence. By biofeedback training we could achieve in this way a sufficient continence after the closure of ileostomy. After an average of 5.0 +/- 4.3 months of training rest pressures improved from 19.3 +/- 2.1 mmHg to 33.0 +/- 3.5 mmHg and squeeze pressures from 60.5 +/- 27.7 mmHg to 93.5 +/- 17.3 mmHg. Prior to IPAA patients with potential incontinence show significantly reduced rest pressures of 51.0 +/- 18.4 mmHg.

[Duodeno-caval fistula: a rare cause of upper gastrointestinal hemorrhage]. / Duodenocavale Fistel: Eine seltene Ursache einer oberen gastrointestinalen Blutung.

Non-traumatic duodenocaval fistulae are rare, but may be the source of massive gastrointestional bleeding with associated fever and sepsis. These fistulae result from penetrating duodenal peptic ulcers or right nephrectomy and subsequent radiation to the upper abdomen. The outcome depends on early diagnosis and surgery before a potentially fatal hemorrhage occurs. The therapy of choice includes closure of the fistula and repair of the duodenum and inferior vena cava. We describe the seventh case with radiogenic duodenal ulcer. Gastrointestinal bleeding occurred 10 years after radical nephrectomy and radiation (60 Gy). The patient survived following partial pancreatoduodenectomy (Whipple).

[Pelvic floor and anal incontinence. Conservative therapy]. / Beckenboden und anale Inkontinenz. Konservative Therapie.

Conservative treatment of fecal incontinence and obstructive defecation can be treated by many conservative treatment modalities. This article presents the options of medication therapy, spincter exercises, electric stimulation, transcutaneous tibial nerve stimulation, anal irrigation and injection of bulking agents. These methods are presented with reference to the currently available literature but the evidence-based data level for all methods is low. For minor disorders of anorectal function these conservative methods can lead to an improvement of anorectal function and should be individually adapted.

[Refractory inflammatory bowel disease: surgical challenges]. / Therapierefraktäre chronisch entzündliche Darmerkrankungen : Eine chirurgische Herausforderung.

Surgery for inflammatory bowel disease under immunosuppressant drugs is a widely discussed topic. Because therapeutic concepts have significantly changed, almost no patient is currently without an immunosuppressant or biologic agent prior to surgery. However, the data whether biological agents and immunosuppressant are a risk factor are very inconsistent. Concerning Crohn's disease, monotherapy with immunosuppressants or biological agents seems to have no negative influence on the postoperative results. In contrast, however, for ulcerative colitis more publications recognise biologic agents and immunosuppressants as a single therapy as a risk factor for infections. To reduce the general risk, all risk factors have to be reduced. In Crohn's disease, nutritional status must be optimised, corticoids should be reduced, biological agents and immunosuppressant drugs should be stopped, protection of an eventual anastomosis by a stoma. For ulcerative colitis in high-risk patients, a three-stage restaurative proctocolectomy is favoured to a one- or two-staged proctocolectomy.

[Acute sigmoid diverticulitis. Are operations more frequent since the introduction of laparoscopy and CT scanning?]. / Akute Sigmadivertikulitis. Wird seit Einführung der Laparoskopie und CT-Diagnostik häufiger operiert?

INTRODUCTION: Sigmoid resection is now considered as a standard procedure for acute and recurrent sigmoid diverticulitis (SD). In the last decade significant changes in preoperative diagnosis with computed tomography (CT) scanning and surgical access (laparoscopy) have been implemented. The aim of this study was to examine whether this has led to changes in the indications for surgical therapy. PATIENTS AND METHODS: Consecutive admissions of 1,154 patients from January 1995 to December 2009 with acute SD were prospectively included. In terms of pre-operative and intraoperative findings and postoperative course 3 treatment periods (TP) were distinguished: TP I 1995-1999, TP II 2000-2004 and TP III 2005-2009. RESULTS: CT scanning was used in more than 90% of cases since TP II compared to 51% during TP I (p<0.001). The ratio of emergency versus elective surgery significantly increased in favor of elective surgery (p<0.001). The rate of laparoscopy-assisted sigmoid resections showed a continuous increase from 53% in TP I to 71% in TP III (p<0.001) while the rate of Hartmann's procedures decreased over time (p<0.001). Overall, the rate of surgically treated patients decreased during the time periods studied despite an increase in the total number of patients with SD (TP III versus TP I +41%.) The rate of conservatively treated patients increased significantly (p<0.001). The morbidity rate decreased (p<0,001) whereas mortality rates remained at a constantly low level (p=0.175). CONCLUSION: The increasing use of CT diagnosis and the laparoscopic approach led to a shift from emergency surgery with a high complication rate to elective surgery with a high rate of primary restoration of continuity and low morbidity. However, the indications for surgery and therefore the overall rate of patients who underwent surgery did not increase due to these changes.

[Therapy of refractory proctocolitis and Crohn's disease. Incisionless laparoscopic proctocolectomy with a Brooke ileostomy]. / Therapierefraktäre Proktocolitis Crohn. Bergeinzisionslose laparoskopische Proktokolektomie mit Brooke-Ileostoma.

BACKGROUND: Laparoscopic colorectal surgery is nowadays also widely used in surgery of inflammatory bowel disease. With the correct indications laparoscopic surgery is an attractive cosmetic alternative for the predominantly juvenile patients. Refractory fistulizing Crohn's proctocolitis is a very severe disease with a maximal limitation on the quality of life. Proctocolectomy with a Brooke ileostomy represents a very effective option for these patients. The laparoscopic technique can at least spare the patients a salvage laparotomy incision. We report about our preliminary experiences PATIENTS AND METHOD: A total of 8 patients (mean age 25 years, range 19 Background 31 years, female:male ratio 5:3) were operated on. The mean preoperative time course of the disease was 28 months (range 12 Background 156 months). All patients had received long-term prednisolone therapy of >15mg, 2 patients received azathioprine medication, 2 underwent anti TNF-alpha therapy and 6 received 5-aminosalicylic acid (5-ASA). The mean preoperative BMI was 19 (range 15 Background 21). All patients suffered from Crohn's pancolitis with anorectal fistulas. Laparoscopic proctocolectomy was performed using 4 trocars place in a semicircular fashion. The resected tissue was salvaged transanally and the Brooke ileostomy was drained via the right lateral trocar. The terminal exit of the rectum occurred transanally with preservation of the pelvic floor and the anal sphincter and the anal fistulas were separated. The small pelvis was filled by a transanally fixed omentum. RESULTS: The median time for surgery was 236.5 mins (range 220-330 mins). A complication of postoperative paralysis of the bowel occurred in two patients and 4 patients could be discharged problem-free according to the fast-track concept. Cosmetic results were excellent in all cases. Perianal and perirectal manifestations healed completely after a median of 4 weeks. CONCLUSIONS: Incisionless proctocolectomy represents a good and realizable alternative to open surgery. The main advantages are excellent cosmetic results and a better preservation of the external integrity of the abdomen.