How to manage anal ulcerations and anorectal stenosis in Crohn's disease: algorithm-based decision making : French National Working Group Consensus 2018.

The French National Society of Coloproctology established national recommendations for the treatment of anoperineal lesions associated with Crohn's disease. Treatment strategies for anal ulcerations and anorectal stenosis are suggested. Recommendations have been graded following international recommendations, and when absent professional agreement was established. For each situation, practical algorithms have been drawn.

An unusual case of proctosigmoiditis secondary to arteriovenous fistulization.

Refractory chronic colitis presents a medical and surgical challenge, and underlying etiologies are diverse with potential for misclassification as inflammatory bowel disease. We present an unusual case of chronic proctosigmoiditis with rare vascular etiology. A 48-year-old Caucasian male presented with severe diarrhea, weight loss, and abdominal pain. Computed tomography (CT) suggested proctosigmoiditis. Colonoscopy and biopsy findings were non-specific but were suggestive of ischemic etiology and venous congestion. He was initially treated with antibiotics, steroids, and mesalamine, which did not show any improvement. Mesenteric angiography showed a fairly large irregular and bizarre vessel consistent with a large arteriovenous fistula (AVF) associated with one of the branches of the inferior mesenteric artery. AVF was too large to be embolized, and he underwent a laparoscopic low anterior resection with creation of a coloproctostomy and protective diverting loop ileostomy. An AVF was found at the origin of the ascending left colic artery. Inferior mesenteric vein thrombosis and arteriovenous fistulization are rare vascular causes of chronic proctosigmoiditis, but these should be considered in refractory cases. Both initial diagnosis and surgical treatment can be challenging.

Manifestaciones extraintestinales en rectocolitis úlcerativa: a propósito de un caso / Extraintestinal manifestations in ulcerative proctocolitis: a case report

La colitis ulcerativa (CU) forma más común de la enfermedad inflamatoria intestinal (EII),¹ es una enfermedad crónica que cursa con inflamación recurrente no controlada del colon,² caracterizada por ulceración de la mucosa, sangrado rectal, diarrea y dolor abdominal.³ Un tercio de los pacientes pueden desarrollar una manifestación extraintestinal.4,5 En la CU estas manifestaciones suelen estar relacionadas con la actividad de la enfermedad.5,6 Presentamos un caso clínico de una paciente con CU quien presenta manifestaciones extraintestinales cutáneas, oculares y en mucosa bucal, con resolución de las mismas posterior a tratamiento médico

Ulcerative colitis (UC) the most common form of inflammatory bowel disease (IBD),¹ is a chronic disease that causes uncontrolled recurrent inflammation of the colon,² characterized by mucosal ulceration, rectal bleeding, diarrhea and abdominal pain.³ A third of patients may develop extraintestinal manifestation.4,5 In UC these manifestations are often associated with disease activity.5,6 We present a case of a patient with UC who presented extraintestinal cutaneous, ocular and oral mucosa, with resolution of the same post-treatment

Análise da qualidade de vida pós-operatória em pacientes com reservatório ileal por retocolite ulcerativa / Quality of life of patients with ulcerative colitis after ileal pouch-anal anastomosis

A proctocolectomia total com reservatório ileal (RI) é a cirurgia mais utilizada em portadores de retocolite ulcerativa (RCUI), porém, trata-se de procedimento de grande porte, que implica em derivação intestinal temporária e elevada morbidade. A experiência adquirida ao longo do tempo evidenciou a ocorrência de várias complicações como distúrbios evacuatórios e a inflamação do reservatório ou bolsite, que podem influenciar negativamente a qualidade de vida do paciente e se contrapor às expectativas iniciais. Objetivo: avaliar a qualidade de vida pós-operatória de pacientes com RI por RCUI. Casuística e métodos: Foram avaliados 31 pacientes operados pela mesma equipe (Grupo de Coloproctologia- FCM/UNICAMP) há pelo menos 1 ano. Empregou-se questionário de avaliação inicial dirigido elaborado pelos autores com o intuito de caracterizar a população e identificar sua satisfação com a cirurgia e questionário específico validado em português para investigação da qualidade de vida após cirurgia de RI (IBDQ), composto por 32 questões que abrangem quatro dimensões: sintomas intestinais, sintomas sistêmicos, aspectos sociais e aspectos emocionais. Cada questão dentro de cada um dos domínios aferidos tem sete alternativas de respostas. Cada opção de resposta vale seu próprio número em pontos, sendo 1 pior qualidade de vida e 7 a melhor. Verificou-se assim, o total de pontos obtidos em cada domínio. Foram avaliados os percentuais com pontuação máxima e mínima para cada item avaliado. Considerou-se resultado satisfatório para as pontuações 5, 6 e 7, regular 4 e insatisfatório valores de 1 a 3.

Restorative proctocolectomy with Ileal pouch-anal anastomosis (IPAA) is the standard surgical treatment for patients with ulcerative colitis (UC), however, involves temporary ileostomy and high morbidity. The acquired experience over time showed the occurrence of various complications, such as, evacuation disturbances and the inflammation of the pouch or pouchitis, which can influence negatively the patients' quality of life (QoL) and as opposed to when compared to the initial expectations. Aim: To evaluate quality of life of patients with UC after IPAA. Patients and Methods: Thirty one patients were evaluated and underwent surgery by the same team with at least one year follow-up after surgery. An initial questionnaire was used for evaluation. It had been elaborated by qualified personnel with the purpose to characterize the patients and to identify their satisfaction with the surgery. A second questionnaire, specifically validated in Portuguese, was used to investigate the QoL after IPAA. It has 32 questions which covered four areas: intestinal and systemic symptoms, plus social and emotional aspects. Each question has seven possible answers. Each answer option has its own value; one represented the worse QoL and seven the best. For classification purposes five to seven points were considered satisfactory, four regular and one to three unsatisfactory. For quantitative analysis, the interval between the minimum and maximum punctuation of each domain were divided by 3, thus considering for physical domain scores between 46 to 54,99 as unsatisfactory, 55 to 62,99 regular, 63 to 70 satisfactory; for systemic domain, 8 to 17,99 unsatisfactory, 18 to 26,99 regular, 27 to 35 satisfactory; for social aspects, 10 to 18,33 unsatisfactory, 18,34 to 26,67 regular and 26,68 to 35 satisfactory; e for emotional aspects, 22 to 42,66 unsatisfactory, 42,67 to 63,32 regular and 63,33 to 84 satisfactory.

The incidence of bacteraemia after argon plasma coagulation in patients with chronic radiation proctocolitis.

AIM: Argon plasma coagulation (APC) is considered a safe treatment for haemorrhagic chronic radiation proctocolitis (CRPC), but bacteraemia is a rare complication. The study aimed to evaluate the frequency of bacteraemia after APC. METHOD: A prospective study of 21 patients who underwent APC (30 procedures) for CRPC was carried out. Blood cultures (Bactec(®) ) were obtained before and 30 min after the procedure (60 samples total). Patients were monitored for 48 h after the procedure to detect signs of infection. RESULTS: None of the 21 patients had fever or any sign suggestive of infection after any of the 30 sessions. All baseline blood cultures were negative and two (7%) of the 30-min blood cultures were positive (Staphylococcus hominis n = 1; Streptococcus bovis and Rhodotorula sp n = 1). The first was likely to be a contaminant and the second patient had no evidence of any other colonic disease (neoplasia or polyps) beside CRPC. CONCLUSION: APC is a low-risk procedure regarding bacteraemia and does not warrant prophylactic antibiotic administration.

Ileal pouch rectal anastomosis: a viable alternative to permanent ileostomy in Crohn's proctocolitis patients.

BACKGROUND: Ileal pouch rectal anastomosis (IPRA) is a possible alternative to permanent ileostomy when a short, normal-appearing rectal stump remains after total colectomy. Its outcomes in Crohn colitis (CC) patients have not been reported. STUDY DESIGN: CC patients who underwent IPRA from 1992 to 2004 were identified. Operative and morbidity data were collected. Functional outcomes and quality-of-life (QOL) data were obtained using a mailed questionnaire and compared with matched patients who underwent straight ileorectal anastomosis (SIRA). RESULTS: Twenty-three CC patients underwent IPRA. Perioperative complications included three pelvic septic fluid collections and five small bowel obstructions or ileus, and were treated nonoperatively. Twenty-two patients were available for longterm followup (median 98 months). Fourteen patients (64%) had disease recurrence. Two (9%) have lost a functioning anastomosis. Nine (41%) required additional operations. Matched SIRA patients had higher level of anastomosis (23.4 +/- 5.5 versus 9.0 +/- 4.1 cm above the dentate line; p < 0.0001). Bowel movement frequency (median 6.5/24 hours in both groups), incontinence, and urgency rates were similar. Nighttime seepage and pad usage were more frequent in IPRA. No differences were found in QOL parameters (Cleveland Global QOL score: 0.78 versus 0.73 [0 = worst, 1 = best], IPRA versus SIRA, respectively; p = 0.31). All patients with a functioning IPRA stated they would have their operation again if needed, and 94% would recommend it to others. CONCLUSIONS: IPRA offers durable preservation of bowel continuity and good function and QOL in selected CC patients who might otherwise require a permanent ileostomy.

Laparoscopic reversal of Hartmann's rectosigmoidectomy.

OBJECTIVE: The aim of this study was to analyse the outcome of laparoscopic restoration of bowel continuity post Hartmann's procedure. METHOD: A prospectively electronic database of colorectal laparoscopic procedures between April 2001 and December 2006 has been used to identify surgical outcomes in 28 consecutive patients who have undergone laparoscopic reversal of an open Hartmann's procedure (LRH). RESULTS: Twenty-eight patients (11 males), median age 66 (32-89), median body mass index 26 have undergone an attempted LRH over a 5-year period. Twenty (71%) had undergone surgery for complicated diverticulitis, eight (29%) for cancer; two followed an anastomotic dehiscence post-laparoscopic high anterior resection. The median operation time was 80 min (40-255 min). Twenty-six procedures (93%) were completed laparoscopically. There was one late conversion (to release a small bowel loop from the pelvis). A small, fibrotic rectal stump split whilst attempting a stapled anastomosis - the procedure was abandoned. The median time to normal diet was 18 h and median hospital stay was 3 days (1-63). There were three (11%) readmissions; wound infection (two) and abdominal pain. There were two deaths (7%) - mesenteric emboli and anticoagulant induced upper gastrointestinal haemorrhage. CONCLUSIONS: We believe that in the hands of appropriately trained and experienced surgeons, laparoscopic 'reversal' of a Hartmann's procedure is a feasible, safe and largely predictive operation that allows for early return of gastrointestinal function and very early hospital discharge.

[Predictive factors of recurrence after surgery in severe attacks of hemorrhagic ulcerative proctocolitis]. / Facteurs prédictifs de recours à la chirurgie dans la rectocolite ulcéro hémorragique en poussée grave.

AIM: The purpose of our study was to determine clinical, biological or endoscopic factors that predict surgery after a glucocortico steroid treatment failure in severe attacks of ulcerative colitis. METHODS: Sixty one patients were analyzed. A therapeutic response for glucocorticosteroid was defined as the absence of resort to surgery within the first 30 days after hospitalization. Predictive factors were assessed using univariate and multivariate analysis. RESULTS: Fifteen patients (24.6%) had a medical response. In univariate analysis, predictive factors of surgery were: male sex, tobacco, number of colitis attacks in case history, temperature over 38 degrees C, erythrocyte sedimentation rate over 30 mm, systolic blood pressure below 11, deep and wide ulcers. During the course, bowel movements/day over 7, pulse over 90/mn, temperature over 38 degrees C on day 3 after treatment initiation as well as passage of blood on day 5 were identified as predictors of surgery. In multivariate analysis, bowel movements over 7/day on day 3 of hospitalization was independently predicted a surgery. CONCLUSION: Bowel movements/day over 7 on day 3 of hospitalization was the only independently predictive factor of surgery after glucortico steroid treatment failure

Is an ileal pouch an alternative for patients requiring surgery for Crohn's proctocolitis?

BACKGROUND: Most surgeons consider Crohn's colitis to be an absolute contraindication for a continent ileostomy, due to high complication and failure rates. This opinion may, however, be erroneous. The results may appear poor when compared with those after pouch surgery in patients with ulcerative colitis (UC), but the matter may well appear in a different light if the pouch patients are compared with Crohn's colitis patients who have had a proctocolectomy and a conventional ileostomy. METHODS: We assessed the long-term outcomes in a series of patients with Crohn's colitis who had a proctocolectomy and a continent ileostomy (59 patients) or a conventional ileostomy (57 patients). The median follow-up time was 24 years for the first group and 27 years for the second group. RESULTS: The outcomes in the two groups of patients were largely similar regarding both mortality and morbidity; the rates of recurrent disease and reoperation with loss of small bowel were also similar between groups. CONCLUSIONS: The possibility of having a continent ileostomy, thereby avoiding a conventional ileostomy-even if only for a limited number of years--may be an attractive option for young, highly motivated patients.

[Surgical treatment in ulcerative rectocolitis . Analysis of a 24 years experience of 50 patients]. / Tratamentul chirurgical în rectocolita ulcerohemoragica. Analiza unei experiente de 50 de pacienti pe o perioada de 24 de ani.

Ulcerative colitis (UC) is an inflammatory bowel disease that may be cured by surgery being indicated for emergency situations resulting from complications of fulminant disease and for elective indications. We analyzed the last 24 years experience regarding 50 patients surgically treated for ulcerative colitis in the Center of General Surgery and Liver Transplantation of Fundeni Clinical Institute. The indications for surgery were: failure of medical treatment in 22 patients, acute disease with complications in 20, chronic complications in 8 cases. We used the following surgical procedures: total proctocolectomy in all 2 cases with associated rectal cancer, total colectomy with ileo-rectal anastomosis (one staged or two staged procedures) in 31, and restorative proctocolectomy in 17 cases (in all cases as a 2 or 3 staged procedure). In acute disease with complications we have performed total colectomy with terminal ileostomy, closure of the rectal stump, or exteriorization of the sigmoid stump in a mucous fistula. The gravity of acute complications does not justify the use of palliative procedures such as ileostomy, colostomy or Hartmann procedure because the mortality rate of these operations is higher than the postoperative mortality rate of total colectomy performed in emergency. Even in the elective surgery, when the patients are in a poor condition, nutritionally depleted, taking large doses of steroids or immunosuppressive drugs, we prefer the staged procedure. Total proctocolectomy is performed only in the cases of ulcerative colitis associated with rectal cancer, severe perianal disease, sphincter incontinence. Total colectomy with ileo-rectal anastomosis is indicated when the rectal stump has minimal inflammatory lesions. Restorative proctocolectomy is the surgery of choice for UC, the functional results being comparable with those of total colectomy with ileo-rectal anastomosis, but having the advantage of curing the disease. The global mortality rate was 12% (6 patients).

Short- and long-term outcomes of ileal pouch-anal anastomosis for ulcerative colitis.

UNLABELLED: Ileal pouch-anal anastomosis was an important advancement in the treatment of ulcerative colitis. The aim of this study was to determine whether early complications of ileal pouch-anal anastomosis in patients with ulcerative colitis are associated with poor late functional results. PATIENTS AND METHODS: Eighty patients were operated on from 1986 to 2000, 62 patients with ileostomy and 18 without. The early and late complications were recorded. Specific emphasis has been placed on the incidence of pouchitis with prolonged follow-up. RESULTS: The ileostomy was closed an average of 9.2 months after the first operation. Fourteen patients were excluded from the long-term evaluation; 6 patients were lost to regular follow-up, 4 died, and 4 patients still have the ileostomy. Of the 4 patients that died, 1 died from surgical complications. Early complications after operation (41) occurred in 34 patients (42.5%). Late complications (29) occurred in 25 patients as follows: 16 had pouchitis, 3 associated with stenosis and 1 with sexual dysfunction; 5 had stenosis; and there was 1 case each of incisional hernia, ileoanal fistula, hepatic cancer, and endometriosis. Pouchitis occurred in 6 patients (9.8%) 1 year after ileal pouch-anal anastomosis, 9 (14.8%) after 3 years, 13 (21.3%) after 5 years, and 16 (26.2%) after more than 6 years. The mean daily stool frequency was 12 before and 5.8 after operation. One pouch was removed because of fistulas that appeared 2 years later. CONCLUSIONS: Ileal pouch-anal anastomosis is associated with a considerable number of early complications. There was no correlation between pouchitis and severe disease, operation with or without ileostomy, or early postoperative complications. The incidence of pouchitis was directly proportional to duration of time of follow-up.

Short- and long-term outcomes of ileal pouch-anal anastomosis for ulcerative colitis

Ileal pouch-anal anastomosis was an important advancement in the treatment of ulcerative colitis. The aim of this study was to determine whether early complications of ileal pouch-anal anastomosis in patients with ulcerative colitis are associated with poor late functional results. PATIENTS AND METHODS: Eighty patients were operated on from 1986 to 2000, 62 patients with ileostomy and 18 without. The early and late complications were recorded. Specific emphasis has been placed on the incidence of pouchitis with prolonged follow-up. RESULTS: The ileostomy was closed an average of 9.2 months after the first operation. Fourteen patients were excluded from the long-term evaluation; 6 patients were lost to regular follow-up, 4 died, and 4 patients still have the ileostomy. Of the 4 patients that died, 1 died from surgical complications. Early complications after operation (41) occurred in 34 patients (42.5 percent). Late complications (29) occurred in 25 patients as follows: 16 had pouchitis, 3 associated with stenosis and 1 with sexual dysfunction; 5 had stenosis; and there was 1 case each of incisional hernia, ileoanal fistula, hepatic cancer, and endometriosis. Pouchitis occurred in 6 patients (9.8 percent) 1 year after ileal pouch-anal anastomosis, 9 (14.8 percent) after 3 years, 13 (21.3 percent) after 5 years, and 16 (26.2 percent) after more than 6 years. The mean daily stool frequency was 12 before and 5.8 after operation. One pouch was removed because of fistulas that appeared 2 years later. CONCLUSIONS: Ileal pouch-anal anastomosis is associated with a considerable number of early complications. There was no correlation between pouchitis and severe disease, operation with or without ileostomy, or early postoperative complications. The incidence of pouchitis was directly proportional to duration of time of follow-up

Results of laparoscopically assisted colon resection for carcinoma.

BACKGROUND: Surgical resection is the primary treatment for colorectal carcinoma. Laparoscopically assisted colon resection technically is feasible for both benign and malignant disease. However, the role of laparoscopically assisted colon resection for carcinoma is controversial. METHODS: We prospectively studied our first 100 patients with colorectal carcinoma who successfully underwent laparoscopically assisted colon resection for the carcinoma. RESULTS: The pathologic stages were Dukes' categories A-16, B-52, C-25, and D-7. Operative mortality and morbidity were 2% and 22%, respectively. During a mean follow-up period of 40.3 months, recurrence by stage was zero patients with stage A disease, five patients with stage B disease, nine patients with stage C disease. Thirteen of these patients died as a result of their disease. At this writing, 60 patients are alive without evidence of disease, and 23 have completed the study disease free after more than 60 months. The 5-year survival probabilities by stage were 100% for stage A, 76.8% for stage B, and 51.7% for stage C. CONCLUSIONS: Laparoscopically assisted colectomy for cancer can be performed safely. The recurrence rate after laparoscopically assisted resection appears to be at least as good as after open resection. Results from ongoing prospective, randomized trials are needed to confirm these findings.

How does pouch construction for a final diagnosis of Crohn's disease compare with ileoproctostomy for established Crohn's proctocolitis?

PURPOSE: There is a difference of opinion concerning the role of ileal pouch-anal anastomosis in Crohn's disease, even in the absence of small-bowel or perianal disease. One view is that ileal pouch-anal anastomosis should never be entertained, the other is that ileal pouch-anal anastomosis, like ileoproctostomy, can be justified sometimes, because it allows young people a period of stoma-free life. The aim of this study was to examine the outcome of ileal pouch-anal anastomosis and to contrast it with ileoproctostomy in patients with Crohn's disease without small-bowel or perianal disease. METHODS: Ileal pouch-anal anastomosis was performed in 23 patients with Crohn's disease (12 of whom had evidence of Crohn's disease at the time of operation and 11 who were eventually found to have Crohn's disease as a result of complications) and ileoproctostomy in 35. Patients were matched for age, gender, follow-up, and medication, but all ileoproctostomy cases had relative rectal sparing. Thus, the groups were not comparable and the reasons for ileal pouch-anal anastomosis and ileoproctostomy were therefore quite different. RESULTS: The outcome in ileal pouch-anal anastomosis at a mean follow-up of 10.2 years was pouch excision, 11 (47.8 percent); proximal stoma, 1 (4.3 percent; patient preference); average small-bowel resection, 65 cm; persistent perineal sinus, 8 of 11 having pouch excision (73 percent); and mean time in hospital, 37 (range, 8-108) days. Of those in circuit having ileal pouch-anal anastomosis (n = 12), 24-hour bowel frequency was 6, with no incontinence or urgency, but 6 (50 percent) were on medication. When ileal pouch-anal anastomosis was done for Crohn's disease in the resection specimen, only 4 of 12 (33 percent) were excised compared with 7 of 11 (64 percent) in whom the diagnosis was made as a result of complications. The outcome in ileoproctostomy at a mean follow-up of 10.9 years was rectal excision in 3 (8 percent), proximal stoma in 1 (3 percent), average small-bowel resection was 15 cm, persistent perineal sinus in 1 (3 percent), and time in hospital was 21 (range, 8-36) days. Of those in circuit (n = 32), 24-hour bowel frequency was 5, 2 had incontinence, 3 had urgency, and 12 (36 percent) were taking medication. CONCLUSIONS: These results indicate that the overall outcome of ileal pouch-anal anastomosis is inferior to that of ileoproctostomy, especially if Crohn's disease was diagnosed as a result of complications. Nevertheless, the functional results of those with a successful outcome are comparable.

Efficacy and safety of Nd:YAG laser for the treatment of bleeding from radiation proctocolitis.

BACKGROUND: Bleeding due to radiation proctocolitis is a frequent and severe complication of radiotherapy in cancers of the pelvis. AIM: The aim of this study was to evaluate the efficacy and safety of endoscopic treatment with Nd:YAG laser in this condition. PATIENTS AND METHODS: A series of 9 patients with radiation-induced damage in the rectum and sigma were treated with endoscopic Nd:YAG laser until significant bleeding stopped and endoscopic features of proctocolitis improved. They received a median of 3 laser treatments (range 1-10) over a maximum time period of 11 months. RESULTS: In 4 cases, bleeding ceased and, in 4, it was reduced to occasional spotting. In the remaining patient, laser therapy led to only a transient improvement, but did not modify the requirement of blood transfusion. In the 5 patients also suffering from urgency, incontinence and/or rectal mucoid discharge, the laser therapy course also relieved these symptoms. No significant treatment-related complications were observed. CONCLUSIONS: Endoscopic Nd: YAG laser is a useful and safe treatment for patients with bleeding due to radiation proctocolitis.