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Clinical impact of colectomy and ileorectal anastomosis in the management of Crohn's disease
ABSTRACTS
has been shown to induce a remission in a large number of patients with Crohn's disease. Younger patients with Crohn's disease have an increased rate of recurrence, 70% compared with a rate of 30% for those over 40. Ulcerative colitis in childhood presents fewer problems than Crohn's disease because the diagnosis is easier, proctocolectomy is curative, medical treatment is more clearly defined, and growth retardation is much less common. However, children are more likely to have active and more extensive disease than adults, with 90% of children having moderate to severe disease. Of those patients who present with fulminant colitis, only one-third will respond quickly to medical management, but the remission is short-lived and the majority come to surgery sooner rather than later. Almost every child developing toxic megacolon comes to early surgery within 48 to 72 hours. Ultimately, proctocolectomy is curative, although sphincter-saving procedures and anorectal pull-throughs are now showing encouraging results. The prognosis in Crohn's disease is in part determined by the site of the disease, in that children with ileocolic lesions fair worse than children with isolated small bowel disease not involving the duodenum. Also, patients under 20 not only have a high recurrence rate, but also have a significantly higher mortality rate than their older counterparts. The prognosis for ulcerative colitis is probably better than that reported in a large retrospective study from the Mayo Clinic (1918 1965) which found a mortality rate of 20% per decade for those in whom total colitis began in childhood. That study also found that in patients with ulcerative colitis, after the first decade, the risk of developing cancer was 20% per decade.--Richard R. Ricketts
Perianal Disease in Children and Adolescents with Crohn's
Disease. J. Markowitz, F. Daum, H. Aifes, et al. A m J Gastroentol 86:829-833, (May), 1984. One hundred forty-nine children and adolescents with Crohn's disease seen between 1972 and 1982 were reviewed with respect to the presence of perianal disease. Perianal disease was defined as, (a) anal canal lesions consisting of large, edematous skin tags and/or deep anal fissures, (b) fistulas, and (c) abscesses. Seventy-three patients (49%) had perianal disease. Patients with perianal disease had essentially the same incidence of active rectal disease as those without perianal disease (61% v 49%). However, those patients with the most severe perianal disease, fistulas, and abscesses, all had active rectal involvement. The frequency of granulomata in the rectal biopsy was significantly greater in the perianal disease group compared with the nonperianal group (30% v 9%). For patients with only fissures or tags, local care and scrupulous perianal hygiene were adequate treatment. Patients with fistulas or abscesses often required surgical therapy. Proper recognition of the perianal lesions seen in children with Crohn's disease is of clinical importance since perianal disease has preceded the development of intestinal symptoms in 10% to 25% of patients with Crohn's disease. Children with "hemorrhoids" should be suspected of having Crohn's disease and, therefore, should be evaluated appropriately.--Richard R. Ricketts
885 Clinical Impact of Colectomy and Ileorectal Anastomosis in the Management of Crohn's Disease, N.S. Ambrose,
M.R.B. Keighley, J. Alexander-Williams, et al. Gut 25:223227, (March), 1984. Sixty-three patients with Crohn's colitis were treated by colectomy and ileorectal anastomosis between 1951 and 1981. Patients were not considered for this procedure if they had several perianal disease or if the rectum was grossly abnormal. The mean follow-up since colectomy in this group of patients was 9.5 years. The cumulative recurrence rates increased with time and reached 64% at ten years. The cumulative reoperation rates also increased with time and was 48% in ten years. Recurrence developing in the ileum proximal to the anastomosis often was resected and intestinal continuity preserved, whereas anorectal recurrence usually required proctectomy. In spite of the high recurrence rate, this procedure has a useful place in restoring the chronically ill patient to good health and it avoids the morbidity of a permanent stoma, pelvic dissection, and rectal e x c i s i o n . Richard R. Ricketts Diagnosis and Treatment of Hirschsprung's Disease in
Japan. K. Ikeda, and S. Goto. A n n Surg 199:400-405, (April), 1984. A nationwide survey in Japan of 1,628 patients with Hirschsprung's Disease from 135 institutions is reported. Diagnosis was generally made by barium enema, anorectal manometry, and histochemical studies. Anorectal manometry has been used increasingly in combination with barium enema for diagnosis. Forty-eight per cent were diagnosed in the first month of life and 83.4% by the end of the first year. The overall incidence of associated anomalies was 11.1% with Down's syndrome and cardiac anomalies being the most frequent. Almost 80% of patients had aganglionosis limited to the rectum and the sigmoid colon. The incidence of total colonic with or without small bowel aganglionosis was 8.5%. The overall incidence of preoperative enterocolitis was 29.2%. Enterostomy was created in 61.3% with disease to the sigmoid, 95.5% in those with right colon extention, and 97.1% in total colonic with our without small bowel aganglionosis. Retrorectal transanal pull-through as described by Duhamel and modified by Ikeda was the most common definitive operation. The Z-shaped anastomosis described by Ikeda was used in 30.7% of all procedures. Endorectal pull-through was used in 27.6% as the definitive operation. The mortality rate was highest in patients with total calonic aganglionosis. Sepsis was the most frequent cause of death.--Richard J. Andrassy Anorectal Manometry in the Diagnosis of Hirschsprung's Disease--Comparison With Clinical and Radiological Criteria. G.A. Lanfranchi, G. Bazzocchi, S. Federici, et al. A m J
Gastroento179:270-275, (April), 1984. Thirty-four patients, 21 males and 13 females (average age: 4.8 years; range 17 days through 16 years) in whom the diagnosis of Hirschsprung's disease was suspected, were analyzed with respect to the reliability of clinical symptoms, radiological parameters, and anorectal manometry in arriv-
has been shown to induce a remission in a large number of patients with Crohn's disease. Younger patients with Crohn's disease have an increased rate of recurrence, 70% compared with a rate of 30% for those over 40. Ulcerative colitis in childhood presents fewer problems than Crohn's disease because the diagnosis is easier, proctocolectomy is curative, medical treatment is more clearly defined, and growth retardation is much less common. However, children are more likely to have active and more extensive disease than adults, with 90% of children having moderate to severe disease. Of those patients who present with fulminant colitis, only one-third will respond quickly to medical management, but the remission is short-lived and the majority come to surgery sooner rather than later. Almost every child developing toxic megacolon comes to early surgery within 48 to 72 hours. Ultimately, proctocolectomy is curative, although sphincter-saving procedures and anorectal pull-throughs are now showing encouraging results. The prognosis in Crohn's disease is in part determined by the site of the disease, in that children with ileocolic lesions fair worse than children with isolated small bowel disease not involving the duodenum. Also, patients under 20 not only have a high recurrence rate, but also have a significantly higher mortality rate than their older counterparts. The prognosis for ulcerative colitis is probably better than that reported in a large retrospective study from the Mayo Clinic (1918 1965) which found a mortality rate of 20% per decade for those in whom total colitis began in childhood. That study also found that in patients with ulcerative colitis, after the first decade, the risk of developing cancer was 20% per decade.--Richard R. Ricketts
Perianal Disease in Children and Adolescents with Crohn's
Disease. J. Markowitz, F. Daum, H. Aifes, et al. A m J Gastroentol 86:829-833, (May), 1984. One hundred forty-nine children and adolescents with Crohn's disease seen between 1972 and 1982 were reviewed with respect to the presence of perianal disease. Perianal disease was defined as, (a) anal canal lesions consisting of large, edematous skin tags and/or deep anal fissures, (b) fistulas, and (c) abscesses. Seventy-three patients (49%) had perianal disease. Patients with perianal disease had essentially the same incidence of active rectal disease as those without perianal disease (61% v 49%). However, those patients with the most severe perianal disease, fistulas, and abscesses, all had active rectal involvement. The frequency of granulomata in the rectal biopsy was significantly greater in the perianal disease group compared with the nonperianal group (30% v 9%). For patients with only fissures or tags, local care and scrupulous perianal hygiene were adequate treatment. Patients with fistulas or abscesses often required surgical therapy. Proper recognition of the perianal lesions seen in children with Crohn's disease is of clinical importance since perianal disease has preceded the development of intestinal symptoms in 10% to 25% of patients with Crohn's disease. Children with "hemorrhoids" should be suspected of having Crohn's disease and, therefore, should be evaluated appropriately.--Richard R. Ricketts
885 Clinical Impact of Colectomy and Ileorectal Anastomosis in the Management of Crohn's Disease, N.S. Ambrose,
M.R.B. Keighley, J. Alexander-Williams, et al. Gut 25:223227, (March), 1984. Sixty-three patients with Crohn's colitis were treated by colectomy and ileorectal anastomosis between 1951 and 1981. Patients were not considered for this procedure if they had several perianal disease or if the rectum was grossly abnormal. The mean follow-up since colectomy in this group of patients was 9.5 years. The cumulative recurrence rates increased with time and reached 64% at ten years. The cumulative reoperation rates also increased with time and was 48% in ten years. Recurrence developing in the ileum proximal to the anastomosis often was resected and intestinal continuity preserved, whereas anorectal recurrence usually required proctectomy. In spite of the high recurrence rate, this procedure has a useful place in restoring the chronically ill patient to good health and it avoids the morbidity of a permanent stoma, pelvic dissection, and rectal e x c i s i o n . Richard R. Ricketts Diagnosis and Treatment of Hirschsprung's Disease in
Japan. K. Ikeda, and S. Goto. A n n Surg 199:400-405, (April), 1984. A nationwide survey in Japan of 1,628 patients with Hirschsprung's Disease from 135 institutions is reported. Diagnosis was generally made by barium enema, anorectal manometry, and histochemical studies. Anorectal manometry has been used increasingly in combination with barium enema for diagnosis. Forty-eight per cent were diagnosed in the first month of life and 83.4% by the end of the first year. The overall incidence of associated anomalies was 11.1% with Down's syndrome and cardiac anomalies being the most frequent. Almost 80% of patients had aganglionosis limited to the rectum and the sigmoid colon. The incidence of total colonic with or without small bowel aganglionosis was 8.5%. The overall incidence of preoperative enterocolitis was 29.2%. Enterostomy was created in 61.3% with disease to the sigmoid, 95.5% in those with right colon extention, and 97.1% in total colonic with our without small bowel aganglionosis. Retrorectal transanal pull-through as described by Duhamel and modified by Ikeda was the most common definitive operation. The Z-shaped anastomosis described by Ikeda was used in 30.7% of all procedures. Endorectal pull-through was used in 27.6% as the definitive operation. The mortality rate was highest in patients with total calonic aganglionosis. Sepsis was the most frequent cause of death.--Richard J. Andrassy Anorectal Manometry in the Diagnosis of Hirschsprung's Disease--Comparison With Clinical and Radiological Criteria. G.A. Lanfranchi, G. Bazzocchi, S. Federici, et al. A m J
Gastroento179:270-275, (April), 1984. Thirty-four patients, 21 males and 13 females (average age: 4.8 years; range 17 days through 16 years) in whom the diagnosis of Hirschsprung's disease was suspected, were analyzed with respect to the reliability of clinical symptoms, radiological parameters, and anorectal manometry in arriv-