Surgical Management of IBD Emergencies: the Approach in a Peripheral Hospital

(1)

Introduction

The most common complications of inflammatory bowel disease (IBD) requiring emergency treatment are toxic colitis, perforation, toxic megacolon, bleeding, 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 centres may be hazardous. This contribution gives true insight into the surgical management of IBD emergencies 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 emergencies, 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 presented 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 developed another psoas abscess. Therefore, besides abscess drainage, an ileocecal resection was performed. Since then, the patient is doing well. Four patients with CD underwent urgent ileocecal resection for intestinal obstruction. In three of them the obstruction was associated with the abscess formation; in one it was associated with an enteroenteric fistula. 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 complications. 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, developed 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 5.2 2.3

rates per 100 000 per year

Rates computed after correcting 6.8 2.8 underestimation

Sex ratio M/F 1.7 1.0

Highest age specific 30-39 20-29

incidence rates years years

(2)

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 rectovaginal 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 obstruction

1989: diagnosis of CD 1998: abscess, enteroenteric fistula and bowel obstruction 2002: psoas abscess (diagnosis 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 carcinoma

Colectomy, end-ileostomy and mucous fistula.

Some months later ileo- anal-pouch

Several operations for perianal- and abdominal-wall fistula

2000: end-ileostomy Laparoscopic appendectomy

Subtotal colectomy, ileo- rectal anastomosis

2001: end-ileostomy

Fistulectomy

Ileal resection and end-to- anastomosis

Appendectomy

Ileocecal resection, abscess drainage relaparotomy for multiple intraperitoneal abscesses 7 days later

1998: ileocecal resection

Drainage, ileocecal resection, re-resection of terminal ileum, abscess drainage

Cecostomy, medical treatment

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 perianal 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 treatment until now

Azothioprin-induced pan- creatitis

Improvement of perineal CD, no evidence for rectovaginal fistula and duodenal CD today

No recurrence of perianal CD

No further surgical therapy

Enterocutaneous fistula for 5 months. Actually on medical treatment without complaints

Good state of health without medical treatment, 2 child- births

Actually on medical therapy without complaints

No evidence for IBD in the right colon and in the rectum

Abdominal wall rupture, stomal problems, rectal stump failure, sepsis, death after two months of intensive care

Actually on medical therapy without complaints Died after right hemicolectomy in his reference hospital

(3)

These symptoms could be successfully managed by an ileostomy. Another patient underwent subtotal colectomy and ileo-rectal anastomosis for Crohn’s disease.

One year later, severe anal CD developed postoperatively with perianal und rectovaginal fistula formation. 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 intestinal 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 disease. 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 postoperative 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 history of duodenal ulcer disease and therefore he underwent 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 frequent 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 “fistulising”, 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 intraabdominal 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 permanent 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 management 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 experience 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 complication of Crohn’s disease, occurring in 5–10% of women [10]. The management of rectovaginal fistulae 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 faecal diversion applied on its own in perianal Crohn’s disease remains unclear. Many perianal lesions, par- ticularly ulcers and fistulae, heal completely without

(4)

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 usually 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 ulcerative 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 intraabdominal 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 therapy 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 multiple 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 suggested 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 complication 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 “fulminant” 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 surgeons. Prompt surgery is indicated for patients with

(5)

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 medical 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 decompression 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 several 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 obstruction is the most common complication requiring surgical 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 intestinal obstruction in Crohn’s disease is medical therapy. Obstruction that is unresponsive to medical treatment 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 complicated” [40]. Extended resection margins confer no advantage to patients in reducing cumulative recurrence 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 compared with ulcerative colitis, where bleeding may diffuse 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 bleeding 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 literature were reviewed [45]. Five patients died, in 30 (90%) surgery was necessary to cease haemorrhage and ileocolectomy was the most frequently performed 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 disease, the largest to date, shows a more favourable result [46]. Acute haemorrhage was defined as acute rectal bleeding originating in diseased bowel, requiring a transfusion of at least 2 units of red blood cells within 24 h. Upper gastrointestinal tract haemorrhage 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 gastrointestinal bleeding in cases of bleeding colonic diverticular disease and angiodysplasia. This approach may be useful for bleeding in Crohn’s disease 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

(6)

toxic colitis or megacolon [28]. Its occurrence without 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 incidence of 13% in 1995. Such different incidence rates are due to the fact that in some reports, abscess formation 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 perforation 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 resulted from a conservative medical approach. Perforative Crohn’s disease is accompanied by more postoperative 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 cancer 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 population. Four patients with bowel perforation

because of carcinoma in Crohn’s disease are described in the literature [61, 62]. In case of a conservative 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 hemicolectomy 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 laparoscopic 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 management 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 hospitals, 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 perforation 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 ulcerative colitis. During recent decades, specialised centres have been created where a team of skilled surgeons, 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,

(7)

bowel perforation, bleeding, and intestinal obstruction, 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 surgical 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 manifestation 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 emergency situations, or better, before these develop, are made in an interdisciplinary way. For instance, every patient with IBD should be evaluated by the gastroenterologist and the surgeon together at the time of the initial hospital admission and at every read- mission thereafter.

Histologic examination of biopsies may be hazardous. A proven diagnosis of Crohn’s disease is generally seen as precluding ileal pouch-anal anastomosis. 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 gastroenterologist 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 emergencies. 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 population-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 permanent 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 treatment. 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 evaluation 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 disease. 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 placement. Inflamm Bowel Dis 9:98–103

18. Schwartz DA, Herdman CR (2004) The medical treatment 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

(8)

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 complications. 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 disease: 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 disease in the small bowel: a randomized controlled trial.

Ann Surg 224:563–573

42. Park R, Roger V, Penna C (1999) Management of hemorrhage. 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-threatening 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 perforation 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 liberal approach to the surgical treatment of Crohn’s disease. 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 perforated 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 literature. 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 perforation due to colonic adenocarcinoma in Crohn’s disease. 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