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Surgery and anorectal function in Crohn's colitis
Linköping University, Department of Biomedicine and Surgery, Surgery. Linköping University, Faculty of Health Sciences.
2003 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

The study concerns surgery in Crohn's disease, particularly Crohn's colitis, its relation to medical treatment, symptomatic load, perceived health, quality of life, outcome on anorectal function and also anorectal physiologic conditions.

Four hundred and thirty-two patients treated at the University Hospital, Linköping from 1970 to 1997 were included in the study. Operations and medical treatment were retrospectively reviewed, whereas symptomatic load, perceived health, quality of life, function outcome and anorectal physiology were prospectively evaluated.

In a cross-sectional analysis of all patients surveilled 1995 the annual incidence of surgery was 5.7% in a population-based cohort and 10.3% in referred patients. Medical maintenance treatment was used in 61 and 55% respectively. This led to 89% of the patients being in clinical remission or having only mild symptoms and to a large proportion with a perception of good health. The treatment was paralleled by a low rate of septic and surgical complications.

Surgical treatment of Crohn's colitis prior to 1990 mainly implied colectomy or proctocolectomy and thereafter almost exclusively segmental resection. The creation of a permanent stoma decreased and was rarely needed at the end of the study period when the annual risk was 0.23%. This development was basically due to a deliberate change in surgical attitude aiming at introducing similar treatment principles as for small bowel Crohn's disease With limited resections and preservation of transanal defecation. The reduced colectomy rate may have been facilitated by the introduction of immunosuppressive medical treatment as a reduction of colectomies tended to be associated with medical maintenance treatment during the later part of the study. Time from diagnosis to surgery was prolonged and stricture replaced active disease as the major indication for surgery. Symptomatic load and anorectal function outcome were better after segmental resection without the expense of an increased reresection rate. Seventy percent of patients with Crohn's colitis were in clinical remission and these patients scored quality of life similar to the general population but patients with active disease scored worse in all indexed aspects. The need of immunosuppression or previous surgery was not related to quality of life except when operated with a permanent stoma which negatively influenced psychological well being.

Anorectal physiology in Crohn's disease differed from controls with increased anal resting pressures and increased rectal sensitivity. This provides possible prerequisites for later development of anal pathology such as fissures and fistulas.

The study indicates that the concept oflimited surgery is applicable also in Crohn's colitis with obvious benefits for the patients. A treatment concept including medical maintenance treatment and limited resections implies that the vast majority of patients with Crohn's disease may live with only minor symptoms and minimal risk of having a permanent stoma, factors associated with a quality of life similar to that of the general population.

Place, publisher, year, edition, pages
Linköping: Linköpings universitet , 2003. , 47 p.
Series
Linköping University Medical Dissertations, ISSN 0345-0082 ; 769
National Category
Medical and Health Sciences
Identifiers
URN: urn:nbn:se:liu:diva-25547Local ID: 9994ISBN: 91-7373-526-4 (print)OAI: oai:DiVA.org:liu-25547DiVA: diva2:245877
Public defence
2003-01-24, Berzeliussalen, Hälsouniversitetet, Linköping, 09:00 (Swedish)
Opponent
Available from: 2009-10-07 Created: 2009-10-07 Last updated: 2012-09-25Bibliographically approved
List of papers
1. Low symptomatic load in Crohn's disease with surgery and medicine as complementary treatments
Open this publication in new window or tab >>Low symptomatic load in Crohn's disease with surgery and medicine as complementary treatments
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1998 (English)In: Scandinavian Journal of Gastroenterology, ISSN 0036-5521, E-ISSN 1502-7708, Vol. 33, no 4, 423-429 p.Article in journal (Refereed) Published
Abstract [en]

Background: The treatment of Crohn's disease has changed owing to the recognition of its chronicity. Medical maintenance treatment and limited resections have evolved as major concepts of management, regarded as complementary, and both aim at reducing the symptoms.

Methods: We investigated the symptomatic load in Crohn's disease as reflected in a cross-sectional study of the symptom index, physicians' assessment, and the patients' perception of health. A cohort of 212 patients from the primary catchment area and 125 referred patients were studied.

Results: Of catchment area patients, 83% were receiving medication, and the annual rate of abdominal surgery was 5.7%. Corresponding figures for the referred patients were 82% and 10.3%. According to the symptom index, 87% of catchment area patients were in remission or had only mild symptoms; according to the physicians' assessment, 90% were. The patients' median perception of health was 90% of perfect health according to the visual analogue scale. The figures were similar for referred patients, except that referrals were considered more diseased by the physician.

Conclusion: The great majority of patients with Crohn's disease are able to live in remission or experience only mild symptoms.

Place, publisher, year, edition, pages
Informa Healthcare, 1998
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-81922 (URN)10.1080/00365529850171062 (DOI)9605265 (PubMedID)
Available from: 2012-09-25 Created: 2012-09-25 Last updated: 2017-12-07
2. Surgery for Crohn colitis over a twenty-eight-year period: fewer stomas and the replacement of total colectomy by segmental resection
Open this publication in new window or tab >>Surgery for Crohn colitis over a twenty-eight-year period: fewer stomas and the replacement of total colectomy by segmental resection
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2002 (English)In: Scandinavian Journal of Gastroenterology, ISSN 0036-5521, Vol. 37, no 1, 68-73 p.Article in journal (Refereed) Published
Abstract [en]

Background: This study describes how surgery for Crohn colitis developed between 1970 and 1997, towards the end of which period limited resection and medical maintenance treatment was introduced.

Methods: A cohort of 211 patients with Crohn colitis (115 population-based), of which 84 had a primary colonic resection (42 population-based), was investigated regarding indication for surgery, the time from diagnosis to operation, type of primary colonic resection, risk for permanent stoma and medication over four 7-year periods.

Results: Comparison of the periods 1970-90 and 1991-97 revealed that active disease as an indication for surgery decreased from 64% to 25% ( P < 0.01) while stricture as an indication increased from 9% to 50% ( P < 0.001). Median time from diagnosis to operation increased from 3.5 to 11.5 years ( P < 0.01). Proctocolectomy or colectomy fell from 68.8% to 10% of the primary resections, whereas segmental resection increased from 31.2% to 90%. At the end of the first 7-year period, 26% had medical maintenance treatment, steroids or azathioprine taken by 7%. Corresponding figures for the last period were 70% and 49%. Patients diagnosed during the last two time-periods had less risk for surgery ( P = 0.017), permanent stoma ( P < 0.01) and total colectomy ( P < 0.01). Findings were similar in the population-based cohort.

Conclusions: Current management of Crohn colitis implies a longer period between diagnosis and surgery, a reduced risk for surgery and permanent stoma, and the replacement of total colectomy by segmental resection.

Keyword
Colectomy, Colitis, Crohn Disease, Population-BASED, Stoma, Surgery
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-24873 (URN)10.1080/003655202753387383 (DOI)9275 (Local ID)9275 (Archive number)9275 (OAI)
Available from: 2009-10-07 Created: 2009-10-07 Last updated: 2012-09-25Bibliographically approved
3. Segmental resection or subtotal colectomy in Crohn's colitis?
Open this publication in new window or tab >>Segmental resection or subtotal colectomy in Crohn's colitis?
2002 (English)In: Diseases of the Colon & Rectum, ISSN 0012-3706, E-ISSN 1530-0358, Vol. 45, no 1, 47-53 p.Article in journal (Refereed) Published
Abstract [en]

PURPOSE: Segmental resection for Crohn's colitis is controversial. Compared with subtotal colectomy, segmental resection is reported to be associated with a higher rate of re-resection. Few studies address this issue, and postoperative functional outcome has not been reported previously. This study compared segmental resection to subtotal colectomy with anastomosis with regard to re-resection, postoperative symptoms, and anorectal function.

METHODS: Fifty-seven patients operated on between 1970 and 1997 with segmental resection (n = 31) or subtotal colectomy (n = 26) were included. Reoperative procedures were analyzed by a life-table technique. Segmentally resected patients were also compared separately with a subgroup of subtotally colectomized patients (n = 12) with similarly limited colonic involvement. Symptoms were assessed according to Best's modified Crohn's Disease Activity Index and an anorectal function score.

RESULTS: The re-resection rate did not differ between groups in either the entire study population (P = 0.46) or the subgroup of patients with comparable colonic involvement (P = 0.78). Segmentally resected patients had fewer symptoms (P = 0.039), fewer loose stools (P = 0.002), and better anorectal function (P = 0.027). Multivariate analysis revealed the number of colonic segments removed to be the strongest predictive factor for postoperative symptoms and anorectal function (P = 0.026 and P = 0.013, respectively).

CONCLUSION: Segmental resection should be considered in limited Crohn's colitis.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-24878 (URN)10.1007/s10350-004-6113-4 (DOI)9280 (Local ID)9280 (Archive number)9280 (OAI)
Available from: 2009-10-07 Created: 2009-10-07 Last updated: 2012-09-25Bibliographically approved
4. Health related quality of life in Crohn's proctocolitis does not differ from a general population when in remission
Open this publication in new window or tab >>Health related quality of life in Crohn's proctocolitis does not differ from a general population when in remission
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2003 (English)In: Colorectal Disease, ISSN 1462-8910, E-ISSN 1463-1318, Vol. 5, no 1, 56-62 p.Article in journal (Refereed) Published
Abstract [en]

Objective  All treatment in Crohn's disease, although palliative, aims at restoring full health. The objective of this study was to compare health-related quality of life and psychosocial conditions in patients with Crohn's proctocolitis with a general population.

Patients and methods  One hundred and twenty-seven patients with Crohn's proctocolitis (median age 44 years, 44.1% men) were compared with 266 controls (median age 45 years, 50.7% men). A questionnaire consisting of the Short Form-36 (SF-36), the Psychological General Well-Being Index (PGWB) and a visual analogue scale (VAS) evaluating general health as well as questions regarding psychosocial conditions was used. Disease activity was evaluated by Best's modification of the classical Crohn's Disease Activity Index.

Results  Patients in remission had a health related quality of life similar to controls according to the SF-36 apart from general health where scores were lower (P < 0.01). Patients with active disease scored lower in all aspects of the SF-36 (P < 0.001 or P < 0.0001) as well as the PGWB (P < 0.0001). In a model for multiple regression including age, gender, concomitant small bowel disease, permanent stoma, previous colonic surgery, disease activity, duration, and aggressiveness, disease activity was the only variable negatively predicting all 8 domains of the SF-36 in the patient group (P < 0.001). The mean annual sick-leave for patients and controls were 33.9 and 9.5 days (P < 0.0001), respectively. Sixty-eight percent of the patients and 78.4% of the controls (P = 0.04) were married or cohabited, 67.7% and 78.0% (P = 0.04), respectively, had children.

Conclusion  The health related quality of life for patients with Crohn's proctocolitis in remission does not differ from the general population. The disease has, however, a negative impact on parenthood, family life and professional performance.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-24877 (URN)10.1046/j.1463-1318.2003.00407.x (DOI)9279 (Local ID)9279 (Archive number)9279 (OAI)
Available from: 2009-10-07 Created: 2009-10-07 Last updated: 2012-09-25Bibliographically approved
5. Increased anal resting pressure and rectal sensitivity in Crohn's disease
Open this publication in new window or tab >>Increased anal resting pressure and rectal sensitivity in Crohn's disease
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2003 (English)In: Diseases of the Colon & Rectum, ISSN 0012-3706, E-ISSN 1530-0358, Vol. 46, no 12, 1685-1689 p.Article in journal (Refereed) Published
Abstract [en]

PURPOSE: Anal pathology occurs in 20 to 80 percent of patients with Crohn's disease in which abscesses, fistulas, and fissures account for considerable morbidity. The etiology is not clearly defined, but altered anorectal pressures may play a role. This study was designed to investigate anorectal physiologic conditions in patients with Crohn's disease compared with healthy controls.

METHODS: Twenty patients with Crohn's disease located in the ileum (n = 9) or the colon (n = 11) without macroscopic proctitis or perianal disease were included. All were subjected to rectal examination, anorectal manometry, manovolumetry, and rectoscopy. Comparison was made with a reference group of 173 healthy controls of whom 128 underwent anorectal manometry, 29 manovolumetry, and 16 both examinations.

RESULTS: Maximum resting pressure and resting pressure area were higher in patients than in controls (P = 0.017 and P = 0.011, respectively), whereas maximum squeeze pressure and squeeze pressure area were similar. Rectal sensitivity was increased in patients expressed as lower values both for volume and pressure for urge (P = 0.013 and P = 0.014, respectively) as well as maximum tolerable pressure (P = 0.025).

CONCLUSIONS: This study demonstrates how patients with Crohn's disease without macroscopic proctitis have increased anal pressures in conjunction with increased rectal sensitivity. This may contribute to later development of anal pathology, because increased intra-anal pressures may compromise anal circulation, causing fissures, and also discharging of fecal matter into the perirectal tracts, which may have a role in infection and fistula development.

Keyword
Crohn's disease, anorectal manometry, manovolumetry, anal pathology
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-24876 (URN)10.1007/BF02660776 (DOI)9278 (Local ID)9278 (Archive number)9278 (OAI)
Available from: 2009-10-07 Created: 2009-10-07 Last updated: 2012-09-25Bibliographically approved

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