title: Sphincter-sparing intersphincteric rectal resection as an alternative to proctectomy in long-standing fistulizing and stenotic Crohn's proctitis?
abstract: OBJECTIVE
  Long-standing fistulizing and stenotic proctitis (LFSP) in Crohn's disease (CD) indicates the end stage of the disease. Definitive diversion such as proctectomy is considered to be the only surgical option. The impact of intersphincteric sphincter-sparing anterior rectal resection (IAR) as an alternative to proctectomy is unclear. The aim of this study was to evaluate feasibility, morbidity, outcome, and quality of life (QL) in patients with LFSP undergoing intended IAR.
  
  
  METHODS
  Out of a single institution database, 15 patients with LFSP intended for surgery from 856 patients with CD were selected for follow-up analyses.
  
  
  RESULTS
  In 12/15 cases, IAR was carried out while 3/15 patients underwent primary proctectomy due to malignancy (n = 2) or due to patient's wish (n = 1). In one case, IAR revealed unexpected malignancy, which led to secondary proctectomy. In patients with IAR, complete healing of fistulas and stenosis was observed in 46% (n = 5) while 36% (n = 4) of patients showed relapse of fistula and 18% (n = 2) developed restenosis. Ileostomy closure was performed in seven patients from which six patients remained stoma free. QL and fecal incontinence measured by standardized scoring systems were unchanged while stool frequency was reduced after IAR in patients with ileostomy closure. The rate of malignancy in this cohort was 20% (n = 3).
  
  
  CONCLUSIONS
  LFSP in CD was associated with 20% of malignant transformation. Although IAR fails to improve QL, it is a suitable procedure for the treatment of fistulas and stenosis associated with acceptable healing rates and can avoid a permanent stoma.
authors.affiliation: Department of General-, Visceral-, Vascular and Pediatric Surgery, University Hospital Wuerzburg, Oberdürrbacherstraße 6, 97080, Wuerzburg, Germany, Schlegel_N@ukw.de.
authors.forename: Nicolas
authors.initials: N
authors.lastname: Schlegel
authors.forename: Mia
authors.initials: M
authors.lastname: Kim
authors.forename: Joachim
authors.initials: J
authors.lastname: Reibetanz
authors.forename: Katica
authors.initials: K
authors.lastname: Krajinovic
authors.forename: Christoph-Thomas
authors.initials: CT
authors.lastname: Germer
authors.forename: Christoph
authors.initials: C
authors.lastname: Isbert
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D001003:Anal Canal / Q000473:pathology / Q000601:surgery*; D003424:Crohn Disease / Q000150:complications / Q000175:diagnosis / Q000601:surgery*; D016208:Databases, Factual; D018450:Disease Progression; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007081:Ileostomy / Q000379:methods; D008297:Male; D008875:Middle Aged; D059351:Organ Sparing Treatments; D011349:Proctitis / Q000150:complications / Q000175:diagnosis / Q000601:surgery*; D016737:Proctocolectomy, Restorative / Q000009:adverse effects / Q000379:methods; D011788:Quality of Life; D012003:Rectal Fistula / Q000150:complications / Q000175:diagnosis / Q000601:surgery*; D012007:Rectum / Q000601:surgery*; D012086:Reoperation / Q000379:methods; D012189:Retrospective Studies; D012307:Risk Factors; D012720:Severity of Illness Index; D016896:Treatment Outcome; D055815:Young Adult
references.citation: Ann Med. 2001 Jul;33(5):337-43
references.pmid: 11491192
references.citation: Br J Surg. 1983 Sep;70(9):519-21
references.pmid: 6616154
references.citation: Dig Liver Dis. 2007 Oct;39(10):957-8
references.pmid: 17723323
references.citation: J Crohns Colitis. 2010 Feb;4(1):28-62
references.pmid: 21122489
references.citation: Dis Colon Rectum. 2000 Jan;43(1):9-16; discussion 16-7
references.pmid: 10813117
references.citation: Scand J Gastroenterol. 2002 Jan;37(1):68-73
references.pmid: 11843039
references.citation: Int J Colorectal Dis. 2009 May;24(5):521-6
references.pmid: 19172284
references.citation: Aliment Pharmacol Ther. 2011 Jan;33(1):5-22
references.pmid: 21083581
references.citation: Ann Surg. 2005 May;241(5):796-801; discussion 801-2
references.pmid: 15849515
references.citation: Ann Surg. 2008 Oct;248(4):608-16
references.pmid: 18936574
references.citation: Cancer. 1981 Dec 15;48(12):2742-5
references.pmid: 7306930
references.citation: Dis Colon Rectum. 1993 Jan;36(1):77-97
references.pmid: 8416784
references.citation: Arch Surg. 1986 Oct;121(10):1187-90
references.pmid: 3767650
references.citation: Am J Gastroenterol. 1999 Sep;94(9):2337-9
references.pmid: 10483989
references.citation: Colorectal Dis. 2003 Sep;5(5):490-5
references.pmid: 12925087
references.citation: Ann Surg. 2012 May;255(5):922-8
references.pmid: 22504191
references.citation: Ann Intern Med. 2001 Nov 20;135(10):906-18
references.pmid: 11712881
references.citation: Dis Colon Rectum. 1992 Aug;35(8):768-72
references.pmid: 1644001
references.citation: Aliment Pharmacol Ther. 2003 May 1;17(9):1145-51
references.pmid: 12752351
references.citation: Z Gastroenterol. 2008 Sep;46(9):1094-146
references.pmid: 18810679
references.citation: Dis Colon Rectum. 2007 Dec;50(12):2067-74
references.pmid: 17680311
references.citation: Gastroenterology. 2003 Nov;125(5):1503-7
references.pmid: 14598267
references.citation: Inflamm Bowel Dis. 2010 Oct;16(10):1643-8
references.pmid: 20186945
references.citation: Colorectal Dis. 2011 Feb;13(2):171-6
references.pmid: 19863597
references.citation: J Gastrointest Surg. 2007 Apr;11(4):529-37
references.pmid: 17436140
references.citation: J Gastrointest Surg. 2010 Jan;14(1):66-73
references.pmid: 19826882
references.citation: Gut. 1980 Dec;21(12):1024-9
references.pmid: 7461462
references.citation: J Pediatr Gastroenterol Nutr. 2013 Sep;57(3):401-12
references.pmid: 23974063
references.citation: Surg Gynecol Obstet. 1989 Jan;168(1):42-8
references.pmid: 2909131
references.citation: World J Surg. 2000 Oct;24(10):1258-62; discussion 1262-3
references.pmid: 11071472
references.citation: Aliment Pharmacol Ther. 2006 Apr 15;23(8):1097-104
references.pmid: 16611269
references.citation: Am J Surg. 1980 Nov;140(5):642-4
references.pmid: 7435823
references.citation: Am Surg. 2008 Jan;74(1):59-61
references.pmid: 18274431