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Complex Anorectal Crohn's Disease: Improving Quality of Life Through Abdominoperineal Resection
Tamar B. Nobel*, Jordan A. Munger, Matthew Sgouros, Joel Bauer, David Chessin, Stephen R. Gorfine, Daniel Popowich
Surgery, The Mount Sinai Hospital, New York, NY
Purpose: Anorectal involvement is common in Crohn's Disease (CD). Patients with severe anorectal CD often undergo multiple surgeries as part of their disease process. When medical and surgical management do not control symptoms, permanent fecal diversion by abdominoperineal resection (APR) may be necessary. This study aims to characterize the types of procedures performed on patients with anorectal CD and to describe trends associated with the need for APR.
Methods: An IRB-approved, retrospective review of a prospectively maintained database identified patients who underwent surgery for anorectal CD from 2001-2014 at a single surgical practice. Demographic, clinical, operative and postoperative data were collected. The primary outcome of interest was APR. Descriptive and univariate analysis was used to examine differences between the APR and non-APR groups.
Results: 123 patients with CD were identified, including 68 females and 55 males. Fourteen (11%) patients had an APR (10 females and four males). In all cases, APR was the most recent operation the patient had undergone. The APR and non-APR groups were similar with respect to age at first operation. There was a longer median time between the first and last operation in the APR group compared to the non-APR group (200 vs. 96 weeks, p=0.032). There was a slightly higher proportion of patients who had an APR amongst those who underwent five or more operations in comparison with those with two to four operations (18% vs. 14%, p=0.046). In the APR group, the percentage of abdominal CD procedures was higher among those with five or more operations than among those with two to four operations (43% vs. 26%, respectively, P=0.024). Thirty-three patients had only one operation and none of these patients had an APR. See Figures 1 and 2.
Conclusions: Anorectal CD remains a challenge to both patients and physicians. Despite advancements in medical therapies and surgical techniques, some patients will require permanent diversion. APR remains the only option that may reliably reduce symptoms and improve quality of life in patients with complex CD. Patients and providers may see APR as an operation of last resort associated with failure of other treatment modalities. This study suggests that patients with active abdominal CD who undergo more anorectal operations are more likely to ultimately fail surgical management and may perhaps have benefited from an APR earlier in their disease process. Although not presented here, it may be that among the patients who undergo a high number of operations (five or more), quality of life is higher in those who undergo an APR than in those who do not. To this aim, we have sent quality of life questionnaires to these patients. These data may help physicians to counsel patients with abdominal CD about their prognosis and in planning optimal treatment for their disease.
Figure 1: Distribution of procedure by total trips to the operating room (Ops) for all patients (N=109)
  Figure 1: Distribution of procedure by total trips to the operating room (Ops) for all patients (N=109)
Figure 2: Distribution of procedure by total individual trips to the operating room (Ops) for patients who underwent abdominoperineal resection (APR), (N=14)
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