TURNBULL-CUTAIT OPERATION IS FEASIBLE IN HIGHLY SELECTED PATIENTS WITH COMPLEX ANORECTAL CROHN'S DISEASE
Olga A. Lavryk*, Carla F. Justiniano, Xue Jia, Bethany Bandi, Stefan D. Holubar, Amy L. Lightner, Scott Steele, Tracy L. Hull
Colorectal surgery, Cleveland Clinic, Cleveland, OH
Background. Medically refractory distal Crohn's disease (CD) including rectal or perianal involvement often requires proctectomy with end colostomy. Turnbull-Cutait (TC) is a salvage procedure for highly motivated patients desiring to avoid a permanent ostomy in various circumstances. The first stage involves a proctectomy with transanal colonic pull through and no anastomosis. The second stage is a delayed hand-sewn coloanal anastomosis performed at 1-2 weeks. The aim of this study is to analyze if TC operation is a feasible option for highly selected patients with anorectal CD requiring proctectomy.
Methods. A prospectively maintained database (1983 – 2021) was queried to identify patients who underwent a two-staged TC procedure with delayed coloanal anastomosis in the setting of complex anorectal CD. Patients' demographics, past surgical history and postoperative outcomes were analyzed.
Results. There were 9 patients with complex anorectal CD who underwent a TC. The majority of the patients were females (n=7, 78%), with mean age of 42 + 8.4 years old, mean BMI was 23 + 2.5 kg/m2. Four (45%) patients were on biologic therapy for CD perioperatively.
The indications for proctectomy were rectovaginal fistula (n=3), rectal stricture (n=1) or complex perianal disease (n=5). All patients had prior attempt of fistula repair including advancement flaps or gracilis muscle interposition which failed.
Four (45%) patients ultimately had a permanent stoma (end colostomy:2, end ileostomy:2). Reasons for permanent stoma were recurrence of complex perianal fistulas (n=2, 23%), rectovaginal fistula recurrence (n=1, 11%) and fecal incontinence (n=1, 11%). The Kaplan Meier stoma free survival curve showed a 66% stoma free survival at 2 years, and 44% at 6 years after TC (Figure). Postoperative complications were: anastomotic stricture (n=3, 33%), anastomotic dehiscence (n=1, 11%), presacral collection (n=1, 11%), fecal incontinence (n=1, 11%). Median follow-up was 2.4 years.
Conclusion. TC is a feasible option for highly selected patients with complex anorectal CD, who previously failed multiple perianal procedures and desire to avoid permanent ostomy.
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