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PubMed1996

Molecular genetic tests as a guide to surgical management of familial adenomatous polyposis.

BACKGROUND: In familial adenomatous polyposis the only curative treatment is colectomy, and the choice of operation lies between restorative proctocolectomy (RPC) and colectomy with ileorectal anastomosis (IRA). The RPC procedure carries a higher morbidity but, unlike IRA, removes the risk of subsequent rectal cancer. Since the course of familial adenomatous polyposis is influenced by the site of mutation in the polyposis gene, DNA analysis might be helpful in treatment decisions. METHODS: We evaluated the incidence of rectal cancer in polyposis patients who had undergone IRA, and examined whether the requirement for subsequent rectal excision because of cancer or uncontrollable polyps was related to the site of mutation. FINDINGS: Between 1956 and mid-1995, 225 patients registered at the Netherlands Polyposis Registry had undergone IRA. In 87 of them, a pathogenetic mutation was detected. 72 patients had a mutation located before codon 1250 and 15 patients after this codon. The cumulative risk of rectal cancer 20 years after surgery was 12%, and at that time 42% had undergone rectal excision. The risk of secondary surgery was higher in patients with mutations in the region after codon 1250 than in patients with mutations before this codon (relative risk 2.7, p < 0.05). INTERPRETATION: On this evidence, IRA should be the primary treatment for polyposis in patients with mutations before codon 1250, and RPC in those with mutations after this codon.

Adenomatous Polyposis Coli↗
PubMed1996

Ileal pouch-anal anastomosis for ulcerative colitis and polyposis coli: is the risk of carcinoma formation conclusively averted?

We took biopsies from the ileal pouch mucosa of 26 patients (13 with ulcerative colitis, 13 with polyposis coli) at least 1 year after the newly formed pouch was finally linked to the faecal flow. Histochemical mucin differentiation was carried out in addition to the ordinary stains. All patients underwent colonization of pouch mucosa with goblet cell multiplication, reduction or loss of villi, and formation of crypts. Only 19 patients could be classified morphologically as bearing large bowel mucosa in the ilea] pouch. Patients with one incidence of ulcerative colitis developed one criterion, those with two incidences two criteria, and those with seven incidences three criteria of the original colitic disease. Patients with two incidences of colitis and those with 10 incidences of polyposis coli developed an excess of sialomucine formation, which is known as an obligate pre-cancerosis. These findings prove, that in ileal pouches, even when affected by systemic diseases with extraintestinal manifestations, a new kind of mucosa develops, which is also prediposed to carcinoma formation. Papers reporting adenocarcinoma arising in ileostomy areas as well as in ileoanal anastomosis, and ileal reservoirs, confirm this presumption. Assuming this conclusion, restorative proctocolectomy cannot hinder malignant transformation of intestinal mucosa, but only delay the onset of cancer, thereby making lifelong follow-ups necessary.

Adolescent↗
PubMed2000

Functional and morphologic changes of the ileal mucosa after ileoanal pouch procedure.

BACKGROUND: Restorative proctocolectomy is used widely for treatment of ulcerative colitis and familial polyposis coli. Limited information is available regarding the morphologic and functional adaptation of the mucosa in a functioning ileoanal pouch. STUDY DESIGN: Ileal pouch specimens from patients who underwent pouch reconstruction (mean 7.5 years postcolectomy, n = 12) were compared with normal ileum (n = 15) and normal colon (n = 5). Amino-oligopeptidase (AOP) and maltase activity were measured as parameters of normal ileal function. Histologic samples were examined for the presence of neutrophils and plasma cells, the villus to crypt height ratio, and the degree of crypt hyperplasia, villus blunting, and goblet cell mass. Data were analyzed by analysis of variance. RESULTS: The AOP activity in the normal ileum was 73 +/- 32 units of enzymatic activity per gram of mucosal protein; the AOP activities of the pouch and colon were 21 +/- 22 and 16 +/- 10, respectively. The maltase activity of the normal ileum measured 254 +/- 116 units of enzymatic activity per gram of mucosal protein, and the maltase activities of the pouch and colon were 57 +/- 71 units and 29 +/- 25 units, respectively. The ileal pouch mucosa demonstrated little acute inflammation and varying degrees of chronic inflammation. Morphologically, the ileal pouch mucosa demonstrated a range of adaptations, including villus blunting and crypt hyperplasia. Several specimens contained immature epithelial cells. CONCLUSIONS: The AOP and maltase activities in mucosa from ileoanal pouches and colon were significantly lower than those in normal ileal mucosa. Ileoanal pouch mucosa from humans undergoes adaptive changes to resemble colonic mucosa both morphologically and functionally.

Adult↗
PubMed2005

[Surgical therapy of complicated inflammatory bowel disease].

The etiology of chronic inflammatoric bowel disease is unknown, conservative treatment will be reduced to the management of immunologic and inflammatoric reaction. The large majority of patients affected with Crohn's disease and also nearly 50% of patients with ulcerous colitis require surgery during their clinical history. The indication for surgery is a balance between the severity and the complications of the disease and the potential disadvantages of surgery. For surgical therapy the differentiation of Crohn's disease and ulcerous colitis is essential because of the differentiated character of both diseases. In Crohn's disease surgical therapy will be performed by the management of Crohn's specific complications like stenosis, fistula, and abscess by bowel preserveration. Limited resection and/or strictureplasty do not influence morbidity and rate and also time of recurrence. Ulcerous colitis can be cured when the colorectal mucosa will be removed totally by radical surgery, i.e. restorative proctocolectomy. The satisfactory outcome in 70 to 90% of patients with a cumulative failure rate of 10 to 15% over a 10-year-period improves the quality of life.

Colectomy↗
PubMed2001

Strategy for the surgical management of patients with idiopathic megarectum and megacolon.

BACKGROUND: Several surgical procedures have been used to treat idiopathic megabowel. A structured approach to the surgical management of megarectum/colon is reported. METHODS: Twenty-eight consecutive patients with megabowel referred for surgery were reviewed. All patients had conservative treatment for 6 months. Those failing to improve underwent full-thickness biopsy of the anorectal junction, anorectal physiology studies, colonic transit studies and evacuation proctography. Surgery involved excision of the abnormal large bowel and formation of an anastomosis (coloanal or ileoanal) using 'normal' bowel identified either by a defunctioning stoma or colonic motility studies. RESULTS: Eight patients responded to conservative management. Two patients were lost to follow-up and one died from unrelated causes. Two of the 17 patients who underwent full-thickness biopsy were cured by the procedure. Anorectal physiology, colonic transit and evacuation studies did not aid selection of the surgical procedure performed in 15 patients: proctectomy and coloanal anastomosis (six), restorative proctocolectomy (three), panproctocolectomy (one) and defunctioning stoma (five). At a median follow-up of 3.6 years, 13 of 15 evaluable patients had a satisfactory outcome. CONCLUSION: Approximately 40 per cent of patients with megabowel referred for surgery responded to conservative treatment. The remaining patients may be treated successfully by surgery. The use of either a 'diagnostic' defunctioning stoma or colonic motility studies may aid in the choice of surgical procedure.

Adolescent↗
PubMed1998

Quality of life after pouch excision.

BACKGROUND: Pouch excision is a devastating experience for patients having restorative proctocolectomy for ulcerative colitis. METHODS: The quality of life among patients having pouch excision for ulcerative colitis was compared with that in those having proctocolectomy and ileostomy for ulcerative colitis using a validated standardized self-administered questionnaire. RESULTS: After pouch excision patients (n = 9) had more troublesome bowel symptoms (mainly from liquid stoma output) than those in the proctocolectomy group (n = 14) (mean(s.d.) score 5.64(0.92) versus 6.13(0.37), P = 0.03). However, the mean scores for the other parameters (systemic symptoms, functional, social and emotional impairment) did not differ significantly. CONCLUSION: Patients having pouch excision for ulcerative colitis have more liquid ileostomy loss but a comparable quality of life to those treated by standard proctocolectomy and ileostomy.

Activities of Daily Living↗
PubMed2000

Immunoglobulin G and albumin levels in whole gut lavage fluid provide an objective measure of pouch ileitis.

BACKGROUND: Gut protein loss is a characteristic of inflammatory bowel disease (IBD), and immunoglobulin (Ig) G, albumin and alpha1-antitrypsin concentrations in whole gut lavage fluid (WGLF) correlate with clinical disease activity. If inflammation in ileoanal pouches is similar to IBD, then measurement of protein-losing enteropathy by analysis of WGLF may provide an objective assessment of disease activity in pouches. METHODS: Forty-two patients who had restorative proctocolectomy for ulcerative colitis underwent whole gut lavage with a polyethylene glycol-electrolyte solution. The first clear effluent was filtered, processed by the addition of protease inhibitors and stored at - 70 degrees C. IgG, albumin and alpha1-antitrypsin were assayed in WGLF. The Pouchitis Disease Activity Index (PDAI) was calculated after pouchoscopy and biopsy; the Moskowitz criteria for pouchitis were also applied. RESULTS: There was a significant correlation of the pouchoscopy score and the PDAI with the concentration of WGLF IgG. All patients with 'pouchitis' according to the Moskowitz criteria had a WGLF IgG concentration greater than 10 microg/ml. The WGLF albumin level also showed a significant correlation with the PDAI, but alpha1-antitrypsin concentration did not. CONCLUSION: Analysis of WGLF for IgG and albumin may be useful in the assessment of disease activity in pouch inflammation.

Adolescent↗
PubMed2001

Transvaginal repair of pouch-vaginal fistula.

BACKGROUND: The results of surgery for ileoanal pouch-vaginal fistula have been disappointing. Intra-anal procedures result in fistula healing in, at best, approximately 50 per cent of patients. A transvaginal approach was developed to achieve direct access to the internal opening, enabling closure without damage to the anal sphincter. METHODS: Fourteen patients were treated between January 1992 and December 1998. All had had restorative proctocolectomy for ulcerative colitis and all were defunctioned. Histological review confirmed the diagnosis in all patients. RESULTS: Median age was 40 (range 25-52) years. Median follow-up was 18 (range 6-60) months. The operation was successful in 11 of the 14 patients, after one attempt in six patients, after two attempts in four, and after three attempts in one patient. The operation failed in three patients, who had a permanent ileostomy. The number of bowel actions in the patients who had successful closure ranged from 2 to 10 (median 6) in 24 h, with no faecal incontinence reported. CONCLUSION: This simple technique achieved healing in 11 of 14 patients. This compares favourably with the poor results in 28 patients treated by other procedures in the same hospital, with certain healing in five and definite failure in 20.

Adult↗
PubMed2003

Patients with familial adenomatous polyposis experience better bowel function and quality of life after ileorectal anastomosis than after ileoanal pouch.

OBJECTIVE: To evaluate the quality of life with emphasis on bowel function in patients undergoing either total colectomy with ileorectal anastomosis (IRA) or restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) for familial adenomatous polyposis (FAP). PATIENTS AND METHODS: All 151 patients operated on in our department between 1971 and 2000 were analysed retrospectively. Since 42 patients had to undergo reoperations, a total of 194 bowel procedures were performed. The final operative breakdown was: 48 IRA, 62 IPAA, 33 total proctocolectomies and 8 other procedures. By the end of the period under consideration, 40 patients had died, 28 had been lost to follow-up, 83 patients were still alive and of these 76 were analysed. Continence function and quality of life with emphasis on overall bowel function (Wexner (WS)-, Jostarndt (JS)-, Oresland (OS)- and Pemberton (PS)-scores) were recorded in 59 patients (22 IRA and 37 IAP). RESULTS: Continence and bowel function were significantly better after IRA than after IPAA (mean scores: WS, 1.1 vs 5.4, P=0.001; JS, 32.5 vs 24.7, P=0.0001; OS, 2.9 vs 7.9, P=0.0001), as was quality of life (PS, 25.6 vs 19.6, P=0.001). The mean values for each single item of all 4 scores were consistently better after IRA. Neither gender, age nor type of pouch-anal anastomosis (stapled vs hand-sewn) had a significant influence on outcome. IPAA patients with uneventful follow-up (n = 27) had better mean values for all 4 scores (WS, 4.2 vs 7.3; JS, 26.1 vs 23.1; PS, 20.4 vs 17.7; OS, 6.6 vs 9.9) than those with postoperative complications (n = 10; 27%), but statistical significance was reached only in the OS (P = 0.026). No such difference was seen after IRA (14% complication rate). CONCLUSION: The significantly better continence after IRA resulting in superior patient comfort and quality of life must be balanced against the oncological disadvantage of this procedure. On the basis of large patient population studies, genotype-phenotype correlations with respect to the risk for rectal cancer may need to be taken into account. Postoperative complications may have a lasting negative effect on outcome after IPAA.

Adenomatous Polyposis Coli↗
PubMed2001

Backwash ileitis is strongly associated with colorectal carcinoma in ulcerative colitis.

BACKGROUND & AIMS: Commonly accepted risk factors for colorectal carcinoma (CRC) in ulcerative colitis are duration and extent of disease. By identifying still unknown risk factors, surveillance strategies may be improved further. We investigated whether backwash ileitis is also a factor associated with CRC in ulcerative colitis. METHODS: Five hundred ninety consecutive patients with ulcerative colitis who received restorative proctocolectomy were classified into 3 groups: (1) pancolitis with backwash ileitis, (2) pancolitis without backwash ileitis, and (3) left-sided colitis. The association with CRC was analyzed in these 3 groups of patients. As further risk factors, we investigated disease duration, dysplasia, primary sclerosing cholangitis, age at diagnosis of disease, disease activity, and gender. Univariate and multivariate logistic regression were used for analysis. RESULTS: CRC was diagnosed in 11.2% of all patients. CRC was found in 29.0% of 107 patients in group 1, compared with 9.0% of 369 patients in group 2, and in 1.8% of 114 patients in group 3 (P < 0.001). Cancer patients in group 1 showed significantly more multiple tumor growth (45.2%) than patients in group 2 (24.2%) and group 3 (0%) (P = 0.041). Estimating the relative risk for CRC in the multivariate analysis, patients in group 1 showed a significantly higher odds ratio than patients in groups 2 and 3 (odds ratio: 19.36 vs. 9.58 vs. 1; P < 0.001). High-grade dysplasia, low-grade dysplasia, disease duration of more than 10 years, and disease duration of less than 10 years in patients older than 45 years were further factors with significantly increased risk (odds ratios: 21.69, 6.36, 3.63, 4.37), but primary sclerosing cholangitis was not (P = 0.080). However, primary sclerosing cholangitis was strongly associated with backwash ileitis. CONCLUSIONS: There is a strong association of backwash ileitis with CRC in patients with ulcerative colitis who undergo proctocolectomy. The predictive value of backwash ileitis for CRC and premalignant dysplasia in patients with ulcerative colitis should be investigated in future studies based on colonoscopic surveillance.

Adolescent↗
PubMed2002

Ulcerative colitis: female fecundity before diagnosis, during disease, and after surgery compared with a population sample.

BACKGROUND & AIMS: Women with ulcerative colitis generally have normal fertility. The aim of this study was to compare patients' fecundability before and after restorative proctocolectomy with ileal pouch-anal anastomosis with the fecundability of the general population. METHODS: Historical follow-up was performed on 343 consecutive female patients aged 10.6-40.5 years at surgery and a reference population of 1200 women aged 25-40 years. A total of 290 (85%) patients and 661 (55%) women in the reference population agreed to participate in a structured telephone interview concerning reproductive behavior and waiting times to pregnancy. Cox regression and Kaplan-Meier plots were used for analysis. RESULTS: Surgery significantly reduced the ratio of patient to reference population fecundability, which decreased to 0.20 (P < 0.0001). Before diagnosis and from diagnosis until colectomy, the fecundability of the patients was similar to that of the reference population. CONCLUSIONS: Female patients with ulcerative colitis have normal fecundity before surgical treatment. Surgery severely reduces female fecundity. Information about this reduction in fecundity should be given before surgery, and if a woman has an unfulfilled wish for pregnancy after surgery, early referral to a gynecologist is recommended.

Adult↗
PubMed2001

[The ileo-anal pouch procedure: Complications, quality of life, and long-term results].

The ileo-anal pouch procedure: Complications, quality of life, and long-term results. Restorative proctocolectomy with construction of an ileal pouch-anal anastomosis (IPAA) has evolved as the surgical therapy of choice for patients with ulcerative colitis (UC) and patients with familial adenomatous polyposis (FAP). 662 patients (493 UC, 169 FAP) consecutively received IPAA. Marked differences were observed between UC and FAP patients regarding the rates of overall complications (33.1 % vs. 12.5 %), pouchitis (29 % vs. 2 %), and pouch extirpation (3.2 % vs. 0.6 %). Pouchitis occurred as primary (79 %) and secundary (21 %) form, with acute (67.2 %) or chronic (32.8 %) course. Each form and course required specific therapy. Chronic pouchitis implies the risk of malignant transformation of the pouch mucosa. Quality of life improves significantly after IPAA in patients with UC and is equal to that in normal individuals, in UC and FAP, if postoperative complications are either prevented or under control.

Adenomatous Polyposis Coli↗
PubMed2001

Allopurinol as prophylaxis against pouchitis following ileal pouch-anal anastomosis for ulcerative colitis. A randomized placebo-controlled double-blind study.

BACKGROUND: Pouchitis is the major long-term complication of restorative proctocolectomy for ulcerative colitis (UC). Allopurinol is a scavenger of oxygen-derived free radicals, which it is suggested play a role in the development of UC and pouchitis. The first aim was to test the hypothesis that the incidence of pouchitis can be reduced by prophylactic Allopurinol, and secondly to evaluate if Allopurinol influences the overall pouch function. METHODS: 273 patients with UC who were planned for proctocolectomy and ileal pouch-anal anastomosis at 12 centres in Sweden between October 1994 and June 1997 were offered the opportunity to participate. 184 patients (67%) were randomized to receive postoperative prophylactic Allopurinol 100 mg twice daily or placebo. All 273 patients had clinical and endoscopic follow-up at 1, 3, 6, 12, 18, 24 months after surgery. RESULTS: Of the 184 randomized patients, 94 were randomized to Allopurinol and 90 to placebo; 116 patients (63%) completed follow-up and the crude incidence of pouchitis among those patients fullfilling the protocol was 31% in the Allopurinol group and 28% in the placebo group (ns). The cumulative risk for a first attack of pouchitis was 30% and 26% after 24 months (ns). The overall pouch function improved over time and did not differ significantly between the two groups. CONCLUSIONS: Prophylactic Allopurinol did not reduce the risk of a first attack of pouchitis.

Adolescent↗
PubMed2001

Altered expression of the lymphocyte activation markers CD30 and CD27 in patients with pouchitis.

BACKGROUND: The mechanism underlying the development of ileal pouch inflammation in ulcerative colitis patients (pouchitis) after restorative proctocolectomy is unclear. Persistent systemic T cell activation or expansion of specific memory cell populations could predispose certain patients to develop local inflammation within the neo-rectum. Therefore, the aim was to study the expression of the lymphocyte activation markers CD27, CD30, CD25 and CD69 on the CD45RO+ memory cell subset of isolated peripheral blood mononuclear cells (PBMC), soluble CD30 levels and mucosal CD30 expression in patients with pouchitis and in controls. METHODS: Flow cytometry was performed on PBMC isolated from patients with pouchitis (n = 9), without pouchitis (n = 10) and normal controls (n = 9). Serum CD30 was measured in patients with pouchitis (n = 25), without pouchitis (n = 26) and normal controls (n = 20) by ELISA. CD30 expression was quantified in pouchitis (n = 15) and normal pouch (n = 15) mucosa using a three-stage immunoperoxidase method. RESULTS: Naive CD45RO-CD27+ PBMC were significantly decreased in pouchitis (25.6%) compared to normal controls (34.4%), (P = 0.03). CD30, CD25 and CD69 subsets did not differ between the groups. Serum CD30 was increased in pouchitis patients 58 (1-380) U/ml compared to non-pouchitis 16.5 (1-290) U/ml, P=0.007, and normal controls 11 (2-80) U/ml, P = 0.0005. In the mucosa, the numbers of CD30+ cells were increased in pouchitis compared to non-inflamed pouches (P = 0.02). CONCLUSIONS: Increased sCD30 in pouchitis is associated with elevated mucosal expression. Of the activation markers studied, only the circulating naïve CD27+ population differed in pouchitis patients compared with controls. The observed decrease in this cell type may reflect antigen priming and subsequent loss of CD27 implying that antigen driven activation of specific T cell subsets may occur in pouchitis.

Adult↗
PubMed2002

Laparoscopic surgery for inflammatory bowel disease: current concepts.

BACKGROUND: The aim of a laparoscopic approach is reduced pain scores, early mobilization, virtual absence of wound sepsis, rapid return of gastrointestinal function, early discharge from hospital and return to normal activity and improved cosmetics. Potential advantages are fewer complications due to adhesion formation, viz. small-bowel obstruction, infertility and chronic abdominal pain-advantages that are of particular importance to patients with inflammatory bowel disease (IBD) since they are young and in the middle of building up their socio-economic life. This review highlights the current status of laparoscopic surgery for patients with IBD. METHODS: Virtually all abdominal procedures carried out in patients with IBD can be done laparoscopically, and vary from stoma formation to restorative proctocolectomy. RESULTS: Conversion rates and operating times depend on the surgical expertise and patient-related factors, viz. prior laparotomy, the presence of intestinal fistula or inflammatory masses. Morbidity rates are similar to those of open surgery provided that the procedures are done by expert laparoscopic surgeons. The observed earlier recovery contributed to laparoscopic surgery has not been proved in well-conducted trials; however, an advantage can be expected. A very obvious feature of laparoscopic surgery is the improved cosmetics, which might turn out to be the most important advantage of the laparoscopic approach in this relatively young patient group. CONCLUSION: The laparoscopic approach can be considered the procedure of first choice in patients with IBD provided the surgery is done by expert laparoscopists ensuring low conversion rates, acceptable operating times and low morbidity.

Colectomy↗
PubMed2006

Does smoking influence the risk of pouchitis following ileal pouch anal anastomosis for ulcerative colitis?

OBJECTIVE: According to epidemiological studies, smoking habit is strongly associated with inflammatory bowel disease. Non-smokers, and especially recent ex-smokers, have an increased risk of ulcerative colitis (UC). Conversely, concerning Crohn's disease, the risk is increased among smokers. Pouchitis is the major long-term complication of restorative proctocolectomy for UC, and seems to be pathogenetically related to this condition. The aims of this study were to test the hypothesis that smoking reduces the risk of pouchitis, and to investigate whether cessation of smoking precedes the onset of the inflammation. MATERIAL AND METHODS: All living patients operated on for UC with proctocolectomy and ileal pouch anal anastomosis (IPAA) between November 1982 and November 1996 at Sahlgren's University Hospital were included in the study (n=410). Data concerning smoking habits and pouchitis were obtained from questionnaires and from medical records. The correlation between smoking habits and incidence of pouchitis was statistically evaluated by means of a survival test and a multivariate analysis, i.e. a Poisson model. RESULTS: In all, 327 patients (80%) completed the questionnaires. Ninety-six (29%) of these patients had had at least one episode of pouchitis. Smoking habits during follow-up did not significantly influence the risk of pouchitis (p=0.29). Nor did smoking habits before and at the time of IPAA correlate with the incidence of pouchitis. Women had a decreased risk of pouchitis, compared to men (p=0.014). There was a non-significant tendency for smoking to increase the risk, which was more pronounced in women. CONCLUSIONS: Smoking does not decrease the risk of pouchitis following IPAA for UC, and in this respect the pathogenetic model of pouchitis, suggested to be a manifestation of UC, is not supported.

Adolescent↗
PubMed1993

Ileal pouch arthritis.

The association between arthritis and intestinal inflammation is well established, but the pathogenesis of the inflammatory joint disease remains speculative. We report six patients who developed a polyarthritis following restorative proctocolectomy with an ileal pouch-anal anastomosis (IPAA) for extensive ulcerative colitis between 1983 and 1990. Six patients were identified with no complaint of joint symptoms before surgery. The average time to onset of arthritis following surgery was 8 months (1 week-yr). The typical features were of an acute symmetrical polyarthritis involving the peripheral and axial skeleton. Early morning stiffness was pronounced in two and minimal in the rest. Three patients were treated with a course of prednisolone and remain in remission (1-4 yr). We believe that this is a novel form of arthritis clearly linked to pouch surgery which may provide important clues to the role of gastrointestinal antigens in rheumatic diseases.

Adult↗
PubMed1994

Current surgical management of inflammatory bowel disease.

When surgery is required for complications of inflammatory bowel disease (IBD) or for failure of medical management, numerous options exist. This review focuses on surgical alternatives, technical considerations, and complications for both routine and unusual problems associated with IBD. Restorative proctocolectomy for chronic ulcerative colitis, intestine-sparing procedures for Crohn's disease, and the management of Crohn's disease in difficult anatomic sites or with unusual complications are discussed.

Chronic Disease↗