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The Role of Surgery in the Management of Patients With Refractory Chronic Granulomatous Disease Colitis

Alvarez-Downing, Melissa M. M.D.1; Kamal, Natasha M.S.2; Inchauste, Suzanne M. M.D.1; Khangura, Sajneet K. M.D.3; Malech, Harry L. M.D.4; Holland, Steven M. M.D.5; Hughes, Marybeth S. M.D.1; Heller, Theo M.D.3; Sherry, Richard M. M.D.1

Diseases of the Colon & Rectum: May 2013 - Volume 56 - Issue 5 - p 609–614
doi: 10.1097/DCR.0b013e3182781504
Original Contribution: Inflammatory Bowel Disease

BACKGROUND: Chronic granulomatous disease is a rare immunodeficiency complicated by dysregulated inflammation and granulomatous complications of the GI tract. The management of chronic granulomatous disease colitis presents the dilemma of an immunocompromised host requiring immunosuppressive therapy which can potentiate fatal infections.

OBJECTIVE: The aim of this study was to identify the types of GI surgery performed in patients and determine the role of surgery in the management of refractory colitis.

DESIGN AND SETTINGS: A retrospective single-institution chart review was performed.

PATIENTS: Of 268 patients with chronic granulomatous disease treated at the National Institutes of Health between 1985 and 2011, 98 (37%) were identified as having colitis; 27 (10%) had a history of GI luminal surgery.

MAIN OUTCOME MEASURES: Patient characteristics, type of GI surgery, and clinical outcomes were documented.

RESULTS: A total of 62 GI luminal surgeries were performed in 27 patients with chronic granulomatous disease and colitis. All 27 had a history of perineal disease requiring intervention. Four (15%) had additional surgery performed for reasons other than colitis. Otherwise, 12 (44%) had surgery limited to the perineum, 2 (7%) had a segmental resection, and 13 (48%) underwent fecal diversion with ileostomy or colostomy. Despite local procedures, 7 (58%) patients in the perineal-only group remained symptomatic. Both patients with a segmental resection had persistent perineal disease, and 1 had a recurrent colovesicular fistula. Of the 13 ostomy patients, 11 initially received a diverting ostomy. Eight (73%) of these ultimately required additional procedures for refractory disease, and 4 (36%) developed peristomal pyoderma gangrenosum. Four patients who underwent proctocolectomy with end ileostomy, either initially (2) or as a definitive procedure (2), experienced resolution of colitis and perineal disease.

LIMITATIONS: This study is limited by its retrospective design, small sample size, and highly selected patient population.

CONCLUSIONS: Proctocolectomy with end ileostomy may offer a definitive treatment in a patient with refractory chronic granulomatous disease colitis given current therapeutic limitations.

1Surgery Branch, National Cancer Institute, Bethesda, Maryland

2University of Maryland School of Medicine, Baltimore, Maryland

3Liver Disease Branch, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Maryland

4Laboratory of Host Defenses, National Institute of Allergy and Infectious Diseases, Bethesda, Maryland

5Laboratory of Clinical Infectious Diseases, National Institute of Allergy and Infectious Diseases, Bethesda, Maryland

Funding/Support: Intramural Research Programs of the National Cancer Institute, National Institute of Allergy and Infectious Diseases, Clinical Center and National Institute of Diabetes and Digestive and Kidney Diseases.

Financial Disclosures: None reported.

Poster presentation at the meeting of The American Society of Colon and Rectal Surgeons, San Antonio, TX, June 2 to 6, 2012.

Correspondence: Melissa M. Alvarez-Downing, M.D., Surgery Branch, National Cancer Institute, 10 Center Dr, Building 10-Hatfield CRC, Rm 3-5888, Bethesda, MD 20891–1201. E-mail: melmalvarez@gmail.com; or Richard M. Sherry, M.D., Surgery Branch, National Cancer Institute, 10 Center Dr, Building 10-Hatfield CRC, Rm 3-5942, Bethesda, MD 20891-1202. E-mail: sherryr@mail.nih.gov

© The ASCRS 2013