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March 2011 IBD Newsletter >>
Surgical Management of Crohn’s Disease
Since Crohn’s disease is not a surgically ‘curable’ disease and surgical recurrence rates approach 55% at 10 years, all surgical therapy must be concerned with preserving bowel length and bowel function, thus maximizing quality of life. Therefore, appropriate intervention is always tailored to the individual patient.
Small Bowel Disease:
The most common site of involvement, and most often surgically resected, remains the terminal ileum. In most cases, for refractory disease without prior resection, the surgical procedure of choice involves a laparoscopic ileo-colic resection with primary anastomosis.
For recurrent cases, a laparoscopic approach is still possible. In these cases partial resection may still be required, however strictureplasty is an alternative often utilized. When preserving bowel length, it is not uncommon to perform multiple strictureplasties at one time. These can be performed without increasing complication risk or recurrence (when compared to surgical resection).
Fistulizing type Crohn’s disease should also be considered. When approaching fistulizing disease, often only the cause of the fistula is removed while the secondary organ is preserved. This is often the case when the bladder, vagina, colon and even adjacent small bowel are secondarily involved. In extreme cases of enterocutaneous fistulae, careful attention must also be given to nutritional status and skin care. It is ideal to wait several months from the time of presentation before surgical intervention, in order to optimize patient status and minimize complication risk.
Refractory disease involving the colon and rectum may require proctocolectomy and end-ileostomy – it is possible that some cases will involve only a portion of the colon and thus be amenable to segmental colectomy. Alternatively, the entire colon may be involved requiring total or subtotal colectomy. In these cases it is important to know the status of the rectum as it is possible that it may be spared, allowing for ileo-rectal anastomosis and continence preservation. Therefore, knowledge of the extent of peri-anal disease and underlying continence is important in evaluating these patients prior to surgery. These cases are commonly treated with a laparoscopic approach, thus minimizing incision size and enhancing recovery whenever possible.
Peri-anal disease (fissures, skin tags and fistulas) may be present in half of all patients with Crohn’s disease. Most surgical management relates to anal fistulas, which can sometimes be the only site of Crohn’s involvement. Optimal treatment involves fistulotomy along with appropriate medical therapy, this is sometimes not possible in order to preserve continence. Other alternatives such as fistula plugs and advancement flaps are options but success rates are lower and optimal medical control of active disease is first required. Therefore, it is not uncommon to manage Crohn’s fistulas either short or long-term with a draining seton. This allows control of the fistula tract and continued medical management. Severe refractory cases may eventually require proctectomy and permanent stoma.