Role of a surgeon : Crohn’s disease

Dr.Patta Radhakrishna MS MChHead,Division of Surgical GE

Desirable goal in treatment of Crohn’s disease

To avoid or delay surgery while keeping patients in remission

Surgery in Crohn’s disease

• Why surgery ?• When surgery ?• What surgery

Surgery in Crohn’s disease

• Strictures• Fistulae• Inflammatory masses• Perforation• cancer

Surgery in Crohn’s disease

• 50% of CD pts develop strictures / fistulae within 20 yrs of diagnosis

• 25% of pts have at least one small bowel stricture• 10% of pts have at least one colonic stricture• Most of these patients will require at least one

surgery in their life time.

Surgery in Crohn’s disease

• Immunomodulators and anti TNF therapy reduced the need for surgery• Need for surgery is a difficult decision and often

needs a multi-disciplinary evaluation’.• Crohn’s disease is a recurring disorder that can not

be cured with surgical resection

Surgery in Crohn’s disease

• Non resectional techniques as ‘strictureplasty’ may be required to avoid excessive loss of the intestine….

• Resectional techniques may be necessary to remove only the severely affected portion of the GIT..leaving the mild asymptomatic diseased areas intact.

Surgery in Crohn’s disease

Surgery in Crohn’s disease

Surgery in Crohn’s disease

Abdominal exploration:• examination of the whole small bowel which

requires release of adhesions.• any inflammatory adhesions should be

suspected to have a fistulous tract.• adhesions that may be result from cancer

should be resected in bloc.

Surgery in Crohn’s disease

• Resection - should be wide enough to encompass the limits of gross disease..

• Wider resection offers no benefit in terms of lessening the rate of recurrence.

• Also the extent of mesenteric resection has no impact on term of recurrence.

Surgery in Crohn’s disease

• Once the resection is completed , the proximal and distal margins of the specimen are examined to ensure they are free of GROSS disease.

Minimal access Surgery in Crohn’s disease

• To date ,the largest experience with Crohns is with ileocecal resection.

• The cecum and ascending colon are mobilized laparoscopically.

• Then, a small incision on the abdomen is made

Minimal access Surgery in Crohn’s disease

• Critically ill pts who are unable to tolerate a pneumoperitoneum due to hypotension or hypercapnia.

• Pts with dense adhesions, intra abdominal sepsis or complex fistulization..

Surgery in Crohn’s disease - strictureplasty

Surgery in Crohn’s disease - strictureplasty

• for jejunoileitis with single or multiple fibrotic strictures

• isolated stricture in the duodenum.• Strictureplasty - 18% morbidity and 34%

operative recurrence rates, comparable to the traditional resectional surgery

Surgery in Crohn’s disease – strictureplasty - contraindications

• Segment with acute inflammation or phlegmon.

• Pt with generalized peritonitis.• Long high grade stricture resulting from

extremely thickened and rigid intestinal wall as this need resection.

Surgery in Crohn’s disease – strictureplasty - contraindications

Finney’s strictureplasty

Surgery in Crohn’s disease – colon

• Segmental colectomy.• Ileocecal resection with primary anastomosis.• Total abdominal colectomy with

ileoproctostomy.• Total proctocolectomy with permennat end

ileostomy.

Surgery in Crohn’s disease – colon

Because of the recurrent nature of crohns ,a restorative procedure as ileal pouch-anal anastomosis is inappropriate.

Surgery in Crohn’s disease – peri-anal disease

• Abscess.• Fistulae.• Fissures.• stenosis.• Hypertrophied skin tags.each one of them is treated accordingly..

Surgery in Crohn’s disease – peri-anal disease

• Dedicated gastroenterologists• Colo-rectal surgeons• radiologistsfor optimal results..

Surgery in Crohn’s disease – peri-anal disease

• Complex perianal CD – non-cutting seton, antibiotics and thiopurines

• Glues, plugs and stem cells – under evaluation

Surgery in Crohn’s disease

• CD multidisciplinary approach• Strictures ; intestinal obstruction• Stricureplasty ; resction ; lap surgery• Colonic resections• Peri-anal Crohns – non-cutting seton; abscess drainage