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Holzheimer RG, Mannick JA, editors. Surgical Treatment: Evidence-Based and Problem-Oriented. Munich: Zuckschwerdt; 2001.

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Surgical Treatment: Evidence-Based and Problem-Oriented.

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Surgical management of Crohn's disease

, M.D.

The Department of Colorectal Surgery, Desk A111, The Cleveland Clinic Foundation, Cleveland, Ohio, U.S.A.

Introduction

Crohn's disease is a chronic inflammatory condition of uncertain etiology that affects the entirety of the alimentary tract. Medical therapy is considered to be the treatment modality of choice for most patients while operative management is reserved for individuals who fail medical treatment or develop potentially life-threatening complications. In the decade that followed the initial description of regional ileitis, bowel resections were generally considered hazardous (Crohn 1932; Garlock 1945). The high mortality rate associated with resection prompted some prominent surgeons to advocate an exclusion bypass operation that was considered much safer. However, following the advent of antibiotics and recognition of a cancer risk with bypassed bowel, enthusiasm for resection gradually prevailed. The latest innovation in the operative management of Crohn's disease has been the strictureplasty procedure that avoids both bypass and resection of the diseased segment (Lee 1982).

Classifications, operative incidence, and operative indications

Classifications

Farmer was among the first to stratify Crohn's disease based on an anatomic pattern of disease that was found to directly correlate with clinical course and prognosis, and included the following subtypes:

  • small intestine;
  • ileocolic
  • colon;
  • anorectal (Farmer 1975).

Rather than using the anatomic pattern of disease, Greenstein preferred to classify Crohn's disease as either a relatively aggressive fistulizing form or a more indolent fibrostenotic type (Greenstein 1988). He found these forms of Crohn's disease tended to retain their distinctive identities following resection, with subsequent operations performed for the same indication as the primary procedure. The experience of others, however, does not support this differentiation (McDonald 1989).

Operative incidence

Most patients with Crohn's disease ultimately require one or more operations over their lifetime. In the National Cooperative Crohn's Disease Study, the probability of surgery was 78% and 90% after 20 and 30 years of disease symptoms, respectively (Mekhjian 1979). The rate of surgery also appears to be dependent on the anatomic site of disease; rates of surgery with disease duration of 5 years are 50%, 75%, and 50% for jejunoileitis, ileocolitis, and colitis, respectively. By 10 years, over 90% of those with ileocolitis undergo surgery while nearly 70% of those with jejunoileitis or colitis require similar intervention (Whelan 1985).

Operative indications

An operation is performed for Crohn's disease when continued nonoperative therapy is ineffective or harmful as well as when the relative operative risk is less than that of alternative treatments. While most clinicians still defer operation until a complication of the disease occurs (e.g., fistula, abscess, obstruction), it is imperative to surgically intercede before that complication becomes further complicated. Conversely, Hulten contends that an operation should be conducted early in the course of Crohn's disease, before serious, especially septic, complications develop (Hulten 1988). When operating on advanced Crohn's disease, usually associated with abscess or fistula, he reported a 49% complication rate. This contrasted with surgery for otherwise uncomplicated Crohn's disease, for which there was a 12% complication rate.

The particular operative indications can be subgrouped into one of two primary groups: elective indications and emergent/urgent indications (table I). The incidence of these indications varies according to anatomic pattern, disease extent, and behavioral pattern; however, fistula, abscess, and obstruction tend to be the most common reasons for operation in Crohn's disease with perforation and massive hemorrhage rarely occurring.

Table I. Operative indications.

Table I

Operative indications.

Fistula and abscess

Several different types of fistula can develop including enteroenteric, enterovesical, enterovaginal, enterocutaneous, perianal, and perirectal. Similarly, abscesses can occur in various sites: enteroparietal, interloop, intramesenteric, and retroperitoneal. Fistulae rarely heal with corticosteroid therapy. However, immunomodulator therapy will promote fistula closure in 30–40% of cases, especially if distal obstruction and active disease are absent. Abscesses can be managed by initial percutaneous drainage and delayed resection or primary resection without preoperative drainage. Jawhari reported his experience with this latter approach of primary resection without initial drainage in 28 Crohn's disease patients with intra-abdominal abscesses; 9 (32%) experienced a recurrent abscess, 4 (14%) developed an enterocutaneous fistula, and 6 (21%) now suffer from short bowel syndrome (Jawhari 1998). Experience suggests that when an abscess is not amenable to percutaneous drainage, appropriate treatment requires laparotomy with thorough abscess drainage, resection of the disease-affected intestine, and the liberal use of fecal diversion. If abscess management risks significant loss of non-diseased bowel, resection is delayed for several months following adequate surgical drainage with proximal diversion (grade C).

Obstruction

Bowel obstruction can be acute or chronic and arise from single or multiple sites of stricturing. Although obstructive symptoms might improve with high-dose corticosteroids, the response is often temporary and symptoms typically recur as the medication is tapered. Moreover, high-grade obstructive lesions usually do not respond to medical therapy and early operative intervention is recommended before symptoms worsen or perforation occurs.

Perforation and hemorrhage

Free perforation, although rare, usually occurs during an acute exacerbation of chronic disease, particularly in the presence of distal obstruction, or during a bout of toxic colitis when transmural ulceration has developed. The transmural ulcers of Crohn's disease more typically result in formation of inflammatory adhesions between the diseased segment and surrounding structures that seal most perforations. However, the resultant abscess may subsequently rupture, spill its contents, and create a communication between the bowel lumen and the peritoneal cavity. Alternatively, the deep ulcers can erode into moderate-sized vessels of the mucosa or submucosa leading to massive intestinal hemorrhage. Emergent operative treatment should be individualized but must be considered in patients with: no other obvious sources of bleeding; life-threatening hemorrhage; failure to attain stabilization after initial transfusion with 4 to 6 units of packed red blood cells; significant rebleed during hospitalization; or coexisting indication for intestinal resection (grade C).

Operative options

Bypass

Internal bypass

Intestinal resection was the procedure of choice when surgery for Crohn's disease was first employed. Early mortality rates associated with resection approached 20%, and led Berg to perform a staged procedure for patients with terminal ileal Crohn's disease, especially those complicated by localized intraperitoneal sepsis. In the first stage, the small bowel was transected proximal to the diseased ileum, the distal ileal limb was oversewn, and an anastomosis was constructed between the proximal bowel limb and the transverse colon. During the second stage, the bypassed segment was resected. In many instances disease of the bypassed segment had resolved leading clinicians to conclude the second stage operation was unnecessary. However, as the risk of malignancy in the bypassed segment became recognized, this staged approach to ileocecal Crohn's disease was largely abandoned.

Bypass operations are still considered reasonable or desirable options for select cases. For instance, continuity bypass is a preferred method of management of symptomatic gastroduodenal Crohn's disease that is refractory to medical treatment. Similarly, in patients with severe ileocecal disease complicated by an extensive, contained perforation adherent to the common iliac vessels or cava, an exclusion ileotransverse colon bypass procedure may be performed. The proximal end of the excluded ileal segment should be exteriorized as a small mucus fistula to vent mucosal secretions that could cause blow-out of the ileal stump. This is usually a successful procedure, at least initially, and the patient may remain asymptomatic for months or years. Elective resection of the bypassed segment is recommended approximately 6 months later, even in the asymptomatic patient. The only possible exception to “early” resection of the bypassed segment is if the disease duration is short (e.g., < 5 years) and the risk of cancer consequently low.

External bypass

Ileostomy alone is used infrequently in current times. Even for free perforation of the small bowel, resection of the perforated segment with exteriorization of the proximal bowel as an end stoma is standard practice. The blow-hole colostomy with ileostomy for toxic colitis and toxic megacolon is a bypass procedure utilized during the 1960s and 1970s. Fortunately, the procedure is infrequently necessary these days, in part because of an overall decline in the incidence of toxic colitis. The principal reason, however, is that toxic colitis rarely worsens to the catastrophic variety of toxic megacolon, for which the blow-hole procedure is most valuable. Physician awareness and access to medical care have improved such that far fewer patients progress to this most severe degree.

Resection

Almost without exception, resection is the procedure of choice for Crohn's disease of the small bowel, especially when it is the patient's first operation. Assuming the resection provides enough tissue for histologic examination, the procedure allows a certainty of diagnosis. Even with scattered proximal skip lesions that may be amenable to strictureplasty, the distal ileal segment usually is the most inflamed site and typically warrants resection. The majority of surgeons strongly favor resectional techniques over bypass procedures for most clinical situations for a variety of reasons. In particular, the recurrence rates are much greater with bypass procedures as evidenced by 15-year reoperation rates of 65%, 82%, and 94% for resection, exclusion bypass, and simple bypass, respectively.

Resectional surgery is also the procedure of choice for Crohn's colitis. Despite the high recurrence rates, segmental resection with ileocolic, ileorectal, colocolic, or colorectal anastomosis provides years of stoma-free life for many patients with Crohn's colitis (grade C).

Resection margins

Historically, surgeons debated whether the small bowel resection margin needed to be microscopically-free of inflammation and, if not, how extensive the macroscopically-free margin needed to measure. While some early studies reported cumulative recurrence rates were greater for patients with microscopic evidence of disease at the resection margins, most recent series have shown no relationship between microscopic inflammation at resection margins and recurrence rates (grade C).

Recently, a randomized, controlled trial of patients (n = 152) undergoing resection of small bowel Crohn's disease randomized patients to resection margins that were macroscopically clear of disease for either 2 cm (limited group; n = 82) or 12 cm (extended group; n = 70); 131 patients underwent anastomoses (Fazio 1996). After a median follow-up of 56 months, disease recurred (reoperation for recurrence) in 29 patients; 25% of patients in the limited group and 18% in the extended group. Patients were also studied to assess the effect of microscopic changes at the macroscopically normal line of resection. The margins were characterized as normal, nonspecific changes, suggestive but not diagnostic of Crohn's disease, or diagnostic for Crohn's disease. Recurrence rates were not significantly different between the 4 categories.

The presence of residual microscopic Crohn's disease at the resection margins does not increase recurrence rates significantly, compared with normal margins, and extended resection margins confer no advantage to patients in reducing cumulative recurrence rates. Therefore, most surgeons favor conservative resection margins dividing the intestine approximately 2 to 5 cm proximal to overt disease (grade B and C).

Anastomotic technique

The neo-terminal ileum tends to be the usual site of recurrence following ileocolic resection for Crohn's disease. Opinions vary as to the preferred technique of anastomosis, whether handsewn or stapled, and which anastomotic configuration is least associated with recurrent inflammation. The presence of a suture line, the size of the anastomosis, and reflux of colonic contents into the ileum have been suggested as potential causative factors. In an effort to resolve the controversy, Cameron randomized Crohn's disease patients undergoing first-time ileocolic resection to either an end-to-end or side-to-end anastomosis (Cameron 1992). The clinical recurrence rate did not significantly differ between the two groups. In a similar study of patients undergoing resection for primary or recurrent ileal disease, patients treated with a side-to-side anastomosis were compared to a historical cohort of patients with side-to-end anastomoses (Scott 1995). The cumulative recurrence rates for both groups were nearly identical. While many common techniques exist, inverting, stapled anastomoses of any standard configuration are generally preferred because of safety, ease, and comparable recurrence rates (grade B and C).

Laparoscopy

As experience with laparoscopy for Crohn's disease increases, the role of this approach broadens as the contraindications lessen and benefits emerge. Singh reported 24 patients who underwent laparoscopy because of Crohn's disease, only 2 required laparotomy with the remainder undergoing a purely laparoscopic or laparoscopic-assisted procedure (Singh 1998). Although there was little difference in the median stay for patients treated laparoscopically or by laparotomy, it seemed the extent or severity of the disease process, rather than the approach used, influenced the length of the stay. Similarly, Wu reported his Crohn's disease experience with laparoscopic-assisted ileocolic resections attempted in 46 patients and conventional open ileocolic resections performed in another 70 individuals (Wu 1997). He found that co-morbid preoperative conditions such as abscess, phlegmon, or recurrent disease at a previous ileocolic anastomosis were not contraindications to a successful laparoscopic-assisted ileocolic resection. Moreover, the operative morbidity and length of stay were significantly less for the group undergoing laparoscopic-assisted resection.

Strictureplasty

As Crohn's disease is panintestinal in its features and since histologic and immunologic changes of the inflammatory process can be found in macroscopically normal-appearing bowel, surgical therapy increasingly has shifted toward conservative approaches. This attitude is supported by the previously discussed trend away from radical resection margins. For patients with multiple strictures of the small bowel, intestinal conservation may be maximally achieved by strictureplasty. The technique was used initially for the successful treatment of tubercular strictures involving the small bowel, but was later described for strictures secondary to Crohn's disease (Katariya 1977, Lee 1982).

Many centers have conducted comprehensive studies on patients undergoing strictureplasty proving the procedure effectively relieves obstructive symptoms with weight gain that accompanies improved food tolerance. In addition, despite diseased segments being left in situ, steroid medication often can be withdrawn or reduced in dosage. The clinical and operative recurrence rates following strictureplasty are comparable to those of resection, and similar between patients undergoing strictureplasty alone and individuals undergoing strictureplasty with concomitant resection. Moreover, reoperation rates are similar after the first and second operations. Of those requiring reoperation, most experience new strictures or perforative disease at a location remote from the original strictureplasty site.

The operation has proven to be quite safe with a low 15% operative morbidity and no mortalities reported from the major series. Septic complications, specifically, are not associated with perforative or phlegmonous disease remote from the strictureplasty site, steroid dosage, synchronous resection, number of strictureplasties, and length of stricture; however, serum albumin values less than 3.0 g/dL are linked to septic complications. Therefore, a patient with multiple strictures and moderate hypoalbuminemia typically requires a diverting stoma created proximal to the strictureplasty sites.

When it is realized that incision and suturing of diseased segments is the basis of the procedure, natural concerns arise regarding suture line healing and the occurrence of intraabdominal abscesses or fistulas. Aside from the meticulous conduct of the procedure, the key to prevention of such complications lies with patient selection (grade C).

The situations for which strictureplasty is considered are as follows:

1.

Diffuse involvement of the small bowel with multiple strictures

2.

Stricture(s) in a patient who has undergone previous major resection (s) of small bowel (> 100 cm)

3.

Rapid recurrence of Crohn's disease manifested as obstruction

4.

Stricture in a patient with short bowel syndrome

5.

Non-phlegmonous fibrotic stricture

The contraindications to strictureplasty are as follows:

1.

Free or contained perforation of the small bowel

2.

Phlegmonous inflammation, internal fistula, or external fistula involving the affected site

3.

Multiple strictures within a short segment

4.

Stricture in close proximity to a site chosen for resection

5.

Colonic strictures

6.

Profound hypoalbuminemia (< 2.0 g/dL)

The occurrence of long strictures may provide technical difficulties in performing a long side-to-side strictureplasty. Unless the bowel is supple enough to bend into a U-shape and still allow for a tension-free anastomosis, leakage and sepsis will likely occur. As well, the function of such segments remains unproven and a remote risk of cancer, occurring later or coexisting, is present. In practice the interest for preserving these types of long strictures by side-to-side strictureplasty is related indirectly to the length of the remaining small bowel.

Conclusions

Crohn's disease continues to be an incurable inflammatory disorder of the alimentary tract that also affects extra-intestinal sites. Although medical therapy has become more specific and effective with better understanding of disease pathogenesis, operative treatment continues to be necessary for the majority of patients due to complications arising from chronic disease. The once popular bypass operation has been nearly abandoned as the safety and utility of limited bowel resection and strictureplasty have been recognized. These surgical options will continue to prominently impact the care of patients with Crohn's disease until the recurrent nature of the disease is better managed.

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2.
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Copyright © 2001, W. Zuckschwerdt Verlag GmbH.
Bookshelf ID: NBK6934

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