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Desirable goal in treatment of Crohn’s disease
To avoid or delay surgery while keeping patients in remission
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
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
• 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 – 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