Management of Ileocecal Crohn’s Disease During Surgical Treatment for Acute Appendicitis: A Systematic Review

Abstract

BACKGROUND In many patients, the diagnosis of Crohn’s disease (CD) is made during surgery for appendicitis in urgent settings. Intraoperative diagnosis can be challenging in certain cases, especially for less experienced surgeons. OBJECTIVE: Review of the literature searching for scientific evidence that can guide surgeons through optimal management of ileocecal CD found incidentally in surgery for acute appendicitis (AA). METHODS: Included studies were identified by electronic search in the PubMed database according to the Preferred Items of Reports for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. The quality and bias assessments were performed by Methodological Index for Non-Randomized Studies (MINORS) criteria for non-randomized studies. RESULTS: A total of 313 studies were initially identified, six of which were selected (all retrospective) for qualitative assessment (two studies were comparative and four only descriptive case series). Four studies identified a high rate of complications when appendectomy or ileocolectomy were performed and in only one, there was no increased risk of postoperative complications with appendectomy. In the sixth study, diarrhea, previous abdominal pain, preoperative anemia and thrombocytopenia were independent predictors for CD in patients previously operated for suspected AA. CONCLUSION: Despite the paucity of data and low quality of evidence, a macroscopically normal appendix should be preserved in the absence of complicated disease when CD is suspected in surgery for AA. Ileocecal resections should be reserved for complicated disease (inflammatory mass, ischemia, perforation or obstruction). Further prospective studies are needed to confirm these claims.

The Enigma of Crohn’s Disease: A Case Report

“…In cases where patients have optimal preoperative nutrition and favorable intraoperative conditions, such as adequate blood supply to the bowel and stable hemodynamics, a primary anastomosis is generally recommended. However, in situations where conditions are less favorable, including septic shock requiring inotropic support, blood acidosis, gross contamination, and uncertain blood supply to the bowel edges, a non-restorative approach with the creation of a bowel stoma should be considered [ 9 ]. In the described patient's situation, the preferred option was to create a stoma due to the nature of the surgery being damage-controlled, and the potential risk of a leak associated with performing an anastomosis.…”

Surgical Management of Adult Crohn’s Disease and Ulcerative Colitis Patients: A Consensus From the Brazilian Organization of Crohn’s Disease and Colitis (Gediib)

“…Restorative proctocolectomy with IPAA may be offered to selected patients with CD in the absence of perianal or small bowel disease. Nevertheless, increased rates of long-term pouch failure in this patient group should be acknowledged and discussed (20,45) . Although usually reserved for patients with UC, the Kock pouch (also known as a continent ileostomy) may be an option in selected cases of isolated colorectal CD and should only be performed by appropriately trained and experienced surgeons (14) .…”

“…Therefore, the authors recommended that, in the absence of complicated disease and suspected CD in acute appendicitis surgery, a macroscopically normal appendix and the terminal ileum should be preserved. In case of complicated disease (inflammatory mass, ischemia, perforation, or obstruction), ileocecal resections are recommended (45) .…”