Indications and surgical options for small bowel, large bowel and perianal Crohn's disease

Abstract

Despite advancements in medical therapy of Crohn’s disease (CD), majority of patients with CD will eventually require surgical intervention, with at least a third of patients requiring multiple surgeries. It is important to understand the role and timing of surgery, with the goals of therapy to reduce the need for surgery without increasing the odds of emergency surgery and its associated morbidity, as well as to limit surgical recurrence and avoid intestinal failure. The profile of CD patients requiring surgical intervention has changed over the decades with improvements in medical therapy with immunomodulators and biological agents. The most common indication for surgery is obstruction from stricturing disease, followed by abscesses and fistulae. The risk of gastrointestinal bleeding in CD is high but the likelihood of needing surgery for bleeding is low. Most major gastrointestinal bleeding episodes resolve spontaneously, albeit the risk of re-bleeding is high. The risk of colorectal cancer associated with CD is low. While current surgical guidelines recommend a total proctocolectomy for colorectal cancer associated with CD, subtotal colectomy or segmental colectomy with endoscopic surveillance may be a reasonable option. Approximately 20%-40% of CD patients will need perianal surgery during their lifetime. This review assesses the practice parameters and guidelines in the surgical management of CD, with a focus on the indications for surgery in CD (and when not to operate), and a critical evaluation of the timing and surgical options available to improve outcomes and reduce recurrence rates.

Crohn’s disease: prevalence, MR features, and clinical significance of enteric and colonic sinus tracts

“…This is consistent with previous observations by Cerqueira et al, who also reported that risk factors for surgery comprised disease at young age, terminal ileal involvement, and stenotic or stenotic-penetrating behavior [31]. The majority of Crohn surgeries are performed due to stenoses, followed by complications of penetrating Crohn's disease and others, such as therapy failure, gastrointestinal bleeding, a toxic megacolon, or neoplasia [32].…”

Fibrostenotic strictures in Crohn’s disease

“…4,5 Surgery will be needed in more than 70% of patients with CD within their lifetime to correct a severe complication such as intestinal obstruction, perforation, fistula and abscess. 3,[6][7][8][9] Despite of surgery, the rates of postoperative recurrence are high. Endoscopic recurrence by the third postoperative year is…”

Diverting Ostomy: For Whom, When, What, Where, and Why

“…Overall, less than 20 to 27% remained symptom free with bowel continuity restored. 20,21 In our experience, patients with refractory Crohn's colitis managed by diverting ileostomy have shown a dismal salvage rate, ultimately requiring total proctocolectomy and permanent ileostomy.…”