Timing of surgery in Crohn’s disease: A key issue in the management

Abstract

The timing of the decision for operation in Crohn's disease is based on an evaluation of the several factors such as the failure of medical treatment, complications due to the Crohn's disease or to the pharmacological therapy, development of dysplasia or cancer and growth retardation. A complete evaluation of these factors should result in operation timed to the patient's best advantage, achieving maximal relief of symptoms with improvement of quality of life. Given the complexity and heterogeneity of the disease and the different options for treatment, is difficult to systematize when the optimal moment for the surgery is arrived. A very important factor in the management of Crohn's disease is the multidisciplinary approach and the patient preference should be a significant factor in determining the choice of therapy. The surgery should be considered such another option in the sequential treatment of Crohn's disease. We have analyzed the factors that are involved in the decision taking of the surgical treatment regarding to the experience and the published literature. When did the medical therapy fail? when is the appropriate moment to operate on the patient? Or which complications of Crohn's disease need surgery? These are some of the questions we will try to answer.

Surgical Management of Primary Crohn’s Disease

“…On the other hand, authors critical of early surgery argue that since relapse and re-operation rates are high, the chances of short bowel syndrome are very low. This argument does not hold because since small resections and strictureplasties are being conducted this syndrome is highly unlikely to occur [3].…”

“…Rarely, we can observe proximal lesions (duodenal, jejunal and ileal), which the most common indication is small bowel obstruction caused by strictures. Chronic fibrosis and scarring that do not respond to conservative management necessitates [3,15]. Table 1 describes the clinical presentation and the indication of surgery depending on location and type of lesion.…”

“…The indication for surgery in CD depends on a number of factors-complications, clinical course, relapse and location. We could say that surgery is timely in any of the following situations: failure of medical treatment, onset of specific complications related to the disease or to pharmacological treatment, dysplasia or cancer and stagnated or retarded growth in children [3,4]. …”

Management of abdominal and pelvic abscess in Crohn’s disease

“…Approximately 10% to 30% of patients with Crohn's disease will spontaneously develop an abdominal or pelvic abscess during the course of their illness [1][2][3] . These abscesses occur from transmural inflammation and microperforation of diseased bowel [4,5] . Fistulas arising from the diseased bowel are often associated with the abscess cavity [6] .…”

“…Fistulas arising from the diseased bowel are often associated with the abscess cavity [6] . In the great majority of cases, the terminal ileum or ileo-cecal region are the foci of Crohn's related activity [1,4,7] . Most commonly, abscesses occur in the abdominal wall, rectus sheath, iliopsoas muscle, gluteus muscle, presacral and subphrenic spaces [1,8] .…”