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Surgical Management of Primary Crohn's Disease

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Surgical Management of Primary Crohn's Disease Open Access Austin Journal of Gastroenterology Special Article - Crohn’s Disease and Colitis Surgical Management of Primary Crohn’s Disease Makni A*, Magherbi H, El Héni A, Daghfous A, Rebai W, Chebbi F, Fterich F, Ksantini R, Jouini Abstract M, Kacem M and Ben Safta Z Inflammatory bowel disease is a chronic gastrointestinal condition that is Department of General Surgery ‘A’, La Rabta Hospital, characterized by chronic gastrointestinal inflammation. The management of Tunisia Crohn’s disease is complex and requires skill, knowledge and experience with *Corresponding author: Makni Amin, Department current advances in the field. Over the past several years, there have been of General Surgery ‘A’, La Rabta Hospital, Jabbari 1007, a number of achievements and progress made in the care and management Tunis, Tunis El Manar University, Faculty of Medicine of of this disorder. The diagnostic tools have greatly improved. The therapeutic Tunis, 15 Rue Djebel Akhdhar, Tunisia armamentarium has expanded. The genetics of IBD has become more detailed and the role of the gut microbiome has been better defined. The evolution Received: February 14, 2017; Accepted: March 13, of biological agents has revolutionized the way we approach this disease. 2017; Published: March 24, 2017 However, surgery is still required in more than 80% of patients with Crohn’s disease (CD). This article aims to study the epidemiological, anatomical and therapeutic principles of surgical forms of CD. Keywords: Crohn’s disease; Surgery; Recurrence; Stricture; Fistula Introduction we should assess the severity and type of symptoms, failure of medical treatment, the onset of adverse effects and surgical risk/ Surgery is required in more than 80% of patients with Crohn’s benefit. All this together will enable gastroenterologists, surgeons and disease (CD) [1]. The aim of surgery is not to cure the disease, patients to agree on optimal time for surgery. Those advocating early which evolves in most cases to the recurrence of the remaining surgery argue that if medical treatment does not achieve substantial intestine [2]. Surgical treatment of intestinal lesions caused by CD improvement there is no reason to await the onset of a serious, is guided by two main criteria: operate only complicated forms, and potentially life-threatening complication, or to increase surgery- refractory to medical treatment, and perform an intestinal resection related risk. On the other hand, authors critical of early surgery argue as limited as possible, removing only lesions responsible for the that since relapse and re-operation rates are high, the chances of short symptoms observed. Indeed, perineal CD is problematic as regards bowel syndrome are very low. This argument does not hold because to the diagnostic, prognostic and specific management. Over the past since small resections and strictureplasties are being conducted this several years, there have been a number of achievements and progress syndrome is highly unlikely to occur [3]. made in the care and management of this disorder. However, surgery is still required in more than 80% of patients with Crohn’s disease Type and topography of lesions: Crohn’s disease (CD) is a (CD). This article aims to study the epidemiological, anatomical and very heterogeneous disease with a relatively unpredictable clinical therapeutic principles of surgical forms of CD. The indications of surgical management Multidisciplinary approach is now mandatory to discuss the therapeutic strategy and the time for surgery. 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]. Chronic complications of Crohn’s disease Surgery in the era of medical management: Today’s, medical management (immunosuppressants, biological therapies) has been used increasingly and was initiated much earlier during the course of CD. However, this evolving therapeutic strategy was not associated with a decrease in the need for surgery or in a decrease of the occurrence of intestinal complications. The real benefit is that large Figure 1: Stenosis of the distal ileum. A- Small bowel opacification: Stenosis intestinal resections became more unusual [5]. extended last two ileum loops. B- Abdominal CT-scan: inflammatory stricture of the distal ileal that takes intensely the contrast. C- Intraoperative view: the Time for surgery: Identifying the best time for surgery is not handle is inflammatory with a sclero-lipomatosis D- Surgical specimen: The always an easy task. In order to determine the best time for surgery ileal stenosis. Austin J Gastroenterol - Volume 4 Issue 1 - 2017 Citation: Makni A, Magherbi H, El Héni A, Daghfous A, Rebai W, Chebbi F, et al. Surgical Management of ISSN : 2381-9219 | www.austinpublishinggroup.com Primary Crohn’s Disease. Austin J Gastroenterol. 2017; 4(1): 1078. Makni et al. © All rights are reserved Makni A Austin Publishing Group Figure 2: Colonic Crohn’s disease. A- Barium enema: presence of multiple Figure 3: Acute peritonitis. Intra-operative view: acute peritonitis related to colonic stenosis with inter-stenotic dilatation. B- Abdominal CT-scan: stenosis the peritoneal rupture of an intra-abdominal abscess complicating Crohn’s of descending colon C- Abdominal CT-scan: Inflammation of the ileum (two disease. arrows) and sigmoid colon (three arrows). course. Nevertheless, important prognostic information is provided by classification based on the anatomic location, disease behavior, surgical history, and response to corticosteroid treatment. The Vienna Classification, a simple phenotypic classification structured on a combination of age at diagnosis, location (upper gastro-intestinal, terminal ileon, ileo-colon) and behavior of disease (stricturing, penetrating, non-stricturing non-penetrating), provides distinct definitions to categorize Crohn’s patients into various subgroups [6- 8]. The most common location of lesions which required surgery is the terminal ileum [9] and the ileocecal junction [10-14]. In this case, the most common indications are symptomatic stricture (Figure 1) or mixed forms (which causes intra-abdominal abscess or complex fistulas) [9]. Followed by the colorectal location, which the most common indication is the resistance to medical treatment of non-stricturing non penetrating form followed by colonic stricture (Figure 2). 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 Figure 4: Intra-abdominal abscess. Abdominal CT-scan: A- Presence of not respond to conservative management necessitates [3,15]. a collection at the right iliac fossa. B- Radiological-guided percutaneous drainage of the abscess. Table 1 describes the clinical presentation and the indication of surgery depending on location and type of lesion. [16] that we prefer to transformation of the perforation in stoma which The acute complications of Crohn’s disease is difficult to perform because of the abondance of sclerolipomatosis. Acute peritonitis: Acute peritonitis (Figure 3) caused by free The intra-abdominal abscesses: They are more common and perforation of a lesion in the peritoneal cavity is very rare [13]. It can be managed sequentially starting first by percutaneous drainage requires resection of the perforated segment and performing a stoma (Figure 4) under radio logical guidance rather than surgical drainage Table 1: Description of the clinical presentation and the indication of surgery depending on location and type of lesion. Behaviour Stricturing Penetrating Non-stricturing non penetrating Location Upper gastrointestinal ++ +/- Frequency* - Intestinal obstruction Digestive by-pass Indications of surgery Ileo-colon/terminal ileon Mixed form Frequency* +++ - Indications of surgery Intestinal obstruction, intra-abdominal abscesss** Colon and rectum + ++ Frequency* - Intestinal obstruction Resistance to medical treatment Indications of surgery Frequency* (-) extremely rare (+/-) rare (+) possible (++) frequent (+++) very common **Complex fistula: ileo-ileal, ileo-cecal, ileo-vesical and/or entero-cutaneous fistula. Submit your Manuscript | www.austinpublishinggroup.com Austin J Gastroenterol 4(1): id1078 (2017) - Page - 02 Makni A Austin Publishing Group [17]. Jawhari, et al. has demonstrated that drainage was technically symptomatic recurrent Crohn’s disease and need for reoperation. possible in half of patients [17]. This radiological technique allowed to [27,28]. For colonic lesions: segmental colonic, sub-total or total surgery to be performed in better conditions: patient better prepared, colonic resection. For segmental colonic lesions, recent data suggests the possibility of immediate digestive anastomosis, a lower operative that segmental colectomy is preferable than total colectomy, indeed morbidity and the opportunity to offer the laparoscopic approach for a similar recurrence rate, segmental colectomy offers a better [17-19]. functional outcome [29]. The acute mechanical bowel obstruction: It is the complication Proctectomy, is a mutilating procedure in young patients. It is of stenosing lesions. However, the indication of surgery in the needed in less than 10% of patients [30]. This gesture
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