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What’s New In Surgical Treatment for Crohn’s Disease Adam Klipfel, MD, and Paul Sturrock, MD Crohn’s disease (CD) has no cure. have reported that on average a Crohn’s studies reporting on Hartmann’s proce- Surgery is reserved for 3 specific catego- patient will have 2.5 operations in a life- dures or abdominoperineal resections. ries of complications: 1) urgent/ emer- time. For these reasons the use of All three studies demonstrated a statisti- gent, 2) chronic type conditions and 3) laparoscopy, a less invasive technique cally significant shorter length of hospi- refractoriness to medical therapy. Ap- thought to produce less scarring and talization and earlier return of bowel proximately 70% of patients with CD trauma to the tissues, is an excellent way function with the laparoscopic ap- will require at least one surgery during to reduce morbidity. proach.2,3,4 Additionally, Tan et al re- their lifetime. ported a lower overall cost in the The type of surgery required de- LAPAROSCOPY IN CROHN’S DISEASE laparoscopic group, likely related to ear- pends upon the clinical and anatomic The technique of laparoscopy has lier discharge.2 Rosman and co-workers presentation. CD can manifest anywhere revolutionized abdominal surgery, allow- showed a lower rate of recurrent CD re- from the mouth to the anus; unfortu- ing smaller incisions, better visibility, and quiring surgery. No difference was ob- nately, for most patients, disease tends to less post-operative pain after procedures served in operative blood loss, rate of eventually recur at the anastomotic site. as diverse as cholecystectomy, appendec- reoperation for complications, or mortal- The goal of treatment is similar in all cases: tomy, hernia repair, and even surgery for ity in any of these analyses. Overall mor- to resolve the symptoms, improve quality morbid obesity. This technique is per- bidity was also found to be lower in the of life and reduce the risk of disease com- formed by using several small incisions (5 laparoscopic group, but there was no dif- plications. The three anatomic areas that to 10 mm each) to gain access to the peri- ference when individual complications most commonly need surgical treatment toneal cavity and employing small instru- were analyzed.3 Conventional open sur- are the distal small bowel, the large bowel ments to dissect under direct visualization gery provided significantly shorter opera- and the ano-rectal area. Surgical treat- provided by a camera (laparoscope.) tive times than the laparoscopic ap- ment of the large bowel or colon will When used for larger procedures includ- proach. These studies concluded that sometimes require a total colectomy or ing colonic surgery, one larger incision is the results justified the use of laparoscopy segmental resection which may require a often made for specimen extraction or for as a safe and viable option in the surgical temporary or permanent ostomy. The the insertion of a hand-assist port. This treatment of CD.2,3,4 small bowel and the ano-rectal area incision is almost always smaller than one Additional data support the position present more difficult challenges. An- that would have to be made for a con- that laparoscopic surgery has the lowest orectal disease can be quite debilitating, ventional open operation. recurrence rate, fewest complications, but can usually be palliated with drain- Compared to conventional open and highest patient satisfaction. A com- age of abscesses and temporary indwell- surgery, improvements include decreased parative study of the two methods by ing drains. A team approach with medi- post-operative pain, shorter hospital stay, Eshuis et al. showed similar rates of re- cal and surgical therapy is associated with better cosmetic result and shorter recov- currence and quality of life after resec- better outcome.1 Severe ano-rectal dis- ery period.2 When applied specifically tion. The open surgery group had a ease may require a permanent ostomy in to CD, the important issues are whether higher rate of hernia formation and rare cases. There are some new tech- or not recurrence rates, morbidity and laparoscopy was associated with better niques for ano-rectal surgery to palliate quality of life are equivalent to open sur- cosmetic result; these results however did the disease. gery, therefore justifying its use to gain not reach statistical significance.5 A pro- For the small bowel, overall treat- the above advantages. The next section spective randomized trial by Stocchi et al ment goals are to preserve bowel length reviews recent evidence regarding mini- confirmed similar recurrence rates and a and thus prevent a short gut syndrome, mally invasive surgical treatment of CD. trend toward higher rate of hernia for- while at the same time providing pallia- Since 2005, three separate meta- mation, as well as a significantly greater tion and resolution of the problem with analyses have evaluated laparoscopy in rate of multiple operations in the open as little resection as possible by the least CD. The predominant operation by far surgery group.6 These studies did not invasive techniques. Long-term studies was ileocolic resection, with a minority of demonstrate a superiority for the laparoscopic approach, but provided fur- Complications: Urgent/Emergent Chronic/Long-term ther evidence that its use in CD is accept- able with better cosmetic results and po- Indications for Bowel perforation/ Stricture / recurrent tentially decreased morbidity. operation obstruction partial obstruction toxic colitis Other operative technologies are evolving, and some may be of assistance Massive hemorrhage Cancer in the surgical management of RD. Abscess Abscess/ Fistula Robotically assisted laparoscopic surgery Refractory disease Refractory disease is used in abdominal surgery, and there 89 VOLUME 92 NO. 3 MARCH 2009 has been speculation that the ability to To justify surgical intervention, the perform intracorporeal suturing may 1. Multiple strictures in a dif- stricture must also be symptomatic, usu- make it advantageous in the performance fusely affected bowel ally manifesting as intermittent obstruc- of strictureplasty. Natural Orifice 2. High risk for “short gut” because tion, restriction of food intake, weight Transluminal Endoscopic Surgery of previous resection and small loss, and/or inability to tolerate certain (NOTES) has gained attention recently, amount of remaining bowel. foods (particularly high residue); malnu- although its application in CD is as yet 3. Fibrotic stricture without in- trition can occur. Even in a patient who unclear. There are no reports of these flammation. meets these criteria there are reasons that techniques applied specifically to the a strictureplasty should not be done. The treatment of inflammatory bowel disease, following is a list of contraindications: but as comfort and experience grow with the technology, there may be a role for each of these approaches. Minimally invasive surgery has be- come an important element of the colorectal surgeon’s arsenal. Patients often request laparoscopy, as they are aware of the potential advantages, includ- ing a faster recovery. While it may not be appropriate for every patient, it is an acceptable initial approach under the correct circumstances. Regardless of an open or laparoscopic approach, the ulti- mate goal is to achieve effective treatment of the diseased intestine and preserve as Image 1. Incision is made along the anti-mesenteric border of the stricture. much bowel length as possible given the high likelihood for disease recurrence and need for reoperation. BOWEL PRESERVATION AND STRICTUREPLASTY An area of surgery that is unique to CD is strictureplasty, which is the open- ing of a fibrotic narrowing (stricture) of the bowel lumen and suturing it back in a different orientation to allow more nor- mal flow of intestinal contents without needing resection. Because CD has no cure, patients are prone to multiple op- erations with multiple bowel resections, Image 2. Then sutured back together transversely. and thus are at high risk of getting “short gut” syndrome, which can lead to death or lifelong dependence on total parenteral nutrition. For this reason the surgical approach to CD has become more and more conservative, focusing on techniques such as strictureplasty to pre- serve bowel length whenever possible. In CD a large inflammatory component can make resection the only possibility. The strictures in CD come in vari- ous types and lengths, and there are dif- ferent techniques to manage different types. If the stricture has a large inflam- matory component refractory to medi- cal treatment, a resection is indicated. Indications for strictureplasty in- clude: Image 3. 90 MEDICINE & HEALTH/RHODE ISLAND There are sev- and can lead to stasis and bacterial over- eral techniques of growth. The technique that was devel- strictureplasty de- oped more recently and seems to provide pending on the size a more physiologic function is a side to side and location of the iso-peristaltic anastamosis. This is done by lesions and the his- transecting the bowel in the middle of the tory of the patient. stricture and placing the two portions of The size of the stric- bowel side by side. By transecting and not tures are general folding it is possible to suture it together broken down into 3 in a way that the lumen remains in conti- categories, <10cm, nuity and thus prevent stasis of the intesti- 10-20cm, and nal contents. See Diagram 2 and Image 3. >20cm, each with Strictureplasty of all types can be done increasing difficulty. with good results. A systematic review with If the tissue is not meta-analysis, done in 2007, examined Diagram 1. amenable to exten- these three types of strictureplasty in 3,259 sive suturing, the patients. The morbidity was low with a simplest, safest pro- septic (abscess/fistula/leak) complication 1. Perforated bowel cedure is always resection; but this must rate of 4%. The recurrence rate overall 2. Severely inflamed loops of bowel be balanced with the amount of remain- was 28% after strictureplasty.

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