Surgical Treatment of Complex Small Bowel Crohn Disease Fabrizio Michelassi, MD and Samuel Sultan, MD

REVIEW Surgical Treatment of Complex Small Bowel Crohn Disease Fabrizio Michelassi, MD and Samuel Sultan, MD Introduction: The clinical presentations of Crohn disease of the small bowel Technical Challenges of Small Bowel Crohn Disease vary from low to high complexity. Understanding the complexity of Crohn Fistulae disease of the small bowel is important for the surgeon and the gastroenterol- As many as one-third of patients with small bowel Crohn dis- ogist caring for the patient and may be relevant for clinical research as a way ease harbor fistulae,12,13 yet, only two-thirds of these at most are to compare outcomes. Here, we present a categorization of complex small diagnosed preoperatively because of symptoms or findings such as bowel Crohn disease and review its surgical treatment as a potential initial drainage of enteric content through enterocutaneous or enterovaginal step toward the establishment of a definition of complex disease. fistulae, or pneumaturia and/or fecaluria in enterovesical fistulae.14 Results: The complexity of small bowel Crohn disease can be sorted into Occasionally, radiological or endoscopic imaging may provide the several categories: technical challenges, namely, fistulae, abscesses, bowel or preoperative diagnosis for enteroduodenal and enteroenteric fistulae ureteral obstruction, hemorrhage, cancer and thickened mesentery; extensive or enterogastric and enterosigmoid fistulae, respectively.15 disease; the presence of short gut; a history of prolonged use of medications, Recognizing that these fistulae follow specific patterns may particularly steroids, immunomodulators, and biological agents; and a high aid in suspecting their existence. For example, the majority of entero- risk of recurrence. duodenal fistulae originate from recurrent disease of the neoterminal Conclusions: Although the principles of modern surgical treatment of Crohn ileum after a prior ileocolic anastomosis16,17; enterovesical fistulae disease have evolved to bowel conservation such as strictureplasty techniques are usually found in patients with primary disease of the terminal and limited resection margins, such practices by themselves are often not ileum18,19 whereas cologastric fistulae originate from Crohn disease sufficient for the management of complex small bowel Crohn disease. This of the transverse colon.20 Also, knowledge of specific patterns may manuscript reviews each category of complex small bowel Crohn disease, also help in the preoperative discussion with the patient: as an exam- with special emphasis on appropriate surgical strategy. ple, one-third to one-half of all patients with an enterovesical fistula 21 Keywords: complex, Crohn disease, review, small bowel, surgery also harbor an enterosigmoid fistula. These patients should be in- formed preoperatively about the possibility of an enterosigmoid fis- (Ann Surg 2014;260:230–235) tula that may require a separate sigmoid colon resection and possibly a temporary stoma. Given that as many as one-third of all fistulae are discovered odern surgical treatment of Crohn disease of the small bowel only during an accurate exploratory laparotomy or laparoscopy, the M is based on well-established principles of bowel conservation surgeon needs to be ready and comfortable in dealing with such un- through bowel-sparing procedures and minimization of gross resec- suspected findings. Moreover, the complexity and magnitude of the tion margins.1–3 Applied in concert to the involved segment(s), these surgical procedure may increase substantially in the presence of a fis- principles usually result in addressing the complications of the disease tula, particularly with a cologastric, enteroduodenal, or enterosigmoid responsible for the need for surgery, with minimal loss of bowel.4–8 In fistula.22 a disease that is prevalent in the young population and tends to be re- Despite the diverse spectrum of the various fistulae, their sur- current, such bowel conservation is essential.9,10 Yet, these principles gical repair rests on common principles: transection of the fistulous by themselves are insufficient in the surgical management of com- tract, drainage of any intervening abscess, resection (or rarely stric- plex small bowel Crohn disease. This article addresses the modern tureplasty) of the diseased segment, and primary closure of the fis- treatment of complex small bowel Crohn disease. tulous opening on the target organ, after appropriate debridement.23 If the target organ is another segment of intestine and the defect is CATEGORIZATION OF COMPLEX SMALL BOWEL large or is located on the mesenteric side or is associated with a CROHN DISEASE substantial inflammatory reaction, the affected segment of intestine A consensus definition of complex small bowel Crohn disease may require a limited resection. The following paragraphs will review 11 unique considerations for the management of specific fistulae. does not exist. Complexity may relate to various factors, including 24 the degree of technical challenge presented by a complication of In a literature review of duodenal fistulae, Murray et al found the disease; the degree of disease extent along the length of the no cases of perforating duodenal disease, an observation which, to small bowel; the presence of short bowel; complications secondary to our knowledge, continues to be accurate. This is an important con- prolonged use of medications such as steroids, immunomodulators, sideration in the treatment of these fistulae in that the fistula may be and biological agents; or a patient at very high risk of recurrence. transected and the duodenum closed primarily, given the fact that the duodenal wall does not have Crohn disease. In the event of a large defect on the duodenum, a duodenojejunostomy may be an option. In the presence of an enterovesical fistula,25 the fistulous opening on the bladder should be closed, if possible, in one or more layers, From the Department of Surgery, New York-Presbyterian Hospital, Weill Cornell using absorbable sutures for the internal layer after drainage of any in- Medical College, New York, NY. Disclosure: The authors declare no conflicts of interest. tervening abscess and/or debridement of necrotic and infected tissue Reprints: Fabrizio Michelassi, MD, Department of Surgery, New York-Presbyterian on the bladder wall.26 Sometimes, the presence of extensive chronic Hospital, Weill Cornell Medical College, 525 East 68th St, Box 129, New York, inflammation precludes the ability to find the opening on the blad- NY 10065. E-mail: [email protected]. der. In this case, an omental flap may be used to fill the dead space Copyright C 2014 by Lippincott Williams & Wilkins ISSN: 0003-4932/14/26002-0230 created by the drainage of the intervening abscess or by the debride- DOI: 10.1097/SLA.0000000000000697 ment of the necrotic and chronically inflamed tissue on the bladder r 230 | www.annalsofsurgery.com Annals of Surgery Volume 260, Number 2, August 2014 Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. r Annals of Surgery Volume 260, Number 2, August 2014 Complex Small Bowel Crohn Disease wall. Postoperatively, bladder decompression with a urinary catheter successive attempt at dissecting the inflammatory adhesions and sav- is necessary to keep the bladder decompressed for a few days, after ing unaffected bowel. which a cystogram may be obtained to check on the integrity of the repair. If closed suction drains have been placed at the time of the Complete Small Bowel Obstruction and Chronic bladder repair, checking creatinine and blood urea nitrogen on the Obstruction drainage fluid may give an earlier indication of whether the bladder Complete small bowel obstruction is a rare condition in Crohn repair is intact. disease, reflected in the fact that Crohn disease accounts for as few Enterocutaneous fistulae pose challenges not only to patients 39 27,28 as 7% of all small bowel obstructions. Most bowel obstructions but also to surgeons. The surgeon must select the appropriate in Crohn disease resolve spontaneously and can be treated initially timing and strategy for surgical approach, whereas the patient must nonsurgically.40,41 The obstruction is usually due to undigested food manage the drainage of enteric contents and maintain proper hy- particles getting trapped in a stenotic area of Crohn disease: such giene. In the patient with abdominal wall sepsis, it may be initially obstructions usually resolve when the food particle is macerated and necessary to drain any intervening abscess to allow for the local sep- 29 pushed through the stenotic segment of intestine by peristaltic con- sis to abate. The senior author finds that physical examinations at tractions. Resolution can be aided by the administration of intravenous regular intervals (bimonthly to monthly) offer the best guidance in 30 corticosteroids to decrease the local inflammation at the site of the terms of selecting the appropriate timing for surgical intervention. diseased intestinal wall. Specifically, the timing is best when the local inflammatory response Yet, when the obstruction does not resolve, surgical interven- has subsided as much as possible and the abdominal wall, initially 31,32 tion is warranted. In these cases, the surgeon should be concerned doughy, has become soft. At the time of a planned intervention for about the possibility that the stenosis might be neoplastic rather than an enterocutaneous fistula, appropriate surgical management consists inflammatory.42 Hence, surgery should be based on oncologic prin- of resection

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