Surgical Management of Primary Crohn’s Disease

Special Article - Crohn’s Disease and Colitis

Austin J Gastroenterol. 2017; 4(1): 1078.

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 M, Kacem M and Ben Safta Z

Department of General Surgery ‘A’, La Rabta Hospital, Tunisia

*Corresponding author: Makni Amin, Department of General Surgery ‘A’, La Rabta Hospital, Jabbari 1007, Tunis, Tunis El Manar University, Faculty of Medicine of Tunis, 15 Rue Djebel Akhdhar, Tunisia

Received: February 14, 2017; Accepted: March 13, 2017; Published: March 24, 2017

Abstract

Inflammatory bowel disease is a chronic gastrointestinal condition that is characterized by chronic gastrointestinal inflammation. The management of Crohn’s disease is complex and requires skill, knowledge and experience with current advances in the field. Over the past several years, there have been a number of achievements and progress made in the care and management of this disorder. The diagnostic tools have greatly improved. The therapeutic armamentarium has expanded. The genetics of IBD has become more detailed and the role of the gut microbiome has been better defined. The evolution of biological agents has revolutionized the way we approach this disease. 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

Surgery is required in more than 80% of patients with Crohn’s disease (CD) [1]. The aim of surgery is not to cure the disease, which evolves in most cases to the recurrence of the remaining intestine [2]. Surgical treatment of intestinal lesions caused by CD is guided by two main criteria: operate only complicated forms, and refractory to medical treatment, and perform an intestinal resection as limited as possible, removing only lesions responsible for the symptoms observed. Indeed, perineal CD is problematic as regards to the diagnostic, prognostic and specific management. Over the past several years, there have been a number of achievements and progress made in the care and management of this disorder. 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.

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 intestinal resections became more unusual [5].

Time for surgery: Identifying the best time for surgery is not always an easy task. In order to determine the best time for surgery we should assess the severity and type of symptoms, failure of medical treatment, the onset of adverse effects and surgical risk/ benefit. All this together will enable gastroenterologists, surgeons and patients to agree on optimal time for surgery. Those advocating early surgery argue that if medical treatment does not achieve substantial improvement there is no reason to await the onset of a serious, potentially life-threatening complication, or to increase surgeryrelated risk. 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].

Type and topography of lesions: Crohn’s disease (CD) is a very heterogeneous disease with a relatively unpredictable clinical 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 not respond to conservative management necessitates [3,15].