ileocecal crohn`s disease
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Ileocecal Crohn`s
Disease:
early surgeryDr Amro Salem, MCh, FRCS
Consultant Colorectal surgeon
Assisstant consultant surgeon
King Fahd Specialist Hospital-Dammam
Evolution
It is not the strongest of the
species that survives, nor the
most intelligent that survives,
it is the one that is the most
adaptable to change.
Charles Darwin
Phenotype
isolated terminal ileum crohn’s
disease
few articles
inevitable outcome
Cons of surgery
-Concern of Recurrent surgery (up to 70%)
-reoperation rate up to 50%
-multiple small bowel resections which may lead to short bowel
syndrome
Am Surg. 1997 Jul;63(7):627-33. Kim, etal
Pros of early surgery
-Issues with medical treatment
-difficulty in inducing remission leads to prolonged disease and
complications
-Quality of life
-Cost
Pros of early surgery (cont.)
• Advances in surgery
-laparoscopic surgery
-short stay
-better cosmosis
-better quality of life
Multidisciplinary decision making
Ileocecal resections
-184 resections 1980-1990
-2% mortality
-anastomotic leak 11%
-wound infection 7%
Andrews HA, et al Strategy for management of distal ileal Crohn's
disease. Br J Surg 1991;78:679–82
Ileocecal resections
-The more advanced the disease the greater the postoperative
complications
-post-operative morbidity increase from 12% up to 48%
-early operation is benificial
Hulten L. Surgical treatment of Crohn's disease of the small bowel. World J Surg
1988;12:180–5
key to successful management is
relief of symptoms
-patient is the best to define optimal time
-postal quesionaire to 80 patients had surgery
-72 % felt surgery should have been done ealier
-reasons: ability to eat normaly, severity of symptoms and better
quality of life
Scott NA, Hughes LE. Timing of ileocolonic resection for symptomatic
Crohn's disease—the patient's view. Gut 1994;35:656–7
What to do with crohn’s diagnosed at
emergency surgery?
-40% do nothing
-33% limited ileocecal resection
-27% remove normal appendix
What to do with crohn’s diagnosed at
emergency surgery?
-Gastroentrologists
-54% prefer surgery
Recurrence
-70% had endoscopic ulcerations after 12 months
- no surgical intervention needed
-reoperation rate 25% at 5 years and 35% at
10 years
-better quality of life
Rutgeerts P, et al. Natural history of recurrent Crohn's disease at the ileocolonic
anastomosis after curative surgery. Gut 1984;25:665–72.
Recurrence
-after 10 years follow up early surgical group has less clinical
recurrence.
- Longer clinical remission
- ?better medications= more remission
Alimentary therapeutics and pharmacology 2007
Minimizing recurrence after surgery
-5-ASA
-Metronidazole
-biological treatment
-surgical technique
-smoking
Hashemi M, et al Side-to-side stapled anastomosis may delay recurrence in
Crohn's disease. Dis Colon Rectum 1998;41:1293–6.
Cost
Quality of life and surgery
-clinical recurrence is low
-35% requires reoperation at 10 years
-quick restoration of quality of life
-Observational study involving patients
with isolated ileocecal Crohn's who
underwent early surgical resection
-within one year of the presentation of
the hospital.
Exclusion criteria
required mandatory surgical
intervention (e.g perforation,
associated dysplasia) or had previous
surgery
Blood workup
blood count, ESR and CRP compared
between the immediate preoperative
value (Pre), 1st postoperative visit (3 – 4
weeks) and last follow up (FU) visit
. Statistical analysis
SPSS program and paired Student-
T test used to compare the different
figures.
Results:
-15 patients
- 2 excluded (perforation and
earlier diagnosis)
Continue results
-female 6 : male 7
-Mean age 27.7
-Surgery indications:
fistula 5
stricure 4
Uncontrolled pain 3
subacute obstruction 1
Continue results
-Ileocecal resection 10
-Rt hemicolectomy 3
-Complications:
wound infection 1
leakage 1
Results continue,
-Average 18.8 months follow up
-No patients required further surgical intervention and controlled
symptoms were achieved in all patients
Results continue
P-values CRP ESR HB WBC
Pre vs Post 0.023 0.325 0.038 0.015
Pre vs FU 0.011 0.021 0.001 0.011
Results continue
Weight BMI Albumin
Pre vs FU 0.001 0.001 0.009
conclusions
conclusions
-phenotype is important
-complications of surgery increase with long medical treatment
-safe to operate
-surgery improve quality of life
-surgery is cost effective
Thank you
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