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