Surgery on Crohn’s Surgery on Crohn’s DiseaseDisease

Dennis KY Ngo

Department of Surgery

Prince of Wales Hospital

Joint Hospital Surgical Grand Round

Background

Chronic transmural inflammatory process that can affect GI tract anywhere, also associated with extraintestinal manifestation

Commonly : ileal, ileocolic, colonic and perianal disease

Diagnosis based on macroscopic, histologic and radiological features

IncidenceMore common in Caucasian

5-6 per 100 000 population ( North American, northern Europe )

Rate is lower in Asia. However, there is increasing trend

1 per 100 000 population ( Hong Kong ) 3 fold over the past decade

Leong at el. Inflammatory Bowel Diseases. 10(5):646-51, 2004 Sep.

Increasing incidence of Crohn’s disease annually, more and more people will keep an eye on the treatment modality, esp in these young age group population.

Apart from medical therapy,

What is the surgeons’ role in treatiWhat is the surgeons’ role in treating this benign disease ? ng this benign disease ?

M/22

Good past health

Presented in March 2006 with right iliac fossa

pain associated with diarrhoea and weight loss

for 1 month

Colonoscopy on 8 March 2006

• Inflammation and ulcers at caecum and ileocaecal valve

• Terminal ileum could not be intubated because of swollen i

leocaecal valve

• Biopsy: Crohn’s disease

Seen by Gastroenterologists on 10 March 2006; Salof

alk 1 g TDS and prednisolone started

Readmission as Emergency

Readmission on 12 March 2006

Increased right iliac fossa pain for 1 day

Fever 38.5 0C

Pulse rate: 100/minute

CXR: no infradiaphragmatic free gas

WCC: 13.5 x 109/L

Thickened terminal

ileum and caecum

Pockets of free gas

Pocket of free gas

Ileocaecal Crohn’s disease with peritonitis and s

uspected perforation

Emergency laparoscopic-assisted righ

t hemicolectomy

Cobblestone appearance

~ 80% will require surgery irrespective of its siteFarmer et al. Gastroenterology 1985; 30:990-5Bernell et al. Ann Surg 2000; 231:38-45

Surgery Curative ( potentially involve the entire intestine )

Recurrence (invariable)Potential benefits of surgery

Symptoms reliefImproved nutritional statusReduced dependence of medication

Development of Surgical procedures focus on treating the complications as well as conserving the bowel length

Indications of SurgeryFailed medical treatment

Growth retardation (Children)Complication of steriod and other medical therapy

ComplicationsObstruction

Perforation

Fistula formation

Abscess formation

Bleeding

Toxic colitis

Malignancy

Management of Stenosis

Non-operativeBalloon dilatation

OperativeBypass

Strictureplasty

Resection

Balloon dilatation55 patients, managed by endoscopic dilatation

18mm balloon, followed by 20/25mmInflated for 2min ( repeat 2-6 inflations)90% successful dilatation8% perforation rate

Mean FU time : 33.6 months18 patient need second dilatation at 1.5 yearLong term successful rate : 62%Operation rate : 38%

Couckuyt H, et al. Gut 1995;36:577-580

Bypass

Popular in the past (1930-1950)

Problems : Active disease in the retained segment

Abscess / Fistula / Perforation / increased rate of malignancy of bypassed segment

No place in modern day surgery, ExceptGastroduodenal Crohn’s with hostile adhesions to adjacent organs preventing a safe excision

Strictureplasty

Mainly used for small bowel

Good symptomatic relief and bowel sparing

Aim at conserving small bowel for the fear of short bowel

Ideal for short stricture

Can be performed for single or multiple strictures

ContraindicationPerforation of bowel

Present of abscess, inflammation and fistula

Multiple strictures over a short segment of bowel

Inability to perform tension-free suture line

Profound hypoalbuminemia

Generally not to be performed on large bowelHigh recurrence rate

High risk of malignancy

Technique

Longitudinal incision with extension to normal looking bowelInspection of lumen, biospy of suspicious lesion ( R/O malignancy )

Stricture < 10cm : close in Heineke-Miculicz fashionStricture 10-20cm : repaired with Finney strictureplasty

Heineke Miculicz Strictureplasty

Recurrence & Reoperation

100 patients included for strictureplastyMean FU 85.1 months ( 0.2-240.9 months )

Overall reoperation rate : 56%

N. S. Fearnhead et al. British Journal of Surgery 2006;93:475-482

162 patients Reoperative rates (5 years) : 31%

Ozuner et al Dis Colon Rectum 1996

Majority – new segments of stricture

Recurrence at strictureplasty site is rare – 3.7%

Stebbing et al Br J Surg 1995

ResectionLimited resection to achieve the goal of symptomatic relief, while preserving the bowel length

Resect macroscopically diseased bowel without concern for microscopic disease

Recurrence is unaffected the width of the margin of resection from marcroscopically involved bowel

Recurrence rate not increase when microscopic disease still present in the resection margin

Fazio et al. Annals of Surgery 1996;224:563-573

Intestinal Fistula

Internal fistula (30-40% CD)Ilijevski et al Eur J Surg 1997

General surgical principle

Resect the 10 diseased segment

Close the 20 involved organs

Colonic operation

Intractable disease ( failed medical therapy )

Severe colitis

Bleeding

Malignancy

Involving entire colon and rectumGold standard : proctocolectomy and ileostomy

Less extensive resectionSubtotal colectomy + mucous fistula

Total colectomy + ileorectal anastamosis

Segmental colonic resection

Role of laparoscopic surgery

Longer operationHigher cost

Faster recoveryLess scarring

Application of laparoscopic technique to Crohn’s disease

Benign disease

Relatively young patients (back to normal duty with economic consideration)

Better cosmesis

Risk of adhesive intestinal obstruction / incisional hernia

Possibility of multiple surgery Ozuner D et al Dis Colon Rectum 1996; 39: 1199-1203

DevelopmentStoma creation (ileostomy / colostomy)Earliest indicationBraga M et al Ann Surg 2002; 236: 759-66

Limited segmental SB resectionIleocaecal resectionMore complex / recurrent disease (fistula, phlegmon, etc)Emergency setting

Meta-analysis for ileocaecal resection in Crohn’s

783 patients (Lap: 338)

15 studies (1995 - 2004)

1 RCT1 RCT; 6 prospective; 8 retrospective

Conversion rate: 6.8%

Tilney HS et al Surgical Endos May 2006

Significant differenceLap vs Open

OT time (longer in Laparoscopic group)~30 mins

Post-op recovery (faster in Laparoscopic group)Tolerates full diet (1.47 days)First flatus (0.68 days)First bowel motion (0.58 days)Shorter hospital stay (2.97 days)

Similar outcome

Blood loss

Post-op complicationsAnastomotic leakage

Wound infection

Bowel obstruction

Intra-abd abscess

Return to work

Issues addressed

Technical feasibility

Safety

Immediate operative outcomes

Postoperative course ( our case )

First bowel motion: D3

Fluid diet resumed: D4

DAT: D6

Full ambulation: D4

Home: D9

No complication

Wound length: 8 cm

Conclusion

Surgical role in Crohn’s disease is Not to cure the disease

treat the complications with improvement of quality of life of these young group of patient

Development of laparoscopic surgery Better cosmesis and body image

Faster recovery

Less adhesion for ease of reoperation latter

Thank you