Crohns

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Presentation by Guy Nash Consultant General & Colorectal Surgeon, Poole, Dorset

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Crohns

  1. 1. Surgery in Crohn’s Guy Nash
  2. 2. Background • Crohn Ginsberg Oppenheimer 1932 in USA described terminal ileitis in 14 surgical cases • Affects any part of the GI track but terminal was not popular with patients, thus regional ileitis or “Crohn’s” • Response to postulated pathogen causes the clinical manifestations of pain, diarrhoea and malabsorption
  3. 3. Investigation • Colonoscopy usually required to view colon and or small bowel • Barium follow through shows Terminal ileal stricture adjacent to ileocaecal junction
  4. 4. Earlier British report? • In 850AD King Alfred, "England's Darling", age 20 suffered chronic pain on eating, and “much embarrassment” • Thought to be due to witchcraft…. In retrospect, probably Crohn's Disease
  5. 5. Aim of treatment Relief of symptoms as “Incurable”
  6. 6. Role of Surgery Traditionally surgery was reserved for: Failure of medical management Complications (eg obstruction/ fistulation)
  7. 7. Why “Last Resort” Too much surgery, resecting too much bowel resulting a bowel too short to absorb fluid and food.
  8. 8. Short bowel syndrome Small bowel must > 1 metre length with intact colon
  9. 9. Protagonism for surgery in Crohns Traditional approach fails to appreciate: 3. Any benefits of early surgery 2. Adverse effects of agents 3. Detrimental effects of delaying surgery [ If surgery, which operation is best ]
  10. 10. 1.Earlier intervention • Early surgery offers favourable course in Crohns? • 36 patients at appendicectomy diagnosed ileocolic Crohn's: 10 patients had immediate ileocolic resection, 50% of these had no further intervention after 12 years of follow up. 26 treated conservatively, 24 eventually required surgery for debilitating symptomatology. Weston LA, Roberts PL, Schoetz DJ jr, et al. Ileocolic resection for acute presentation of Crohn's disease of the ileum. Dis Colon Rectum 1996;39:841–6.
  11. 11. 2. Medical adverse effects • Steroids & Cytotoxics side effects plentiful
  12. 12. 2. Smoking in Crohns • Smoking improve UC but worsens Crohns, does this give us a clue to the pathophysiology of Crohns? • Underlying pathology is ischaemic insult, does smoking act by worsening ischaemia? • Ischaemia induces VEGF secretion and nearly all Crohns treatments [ASA, steroids/heparin] reduce angiogenesis. • Is this an important step in treatment of Crohns? Increased vascular endothelial growth factor production in fibroblasts isolated from strictures in patients with Crohn's diseaseBr J Surg 2004; 91: 72-77 p646 Nash G.F
  13. 13. 3.Delay of surgery • Series of 184 ileocolic resections: 2% mortality, 7% wound infection, 9% postoperative abscess and 11% anastomotic leak Factors associated with complications were current steroid use, low albumin, and sepsis (abscess and fistula), which are indicators of advanced disease Andrews HA, Keighley MR, et al.Strategy for management of distal ileal Crohn's disease Br J Surg 1991;78:679– 82
  14. 14. 3. Delay of surgery • Study looking at patients perspective shows 72% of patients would have preferred earlier surgical intervention. Median of a year earlier! Scott NA, Hughes LE. Timing of ileocolonic resection for symptomatic Crohn's disease—the patient's view. Gut 1994;35:656–7
  15. 15. Stapled “side to side” makes a bigger join between the bowel ends
  16. 16. Stapled anastomosis • Prospective Randomized Trial: Stapled anastomoses vs hand-sewn 63 patients undergoing Crohns resection • Significant difference in cumulative recurrences between the groups (P = 0.022) • Stapled anastomotic resection for Crohn's disease may delay reoperation in patients with symptomatic recurrence. Long-Term Results of Stapled and Hand-Sewn Anastomoses in Patients with Crohn's Disease Hiroki Ikeuchi, Masato Kusunoki, Takehira Yamamura. Digestive Surgery 2000;17:493-496
  17. 17. Recurrence needing reoperation Handsewn (end to end) [P = 0.022] Stapled (side to side) Thus is makes sense to carry out a side to side join for Crohns to reduce the chance of the join blocking in the future.
  18. 18. Laparoscopic right hemicolectomy • Potential reduction in surgical morbidity (less wound problems & fewer adhesions) • Young population of patients who may need surgery every 10 years on average.
  19. 19. Laparoscopic results • Smaller incisions, less pain & analgesia requirement, faster return to bowel function & home.

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