2. 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
5. 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
6. Pros of early surgery
-Issues with medical treatment
-difficulty in inducing remission leads to prolonged disease and
complications
-Quality of life
-Cost
7. Pros of early surgery (cont.)
• Advances in surgery
-laparoscopic surgery
-short stay
-better cosmosis
-better quality of life
9. 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
10. 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
11. 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
12. What to do with crohn’s diagnosed at
emergency surgery?
-40% do nothing
-33% limited ileocecal resection
-27% remove normal appendix
13. What to do with crohn’s diagnosed at
emergency surgery?
-Gastroentrologists
-54% prefer surgery
14. 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.
15. 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
16. 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.
19. Quality of life and surgery
-clinical recurrence is low
-35% requires reoperation at 10 years
-quick restoration of quality of life
20. -Observational study involving patients
with isolated ileocecal Crohn's who
underwent early surgical resection
-within one year of the presentation of
the hospital.
22. 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
27. Results continue,
-Average 18.8 months follow up
-No patients required further surgical intervention and controlled
symptoms were achieved in all patients
