Crohn's Colitis

Steve R Brown

Powerpoint File

Although Crohn’s disease mainly affects the small bowel, a significant proportion of patients have large bowel disease as well and in about 20% the colon is the only affected organ. Medical management is increasingly the mainstay of treatment but even with the huge developments in therapies over the last 10 years, most patients still end up having surgery at some time. The indications for surgery, remain the same; namely failure or intolerance of medical therapy, complications arising from the disease or cancer risk.

The underlying ideology of Crohn’s surgery (particularly for small bowel disease) is minimal resection and the trend of resecting only the area of bowel responsible for the symptoms even if that means leaving disease behind. When surgery is indicated for large bowel disease, these principles remain true to a certain extent. Some surgical principles do differ however, and there are areas of controversy. These areas will be the focus of the presentation and are listed below.

• Primary surgery may be indicated in patients with localised ileocaecal Crohn’s disease with obstructive symptoms.

Although the current trend is for medical management as the primary treatment, over half of those presenting with localised obstructive disease who undergo surgery will never have another operation. In contrast, although medical management will often resolve symptoms, this is usually only temporary. However, no data exists concerning quality of life with medical verses early surgical management.

• A wide lumen functional end to end anastomosis may reduce recurrence.

Several studies have tried to address the issue of anastomotic technique and most appear to favour the wide lumen technique. Quality of the studies is an issue.

• Laparoscopic resection

Most patients with Crohn’s disease understand that they have a high probability of needing surgery at some time. They are thus extremely motivated to undergo an operation that could involve minimal scarring and a faster recovery. Whether the claims of fewer complications and the more rapid recovery are real remains contentious.

• Limited colonic Crohn’s disease should be treated with segmental resection.

The extent of resection in limited disease is still a topic of debate and depends mainly on the extent of disease. For left sided disease with rectal sparing, a limited resection rather than a proctocolectomy may be appropriate in that it avoids a permanent ileostomy. However, the rate of recurrence is higher. For localised proximal disease or multiple segment disease with rectal sparing, segmental resection or colectomy and ileorectal anastomosis appear equivalent in terms of post-operative complications and need for a permanent ileostomy, but there is a trend towards favouring the ileo rectal anastomosis in terms of time to recurrence. Patients with diffuse, distal and perineal disease are at highest risk of recurrence and aggressive treatment with total proctocolectomy is probably the surgical treatment of choice.

• Endoscopic dilation of colonic strictures is the preferred method for accessible short strictures. Stricturoplasty in the colon is not recommended.

There are several centres utilising the technique of hydrostatic balloon dilation for colonic strictures to good effect and with minimal complications. However, the risks of perforation necessitate easy access to surgical back up. Colonoscopic exclusion of cancer and rigorous follow up is essential because of the increased risk of cancer in a colonic stricture compared with a small bowel stricture. It is for this reason that surgical stricturoplasty is not recommended although the evidence for this recommendation is poor.

• Ileo-pouch-anal anastomosis is not recommended.

Data from patients with an unsuspected diagnosis of Crohn’s colitis after IPAA suggests these patients are burdened with the most complications and up to 50% may have the pouch removed. Nevertheless there are some Crohn’s patients who do well with a pouch and would prefer the increased risk of complications and failure to a permanent ileostomy.

References

1. Travis SPL et al. European evidence based consensus on the diagnosis and management of Crohn’s disease: current management. Gut 2006;55(Suppl 1):i16-i35.
2. Tekkis PP et al. A comparison of segmental vs subtotal/total colectomy for colonic Crohn's disease: a meta-analysis. Colorect Dis 2006;8:82-90.
3. Reese GE et al. The Effect of Crohn's Disease on Outcomes After Restorative Proctocolectomy. Dis Colon Rectum 2006 Epub.