Difficult Small Bowel Crohn's Disease

John Northover

Powerpoint File

Crohn’s disease is the most protean condition confronting colorectal surgeons, requiring the widest range of planning skills and technical expertise if surgical pitfalls are to be avoided and much misery besides. So long as some basic rules are followed surgery is straightforward in most Crohn’s patients, and post-operative complications are uncommon so long as the patients general fitness has been addressed pre-operatively. The same cannot be said for a whole range of others.
Today we will examine some of the issues involved in the management of several difficult clinical scenarios in small bowel Crohn’s disease:
• Duodenal involvement
• Multiple strictures
• Enterocutaneous fistula

Duodenal Crohn’s disease
This is relatively rare (<5%), and almost always part of a wider pattern of disease. It may produce peptic ulcer-like symptoms, but for the surgeon obstruction and fistulation are more relevant problems. Careful investigation should clarify the significance of the lesion, and whether intervention is required. As medical therapy can be relatively ineffective, balloon dilatation, bypass and strictureplasty all have their place. As with all Crohn’s cases, particularly if there is obstruction with several significant lesions present, a ‘road map’ produced using a composite of radiology is central in the conduct of potentially difficult surgery.

Multiple strictures
This pattern of disease may be seen primarily or as post-surgical recurrence; a conservative approach is mandatory, while nevertheless needing to do enough to achieve symptomatic relief. At the first operation resection of particularly severe disease is appropriate, perhaps with one or more strictureplasties if distantly separated lesions are present. If the surgeon is confronted with multiple strictures in the previously operated patient, careful assessment of each lesion, with limited resection or strictureplasty confined to symptomatically significant lesions, should be the strategy. This requires meticulous preoperative radiological assessment, and perhaps the use of a Foley catheter to check the calibre of strictures before operating on them individually. It is not necessary to intervene with clinically silent lesions, so long as the surgeon can be confident of this at intra-operative assessment. Complicated long strictureplasties (Finney, Michelassi) in order to retain long segments of diseased bowel have never been proven to be superior to conservative resection, even if this leads to critical shortening of an already shortened small bowel.

Enterocutaneous fistula
This may occur spontaneously or follow surgery. Vigorous attention to nutrition and fluid balance, and complete endoscopic and radiological assessment are vital if the patient is to get the best chance of successful surgical intervention. The temptation to re-operate too soon in the post-surgical fistula should be strenuously resisted: if possible at least four months should elapse to allow settling of the post-operative peritoneal inflammatory response, thus decreasing the risk of further iatrogenic trauma. It is important to establish the number of tracks, their point of origin along the length of bowel, the track length(s), and whether there are any associated cavities or occult internal fistulae. Through careful pre-operative investigation there should be as little room left as possible for surprises during the procedure.

Some useful recent publications
Mottet C, Juillerat P, Gonvers J-J, et al. Treatment of gastroduodenal Crohn’s disease Digestion 2005 71: 37-40
Reese GE, Purkayastha S, Tilney HS, von Roon A, Yamamoto T, Tekkis PP. Strictureplasty vs resection in small bowel Crohn's disease: an evaluation of short-term outcomes and recurrence Colorectal Disease 2006 (OnlineEarly Articles). 
doi:10.1111/j.1463-1318.2006.01114.x
Windsor ACJ Ileal Crohn’s disease is best treated by surgery (PROTAGONIST) Gut 2002 51: 11-12
Farthing MJG Ileal Crohn’s disease is best treated by surgery (ANTAGONIST) Gut 2002 51: 13-14