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296
P. Rooney and N. Eardley
Table 21.1 (continued)
Treatment Induction of remission? Maintenance of remission?
Prevention of recurrence after
surgery?
Side effects/complications
Antibiotics No. Little evidence to support their
use in uncomplicated ileal
disease
No Yes. Evidence that nitroimida-
zole antibiotics reduce
endoscopic and clinical
recurrence rates [
22, 23 ]
Prolonged treatment with
metronidazole may cause a
peripheral neuropathy in up
to 50% of patients, and thus
limit its use
Biologic therapy Yes. ACCENT I trial: 58% of
patients with chronic active
Crohn’s disease clinically
responded to a single dose of
infl iximab.
Yes. ACCENT I trial: those
responding to initial
dose of infl iximab were
treated with regular
scheduled infusions of
either infl iximab or
placebo over a year;
after which time, 35%
of those treated with
infl iximab were in
clinical remission as
compared to 15% in the
placebo group [ 24 ] .
Maintenance therapy
with regular infl iximab
infusions was
subsequently shown to
be more effective than
episodic infusion [ 25 ] .
No Increased susceptibility to severe
infection. Active infection,
recent severe infection, and
presence of an abscess are
contraindications; so caution
should be used in patients
with fi stulating disease.
Patients should be screened
for tuberculosis prior to
treatment
ACCENT II trial: assessed effect of
infl iximab in fi stulating Crohn’s
disease, demonstrating a
decreased need for surgery in
those treated with infl iximab as
compared to placebo (7% vs.
30%), but the majority of patients
in this trial had perianal rather
than abdominal fi stulation [ 26 ] .
Effi cacy of adalimumab in inducing
remission was demonstrated in
the CLASSIC I trial [ 27 ] and
CLASSIC II [ 28 ] trial
Effi cacy of adalimumab in
maintaining remission
was demonstrated in the
CLASSIC II trial [ 28 ]
297
21 Surgery for Small Bowel Crohn’s Disease
The gastroenterologist should consider referral to a colorectal surgeon when medi-
cal management has failed or has not been tolerated, when there are complications
of the disease (fi stulae, abscess formation, fi brotic strictures, bleeding, dysplasia)
and surgery may be considered appropriate primary therapy in patients with limited
ileal or ileocecal disease (Box
21.1 ).
Intestinal fi stulae are common in Crohn’s disease [
34 ] and may be classifi ed as
either primary (type I – formed as a direct result of the disease process) or secondary
(type II – due to either anastamotic dehiscence, or as a complication of enterotomy
repair, or an unrecognized enterotomy at the time of surgery). In the ACCENT II study
assessing the effect of regular maintenance infl iximab infusions on fi stulating Crohn’s
disease (although the majority of these were perianal fi stulae), only 36% appeared to
have healed at 1 year [ 26 ] , and Poritz et al. demonstrated no healing of enterocutaneous
or peristomal fi stulae with infl iximab [ 35 ] . The take home message here would be that
primary intestinal fi stulae in Crohn’s disease will rarely heal without surgery. Secondary
fi stulae, however, may be managed nonoperatively in the same way a patient without
Crohn’s disease may be managed as these may heal with conservative measures.
21.4.2 Do I Need to Operate Now?
Patients with fi stulating Crohn’s disease are dominated by the problems of sepsis and
nutrition, often with a clinically palpable mass due to a psoas abscess or an abscess
involving and possibly discharging through the abdominal wall. Simple resuscitative
measures in this situation are obvious, but wound care and psychological support are just
as important. All treatment options must be balanced against both the fears of the sur-
geon and fears of the patient including the prospect of disfi gurement, stoma, short gut
syndrome, or even death. Surgical treatment is often based on a number of delaying
tactics. Draining and eradicating the sepsis along with nutritional support may allow the
Box 21.1: Indications for Surgery
Emergency presentation Peritonitis (rarely)
Obstruction
Abscess drainage
Medical management
failure
Crohn’s mass (fi stula/abscess)
Fibrotic stricture
Dysplasia
Bleeding
Chronic ill health (children growth failure)
Complications of
medical treatment
Avascular necrosis
Diabetes
Rarely sycosis
Primary therapy ileal/ileocolic disease
298
P. Rooney and N. Eardley
patient to recover such that the risks of surgery are less. Sometimes, however, this merely
delays the prospect of surgery, and it may the ore be preferable to perform a laparotomy
with simultaneous resection of the disease and drainage of the associated abscess.
If the plan is to delay surgery until the patient improves clinically, the “SNAP”
algorithm [
36 ] for the management of fi stulae should be adhered to (Box 21.2 ) .
21.4.3 Will Recent Biologic Therapy Increase the Risk
of Postoperative Complications?
Infl iximab is a chimeric human-murine monoclonal antibody that binds to TNF- a
inhibiting its functional activity resulting in mucosal healing [ 37 ] , and this is refl ected
in a clinical response [ 38 ] . Adalimumab is a more recently developed recombinant
human monoclonal antibody that binds specifi cally to TNF- a and has the potential
advantage of subcutaneous administration. One of the concerns with the use of these
biologic therapies is that the immune response is impaired, increasing susceptibility
to severe infection. Active infection, recent severe infection, and presence of an
Box 21.2: “SNAP” Approach to Intestinal Fistulae (Modifi ed from
Kaushal and Carlson [ 36 ] )
Sepsis/skincare/psychology
Controlling sepsis is a crucial early step (either radiologically guided per-•
cutaneous drainage or surgical drainage)
Involve a stoma therapist early to ensure good skincare and also help with •
discussions about the prospect of a stoma
Psychological support at this stage should not be overlooked •
Nutrition
Common for patients to be malnourished as a result of chronic symptoms •
and sepsis
Assess the nutritional status early on and provide support with nutritional •
therapy (ideally enteral feeding or occasionally with total parenteral
nutrition)
Anatomy
Apart from in the emergency setting, patients should have been imaged •
(CT/MRI/fi stulogram) and cases discussed at an infl ammatory bowel dis-
ease multidisciplinary team meeting so that the surgeon has as much infor-
mation as possible prior to surgery
Plan
Consider risk factors for anastomotic failure when planning surgery •
Discuss with the patient what they can expect •
The site of potential stomas should be marked preoperatively •
Allow plenty of operating time and arrange appropriate postoperative care •
299
21 Surgery for Small Bowel Crohn’s Disease
abscess are contraindications to anti-TNF- a therapy; so caution should be used in
patients with fi stulating disease, and patients should be screened for tuberculosis
prior to starting treatment. We are seeing an increasing number of patients being
treated with these therapies, and there is often concern that biologic therapy may
increase the risk of septic complications in the perioperative period and that this
might be an argument for delaying surgery. Several studies report confl icting results,
and thus at present, it is diffi cult to draw a conclusion [
39– 41 ] . Although increas-
ingly many patients are started on biologic therapy early on in the course of the dis-
ease, many patients on biologic therapy will have more advanced disease. We do not
feel that in practice biologic therapy in itself is a risk factor for anastomotic failure,
and therefore recent use should not necessarily be a reason to delay surgery.
21.4.4 Are There Any Other Preoperative Considerations?
Chronic fi brostenotic disease will not be affected by medical therapy, and thus sur-
gery should be considered if the patient is symptomatic. Although surgery for
Crohn’s disease is often considered to be a last resort after medical management has
failed, there is an argument that late surgery means operating on more advanced
disease with a patient who is less well as a result of malnutrition, sepsis, and pro-
longed steroid therapy and therefore has an associated increase in complications
[ 42 ] . Indeed, 74% of patients asked for their views on timing of their surgery for
Crohn’s disease felt that they should have been offered surgery earlier with a median
preferred time to surgery being 12 months earlier [ 43 ] .
Patients with infl ammatory bowel disease have a threefold increase in risk of deep
vein thrombosis and pulmonary embolism [ 44 ] ; thus, it is important that thromboem-
bolic prophylaxis is instituted. If patients are on or have recently been on steroid
therapy, then steroid supplementation in the perioperative period should be consid-
ered in order to prevent an Addisonian crisis [ 45 ] . Sometimes, patients may not have
been on steroids for a while (few months) but, prior to this, were treated for some
time with high doses. We would consider these patients to also be in the higher-risk
group, both for developing an Addisonian crisis and also for anastomotic failure.
21.4.5 It Is Time to Operate: Should I Perform the Surgery
Laparoscopic or Open?
Laparoscopic surgery is becoming increasingly popular for resection of Crohn’s
disease, and there is good evidence to suggest that it is safe with no increase in
postoperative complications or recurrence rates [ 46 ] . It offers the prospect of earlier
recovery of pulmonary function, reduced postoperative ileus, earlier discharge from
hospital, earlier return to work, improved cosmesis, and a decreased chance of sub-
sequent adhesional obstruction. It has been said that there are two sorts of Crohn’s
disease: complicated and very complicated (!), and thus there is a great deal of
300
P. Rooney and N. Eardley
potential for causing harm during Crohn’s surgery. Although laparoscopic resection
is being increasingly used for recurrent and even fi stulating disease, the surgeon
should select patients for laparoscopic resection carefully. Factors which should
make the surgeon think towards an open operation are the presence of fi stula/
abscess, multifocal, and multiorgan (often fi stulating) disease. Whichever approach
is used, the surgeon should consider that the patient may require surgery in the
future and avoid making incisions at potential stomas sites.
21.4.6 What Will I Find?
So you have fi nally bitten the bullet and taken the patient to theater. The fi ndings can
be variable, from isolated simple terminal ileal disease to a large infl ammatory mass
with fi stulation to the abdominal wall or other loops of bowel.
The macroscopic signs of Crohn’s disease include “fat wrapping,” where the
mesenteric fat appears to creep around the side of the bowel wall and also thick-
ened mesentery due to lymphadenopathy and edema. Care must be taken when
handling the mesentery as it is very easy to cause bleeding or development of a
mesenteric hematoma (this may be a particular problem in laparoscopic surgery
when having performed a nice laparoscopic mobilization; it is then diffi cult to
extract the chunky, infl exible bowel/mesentery through a small abdominal inci-
sion). During resection, the mesentery should be divided carefully, with many
surgeons preferring to use a transfi xion stitch to secure the vessels in order to
prevent such complications. We frequently use the LigaSure
TM
device (Covidien)
for this and have found it effective and time saving. The Crohn’s affected bowel
wall appears thickened, with increased vascularity and tends be fairly rigid.
Crohn’s disease is typifi ed by “skip lesions,” areas of normal bowel in between
areas affected by Crohn’s disease. Segments of bowel proximal to strictures may
appear dilated due to obstruction. Approximately 5% of patients will suffer from
diffuse small bowel disease, and thus, it is important intraoperatively to identify
all segments of bowel which may be strictured. This should be done by assessing
the luminal diameter of the bowel rather than the external appearance and can be
done by either passing a Foley catheter (with 5 mL water in the balloon to give
a diameter of approximately 2 cm) or the method we prefer which is passing a
ball bearing (with a diameter of 2 cm) along the length of the small bowel
(Figs. 21.1 , 21.2 , and 21.3 ) .
21.4.7 What Should I Do: Resection, Strictureplasty, or Bypass?
There are essentially three types of surgery for Crohn’s disease: resection, stricture-
plasty, and bypass. For the initial surgery in Crohn’s disease and when there is fi stulat-
ing disease, resection is the best option. The extent of resection should be confi ned to
the section of bowel which has caused the symptoms/complications and limited to the
301
21 Surgery for Small Bowel Crohn’s Disease
excision of macroscopic disease as evidence would suggest that leaving microscopic
disease at the resection margins has no effect of the chance developing of recurrent
disease [ 47 ] . If there is fi stulating disease, the fi stula can frequently be broken down,
“pinching” between the Crohn’s affected loop of bowel and the loop (or abdominal
wall) to which it has fi stulated. The primary disease should be resected, and a decision
should be made as to how to manage the other loop. Options include either resection
of that segment of bowel (if it appears to be affected by Crohn’s) or if it appears unaf-
fected by Crohn’s disease, closure of the enterotomy.
Due to the poor results and potential complications, bypass is now rarely
performed.
Bypass of the affected segment of bowel has little role now; historically, it was
used as a way of reducing mortality and also conserving bowel length. The diseased
bowel remains in situ, and so therefore, there may be persistent problems with sep-
sis and fi stulation. There is also the problem of bacterial overgrowth as a result of a
blind loop, and in addition, there is the risk of development of malignancy in the
bypassed segment [ 48 ] . Such malignancies frequently present late and have an asso-
ciated poor prognosis. Due to the poor results and potential complications, bypass
is now rarely performed.
Fig. 21.1 Ball bearing
held up at occult Crohn’s
stricture
302
P. Rooney and N. Eardley
In an attempt to avoid multiple resections and loss of small bowel mass, stricture-
plasty was developed to deal with multiple Crohn’s segments interspersed by normal
bowel. Different techniques may be utilized depending upon the length of bowel
affected. Short fi brotic strictures (<10 cm) may be suitable for the Heineke-Mikulicz
technique, longer strictures (10–20 cm) for the Finney technique and even longer
Fig. 21.2 Ball bearing
passed through opened ileum
to identify occult strictures
Fig. 21.3 Longitudinal
enterotomy – orientated
transversely for repair
303
21 Surgery for Small Bowel Crohn’s Disease
strictures (>20 cm) for a side-to-side isoperistaltic technique. We like to use a continu-
ous single-layer serosubmucosal 3/0 PDS (Ethicon) suture for this. A recent meta-
analysis by Yamamoto et al. demonstrated a 5-year recurrence rate after strictureplasty
of 28% (although in 90% the recurrence occurred at nonstrictureplasty sites). Septic
complications (leak/fi stula/abscess) occurred in 4% of patients [
49 ] (Box 21.3 ).
21.4.8 I Have Resected: Should I Join Them Up?
Anastamosis and/or Stoma?
Intra-abdominal septic complications (anastamotic leak, intra-abdominal abscess, or
enterocutaneous fi stula) carry a risk of signifi cant morbidity and mortality. Yamamoto
et al. [ 11 ] demonstrated that intra-abdominal septic complications were signifi cantly
associated with preoperative low albumin level (<30 g/L), preoperative steroids use,
abscess at the time of laparotomy, and fi stula (enterocutaneous, enteroenteric, or
enterovesical) at the time of laparotomy. The intra-abdominal septic complication
rate was 50% in patients with all of these four risk factors, 29% in patients with three
risk factors, 14% in patients with two risk factors, 16% in patients with only one risk
factor, and 5% in patients with none of these risk factors. Thus, the surgeon should
take these factors into account when deciding whether to anastamose, anastamose
and defunction proximally, or create an end stoma (+/− mucous fi stula). If there are
too many risk factors for failure, then our preference would be to bring both ends of
bowel out through the same hole, leaving the distal end stapled off subcutaneously
and the proximal end as an end stoma. This is a safe option and will provide a stoma
that is easier to manage than a double-barreled stoma or two separate stomata, and
when it comes to reanastomosing the patient at a later date, a peristomal incision may
be all that is required rather than a full laparotomy. Despite careful assessment of
risk, patients may still have anastomotic complications. A temporary stoma has the
benefi t of being safe, allowing the patient and the surgeon to fi ght another day when
both are in better shape, and the risk of failure is lower.
Box 21.3: Intraoperative Decisions
Recognizing disease Fat wrapping
Collateral fi stulation (small bowel, sigmoid,
bladder, duodenum)
Skip lesions (Foley catheter; ball bearing)
The mesentery – thick and
dangerous
Transfi x do not tie
(Laparoscopic – ? LigaSure™)
Intervention Resection of obstructing fi stulating disease
Collateral damage strategy
Strictureplasty – occasional use
Bypass – historical interest only
304
P. Rooney and N. Eardley
21.4.9 I Am Going to Join Them Up, What Type of Anastomosis
Should I Create?
A Cochrane review [ 50 ] has demonstrated that a stapled ileocolic anastomosis (in
resections for Crohn’s disease or cancer) results in signifi cantly fewer anastamotic
leaks than with a hand-sewn anastomosis (although too few patients with Crohn’s
disease were included to allow a subgroup analysis). A study by Resegotti et al. look-
ing specifi cally at resections for Crohn’s disease demonstrated a decreased anasta-
motic leak rate with stapled anastomoses [ 51 ] (although this study was not randomized
and so there are potential problems with bias). With regard to whether the confi gura-
tion of the anastomosis affects recurrence rates, the evidence in the literature is
inconclusive. Some authors report a lower incidence of recurrence with a stapled
side-to-side anastomosis, although others report no difference when compared with
a sutured end-to-end anastomosis. A recent multicenter randomized controlled trial
(CAST – Canadian and American Surgical Crohn’s Disease Trial) demonstrated no
difference in either endoscopic or clinical recurrence rates [ 52 ] with either type of
anastomosis. Once you have created your anastomosis, think about the possibility of
the patient developing recurrent Crohn’s disease in the future (which is frequently at
the anastomosis) and try not to place your ileocolic anastomosis close to the duode-
num, if necessary, placing omentum between the two (Box 21.4 ).
21.4.10 How Should I Manage Gastroduodenal
Crohn’s Disease?
Fortunately, this is uncommon. These patients should be managed medically if at
all possible. Omeprazole may be used in combination with the other medical thera-
pies available. Surgery should be reserved for problems with stenosis, bleeding, or
Box 21.4: Anastomosis Yes or No?
Yes No
Why Well nourished Malnourished – signifi cant (>10%)
preoperative weight loss
No intra-abdominal sepsis Intra-abdominal abscess cavity
No systemic sepsis (albu-
min >30 g/L)
Complicated collateral fi stulation
No high-dose steroids Systemic sepsis (albumin <30 g/L)
High-dose steroids
What End to end Defunctioning stoma above repairs/
anastomosis
End to side Proximal end brought out distal
end stapled closed
Stapled side to side Both bowl ends exteriorized
305
21 Surgery for Small Bowel Crohn’s Disease
fi stulation. Fortunately, fi stulation is usually as a result of ileal or colonic disease
rather than primary disease of the duodenum and can frequently be managed by
excision of the affected segment of ileum/colon then closure of the duodenal defect
with a serosal patch.
Primary duodenal resection for duodenal Crohn’s disease is usually avoided and
is one of the rare instances when bypass of disease may be indicated.
21.4.11 What Should I Do if Crohn’s Disease Is an Unexpected
Finding at Appendicectomy?
Occasionally, terminal ileal Crohn’s disease may mimic appendicitis, but more fre-
quently, there has been a longer history, and the patient may have had intermittent
episodes of similar pain in the past. There may also be other associated symptoms
including diarrhea and weight loss. When operating for suspected appendicitis, if
the appendix appears macroscopically normal, then the terminal ileum should be
inspected carefully for signs of Crohn’s disease. If a patient who was suspected to
have appendicitis turns out to have Crohn’s disease at surgery, the surgeon must
decide how to proceed.
Traditionally, surgeons have been taught to perform an appendicectomy (pro-
vided the caecum appears unaffected) if a right iliac fossa incision has been used in
order to prevent any diagnostic doubt in the future. However, appendicitis is rare in
Crohn’s disease and most patients, if told that their appendix has not been removed,
should be able to recall this information for future admissions. If the appearances
are typical of Crohn’s disease, then we would advocate an ileocecectomy as over
90% will subsequently require surgery with 65% of these being within the next
3 years if the diseased bowel is left in situ [ 53 ] .
21.4.12 How Do I Prevent Recurrent Disease?
One of the most important factors in maintenance of remission and also prevention
of recurrence after surgery is cessation of smoking [ 30– 32 ] . A recent Cochrane
review [ 17 ] assessed the use of medical therapies for the prevention of postoperative
recurrence. They concluded that the use of nitroimidazole antibiotics appeared to
reduce the risk of clinical (RR 0.23; 95% CI 0.09–0.57, NNT = 4) and endoscopic
(RR 0.44; 95% CI 0.26–0.74, NNT = 4) recurrence. Mesalamine appeared to reduce
the risk of clinical (RR 0.76; 95% CI 0.62–0.94, NNT = 12) and severe endoscopic
(RR 0.50; 95% CI 0.29–0.84, NNT = 8) recurrence. Azathioprine/6-mercaptopurine
was also shown to reduce the risk of clinical (RR 0.59; 95% CI 0.38–0.92, NNT = 7)
and severe endoscopic (RR 0.64; 95% CI 0.44–0.92, NNT = 4) recurrence. There
were insuffi cient randomized controlled trials of treatment with any other therapies
to allow other conclusions to be drawn. The benefi ts of postoperative therapy should
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