1. Surgery on Crohn’s Disease
Joint Hospital Surgical Grand Round
Dennis KY Ngo
Department of Surgery
Prince of Wales Hospital

2. Background
Chronic transmural inflammatory process that can affect GI tract anywhere, also associated with extraintestinal manifestation
Commonly : ileal, ileocolic, colonic and perianal disease
Diagnosis based on macroscopic, histologic and radiological features

3. Incidence More common in Caucasian Rate is lower in Asia.
5-6 per population ( North American, northern Europe )
Rate is lower in Asia.
However, there is increasing trend
1 per population ( Hong Kong )
 3 fold over the past decade
Leong at el. Inflammatory Bowel Diseases. 10(5):646-51, 2004 Sep.

4. What is the surgeons’ role in treating this benign disease ?
Increasing incidence of Crohn’s disease annually, more and more people will keep an eye on the treatment modality, esp in these young age group population.
Apart from medical therapy,
What is the surgeons’ role in treating this benign disease ?

5. M/22
Good past health
Presented in March 2006 with right iliac fossa pain associated with diarrhoea and weight loss for 1 month

6. Colonoscopy on 8 March 2006
Inflammation and ulcers at caecum and ileocaecal valve
Terminal ileum could not be intubated because of swollen ileocaecal valve
Biopsy: Crohn’s disease
Seen by Gastroenterologists on 10 March 2006; Salofalk 1 g TDS and prednisolone started

7. Readmission as Emergency
Readmission on 12 March 2006
Increased right iliac fossa pain for 1 day
Fever C
Pulse rate: 100/minute
CXR: no infradiaphragmatic free gas
WCC: 13.5 x 109/L

8. Thickened terminal ileum and caecum

9. Pockets of free gas

10. Pocket of free gas

11. Ileocaecal Crohn’s disease with peritonitis and suspected perforation
Emergency laparoscopic-assisted right hemicolectomy

12. Cobblestone appearance

13. ~ 80% will require surgery irrespective of its site
Farmer et al. Gastroenterology 1985; 30:990-5
Bernell et al. Ann Surg 2000; 231:38-45
Surgery  Curative ( potentially involve the entire intestine )
Recurrence (invariable)
Potential benefits of surgery
Symptoms relief
Improved nutritional status
Reduced dependence of medication
Development of Surgical procedures focus on treating the complications as well as conserving the bowel length

14. Indications of Surgery
Failed medical treatment
Growth retardation (Children)
Complication of steriod and other medical therapy
Complications
Obstruction
Perforation
Fistula formation
Abscess formation
Bleeding
Toxic colitis
Malignancy

15. Management of Stenosis
Non-operative
Balloon dilatation
Operative
Bypass
Strictureplasty
Resection

16. Balloon dilatation 55 patients, managed by endoscopic dilatation
18mm balloon, followed by 20/25mm
Inflated for 2min ( repeat 2-6 inflations)
90% successful dilatation
8% perforation rate
Mean FU time : 33.6 months
18 patient need second dilatation at 1.5 year
Long term successful rate : 62%
Operation rate : 38%
Couckuyt H, et al. Gut 1995;36:

17. Bypass Popular in the past (1930-1950) Problems :
Active disease in the retained segment
Abscess / Fistula / Perforation / increased rate of malignancy of bypassed segment
No place in modern day surgery, Except
Gastroduodenal Crohn’s with hostile adhesions to adjacent organs preventing a safe excision

18. Strictureplasty Mainly used for small bowel
Good symptomatic relief and bowel sparing
Aim at conserving small bowel for the fear of short bowel
Ideal for short stricture
Can be performed for single or multiple strictures

19. Contraindication Perforation of bowel
Present of abscess, inflammation and fistula
Multiple strictures over a short segment of bowel
Inability to perform tension-free suture line
Profound hypoalbuminemia
Generally not to be performed on large bowel
High recurrence rate
High risk of malignancy

20. Technique Longitudinal incision with extension to normal looking bowel
Inspection of lumen, biospy of suspicious lesion ( R/O malignancy )
Stricture < 10cm : close in Heineke-Miculicz fashion
Stricture 10-20cm : repaired with Finney strictureplasty

21. Heineke Miculicz
Strictureplasty

24. Recurrence & Reoperation
100 patients included for strictureplasty
Mean FU 85.1 months ( months )
Overall reoperation rate : 56%
N. S. Fearnhead et al. British Journal of Surgery 2006;93:
162 patients
Reoperative rates (5 years) : 31%
Ozuner et al Dis Colon Rectum 1996

25. Majority – new segments of stricture
Recurrence at strictureplasty site is rare – 3.7%
Stebbing et al Br J Surg 1995

26. Resection
Limited resection to achieve the goal of symptomatic relief, while preserving the bowel length
Resect macroscopically diseased bowel without concern for microscopic disease
Recurrence is unaffected the width of the margin of resection from marcroscopically involved bowel
Recurrence rate not increase when microscopic disease still present in the resection margin
Fazio et al. Annals of Surgery 1996;224:

27. Intestinal Fistula Internal fistula (30-40% CD)
Ilijevski et al Eur J Surg 1997
General surgical principle
Resect the 10 diseased segment
Close the 20 involved organs

28. Colonic operation Intractable disease ( failed medical therapy )
Severe colitis
Bleeding
Malignancy
Involving entire colon and rectum
Gold standard : proctocolectomy and ileostomy

29. Less extensive resection
Subtotal colectomy + mucous fistula
Total colectomy + ileorectal anastamosis
Segmental colonic resection

30. Role of laparoscopic surgery
Longer operation
Higher cost
Faster recovery
Less scarring

31. Application of laparoscopic technique to Crohn’s disease
Benign disease
Relatively young patients (back to normal duty with economic consideration)
Better cosmesis
 Risk of adhesive intestinal obstruction / incisional hernia
Possibility of multiple surgery
Ozuner D et al Dis Colon Rectum 1996; 39:

32. Development Stoma creation (ileostomy / colostomy) Earliest indication
Braga M et al Ann Surg 2002; 236:
Limited segmental SB resection
Ileocaecal resection
More complex / recurrent disease (fistula, phlegmon, etc)
Emergency setting

33. Meta-analysis for ileocaecal resection in Crohn’s
783 patients (Lap: 338)
15 studies ( )
1 RCT; 6 prospective; 8 retrospective
Conversion rate: 6.8%
Tilney HS et al Surgical Endos May 2006

34. Significant difference Lap vs Open
OT time (longer in Laparoscopic group)
~30 mins
Post-op recovery (faster in Laparoscopic group)
Tolerates full diet (1.47 days)
First flatus (0.68 days)
First bowel motion (0.58 days)
Shorter hospital stay (2.97 days)

35. Similar outcome Blood loss Post-op complications Return to work
Anastomotic leakage
Wound infection
Bowel obstruction
Intra-abd abscess
Return to work

36. Issues addressed Technical feasibility Safety
Immediate operative outcomes

37. Postoperative course ( our case )
First bowel motion: D3
Fluid diet resumed: D4
DAT: D6
Full ambulation: D4
Home: D9
No complication
Wound length: 8 cm

38. Conclusion Surgical role in Crohn’s disease is
Not to cure the disease
treat the complications with improvement of quality of life of these young group of patient
Development of laparoscopic surgery
Better cosmesis and body image
Faster recovery
Less adhesion for ease of reoperation latter

39. Thank you