DIFFICULT SMALL BOWEL CROHN’S DISEASE John Northover St Mark’s Hospital, London

LOOK BEFORE YOU LEAP

Causes of intestinal failure St Mark’s & Hope,

Difficult SB Crohn’s Duodenal disease Duodenal disease Multiple strictures Multiple strictures Enterocutaneous fistula Enterocutaneous fistula

Duodenal Crohn’s

A few facts Rare - <5% Rare - <5% Differential diagnosis Differential diagnosis Rarely sole site Rarely sole site Often overshadowed Often overshadowed

Duodenum plus.... D3 stricture D3 stricture Advanced ileal disease Advanced ileal disease

Clinical scenarios ‘Peptic ulcer-like’ ‘Peptic ulcer-like’ Obstruction Obstruction Fistula Fistula

Patterns of disease *

Symptoms ‘Peptic ulcer’ pain 70% ‘Peptic ulcer’ pain 70% Vomiting 50% Vomiting 50% Weight loss 26% Weight loss 26% Diarrhoea 22% Diarrhoea 22% Bleeding 7% Bleeding 7%

Investigation Barium studies Barium studies Scanning Scanning Endoscopy Endoscopy

Conventional Ba meal Anatomical clarity Anatomical clarity Endoscopy needed Endoscopy needed

BaM in D3 obstruction Poor view Poor view No distal information No distal information

CT in D4 obstruction

Endoscopy Differential diagnosis Differential diagnosis Dilatation Dilatation

Treating obstruction Balloon dilatation Balloon dilatation Bypass Bypass Strictureplasty Strictureplasty

Balloon dilatation May avoid surgery May avoid surgery Few data Few data Distal disease Distal disease

Bypass Check for distal disease Check for distal disease ? need for vagotomy ? need for vagotomy –“4/6 without  re-operation” (Cleveland, ‘83) –“Most re-do surgery after Vx; risk of diarrhoea” (Lahey, ‘89) –“Remains controversial” (B’ham, ‘99)

Strictureplasty 13 patients (10 primary) 13 patients (10 primary) 2/10 leaked 2/10 leaked 6 re-strictured  surgery 6 re-strictured  surgery Overall 9/13 re-operated Overall 9/13 re-operated Birmingham, 1999

‘Plasty v Bypass Historical and parallel comparison Historical and parallel comparison Bypass 21; strictureplasty 13 Bypass 21; strictureplasty 13 Same: Same: – Complications (2/21; 2/13) – Recurrence  Re-op. (1/21; 1/13) Cleveland Clinic, 1999

Fistulating duodenal Crohn’s Usually secondary Usually secondary To colon or terminal SB To colon or terminal SB Duodenocutaneous rare Duodenocutaneous rare Most OK for oversew Most OK for oversew

D2-transverse colic fistula Normal duodenum Normal duodenum Penetrating ulcers Penetrating ulcers Simple closure after colectomy Simple closure after colectomy

Multiple strictures

Failure to thrive Failure to thrive Obstruction Obstruction

Multiple strictures

What trouble are they? What trouble are they? Other modalities? Other modalities? Previous surgery? Previous surgery? Is there a ‘dominant’ stricture? Is there a ‘dominant’ stricture? AND ONLY THEN... AND ONLY THEN...

Multiple strictures Might surgery help? Might surgery help? If so, what surgery? If so, what surgery? –(Bypass) –Resection –Strictureplasty

Multiple strictures Pros and cons of strictureplasty Bowel conservation Bowel conservation Safety Safety Relapse rate Relapse rate

Multiple strictures Recurrence avoidance Oxford, 1995

Multiple strictures Recurrence avoidance 2006 meta analysis Tekkis et al.

Strictureplasty What’s available?

What do they achieve?

Strictureplasty What’s available?

Strictureplasty Beware the occult stricture

Strictureplasty Pick ‘n’ Mix...

Enterocutaneous fistula

Surgery rarely avoided

Avoiding re-operation

NO UNEXPECTED EXTRA PROCEDURES

Avoiding DISASTER DON’T GO IN TOO EARLY

Avoiding DISASTER DON’T GO IN TOO EARLY

Avoiding DISASTER DON’T GO IN TOO EARLY WAIT!!

Avoiding DISASTER DON’T GO IN TOO EARLY WAIT!! and PREPARE

Exclude distal obstruction Exclude septic collections Find the optimal entry site Pre-operative preparation

Avoiding re-operation ROADMAP ROADMAP Composite image Composite image Pre-operate in head Pre-operate in head

DIFFICULT SMALL BOWEL CROHN’S DISEASE John Northover St Mark’s Hospital, London