2. Surgical Management Inflammatory Bowel Disease Ernesto R. Drelichman, MD, FACS St. John Health Systems

3. VARIETIES OF COLITIS

4. ULCERATIVE COLITIS AND CROHN’S DISEASE

5. DISTINGUISHING FEATURES OF CROHN’S DISEASE

6. ANATOMIC DISTRIBUTION

8. INFLAMMATION

9. OBSTRUCTION

10. ENDOSCOPIC APPEARANCES

11. ENDOSCOPIC FEATURES

12. COBBLESTONING

13. Crohn’s Stricture

15. FISTULIZATION

16. Enterovesical Fistula

18. PERIANAL FISTULAE AND ABSCESS

19. GOALS OF THERAPY

20. CONVENTIONAL DRUG THERAPIES

21. “OK, OK, you guys have had your chance – the horses want another shot at it.”

22. BALLOON DILATION OF CROHN’S DISEASE STRICTURES

23. Philosophy of Surgical Management There is no Cure for Crohn’s Disease There is no Cure for Crohn’s Disease Surgery only overcomes the complications Surgery only overcomes the complications Potential for pan-intestinal involvement Potential for pan-intestinal involvement

24. Surgery: Risks and Benefits Symptom relief Improved nutrition Reduced medication Surgical risk Disease recurrence Short bowel syndrome

25. INDICATIONS FOR SURGERY IN CROHN’S DISEASE

26. Crohn’s Disease Surgical Indications 75% undergo surgery 50% undergo repeat surgery Collaborative decision Collaborative decision Patient Patient Gastroenterologist Gastroenterologist Surgeon Surgeon

27. SURGICAL OPTIONS FOR INTRA- ABDOMINAL DISEASE IN CROHN’S DISEASE

28. Inflammatory Bowel Disease Disease Related Challenges Inflammatory Bowel Disease Disease Related Challenges Immunosuppression Immunosuppression Malnutrition Malnutrition fistulas fistulas abscess abscess phlegmon phlegmon thickened, shortened mesentery thickened, shortened mesentery friable tissues and vessels friable tissues and vessels Extensive disease Extensive disease

30. Step 5: Exteriorization, Resection, and Anastomosis

31. Step 4: Externalization

32. Step 5: Resection and Anastomosis

35. Crohn’s Disease Laparoscopic Colectomy - Advantages *33 patients with ileocolic Crohn’s underwent laparoscopic ileocectomy were case matched for potential confounders to an open group *33 patients with ileocolic Crohn’s underwent laparoscopic ileocectomy were case matched for potential confounders to an open group * > 60% had undergone previous surgery Young-Fadok et al. Surg Endosc 2001;450-4: Young-Fadok et al. Surg Endosc 2001;450-4: