surgical management of crohn’s disease · surgical management of crohn’s disease aaron winnick,...

Surgical Management of Surgical Management of CrohnCrohn’’ss DiseaseDisease

Aaron Winnick, M.D.Aaron Winnick, M.D.Kings County Hospital CenterKings County Hospital Center

SUNY Downstate Medical CenterSUNY Downstate Medical CenterSeptember 29, 2006September 29, 2006

Case PresentationCase Presentation

•• xx xx yoyo female c/o abdominal pain x 1 monthfemale c/o abdominal pain x 1 month–– EpigastricEpigastric and LUQand LUQ–– vomiting, constipation x2 daysvomiting, constipation x2 days–– Denied diarrhea, Denied diarrhea, melenamelena, weight loss, weight loss–– Treated at Treated at xxxx Hospital 1 month prior for SBOHospital 1 month prior for SBO


•• PMH: DeniesPMH: Denies•• PSH: DeniesPSH: Denies•• Meds: NoneMeds: None•• Allergies: NKDAAllergies: NKDA•• Social: Denies Social: Denies TobTob, , EtohEtoh, Drugs, Drugs


•• T 98.8 BP 145/83 P 94 Weight 116kg T 98.8 BP 145/83 P 94 Weight 116kg •• Gen: NADGen: NAD•• CV: s1,s2 CV: s1,s2 rrrrrr•• Lungs: CTA Lungs: CTA b/lb/l•• AbdAbd: Soft, obese, Hypoactive BS : Soft, obese, Hypoactive BS ++EpigastricEpigastric tenderness. tenderness.

No hernias, scars, or No hernias, scars, or ecchymosisecchymosis

Case PresentationCase Presentation•• ADMISSION LABSADMISSION LABS::

813

39365 132 99 7

22 0.64.3 80 12 261.0

Alk Phos 72 T Bili 0.5AST 28 Amylase 69ALT 26 Lipase 25

Urinalysis- negative UCG- negative

Hospital CourseHospital Course

•• HD #1 not responding to conservative HD #1 not responding to conservative management with NGTmanagement with NGT•• Taken to OR for exploratory Taken to OR for exploratory laparotomylaparotomy

–– Transition point in Transition point in ileocecalileocecal region with firm massregion with firm mass–– Appendix involved, firmly adherent to massAppendix involved, firmly adherent to mass–– FibroticFibrotic changes in mesentery of right colonchanges in mesentery of right colon–– Multiple lymph nodes visibleMultiple lymph nodes visible–– Pt underwent Right Pt underwent Right hemicolectomyhemicolectomy

Hospital CourseHospital Course

•• POD #1POD #1 TachycardicTachycardic in RRin RRABG 7.34/43/162/24/0.2/99ABG 7.34/43/162/24/0.2/99

•• POD #2POD #2 Transferred to SICUTransferred to SICUCTA negative for PECTA negative for PE

•• POD #6POD #6 Tolerates clear liquid dietTolerates clear liquid dietTransferred to floorTransferred to floor

•• POD #13POD #13 Discharged homeDischarged home

PathologyPathology

•• StenosisStenosis of ileum at of ileum at ileocecalileocecal valvevalve•• Sections with Sections with apthousapthous ulcers with abscess formationulcers with abscess formation•• Crypt distortionCrypt distortion•• TransmuralTransmural lymphoid infiltratelymphoid infiltrate•• Marked Marked submucosalsubmucosal and and serosalserosal edema associated edema associated with with lymphagiectasialymphagiectasia•• Lymph nodes with nonLymph nodes with non--caseouscaseous granulomasgranulomas

–– negative for AFBnegative for AFB

•• Consistent with chronic IBD, favor Consistent with chronic IBD, favor CrohnCrohn’’ss diseasedisease

Surgical Management of Surgical Management of CrohnCrohn’’ss DiseaseDisease

Aaron Winnick, M.D.Aaron Winnick, M.D.Kings County Hospital CenterKings County Hospital Center

SUNY Downstate Medical CenterSUNY Downstate Medical CenterSeptember 29, 2006September 29, 2006

HistoryHistory

•• 19321932-- Drs. Drs. CrohnCrohn, Ginsberg, and, Ginsberg, andOppenheimer of Mount SinaiOppenheimer of Mount SinaiHospital described Hospital described ““nonspecific nonspecific granulomasgranulomas of theof theintestine.intestine.””

•• Recommended complete surgical resection Recommended complete surgical resection to cure the diseaseto cure the disease

CrohnCrohn BB, Ginsberg L, Oppenheimer GD. BB, Ginsberg L, Oppenheimer GD. Regional Ileitis: A Pathologic and clinical Regional Ileitis: A Pathologic and clinical entityentity. JAMA 1932; 99: 1323. JAMA 1932; 99: 1323--9.9.

Surgical Management of Crohn’s Disease

ClassificationClassification

•• Chronic inflammatory conditionChronic inflammatory condition––TransmuralTransmural inflammation andinflammation andGranulomaGranuloma formationformation

•• Involves any portion of GI Involves any portion of GI tracttract

––Mouth to AnusMouth to Anus•• 41% 41% ileocolonicileocolonic diseasedisease•• 28% limited to small intestine28% limited to small intestine•• 30% limited to colon or 30% limited to colon or anorectumanorectum

•• Acute inflammation vs. Chronic Acute inflammation vs. Chronic fibrosisfibrosis


Medical ManagementMedical Management

•• AminosalicylatesAminosalicylates–– SulfasalazineSulfasalazine, 5, 5--ASA, ASA, PentasaPentasa, , AsacolAsacol

•• CorticosteriodsCorticosteriods–– induce remissioninduce remission

•• relief seen in 70% after 4 weeksrelief seen in 70% after 4 weeks•• NOT used to maintain remissionNOT used to maintain remission

–– Side effectsSide effects•• immunosuppressionimmunosuppression, Adrenal suppression, bone loss, , Adrenal suppression, bone loss, cataract, weight gain, delayed wound healingcataract, weight gain, delayed wound healing


Medical ManagementMedical Management

•• Immunosuppressive drugsImmunosuppressive drugs–– 66--mercaptopurine, mercaptopurine, azathioprineazathioprine ((ImuranImuran))

•• steroidsteroid--sparing drugssparing drugs•• started after remission, response up to 4 monthsstarted after remission, response up to 4 months•• Side effects: Bone marrow suppression, Side effects: Bone marrow suppression, pancreatitispancreatitis

•• AntiAnti-- Tumor Necrosis Alpha Antibody Tumor Necrosis Alpha Antibody –– InfliximabInfliximab–– chimericchimeric mousemouse--human antibody against TNFhuman antibody against TNF--αα


Surgical ManagementSurgical Management

•• Up to 75% of patients with CD will eventually Up to 75% of patients with CD will eventually require surgical interventionrequire surgical intervention

–– Obstruction (35%)Obstruction (35%)–– Internal fistula (30%)Internal fistula (30%)–– Toxic Toxic megacolonmegacolon–– PerianalPerianal diseasedisease–– Perforation or abscessPerforation or abscess–– Failure of longFailure of long--term medical managementterm medical management


Surgical Management of Surgical Management of ObstructionObstruction

•• Incidental discoveryIncidental discovery•• Planned surgeryPlanned surgery

–– SB contrast exam, barium enema, colonoscopySB contrast exam, barium enema, colonoscopy–– nutritional supportnutritional support–– Examine entire intestineExamine entire intestine

•• thickened bowel wallthickened bowel wall•• narrowed lumennarrowed lumen•• serosalserosal inflammation, creeping fatinflammation, creeping fat•• thickening of mesenterythickening of mesentery•• Skip lesionsSkip lesions•• Note length of uninvolved small intestineNote length of uninvolved small intestine


Surgical Management of Surgical Management of ObstructionObstruction

•• ““OncologicOncologic”” modelmodel•• PanentericPanenteric nature of disease nature of disease --> preservation > preservation of normal bowelof normal bowel

–– NonobstrucingNonobstrucing, , nonhemorrhagicnonhemorrhagic segments of segments of involved bowel need not be involved bowel need not be resectedresected

•• RecurrenceRecurrence–– 50% of patients 50% of patients requrierequrie rere--operation within 10 operation within 10 yrsyrs



•• Surgical Margins in Surgical Margins in ileocolicileocolic diseasedisease–– Cleveland ClinicCleveland Clinic

•• prospective randomized study, 152 patients, looking at prospective randomized study, 152 patients, looking at 2cm vs. 12cm margin of normal bowel2cm vs. 12cm margin of normal bowel•• Recurrence of CD is unaffected by the width of the Recurrence of CD is unaffected by the width of the margin of resection from macroscopically involved bowelmargin of resection from macroscopically involved bowel•• Recurrence rates also do not increase when microscopic Recurrence rates also do not increase when microscopic CD is present at the resection marginsCD is present at the resection margins•• Therefore, extensive resection margins are unnecessaryTherefore, extensive resection margins are unnecessary

FazioFazio VW, VW, MarchettiMarchetti F, Church JM, F, Church JM, et.alet.al. . Effect of resection margins on the recurrence of Effect of resection margins on the recurrence of CrohnCrohn’’ssDisease in the small bowel: a randomized controlled trialDisease in the small bowel: a randomized controlled trial. Annals of Surgery. 224(4): 563. Annals of Surgery. 224(4): 563--573. 1996.573. 1996.



•• Corticosteroids and postCorticosteroids and post--operative complicationsoperative complications–– BruewerBruewer, et al. reviewed 397 patients with , et al. reviewed 397 patients with CrohnCrohn’’ss disease disease who underwent bowel resectionwho underwent bowel resection

•• 3 groups3 groups–– No steroidsNo steroids–– lowlow--dose steroidsdose steroids–– highhigh--dose steroidsdose steroids

•• No difference among the groups with postNo difference among the groups with post--op complicationsop complications

–– concluded that highconcluded that high--dose steroid administration is not an dose steroid administration is not an absolute contraindication to bowel absolute contraindication to bowel anastomosisanastomosis

BruewerBruewer M, M, UtechUtech M, M, RijckenRijcken E, et al. E, et al. Preoperative steroid administration: Effect on Preoperative steroid administration: Effect on morbidity among patients undergoing intestinal resection for morbidity among patients undergoing intestinal resection for CrohnCrohn’’ss disease.disease. World J World J SurgSurg2003; 27: 13062003; 27: 1306--10.10.


StricturoplastyStricturoplasty

•• Stricture <10cm long Stricture <10cm long HeinekeHeineke--MikuliczMikulicz stricturoplastystricturoplasty

-- Hand sewn or stapledHand sewn or stapled



•• Stricture 10cmStricture 10cm--20cm long 20cm long FinneyFinney--type type stricturoplastystricturoplasty

-- bacterial overgrowth in bacterial overgrowth in the long the long diverticulumdiverticulum--like like outpouchingoutpouching



•• SideSide--toto--side side IsoperistalticIsoperistaltic StricturoplastyStricturoplasty (SSIS)(SSIS)–– Patients high risk for short bowel syndromePatients high risk for short bowel syndrome


StricturoplastyStricturoplasty•• IndicationsIndications

–– Multiple stricturesMultiple strictures–– Previous resection Previous resection >100cm small bowel>100cm small bowel–– rapid recurrence, SBOrapid recurrence, SBO–– Short bowel syndromeShort bowel syndrome–– NonphlegmonousNonphlegmonousfibroticfibrotic stricturestricture


• Contraindications– Perforation– Multiple strictures in short segment– Colonic strictures– Extensive ulceration of mesenteric margin– Suspicion of Cancer

Resection vs. Resection vs. StricturoplastyStricturoplasty•• MichelassiMichelassi F: F: SideSide--toto--side side isoperistalticisoperistaltic stricturoplastystricturoplasty for for multiple multiple CrohnCrohn’’ss strictures. strictures. DisDis Colon Rectum 39: 346, Colon Rectum 39: 346, 19961996

–– 57 patients 57 patients --> 60 operations with > 60 operations with stricturoplastystricturoplasty–– 109 109 stricturoplastiesstricturoplasties

•• 90 90 HeinekeHeineke--MikuliczMikulicz•• 6 Finney6 Finney•• 13 SSIS13 SSIS

–– Recurrence in 5 patients after 38 monthsRecurrence in 5 patients after 38 months

•• Authors concluded that Authors concluded that stricturoplastystricturoplasty is is comparable with resection therapycomparable with resection therapy


Resection vs. Resection vs. StricturoplastyStricturoplasty•• FazioFazio VW, VW, MarchettiMarchetti F, Church JM, F, Church JM, et.alet.al. . Effect of Effect of resection margins on the recurrence of resection margins on the recurrence of CrohnCrohn’’ss Disease in Disease in the small bowel: a randomized controlled trialthe small bowel: a randomized controlled trial. Annals of . Annals of Surgery. 224(4): 563Surgery. 224(4): 563--573. 1996.573. 1996.

–– 162 patients 162 patients --> 191 operations> 191 operations–– 698 698 stricturoplastiesstricturoplasties (average 3 per patient)(average 3 per patient)

•• 617 617 HeinekeHeineke--MikuliczMikulicz•• 81 Finney81 Finney

–– ReoperationReoperation rates at 5 yearsrates at 5 years•• StricturoplastyStricturoplasty without resection 31%without resection 31%•• StricturoplastyStricturoplasty with concomitant resection 27%with concomitant resection 27%

–– No statistical significanceNo statistical significance

•• Authors concluded similar Authors concluded similar reoperativereoperative ratesrates


Surgical ManagementSurgical ManagementUpper GI DiseaseUpper GI Disease

•• GastrojejunostomyGastrojejunostomy with with vagotomyvagotomy–– marginal ulcermarginal ulcer

•• Duodenal Duodenal strictureplastystrictureplasty–– limited by pliability of duodenumlimited by pliability of duodenum–– Avoid Avoid anastomosisanastomosis overlying duodenumoverlying duodenum

•• risk of fistula or injury during risk of fistula or injury during reoperationreoperation

•• JejunoilealJejunoileal diseasedisease–– Highest recurrence ratesHighest recurrence rates–– Short bowel syndromeShort bowel syndrome



•• Guiding principle Guiding principle –– Preservation of intestinal lengthPreservation of intestinal length

•• AnastomosisAnastomosis–– EndEnd--toto--end vs. sideend vs. side--toto--end vs. sideend vs. side--toto--sideside–– Stapled vs. handStapled vs. hand--sewnsewn


AnastomosisAnastomosisScarpaScarpa M, M, et.alet.al.. Role of stapled and handRole of stapled and hand--sewn sewn anastomosesanastomoses in in recurrence of recurrence of Crohn'sCrohn's disease. disease. HepatogastroenterologyHepatogastroenterology.. 2004 2004 JulJul--Aug;51(58):1053Aug;51(58):1053--7 7

•• 84 patients 84 patients s/ps/p ileocolonicileocolonic resectionresection–– 12 stapled side12 stapled side--toto--sideside–– 36 stapled end36 stapled end--toto--sideside–– 36 hand36 hand--sewn sidesewn side--toto--sideside

•• ReoperationReoperation rates significantly lower in siderates significantly lower in side--toto--side group (p=0.01, p=0.05) side group (p=0.01, p=0.05)


Type of Type of AnastomosisAnastomosisCaseCase--controlled comparative analysiscontrolled comparative analysis•• 138 patients138 patients

–– 69 wide69 wide--lumen stapled lumen stapled anastomosisanastomosis–– 69 conventional end69 conventional end--toto--end end anastomosisanastomosis

•• Fewer complications with wideFewer complications with wide--lumen stapled (p=0.048)lumen stapled (p=0.048)•• 55 patients with recurrent symptoms55 patients with recurrent symptoms

–– 39 (57%) CSEE 39 (57%) CSEE --> 18 > 18 reoperationsreoperations•• 15 stricture15 stricture•• 3 3 fistulizationfistulization

–– 16 (24%) WLS 16 (24%) WLS --> 3 > 3 reoperationsreoperations•• 2 stricture2 stricture•• 1 1 fistulizationfistulization

•• Cumulative Cumulative reoperationreoperation rate lower for WLS (P=0.017)rate lower for WLS (P=0.017)

MunozMunoz--Juarez M, Juarez M, YamomotoYamomoto T, T, et.alet.al. Wide. Wide--lumen stapled lumen stapled anastomosisanastomosis vs. conventional endvs. conventional end--toto--end end anastomosisanastomosis in the treatment of in the treatment of Crohn'sCrohn's disease. disease. DisDis Colon Rectum.Colon Rectum. 2001 Jan;44(1):202001 Jan;44(1):20--5; discussion 255; discussion 25--6 6


Colonic diseaseColonic disease•• Differentiation between Differentiation between CrohnCrohn’’ss and UCand UC•• Indications for Operative managementIndications for Operative management

–– StrictureStricture–– malignancymalignancy–– dysplasiadysplasia–– failure of medical therapyfailure of medical therapy

•• Toxic Toxic megacolonmegacolon


Colonic diseaseColonic disease•• Total Total proctocolectomyproctocolectomy with end with end ileostomyileostomy

–– IntersphinctericIntersphincteric approachapproach–– 88--15% recurrence rate proximal to stoma15% recurrence rate proximal to stoma–– Delayed healing of Delayed healing of perinealperineal wound in 30%wound in 30%

•• Subtotal Subtotal colectomycolectomy with with ileorectal/ileosigmoidileorectal/ileosigmoidanastomosisanastomosis

–– 70% recurrence rate 70% recurrence rate ((GoligherGoligher JC. Surgical treatment of JC. Surgical treatment of CrohnCrohn’’ss disease disease affecting mainly or entirely the large bowel. World J affecting mainly or entirely the large bowel. World J SurgSurg 12: 186, 1988.)12: 186, 1988.)

•• Segmental resectionSegmental resection–– limited diseaselimited disease


Colonic diseaseColonic disease•• ColectomyColectomy with with IlealIleal pouchpouch--anal anal anastomosisanastomosis(IPAA)(IPAA)

–– not knowingly performed for not knowingly performed for CrohnCrohn’’ss–– In absence of In absence of fistulizingfistulizing disease can maintain disease can maintain pouchpouch


Anal and Anal and PerianalPerianal diseasedisease•• 35% of all patients35% of all patients

–– Skin tagsSkin tags–– Fissures in lateral positionFissures in lateral position–– hemorrhoidshemorrhoids

•• Treatment to alleviate symptomsTreatment to alleviate symptoms•• Skin tags and hemorrhoids should NOT be Skin tags and hemorrhoids should NOT be routinely excised routinely excised --> chronic, > chronic, nonhealingnonhealing woundwound•• SphincterotomySphincterotomy contraindicated unless EUAcontraindicated unless EUA


Anal and Anal and PerianalPerianal diseasedisease•• Complex anal fistulaComplex anal fistula

–– Control sepsisControl sepsis–– Delineation of complex anatomyDelineation of complex anatomy–– Treatment of underlying mucosal diseaseTreatment of underlying mucosal disease–– Sphincter preservationSphincter preservation–– ProctectomyProctectomy


SummarySummary

•• Medical therapy firstMedical therapy first•• Preservation of bowel lengthPreservation of bowel length•• Resection vs. Resection vs. StricturoplastyStricturoplasty•• BiopsyBiopsy•• Remember wound healingRemember wound healing

surgical management of crohn’s disease · surgical management of crohn’s disease aaron winnick,...

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