1. Surgery has traditionally been a last resort for treating Crohn's disease due to risks of short bowel syndrome from removing too much intestine. 2. However, recent evidence suggests early surgery may be beneficial as it offers a more favorable long-term course by preventing complications from advanced disease. 3. Stapled, side-to-side anastomoses also help reduce recurrence rates compared to hand-sewn, end-to-end anastomoses.

1. Surgery in Crohn’s
Guy Nash

2. Background
• Crohn Ginsberg Oppenheimer 1932 in USA described
terminal ileitis in 14 surgical cases
• Affects any part of the GI track but terminal was not
popular with patients, thus regional ileitis or “Crohn’s”
• Response to postulated pathogen causes the clinical
manifestations of pain, diarrhoea and malabsorption

3. Investigation
• Colonoscopy
usually required to
view colon and or
small bowel
• Barium follow
through shows
Terminal ileal
stricture adjacent to
ileocaecal junction

4. Earlier British report?
• In 850AD King Alfred,
"England's Darling",
age 20 suffered
chronic pain on
eating, and “much
embarrassment”
• Thought to be due to
witchcraft…. In
retrospect, probably
Crohn's Disease

5. Aim of treatment
Relief of symptoms as “Incurable”

6. Role of Surgery
Traditionally surgery was reserved for:
Failure of medical management
Complications (eg obstruction/ fistulation)

7. Why “Last Resort”
Too much surgery, resecting too much
bowel resulting a bowel too short to
absorb fluid and food.

8. Short bowel syndrome
Small bowel
must
> 1 metre
length with intact
colon

9. Protagonism for surgery in Crohns
Traditional approach fails to appreciate:
3. Any benefits of early surgery
2. Adverse effects of agents
3. Detrimental effects of delaying surgery
[ If surgery, which operation is best ]

10. 1.Earlier intervention
• Early surgery offers favourable course in Crohns?
• 36 patients at appendicectomy diagnosed ileocolic
Crohn's:
10 patients had immediate ileocolic resection, 50% of
these had no further intervention after 12 years of follow
up.
26 treated conservatively, 24 eventually required surgery
for debilitating symptomatology.
Weston LA, Roberts PL, Schoetz DJ jr, et al. Ileocolic resection for acute presentation of Crohn's disease
of the ileum. Dis Colon Rectum 1996;39:841–6.

11. 2. Medical adverse effects
• Steroids & Cytotoxics side effects plentiful

12. 2. Smoking in Crohns
• Smoking improve UC but worsens Crohns, does this
give us a clue to the pathophysiology of Crohns?
• Underlying pathology is ischaemic insult, does smoking
act by worsening ischaemia?
• Ischaemia induces VEGF secretion and nearly all
Crohns treatments [ASA, steroids/heparin] reduce
angiogenesis.
• Is this an important step in treatment of Crohns?
Increased vascular endothelial growth factor production in fibroblasts isolated from
strictures in patients with Crohn's diseaseBr J Surg 2004; 91: 72-77 p646 Nash G.F

13. 3.Delay of surgery
• Series of 184 ileocolic resections:
2% mortality, 7% wound infection, 9% postoperative
abscess and 11% anastomotic leak
Factors associated with complications were current
steroid use, low albumin, and sepsis (abscess and
fistula), which are indicators of advanced disease
Andrews HA, Keighley MR, et al.Strategy for management of distal ileal Crohn's disease Br J Surg 1991;78:679–
82

14. 3. Delay of surgery
• Study looking at patients perspective
shows 72% of patients would have
preferred earlier surgical intervention.
Median of a year earlier!
Scott NA, Hughes LE. Timing of ileocolonic resection for symptomatic Crohn's
disease—the patient's view. Gut 1994;35:656–7

15. Stapled “side to side” makes a
bigger join between the bowel ends

16. Stapled anastomosis
• Prospective Randomized Trial: Stapled anastomoses vs hand-sewn
63 patients undergoing Crohns resection
• Significant difference in cumulative recurrences between the groups
(P = 0.022)
• Stapled anastomotic resection for Crohn's disease may delay
reoperation in patients with symptomatic recurrence.
Long-Term Results of Stapled and Hand-Sewn Anastomoses in Patients with Crohn's Disease Hiroki Ikeuchi,
Masato Kusunoki, Takehira Yamamura. Digestive Surgery 2000;17:493-496

17. Recurrence needing reoperation
Handsewn (end to end)
[P = 0.022]
Stapled (side to side)
Thus is makes sense to
carry out a side to side
join for Crohns to reduce
the chance of the join
blocking in the future.

18. Laparoscopic right hemicolectomy
• Potential reduction in surgical morbidity
(less wound problems & fewer adhesions)
• Young population of patients who may
need surgery every 10 years on average.

19. Laparoscopic results
• Smaller incisions, less
pain & analgesia
requirement, faster
return to bowel
function & home.