Editing Crohn's disease (section)

=== '''Surgery''' ===

* 70% of patients will require bowel resection within 15 years of diagnosis
** Pre-op
*** Medical optimisation - correct anaemia, treat malnutrition (TPN), literature says can operate on infliximab
** Post-op
*** Clinical monitoring
*** Endoscopic surveillance 6-12 months for recurrence
* Minimise surgery, and extent of surgery
** Operative treatment of a complication should treat only that complication - don't attempt to resect more bowel, even if disease is grossly apparent
* General indications:
** Neoplastic and pre-neoplastic lesions
*** Total proctocolectomy is preferable to segmental resection if this occurs in colon
** Obstructing stenoses
** Suppurative complications
*** Fistula (rarely requires operation unless the fistula involves bladder, vagina or skin)
*** Abscess not amenable to conservative management
** Medically intractable disease, including growth retardation
** Haemorrhage
** Free perforation
** Steroid dependence
* '''General tips for operating'''
** Suture ligate mesenteric pedicles rather than simply tying - risk of haematoma/bleeding due to thick, stiff and vascular mesentery
** Low threshold for giving a stoma, if patient is nutritionally depleted. Mostly do a double-barrelled stoma.
* Common situations/general advice
** Operating for RIF pain - acute ileitis found with normal appendix
*** Resect appendix if caecum and appendix appear normal - remove potential cause of pain in the future
*** Do not resect ileum
** Known CD and concomitant appendicitis
*** If base is healthy, resect as normal
*** If base/caecum are unhealthy, consider either treating with antibiotics or performing an ileocaecectomy 
** Stricturing disease causing obstruction
*** See below under 'obstruction'
** Initial resection of short segment of diseased TI
*** Also resect caecum unless there are >6 inches of uninvolved TI distal to diseased segment, as there is highly likely to be a recurrence in this segment
** Bypass procedure
*** Indications:
**** Severe gastroduodenal disease not amenable to stricturoplasty
**** Older poor-risk patients
**** Patients who have had several prior resections and cannot afford to lose any more bowel
**** Resection would necessitate entering an abscess or endangering a normal structure
** Penetrating disease
*** Enteroenteral fistula - not itself an indication for surgery in the absence of sepsis. Medical management with anti-TNF drugs is best.
*** Enterocutaneous fistula - rarely spontaneous, most likely after bowel resection or drainage of an intra-abdominal abscess. May close spontaneously. Follow usual ECF protocol. If conservative management fails, excise the fistula tract and perform a primary anastomosis.
*** Fistula between bowel and other viscera - excise the diseased segment of bowel and the fistula tract, and close the defect in the viscera primarily.
*** Ileosigmoid fistula - only excise the sigmoid if it is also diseased, which is rarely the case.
** Perianal disease
*** Aim for non-operative treatment unless an abscess or complex fistula develops - trial one month metronidazole (or ciprofloxacin), another month antibiotics, then consider seton
*** Don't excise haemorrhoids or large anal skin tags
**** Differentiate between oedematous skin tags vs loose/soft skin tags - the latter can reflect less active disease and may be more ok to excise
*** Non-suppurative, chronic fistulisation or perianal fissuring is treated with antibiotics, immunosuppressive agents and infliximab (results in much improved rates of fistula closure)
**** Can often start medical management with infliximab (targeted to degree of persistent luminal disease/other disease activity/drug levels), then consider removing seton once treatment is established - work closely with gastroenterologists
**** If disease control is unable to be established, keep going with setons
**** If disease is well-controlled, consider definitive fistula treatment
*** Operate carefully, with as small of an intervention as possible
*** Liberal placement of drainage catheters and non-cutting setons
*** Superficial, low trans-sphincteric and low inter-sphincteric fistulas - fistulotomy
*** High trans-sphincteric, supra-sphincteric and extra-sphincteric fistulas - non-cutting setons
*** Fissures are usually lateral, relatively painless, large and indolent and often respond to conservative management
*** Drain abscesses without large excisions of tissue
**** Two weeks post-op metronidazole
*** Proctectomy is sometimes required for patients who have persistent and unremitting symptoms despite conservative medical and surgical therapy
** Duodenal disease
*** Occurs in <5%, most commonly in the duodenal bulb
*** Primary indication for surgery is duodenal obstruction not responding to medical therapy
**** Endoscopic balloon dilation
**** Gastrojejunostomy to bypass
**** Consider stricturoplasty if possible