Case Presentation

Ali Chami PGY415/12/2015

50 year old male known to have Crohn’s disease presents for recurrent attacks of abdominal pain over a one year period. Pain is colicky, diffuse and not related to meals. It was associated with intermittent mucoid non bloody diarrhea. Patient did not report any nausea, vomiting, fevers or chills.

PMH: Crohn’s (since 10 years)PSH: NoneMedications: Asacol, Imuran SmokerNKFDA

Colonoscopy: Sigmoid ulcers, edema, aphthous lesionsEGD: Severe gastroduodenitis

CT scan

Small bowel series: Moderate dilatation of jejunum and ileum with mucosal destruction, mass effect of cecum

Pathology: Mild ileitis, no ulceration or granulomaColon: Ulcerated mucosa with fibrino leukocytic materialStomach, duodenum: ulceration, inflammation, erosion and atrophy

14/05/2014Started on Remicade (Infliximab)

27/04/2015One week duration of lower abdominal pain, chills and constipation

CT scan

Antibiotics

09/07/2015Severe RLQ abdominal painDistended abdomenDiffuse tenderness

CT scan

Hb Hct WBC Neu% Plt INR

12.3 38.5 9.2 61.5% 471 1.19

BUN Crea Na K CO2 Cl CRP Alb

18 0.6 140 4.19 21 92 33 2.43

Laparotomy

Pathology

• Severe ileitis• Transmural inflammation• Intramural abscesses

Post-op

• No major complications• Ileostomy reversal: 3 months

Surgery for Crohn’s Disease

• Introduction• Medical management• Ileocolic disease- Indications for surgery- Surgical considerations- Complications• Large bowel disease• Future and conclusion

• Site of disease remains constant in 85 % of patients over 10 years• Non-stenosing/nonpenetrating disease will often evolve over this time into

stenosing or penetrating disease (27 and 29 % of cases respectively)

Louis E, Collard A, Oger AF, Degroote E, Aboul Nasr El Yafi F, Belaiche J. Behaviour of Crohn’s disease according to the Vienna classifi cation: changing pattern over the course of the disease. Gut. 2001;49(6):777–82.

Montreal Classification

Macroscopic Features• Fat wrapping• Ulceration• Bowel wall thickening• Strictures• Fistula formation• Cobblestoning• Increased mesenteric vascularity• Skip lesions• Obstruction• Sacculation• Pseudopolyposis

A. Rajesh, R. Sinha (eds.), Crohn’s Disease: Current Concepts

Macroscopic Features

A. Rajesh, R. Sinha (eds.), Crohn’s Disease: Current Concepts

Location

• Ileo-colic disease in >50%• Multisite small bowel and colonic disease 15-

30%• Perianal disease 20%

Farmer RG, Whelan G, Fazio VW. Long-term followup of patients with Crohn’s disease. Relation- ship between the clinical pattern and prognosis. Gastroenterology. 1985;88(6):1818–25.Michelassi F, Balestracci T, Chappell R, Block GE. Primary and recurrent Crohn’s disease. Experience with 1379 patients. Ann Surg. 1991;214(3):230–40.Schwartz DA, Loftus Jr EV, Tremaine WJ, et al. The natural history of fi stulizing Crohn’s disease in Olmsted County, Minnesota. Gastroenterology. 2002;122(4):875–80.

Overview of Treatment• Improved medical induction and maintenance of remission: thiopurines and anti-TNF agents• Less invasive approach to surgical management:- Very limited resections- Strictureplasty- Laparoscopic surgery• Major abdominal surgery: 60% at 20 years• Likelihood:- Non colonic disease- Smoking- Male gender- Penetrating disease- Early steroid use

Dignass A, Van Assche G, Lindsay JO, Lémann M, Söderholm J, Colombel JF, Danese S, D’Hoore A, Gassull M, Gomollón F, Hommes DW, Michetti F, O’Morain C, Öresland T, Windsor A, Stange EF, Travis SPL, European Crohn's and Colitis Organisation (ECCO). The second European evidence- based Consensus on the diagnosis and management of Crohn’s disease: Current management. J Crohns Colitis. 2010;4(1):28–62.Mowat C, Cole A, Windsor A, Ahmad T, Arnott T, Driscoll R, Mitton S, Orchard T, Rutter M, Younge L, Lees C, Ho GT, Satsangi J, Bloom S, IBD Section of the British Society of Gastroenterology. Guidelines for the management of infl ammatory bowel disease in adults. Gut. 2011;60(5):571–607.Peyrin-Biroulet L, Harmsen WS, Tremaine WJ, Zinsmeister AR, Sandborn WJ, Loftus Jr EV. Surgery in a population-based cohort of Crohn’s disease from Olmsted County, Minnesota (1970–2004). Am J Gastroenterol. 2012;107(11):1693–701.

ILEOCOLIC DISEASE

Initial Medical Management

• Symptomatic improvement in those who achieve and maintain remission

• Avoidance of surgery and its complications• Avoiding the need for a stoma.• Benefits must be weighed against:- Medication side effects- Expenses- Inevitable surgery

38, 48 and 58 % at 5, 10 and 20 years after diagnosis respectively

Mild Disease

• No treatment: 18% spontaneous remission• Locally active budesonide:- Less active than systemic steroids- Less side effects - More active than mesalamine

Su C, Lichtenstein GR, Krok K, Brensinger CM, Lewis JD. A meta-analysis of the placebo rates of remission and response in clinical trials of active Crohn’s disease. Gastroenterology. 2004;126(5):1257–69.Seow, CH, Benchimol EI, Griffi ths AM, Otley AR, Steinhart AH. Budesonide for induction of remission in Crohn’s disease. Cochrane Database Syst Rev. 2008 Jul 16;(3):CD000296. doi: 10.1002/14651858. CD000296.pub3 . 2009:971–79.

Systemic Steroids

• More effective than Mesalamine• Remission:- 40% at 30 days- 38% at 1 year- 24% steroid dependent- 35% required surgery

Benchimol EI, Seow CH, Steinhart AH, Griffi ths AM. Traditional corticosteroids for induction of remission in Crohn’s disease. Cochrane Database Syst Rev. 2008 Apr 16;(2):CD006792. doi: 10.1002/14651858. CD006792.pub2 . 2008:(2):CD006792Ho GT, Chiam P, Drummond H, Loane J, Arnott IDR, Satsangi J. The effi cacy of corticosteroid therapy in infl ammatory bowel disease: analysis of a 5 year UK inception cohort. Aliment Pharmacol Ther. 2006;24(2) 319–30.‐

Azathioprine/Anti-TNF• Steroid refractory, steroid resistant and complex fistulating disease• Started early for higher remission rates: Perianal disease, active

inflammation• Infliximad:- Sustained mucosal healing: predictive of long term improvement- Preserves bowel length- Reduces hospitalizations and operation rates- Better results with combination therapy

D’Haens GR, Panaccione R, Higgins PD, Vermeire S, Gassull M, Chowers Y, Travis SPL. The London Position Statement of the World Congress of Gastroenterology on Biological Therapy for IBD with the European Crohn’s and Colitis Organization: when to start, when to stop, which drug to choose, and how to predict response. Am J Gastroenterol. 2011;106(2):199–212.Feagan BG, Lemann M, Befrits R, Connell W, D’Haens G, Ghosh S, Rutgeerts P. Recommendations for the treatment of Crohn’s disease with tumor necrosis factor antagonists: an expert consensus report. Infl amm Bowel Dis. 2012;18(1):152–60. Colombel JF, Sandborn WJ, Reinisch W, et al. Infl iximab, azathioprine, or combination therapy for Crohn’s disease. N Engl J Med. 2010;362(15):1383–95.

Outcomes

• Temporary reduction in surgery• No long term reduction in surgery• Stable cumulative risk for surgery: last 40 years• Need for early diagnosis: Before fibro-stenosis

starts

Ramadas AV, Gunesh S, Thomas GA, Williams GT, Hawthorne AB. Natural history of Crohn’s disease in a population-based cohort fom Cardiff (1986–2003): a study of changes in medical treatment and surgical resection rates. Gut. 2010;59(9):1200–6. Cosnes J, Nion-Larmurier I, Beaugerie L, Afchain P, Tiret E, Gendre JP. Impact of the increasing use of immunosuppressants in Crohn’s disease on the need for intestinal surgery. Gut. 2005;54(2):237–41.Jones DW, Finlayson SR. Trends in surgery for Crohn’s disease in the era of infl iximab. Ann Surg. 2010;252(2):307–12.Limketkai BN, Bayless TM. Editorial: Can stenosis in ileal Crohn’s disease be prevented by current therapy? Am J Gastroenterol. 2013;108(11):1755–6.Schoepfer AM, Dehlavi MA, Fournier N, Safroneeva E, Straumann A, Pittet V, et al. Diagnostic delay in Crohn’s disease is associated with a complicated disease course and increased operation rate. Am J Gastroenterol. 2013;108(11):1744–53.

Failure of Medical Management

• Most frequent indication for surgery• Broad consensus and considerable latitude• Decisions vary for individual patients• Threshold high in extensive disease and probability of

permanent stoma• Recurrent obstruction: Refractory to medical therapy• Radiological evidence• Steroid dependency: Over 3 months, twice within 6 months• Drug intolerance

Alós R, Hinojosa J. Timing of surgery in Crohn’s disease: a key issue in the management. World J Gastroenterol. 2008;14(36):5532–9.Peyrin-Biroulet L, Reinisch W, Colombel JF, Mantzaris GJ, Kornbluth A, Diamond R, et al. Clinical disease activity, C-reactive protein normalisation and mucosal healing in Crohn’s disease in the SONIC trial. Gut. 2014;63(1):88 95.

Indications

Emergency Surgery

Early Surgery

• Non-inflamed limited fibrotic disease <40cm• Less clear which other patients may benefit from early surgery

and how to select these patients• Surgery can improve quality of life long-term and provide a long

medication-free period in many patients

Dignass A, Van Assche G, Lindsay JO, Lémann M, Söderholm J, Colombel JF, Danese S, D’Hoore A, Gassull M, Gomollón F, Hommes DW, Michetti F, O’Morain C, Öresland T, Windsor A, Stange EF, Travis SPL, European Crohn's and Colitis Organisation (ECCO). The second European evidence- based Consensus on the diagnosis and management of Crohn’s disease: Current management. J Crohns Colitis. 2010;4(1):28–62.

• 136 patients• Median follow up: 16.6 years• Good functional results• Low morbidity and mortality• Repeat surgery: 40% at 10 years• Median cumulative resected bowel length: 8%

• 181 patients• 14.3 years• 69% one resection• 20.4% two resections• 8.3% three resections• 2.2% short bowel syndrome

Surgery Delay• More complex eventual

surgery• Increased post-op

complications• Increased number of

abdominal structures involved

• Increased number of septic complications

Iesalnieks I, Kilger A, Glass H, Obermeier F, Agha A, Schlitt HJ. Perforating Crohn’s ileitis: delay of surgery is associated with inferior postoperative outcome. Infl amm Bowel Dis. 2010;16(12):2125–30.

Extent of Resection

• Radical resection to obtain wide clearance is unnecessary

• Shorter small bowel length in CD• Short bowel syndrome is less likely to develop from repeated resections for recurrent disease• No significant long term problems if >200 cm

McLeod RS. Resection margins and recurrent Crohn’s disease. Hepatogastroenterology. 1990;37(1):63–6.Fazio VW, Marchetti F, Church M, Goldblum JR, Lavery C, Hull TL, et al. Effect of resection margins on the recurrence of Crohn’s disease in the small bowel. A randomized controlled trial. Ann Surg. 1996;224(4):563–71.Sinha R, Trivedi D, Murphy PD, Fallis S. Small intestinal length measurement on MR enterography: comparison with in-vivo surgical measurement. AJR Am J Roentgenol. 2014;203(3):W274–9.Glehen O, Lifante JC, Vignal J, Francois Y, Gilly FN, Flourie B, et al. Small bowel length in Crohn’s disease. Int J Colorectal Dis. 2003;18(5):423–7.Nightingale J, Woodward M. Guidelines for management of patients with a short bowel. Gut. 2006;55: 1–12.

Anastamosis

• Superior in terms of overall postoperative complications [odds ratio (OR), 0.54; 95 % confidence interval (CI) 0.32–0.93]

• Anastomotic leak (OR 0.45; 95 % CI 0.20–1.00), recurrence (OR 0.20; 95 % CI 0.07–0.55)

• Re-operation for recurrence (OR 0.18; 95 % CI 0.07–0.45). • Postoperative hospital stay, mortality, and complications other than anastomotic

leak were comparable.

Intra-Abdominal Fistula

• Ileo-ileal and ileo-sigmoid most common• Indication for surgery in 7-10%• Penetrating disease most affected

Bellolio F, Cohen Z, Macrae HM, O’Connor BI, Huang H, Victor JC, McLeod RS. Outcomes following surgery for perforating Crohn’s disease. Br J Surg. 2013;100(10):1344–8.Michelassi F, Stella M, Balestracci T, Giuliante F, Marogna P, Block GE. Incidence, diagnosis, and treatment of enteric and colorectal fi stulae in patients with Crohn’s disease. Ann Surg. 1993;218(5):660–6.Sampietro GM, Casiraghi S, Foschi D. Perforating Crohn’s disease: conservative and surgical treatment. Dig Dis. 2013;31(2):218–21.

Surgery• Resection of the primary ileo-colic

disease and surgical management of the non diseased bowel at the ‘recipient’ or ‘target’ end of the fistula

• A ‘cuff excision’ and repair of the recipient bowel may be sufficient, but if fistulation tracks through the mesentery of the recipient bowel segment, or has multiple entry points, then resection will be needed

• Most complex: Ileo-colic fistula tracking to rectum through mesorectum necessitating limited anterior rectal resection

Rajesh, R. Sinha (eds.), Crohn’s Disease: Current Concepts

Intra-Abdominal Abscess• Most common in penetrating ileo-

colic disease• Diagnosed clinically and radiologically• May settle with medical management• Percutaneous drainage: treatment or

bridge to surgery• Failure: Fistula, perianal and ileal

disease

Ananthakrishnan AN, McGinley EL. Treatment of intra-abdominal abscesses in Crohn’s disease: a nationwide analysis of patterns and outcomes of care. Dig Dis Sci. 2013;58(7):2013–8.Lee H, Kim YH, Kim JH, Chang DK, Son HJ, Rhee PL, et al. Nonsurgical treatment of abdominal or pelvic abscess in consecutive patients with Crohn’s disease. Dig Liver Dis. 2006;38(9):659–64.

Recurrent Crohn’s Disease• Relapse rates: 28% after 5

years, 36% after 10 years• Further resection: 40% after 5

years, 45% after 10 years• Diseases develops proximal to

anastomosis as aphthous ulceration progressing to confluent ulceration and stenosis

Bernell O, Lapidus A, Hellers G. Risk factors for surgery and recurrence in 907 patients with primary ileocaecal Crohn’s disease. Br J Surg. 2000;87(12):1697–701.Nordgren SR, Fasth SB, Oresland TO, Hultén LA. Long-term follow-up in Crohn’s disease. Mortality, morbidity, and functional status. Scand J Gastroenterol. 1994;29(12):1122–8.

Prophylaxis and Treatment• Asymptomatic until much later• Limited resection or strictureplasty on anastomotic recurrence• High risk:- Smoking: 2.5 times increased risk- Penetrating disease- Perianal disease- Previous resections

Olaison G, Smedh K, Sjödahl R. Natural course of Crohn’s disease after ileocolic resection: endoscopically visualised ileal ulcers preceding symptoms. Gut. 1992;33(3):331–5.Yamamoto T, Allan RN, Keighley MR. Strategy for surgical management of ileocolonic anastomotic recurrence in Crohn’s disease. World J Surg. 1999;23(10):1055–60.Reese GE, Nanidis T, Borysiewicz C, Yamamoto T, Orchard T, Tekkis PP. The effect of smoking after surgery for Crohn’s disease: a meta-analysis of observational studies. Int J Colorectal Dis. 2008;23(12):1213–21.Yamamoto T, Watanabe T. Strategies for the prevention of postoperative recurrence of Crohn’s disease. Colorectal Dis. 2013;15(12):1471–80.Riss S, Schuster I, Papay P, Mittlböck M, Stift A. Repeat intestinal resections increase the risk of recurrence of Crohn’s disease. Dis Colon Rectum. 2013;56(7):881–7.

Entero-Cutaneous Fistula Followingan Anastomotic Leak

• Management of sepsis, fluid replacement, nutrition, skin and wound care

• Spontaneous healing unlikely• Surgery delayed to allow improvement in health and

nutrition, map extent of disease and await resolution of inflammatory peritoneal process

Rahbour G, Gabe SM, Ullah MR, Thomas GP, Al-Hassi HO, Yassin NA, et al. Seven-year experience of enterocutaneous fi stula with univariate and multivariate analysis of factors associated with healing: development of a validated scoring system. Colorectal Dis. 2013;15(9):1162–70.Datta V, Engledow A, Chan S, Forbes A, Cohen CR, Windsor A. The management of enterocutaneous fi stula in a regional unit in the United kingdom: a prospective study. Dis Colon Rectum. 2010;53(2):192–9.Ravindran P, Ansari N, Young CJ, Solomon MJ. Defi nitive surgical closure of enterocutaneous fi stula: outcome and factors predictive of increased postoperative morbidity. Colorectal Dis. 2014;16(3):209–18.

Entero-Cutaneous Fistula FollowingDrainage of an Abscess

• Shorter and more direct than the post-anastomotic complication fistulas.

• May heal with anti-TNF therapy

• Sands BE, Anderson FH, Bernstein CN, Chey WY,Feagan BG, Fedorak RN, et al. Infl iximab maintenance therapy for fi stulizing Crohn’s disease. N Engl J Med. 2004;350(9):876–85.

Risk Factors for Surgery

• Poor nutritional status• Low albumin• Steroids, anti-TNF, thiopurines• Presence of abscess or fistula

Yamamoto T, Allan RN, Keighley MR. Risk factors for intra-abdominal sepsis after surgery in Crohn’s disease. Dis Colon Rectum. 2000;43(8):1141–5.Tzivanakis A, Singh JC, Guy RJ, Travis SP, Mortensen NJ, George BD. Infl uence of risk factors on the safety of ileocolic anastomosis in Crohn’s disease surgery. Dis Colon Rectum. 2012;55(5):558–62.Alves A, Panis Y, Bouhnik Y, Pocard M, Vicaut E, Valleur P. Risk factors for intra-abdominal septic complications after a fi rst ileocecal resection for Crohn’s disease: a multivariate analysis in 161 consecutive patients. Dis Colon Rectum. 2007;50(3):331–6.Kopylov U, Ben-Horin S, Zmora O, Eliakim R, Katz LH. Anti-tumor necrosis factor and postoperative complications in Crohn’s disease: systematic review and meta-analysis. Infl amm Bowel Dis. 2012;18(12):2404–13.Narula N, Charleton D, Marshall JK. Meta-analysis: Peri-operative anti-TNFα treatment and postoperative complications in patients with infl ammatory bowel disease. Aliment Pharmacol Ther. 2013;37(11):1057–64.El-Hussuna A, Krag A, Olaison G, Bendtsen F, Gluud LL. The effect of anti-tumor necrosis factor alpha

Split Ileostomy

• Proximal ileum: End ileostomy• Distal bowel: Brought adjacent to ileostomy• Allows delayed closure without laparotomy• Lower risk of complications and overall

hospital stay

Myrelid P, Söderholm JD, Olaison G, et al. Split stoma in resectional surgery of high-risk patients with ileocolonic Crohn’s disease. Colorectal Dis. 2012;14(2):188–93.

Coincidental Ileitis

• Options:- No surgery- Appendectomy: If cecum looks normal- Ileo-colic resection

Dignass A, Van Assche G, Lindsay JO, Lémann M, Söderholm J, Colombel JF, Danese S, D’Hoore A, Gassull M, Gomollón F, Hommes DW, Michetti F, O’Morain C, Öresland T, Windsor A, Stange EF, Travis SPL, European Crohn's and Colitis Organisation (ECCO). The second European evidence- based Consensus on the diagnosis and management of Crohn’s disease: Current management. J Crohns Colitis. 2010;4(1):28–62.Weston LA, Roberts PL, Schoetz Jr DJ, et al. Ileocolic resection for acute presentation of Crohn’s disease of the ileum. Dis Colon Rectum. 1996;39(8):841–6.

Laparoscopy

• Potential difficulties:- Adherent nature of

disease- Presence of fistula- Thickened vascular

mesentery• Subtle nature of some

multisite small bowel strictures

Rajesh, R. Sinha (eds.), Crohn’ Disease: Current Concepts

Benefits

• Safe as open, 2% conversion rate• Lower minor and major complications• No influence on recurrence rates• Can be considered for complex and recurrent disease• Less adhesions: No decrease in obstructive episodes

Nguyen SQ, Teitelbaum E, Sabnis AA, et al. Laparoscopic resection for Crohn’s disease: an experience with 335 cases. Surg Endosc. 2009;23(10): 2380–4.Dasari BV, McKay D, Gardiner K. Laparoscopic versus open surgery for small bowel Crohn’s disease. Cochrane Database Syst Rev. 2011;(1):CD006956.Tavernier M, Lebreton G, Alves A. Laparoscopic surgery for complex Crohn’s disease. J Visc Surg. 2013;150(6):389–93.Pinto RA, Shawki S, Narita K, et al. Laparoscopy for recurrent Crohn’s disease: how do the results compare with the results for primary Crohn’s disease? Colorectal Dis. 2011;13(3):302–7.

Technique

• Mobilization of distal ileum and rightcolon (from lateral to medial)• Delivery of diseases section through a small

incision for division of mesentery and fashioning of anastomosis

• Intra-corporeal anastomosis can be performed successfully

Chang K, Fakhoury M, Barnajian M, et al. Laparoscopic right colon resection with intracorporeal anastomosis. Surg Endosc. 2013;27(5):1730–6.HALS Study Group. Hand-assisted laparoscopic surgery vs standard laparoscopic surgery for colorectal disease: a prospective randomized trial. Surg Endosc. 2000;14(10):896–901.

Multisite Small Bowel Disease• Stricturing disease of jejunum and ileum• Difficult to identify and under-estimated by radiology• Options:- Multiple strictures: Single resection- Strictureplasty- Long strictures: side to side iso-peristaltic technique- Many multiple strictureplasties- Synchronous resection in 66%

Lee EC, Papaioannou N. Minimal surgery for chronic obstruction in patients with extensive or universal Crohn’s disease. Ann R Coll Surg Engl. 1982;64(4):229–33.Yamamoto T, Fazio VW, Tekkis PP. Safety and effi - cacy of strictureplasty for Crohn’s disease: a systematic review and meta-analysis. Dis Colon Rectum. 2007;50(11):1968–86.Michelassi F, Taschieri A, Tonelli F, et al. An international, multicenter, prospective, observational study of the side-to-side isoperistaltic strictureplasty in Crohn’s disease. Dis Colon Rectum. 2007;50(3):277–84.Dietz DW, Laureti S, Strong SA, et al. Safety and longterm effi cacy of strictureplasty in 314 patients with obstructing small bowel Crohn’s disease. J Am Coll Surg. 2001;192(3):330–7.

Heinicke-Mickulcz strictureplasty

Finney-type Strictureplasty

Side-to-side IsoperistalticStrictureplasty

Outcomes• Anastomotic leak: 4%• No significant complications• Higher recurrence rates compared to ileo-colic resection• 3% were at previous strictureplaty sites

Yamamoto T, Fazio VW, Tekkis PP. Safety and effi - cacy of strictureplasty for Crohn’s disease: a systematic review and meta-analysis. Dis Colon Rectum. 2007;50(11):1968–86.Keh C, Shatari T, Yamamoto T, et al. Jejunal Crohn’s disease is associated with a higher postopera-tive recurrence rate than ileocaecal Crohn’s disease. Colorectal Dis. 2005;7(4):366–8.Fearnhead NS, Chowdhury R, Box B, et al. Longterm follow-up of strictureplasty for Crohn’s disease. Br J Surg. 2006;93(4):475–82.

LARGE BOWEL CROHN’S DISEASE

Segmental Colectomy and TotalColectomy with Ileo-Rectal

Anastomosis

• Segmental resection preferred for localized disease

• Colectomy for more multiple diseased segments• 30% required proctectomy at 10 years

Martel P, Betton PO, Gallot D, Malafosse M. Crohn’s colitis: experience with segmental resections; results in a series of 84 patients. J Am Coll Surg. 2002;194(4):448–53.Tekkis PP, Purkayastha S, Lanitis S, et al. A comparison of segmental vs subtotal/total colectomy for colonic Crohn’s disease: a meta-analysis. Colorectal Dis. 2006;8(2):82–90.Kiran RP, Nisar PJ, Church JM, Fazio VW. The role of primary surgical procedure in maintaining intestinal continuity for patients with Crohn’s colitis. Ann Surg. 2011;253(6):1130–5.O’Riordan JM, O’Connor BI, Huang H, et al. Longterm outcome of colectomy and ileorectal anastomosis for Crohn’s colitis. Dis Colon Rectum. 2011;54(11):1347–54.

Proctocolectomy• Diffuse pancolitis• Distal disease • Neoplasia• Recurrence 13, 17 and 25% at 5, 10 and 15 years• Complication:- Sepsis- Stoma problems- Delayed perianal healing: 35%

Yamamoto T, Allan RN, Keighley MR. Audit of single-stage proctocolectomy for Crohn’s disease: postoperative complications and recurrence. Dis Colon Rectum. 2000;43(2):249–56.Yamamoto T, Keighley MR. Proctocolectomy is associated with a higher complication rate but carries a lower recurrence rate than total colectomy and ileorectal anastomosis in Crohn colitis. Scand J Gastroenterol. 1999;34(12):1212–5.Fichera A, McCormack R, Rubin MA, et al. Longterm outcome of surgically treated Crohn’s colitis: a prospective study. Dis Colon Rectum. 2005;48(5): 963–9.Amiot A, Gornet JM, Baudry C, et al. Crohn’s disease recurrence after total proctocolectomy with defi nitive ileostomy. Dig Liver Dis. 2011;43(9):698–702.

Defunctioning Stoma

• Useful in semi-urgent situations• Not usually undertaken since only a relatively

small proportion of patients achieve a definitive long-term benefit

Edwards CM, George BD, Jewell DP, et al. Role of a defunctioning stoma in the management of large bowel Crohn’s disease. Br J Sur 2000;87(8):1063–6.

Restorative Ileal Pouch-AnalAnastomosis Surgery

• Risk of recurrent disease and poor functional results

• Increased anastomotic stricture rates• Higher than in ulcerative colitis (32 vs 4.8%)

Reese GE, Lovegrove RE, Tilney HS, et al. The effect of Crohn’s disease on outcomes after restorative proctocolectomy. Dis Colon Rectum. 2007;50(2):239–50.

Laparoscopy

• Similar complications rates to open• For emergency colectomy and elective

proctocolectomy

Tilney HS, Lovegrove RE, Purkayastha S, et al. Laparoscopic versus open subtotal colectomy for benign and malignant disease. Colorectal Dis. 2006;8(5):441–50.Seshadri PA, Poulin EC, Schlachta CM, et al. Does a laparoscopic approach to total abdominal colectomy and proctocolectomy offer advantages? Surg Endosc. 2001;15(8):837–42.Marohn MR, Hanly EJ, McKenna KJ, Varin CR. Laparoscopic total abdominal colectomy in the acute setting. J Gastrointest Surg. 2005;9(7):881–6.

Future

• Less invasive surgery• Reverse proctectomy techniques• Robotics• Alternative anastomotic approach: Kono S• New biologicals: anti-TNF biosimilar• Multidisciplinary teams

Kono T, Ashida T, Ebisawa Y et al. A ne antimesenteric functional end-to-end handsewn anastomosis: surgical prevention of anastomotic recurrence in Crohn’s disease. Dis Colon Rectum 2011; 54: 586–92.