With the progressive understanding of Crohn’s disease, it is now generally accepted that drug therapy is the primary treatment for Crohn’s disease, and that the vast majority of patients require drugs to control and alleviate the disease and delay recurrence. Despite this, surgery remains irreplaceable in the treatment of Crohn’s disease, and many of the complications of Crohn’s disease must still be addressed surgically, and in some critically ill patients, surgery is even the only means of saving lives.
Although drug therapy is the main treatment for Crohn’s disease, most patients still require surgery during the course of the disease. Statistics show that 78% of Crohn’s disease patients with a history of more than 20 years require surgical treatment, but frequent bowel resections can rapidly turn patients into short syndromes; therefore, surgical resection should be treated with great caution. It is generally accepted that surgical treatment is mainly indicated in cases where drug therapy has failed or surgical complications have arisen, so-called complex Crohn’s disease. Failure of drug therapy refers to ineffective hormone therapy, hormone dependence, flare-ups or persistent deterioration during drug therapy, and significant drug-related complications, while surgical complications refer to intestinal stricture, obstruction, bleeding, perforation, intestinal fistula, toxic colitis, abscesses, and carcinoma. In cases without surgical complications, resection is not advocated, even if the lesion is found during surgery. In the specific implementation process, if the lesion seriously affects the systemic condition, leading to severe malnutrition, anemia and adolescent growth retardation, the surgical indications can be relaxed appropriately; while for patients with combined abnormalities of other organ functions, organ damage easily aggravated after surgery or highly likely to rapidly lead to short bowel syndrome, the surgical indications should be strictly controlled.
Optimization of treatment strategy
Crohn’s disease is often complicated by chronic intestinal perforation and penetration to adjacent organs, resulting in the formation of fistulas between the intestine and the intestinal canal, bladder, vagina, abdominal wall, etc. If penetration is made to the abdominal cavity or retroperitoneum, abdominal or retroperitoneal abscesses will be formed. If the patient has malnutrition, long-term use of glucocorticoids or immunomodulators, the abscess will not be easily confined and systemic infection will easily occur, leading to various degrees of impairment of organ functions. Therefore, active infection control is the key to successful treatment of such patients, and effective surgical drainage in particular needs to be emphasized.
Since patients are often very sick and do not tolerate any deviation in treatment measures, it is important to be very strategic in infection control. We often see in the clinic that many patients have been “bombarded” with prolonged broad-spectrum antibiotics prior to surgical treatment, and some patients have severe fungal or drug-resistant infections that leave the clinician with no antibiotics to choose from. According to the principle of surgical treatment, if a clear intestinal perforation or abscess has been formed, surgical drainage must be performed, and if hope is still placed on drugs to control the infection, it will only be a delay in treatment and create problems for subsequent treatment. Although it has been reported that TNF monoclonal antibody infliximab can make the fistula heal spontaneously, the fistula will not heal if the infection is not drained.
In the method of drainage, the best result with the least trauma should be pursued. With the high level of development of imaging technology, this goal is not difficult to achieve today. For confined abscesses, CT-guided puncture and drainage is the basic technique. The basic purpose of puncture and drainage is to solve the infection problem as soon as possible, and then elective surgery after the infection is controlled and the patient’s general condition is improved, in order to achieve a high success rate of treatment and avoid doing resection anastomosis in the case of combined abscesses or cutting abscesses in the abdominal cavity, which exposes the whole abdomen to pus contamination. Some patients can be cured by puncture and drainage of the enterocutaneous fistula. Care should also be taken when puncturing and draining to avoid passing through vital organs or the intestinal canal to prevent medically induced injury. When puncturing and draining, strive to achieve the ideal drainage effect in the shortest possible time and choose a larger caliber drainage tube; after successful puncture, if the pus is thick, negative pressure drainage or negative pressure drainage + flushing can be used. After the abscess caused by intestinal perforation is drained, the intestinal contents can still enter the abscess cavity and the infection cannot be easily controlled. Therefore, from the perspective of controlling infection and clearing the abscess cavity, the implementation of external stoma in the small intestine proximal to the fistula while draining the abscess and blocking the way for intestinal contents to enter the abscess is conducive to the rapid elimination of the infection and control of the disease.
In the case of combined abdominal or retroperitoneal abscesses, it is necessary to be very cautious in performing a one-stage resection and anastomosis of the diseased intestine, because the patient is in a state of systemic infection, and factors such as severe catabolism, malnutrition, organ insufficiency, immunosuppression and abdominal infection can seriously affect the healing of the intestinal anastomosis, and once an anastomotic fistula occurs, the patient suffers a second blow and is prone to multi-organ failure and death. Therefore, when dealing with critically ill patients, the principle of damage control surgery should be actively used to address key issues such as infection using the least invasive surgical means and actively correct acidosis and coagulation dysfunction in order to ensure successful treatment. The author has successfully treated many cases of combined severe abdominal or retroperitoneal abscesses in recent years, and here is an example to illustrate.
Application of the principles of damage control surgery
Patient Wang XX, male, 41 years old, was admitted to a local hospital for 5 years with ileal Crohn’s disease with right lower abdominal mass for 2 months. He was treated with prednisone, methylprednisolone, high-dose cyclophosphamide and other immunosuppressant shock therapy, which was ineffective, with recurrent hyperthermia, extreme malnutrition, complete cytopenia, a huge right retroperitoneal abscess with trans-scrotal rupture, and a CDAI score of 280, and was transferred to our department due to ineffective medical treatment. After admission, he was actively corrected for endostasis and treated with emergency surgery. As the abdominal cavity was free of contamination, the abdomen was advanced, the ileum was cut at the proximal end of the abscess, an external stoma was placed proximally to create conditions for postoperative enteral nutritional support, the distal end was closed to prevent the intestinal contents from entering the abscess cavity, and the abdomen was closed. Another incision was made from the right lumbar region to enter the abscess cavity, and about 2000 ml of pus was drained. After drainage, it was seen that the right retroperitoneal organs were completely exposed, and large blood vessels were exposed in the abscess cavity, which were very prone to rupture and bleeding, so the abscess cavity was filled with several iodine voltaic gauze pads wrapped with negative pressure drainage tubes to end the operation. After the operation, the patient was admitted to the ICU, actively resuscitated, corrected endostasis, restored enteral nutrition, and changed the gauze pad every 48h-72h in the operating room. After half a month, the abscess cavity was obviously reduced, the granulation was fresh, the abscess cavity was closed, and the patient was discharged after 1 month with built-in double cannula for flushing and drainage.
The treatment process of this patient fully reflects the principle of damage control surgery: in the case of severe retroperitoneal infection and dysfunction of various organs, if intestinal resection anastomosis is performed, the surgery is traumatic, the pus cavity is open in the abdominal cavity, and various serious postoperative complications are bound to occur, even life-threatening. If the infection can be cleared and the general condition can be improved, the patient has a hope of survival. Therefore, performing abscess drainage and ileostomy not only solves the problem of infection but also provides an intestinal nutrition pathway. The abscess cavity is filled with tamponade to avoid postoperative residual abscess formation and hemorrhage.
Note the distinction between colonic Crohn’s disease and ulcerative colitis
Crohn’s disease can occur in all parts of the gastrointestinal tract, including the colon. Patients with UC should be treated surgically if medication fails, but the surgical procedure is a total colorectal resection with Soave and other surgical procedures to preserve the function of the anal sphincter and use ileal pouches to improve the patient’s postoperative bowel function. The patient’s postoperative bowel function is improved by using ileal pouch. If the wrong diagnosis is made and a partial resection is performed in a patient with UC, postoperative symptoms persist and even surgical complications can occur. If total colectomy is performed in patients with Crohn’s disease, the healthy colon that is not affected by the lesion is also innocently removed, which does not prevent the recurrence of the lesion. UC and Crohn’s disease may be difficult to distinguish in the acute phase, especially when complicated by fulminant colitis, when total colectomy can be performed, but ileoanal anastomosis or ileostomy pouch should not be done, instead, ileostomy should be done, and after the diagnosis of gross pathology is clear, the corresponding GI reconstruction will be performed according to the diagnosis in the second stage of surgery.
Pay attention to perioperative organ function maintenance and nutritional support
Many patients with complicated Crohn’s disease suffer from malnutrition due to insufficient nutritional intake and increased nutritional consumption due to infection, and are prone to postoperative complications such as poor healing of incision and anastomosis, pulmonary, abdominal or systemic infection, deterioration of nutritional status, electrolyte disturbance and organ dysfunction. Therefore, special attention should be paid to the support and maintenance of perioperative organ function during the treatment process. Adequate preoperative discussion and assessment of the function of each organ, including the nutritional status, are performed to adequately prepare for possible postoperative problems and to actively prevent and manage them. For patients in poor general condition preoperatively, if postoperative recovery is estimated to be difficult, nutritional support should be actively provided preoperatively when conditions allow. Relying on food alone to improve nutritional status is often very slow, and in the case of intestinal dysfunction or postoperative complications, patients are limited in eating, while enteral or parenteral nutrition can mostly be implemented. Malnourished patients often have a series of clinical symptoms after surgery, such as imbalance of internal homeostasis, low protein edema or thoraco-abdominal fluid, difficulty in ventilator deconditioning or pulmonary infection, etc. The most effective management measure at this time is nutritional support, which can often achieve unexpected results. The issue of postoperative nutritional support routes should be considered during surgery, and gastrostomy or jejunostomy should be done if necessary to facilitate postoperative nutritional support.
The problem of glucocorticoids
Glucocorticoid (GC) is one of the most important drugs for the treatment of Crohn’s disease, and many patients are considered for surgery only after GC therapy has failed. Therefore, the use of perioperative GC is an important topic, and improper management may not only lead to serious complications, but also induce adrenal crisis and even death.
The main hormone released by the adrenal cortex is cortisol, and the secretion of cortisol increases significantly in stressful situations, and the magnitude of the increase is related to the degree of stress. Cytokines in the circulation regulate cortisol secretion by affecting the hypothalamic-pituitary-adrenal (HPA) axis system and influence the metabolism of cortisol and its binding to receptors. Neutrophil elastase in inflamed tissues increases the concentration of free cortisol in tissues by breaking down cortisol-binding proteins, and these effects are important in regulating the inflammatory response. High concentrations of cytokines in the blood of infected patients can inhibit adrenocortisol synthesis and lead to systemic tissue resistance to GC; therefore, the organism may still show symptoms of adrenocortical insufficiency even if the adrenocortical secretion function is normal. Exogenous GC treatment can inhibit the release of CRH and ACTH, and even lead to adrenal atrophy. The inhibitory effect is related to the amount and duration of GC use, and varies greatly among individuals. The inhibitory effect can last for several months after discontinuation of exogenous GC treatment. Therefore, in patients using more than 30 mg of hydrocortisone, 7.5 mg of prednisone or 0.75 mg of dexamethasone per day for more than 3 weeks, care should be taken to prevent adrenal insufficiency. the duration of GC treatment, maximum dose and total dose are important indicators to assess the presence or absence of HPA axis suppression. the amount of GC secretion does not vary much with age, but is related to body weight, GC metabolism and other drug The effect of GC is related to the effect of body weight, GC metabolism and other drugs.
The clinical diagnosis of adrenocortical insufficiency is sometimes difficult because of the lack of specificity of symptoms, as is the case in patients with Crohn’s disease. In patients with long-term GC use, adrenocortical insufficiency should be considered if symptoms such as weakness, nausea, vomiting, and postural syncope occur after discontinuation of the drug. In perioperative patients, adrenocortical insufficiency should be highly suspected if symptoms such as diarrhea, low sodium and high potassium, or hypotension are present despite adequate blood volume.
In situations such as stress or surgery, the body’s demand for GC increases and exogenous supplementation is required. If the patient is on GC preoperatively or has been on it within 1 year, unless it is for a very short period of time (<3 weeks) or has been shown to have normal HPA axis function, hypoadrenocorticism should be considered and supplementation should be given. Do not rely on the results of GC level testing, as the results are influenced by a variety of factors, and treatment should be considered as long as there is a history of relevant disease: hydrocortisone at a dose of 300 mg/d before surgery, continuous titration of hydrocort every 4 h during surgery, and hydrocort 200-300 mg/d is still required after surgery, and if the degree of stress increases, the amount of GC given should also be increase, and gradually reduce the dose after stabilization.
Most immunosuppressive agents can be safely withdrawn prior to surgery, including azathioprine, 6-mercaptopurine, and infliximab, with no significant increase in the incidence of postoperative complications, but not in patients on GC. an Aberra review looked at 159 patients with IBD undergoing elective surgery, 56 on GC preoperatively and 52 on 6-MP or azathioprine, and showed that the use of GC was able to significantly increase the incidence of serious postoperative infectious complications (14). After the development of infection in patients using GC, body temperature and white blood cell count may be normal, and the local inflammatory response is not strong, often not being detected until the infection is more severe. The incidence of infection is related to the severity of the disease and the time and dose of GC use; therefore, patients who use GC preoperatively should be alert to the occurrence of infection after surgery, strive for early detection, and give timely measures such as drug treatment and surgical drainage. GC can also promote abnormal small-vessel neovascularization and capillary dilation, and at the same time, due to infection and other reasons, it is easy to lead to acidosis and abnormal coagulation, so intraoperative bleeding, which should be prevented. Patients using GC are prone to incisional dehiscence or incisional hernia due to the inhibition of colloid fiber growth and reduced healing ability of the incision, so suture removal should be delayed and attention should be paid to the reduction of tension suture.
GC is one of the important treatments for Crohn’s disease and has saved the lives of many patients, but conventional GC can only be used to induce remission and cannot be used for maintenance treatment because its side effects are too great and the risk of surgery increases significantly after long-term use, so the choice of maintenance medication should be considered while using GC to induce remission of Crohn’s disease symptoms, and there should be no fear of recurrence of symptoms and long-term dependence on GC.