In my daily work and in answering questions from patients online, I often encounter questions from Crohn’s patients about surgery, such as “What kind of Crohn’s disease requires surgery?” “When do I need surgery?” And so on. Recently, the American College of Colorectal Surgeons released the 2015 edition of the Surgical Practice Guidelines for Crohn’s Disease, and with my own experience in clinical work, I would like to introduce the progress of Crohn’s disease surgery to all patients here.
Crohn’s disease is a chronic, unrelenting, incurable inflammatory disease of the intestine that can involve all parts of the GI tract and can also have some extraintestinal manifestations. The main symptoms are abdominal pain, diarrhea, low-grade fever, and weight loss. According to the disease behavior, it can be divided into non-stenotic, non-perforated, fibrous stenotic and perforated types, which are interchangeable during the course of the disease. According to statistics, about 19%-38% of patients have a combination of surgical complications such as stenosis or perforation at the time of initial diagnosis of Crohn’s disease. These complications occur progressively in 61%-88% of patients during the 20 years of follow-up after the disease. Prior to the advent of antibodies to tumor necrosis factor, such as classical grams, studies have shown that approximately 27%-61% of patients required surgery within 5 years of a diagnosis of Crohn’s disease. Factors affecting initial surgery include recent history of smoking, disease behavior such as lesion location, stenosis or perforation, and early use of high doses of hormones or immunosuppressive drugs.
Surgical indications
I. Failure of drug therapy
1. Surgery should be considered if the patient does not respond to drug therapy, if complications arise, or if drug therapy cannot be tolerated. Patients using hormones should be replaced with other medications if side effects of hormones occur, regardless of the severity of the disease. If other medications are not tolerated, or if the lesion is limited in extent, surgery must be considered.
2. Patients who are being treated with steroids, high doses of hormones and cyclosporine often need to have their surgery done in stages due to concerns about easy postoperative complications. Of course, the decision to stage surgery also requires a comprehensive assessment based on the patient’s risk classification, clinical status, and the surgeon’s judgment. In general, due to drug metabolism, the use of drugs such as classical grams requires 2 months of drug withdrawal before surgery can be considered.
II. Inflammation
Surgery is considered for patients in the acute inflammatory phase who show signs of imminent perforation or have already perforated. The acute inflammatory phase is defined as >/6 bloody stools per day plus any of anemia, elevated sedimentation, fever, and accelerated heart rate. Patients will improve after 2-3 days of intravenous hormone use, but if not, consider classical grams or surgery. Surgery is considered if there is no improvement after 5-7 days of classical grams.
III. Stenosis
1. When symptomatic small bowel or anastomotic stenosis cannot be cured with medications, endoscopic dilatation can be considered. Strictures can be classified as inflammatory or fibrotic, and both types can coexist. For small bowel strictures, CTE and MRI are more accurate for diagnosis. Drugs remain the first choice for the treatment of strictures, and endoscopic dilatation can also be considered, especially for anastomotic strictures. The most common complications of endoscopic dilatation are bleeding, perforation and sepsis. Although the success rate is as high as 90%, the clinical recurrence rate is also 36% within 5 years.
2. Surgery should be considered for symptomatic small bowel or anastomotic strictures that cannot be cured with medications or endoscopic dilatation.
3. Surgical resection should be considered for colonic strictures that cannot be adequately visualized by colonoscopy. About 17% of patients with colonic strictures will have symptoms of obstruction, and even if there are no symptoms, occult cancer will be latent in about 7% of cases. If the stricture is relatively short and prolonged disease, there is usually a higher incidence of cancer. If stenosis cannot exclude concomitant tumors, surgical removal of the lesion site needs to be considered.
IV. Perforation
1. Surgery needs to be considered in patients with free perforation of the intestine. In the case of free perforation of the small intestine, resection of the perforated site is usually used rather than repair, and anastomosis may also be considered. In patients with free perforation of the colon, fecal diversion or enterostomy needs to be considered after anastomosis.
2. When the patient presents with an abscess outside the intestinal wall, between intestinal collaterals, within the mesentery, or retroperitoneum, antibiotics are required without or with percutaneous perforator drainage. If the above treatment fails, surgical drainage needs to be considered, with or without removal of the intestinal canal.
3. Patients with extraintestinal fistulas and persistent local or systemic septic infection need to be considered for surgery, whether or not surgery is appropriate. If asymptomatic, intestinal fistulas do not require surgery, especially in the absence of impaired absorption, diarrhea and recurrent infection.
V. Bleeding
Patients with significant gastrointestinal bleeding can be evaluated and treated with endoscopic and radiological interventional techniques in stable cases, while those with unstable conditions should undergo surgical exploration.
VI. Growth retardation
Pre-pubertal patients who show retarded growth despite proper medication need to consider surgery.
Tumor formation
1. Patients with Crohn’s disease who have long-term lesions in the ileum or colon region need to be considered for colonoscopy.
2. For patients with cancer, non-adenocarcinoma-like atypical hyperplastic lesions or masses, high-grade atypical hyperplasia or multiple low-grade atypical hyperplasia in the colorectum, total colectomy with rectal resection needs to be considered.
3. For suspicious lesions, such as masses and ulcers, pathological biopsies need to be routinely performed, especially for patients who are considered for small bowel strictureplasty.
Conclusion
Overall, except for some emergency surgeries, the surgical treatment of Crohn’s disease patients needs to be adjusted to the best possible condition before surgery, such as correcting malnutrition, active inflammation, and systemic infection, so as to reduce the occurrence of postoperative complications.