Monday, March 23, 2009

Surgery for Chrohn's Disease

Surgery in Crohn's disease carries much less concern than it used to and Postoperative fistulas are now very rare. This may be partly attributable to improved surgical techniques but the routine use of perioperative antibiotics, particularly metronidazole, has probably had the major impact. There are few absolute indications for surgery apart from complete obstruction or peritonitis. Episodes of partial obstruction often settle with 24-48 hours of intravenous fluids and bowel rest without surgical intervention. After resection of ileal or ileocaecal disease there, is about a 50% chance of five years without significant symptoms and, ten years without further surgery.

Thus if the diseased segment is short- eg, 20 centimetres or less of ileum - then surgery even as primary therapy may be the best option. Very short strictures, particularly if multiple, may be suitable for stricturoplasty without significant loss of bowel. Recurrence after surgical resection occurs at, or closely proximal to, the anastomosis in about two-thirds of cases and is sometimes treatable by endoscopic balloon dilatation, thus avoiding or postponing further resection.

Perianal disease needs careful conservative management. Fluctuant abscesses should be treated by simple surgical drainage without extensive deroofing. Fistulas may respond to antibiotic therapy with either metronidazole or ciprofloxacin, but if persistent will often be considerably improved by insertion of a loose 'Seton' suture which allows continued drainage and reduces the risk of abscess formation. Severe pervianal disease often coexists with active disease elsewhere in the terminal ileum or colon and sometimes improves when the active distant disease is resected. Defunctioning surgery alone is often not sufficient to Improve perianal disease, although can bring relief if incontinence has been a problem.

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