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General Surgery
Crohn’s Disease
Built from Maingot's Abdominal Operations
What’s inside
13 sections · 183 slides
Overview
- Definition and scope of Crohn's disease
- Scope of this presentation
- Challenges in managing Crohn's disease
- Terms used to describe Crohn's lesions
History
From seventeenth-century case reports to the modern surgical approach
- Recognition as a distinct disease
- Rising awareness after 1932
- Evolution of surgical strategy
Epidemiology
Who gets Crohn's disease, where, and at what age
- Trends in incidence and geographic distribution
- Age, ethnicity and familial clustering
Etiology
Genes, environment and the immune system
- Current understanding of the cause
- Increased intestinal permeability
- Genetic susceptibility
- Infectious agents investigated
- Diet and cigarette smoking
- Proposed sequence in the development of Crohn's disease
Pathology
What the disease does to the bowel wall and its mesentery
- Microscopic features
- Non-caseating granulomas
- Earliest gross changes in the mucosa
- Progression of mucosal ulceration
- Deep penetration and mesenteric change
- Depth of involvement through the bowel wall
Clinical presentation
Three patterns of disease, and what each site of involvement feels like
- Determinants of the clinical picture
- Three patterns of Crohn's disease
- Stricturing pattern
- Perforating pattern
- Inflammatory pattern
- Oral, esophageal and gastroduodenal disease
- Crohn's disease of the small intestine
- Crohn's colitis
- Perineal Crohn's disease
- Extraintestinal manifestations
- Response of extraintestinal disease to treatment
Diagnosis
History, examination, contrast radiography, endoscopy and cross-sectional imaging
- Basis of the diagnosis
- History taking
- Physical examination
- Small bowel contrast radiography
- Terminal ileal disease on small bowel radiograph
- High-grade ileal strictures with ulceration
- Jejunal strictures on small bowel radiograph
- Limitations and staging value of contrast studies
- Inflammatory narrowing versus fibrostenotic stricture
- Endoscopy
- Capsule endoscopy
- Computed tomography
- CT enterography
- Magnetic resonance enterography
- Differential diagnosis of small bowel disease
- Small bowel cancer and tuberculosis
- Small bowel injury from anti-inflammatory drugs
- Differential diagnosis of Crohn's colitis
- Separating Crohn's colitis from ulcerative colitis
Medical management
Steroids, aminosalicylates, immunomodulators and anti-TNF therapy
- Goals of medical treatment
- Corticosteroids
- Side effects of corticosteroids
- Aminosalicylates: mechanism of action
- Clinical role of aminosalicylates
- Delivery of aminosalicylate preparations
- Azathioprine and 6-mercaptopurine
- Infliximab
- Perioperative risk with infliximab and other agents
- Metronidazole
Principles and indications for surgery
When to operate, and the philosophy that governs how much to remove
- Goals of surgical treatment
- Preserving intestinal length
- Failure of medical treatment
- Intestinal obstruction
- Initial management of complete obstruction
- Fistulas as an indication for surgery
- Specific fistulas needing surgery
- Abscesses and inflammatory masses
- Resection after abscess drainage
- Free perforation
- Haemorrhage
- Source and recurrence of bleeding
- Cancer risk in Crohn's disease
- Surveillance and growth retardation
- Preoperative assessment of the gut
- Medical optimisation before surgery
- Bowel preparation and perioperative measures
- Stopping Crohn's medication before surgery
Surgical options
Resection, anastomosis, stomas, bypass and the strictureplasty techniques
- Intestinal resection
- Resection margins
- Dividing the thickened mesentery
- Division of the thickened Crohn's mesentery
- Intestinal anastomosis
- Safety of anastomosis and when to protect it
- Stomas in Crohn's disease
- Bypass procedures
- Indications and rationale for strictureplasty
- Choice of strictureplasty by stricture length
- Heineke-Mikulicz strictureplasty
- Longitudinal incision closed in the transverse direction
- Finney strictureplasty
- Stages of the Finney strictureplasty
- Completing and assessing the Finney
- Spacing multiple strictureplasties
- Side-to-side isoperistaltic strictureplasty
- Drawing the divided limbs together
- Longitudinal enterotomies along both limbs
- Completed side-to-side strictureplasty
- Safety of strictureplasty
- Bleeding, recurrence and cancer after strictureplasty
Laparoscopy
Keyhole surgery for Crohn's disease, and how the ileocolic resection is done
- Role of laparoscopy
- Suitability of Crohn's patients
- Comparative studies of laparoscopic resection
- Indications and contraindications
- Set-up and anaesthesia
- Port site placement for laparoscopic ileocecectomy
- Operating room set-up for laparoscopic ileocecectomy
- Intraoperative examination of the entire gut
- Steps of laparoscopic ileocolic resection
- Laparoscopic isolation of the ileocolic vessels
- Submesenteric mobilization of the ascending colon
- Division of the lateral peritoneal attachments
- Final mobilization of the hepatic flexure
- Completing the resection
Complicated Crohn's disease
Site by site: duodenum, small bowel, colon and rectum, and the perineum
- Crohn's disease of the duodenum
- Duodenal strictures on upper gastrointestinal study
- Duodenal strictureplasty
- Bypass for duodenal disease
- Duodenal fistulas
- Repair of duodenal defects
- Complete small bowel obstruction
- Ileosigmoid fistula
- Large ileosigmoid fistula on contrast enema
- Surgical management of ileosigmoid fistula
- Ileovesical fistula
- Surgery for ileovesical fistula
- Enterovaginal and enterocutaneous fistulas
- Intra-abdominal abscess
- Pelvic Crohn's abscess on computed tomography
- Drainage of Crohn's abscesses
- Management after percutaneous drainage
- Free perforation of the small bowel
- Haemorrhage from small bowel disease
- Severe Crohn's colitis with high-grade strictures
- Choice of operation by distribution of colonic disease
- Cecal disease
- Right-sided colitis
- Extensive colitis with rectal sparing
- Proctocolitis
- Restorative procedures in Crohn's colitis
- Proctitis
- Technique of proctectomy
- Difficult perineal wounds
- Segmental colitis
- Descending and sigmoid disease
- Perianal Crohn's disease
- Crohn's fistula-in-ano on dynamic proctogram
- Drainage of perianal abscess
- Perirectal abscess on computed tomography
- Treatment of simple perianal fistulas
- Treatment of complex perianal fistulas
- Fibrin glue and rectal advancement flap
- Diversion and proctectomy for perianal disease
Recurrence and maintenance
How often disease comes back, what drives it, and what reduces it
- Defining recurrence
- Symptomatic and surgical recurrence
- Reported recurrence rates
- Pattern of recurrent disease
- Smoking and recurrence
- Stopping smoking and avoiding NSAIDs
- Postoperative maintenance therapy
- Key points on diagnosis and pattern
- Key points on surgical management
- Key points on recurrence
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- Maingot's Abdominal Operations, 12th Edition