Crohn's disease surgery: Difference between revisions
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__NOTOC__ | __NOTOC__ | ||
{{Crohn's disease}} | {{Crohn's disease}} | ||
{{CMG}} | {{CMG}};{{AE}}[[User: Fahad Alkhalfan|Fahad AlKhalfan, M.D.]] | ||
==Overview== | |||
Two-thirds to three-quarters of patients with Crohn’s disease will require surgery at some point in their lives. Surgery becomes necessary when medications can no longer control symptoms. Surgery is used either to relieve symptoms that do not respond to medical therapy or to correct complications such as blockage, perforation, abscess, or bleeding in the intestine. Surgery to remove part of the intestine can help people with Crohn’s disease, but it is not a cure. Surgery does not eliminate the disease, and it is not uncommon for people with Crohn’s Disease to have more than one operation, as inflammation tends to return to the area next to where the diseased intestine was removed. | |||
==Surgery== | ==Surgery== | ||
Two-thirds to three-quarters of patients with Crohn’s disease will require [[surgery]] at some point in their lives. Surgery becomes necessary when medications can no longer control symptoms. Surgery is used either to relieve symptoms that do not respond to medical therapy or to correct complications such as blockage, [[perforation]], [[abscess]], or [[bleeding]] in the intestine. Surgery to remove part of the intestine can help people with Crohn’s disease, but it is not a cure. Surgery does not eliminate the disease, and it is not uncommon for people with Crohn’s Disease to have more than one operation, as inflammation tends to return to the area next to where the diseased intestine was removed. | Two-thirds to three-quarters of patients with Crohn’s disease will require [[surgery]] at some point in their lives. Surgery becomes necessary when medications can no longer control symptoms. Surgery is used either to relieve symptoms that do not respond to medical therapy or to correct complications such as blockage, [[perforation]], [[abscess]], or [[bleeding]] in the intestine. Surgery to remove part of the intestine can help people with Crohn’s disease, but it is not a cure. Surgery does not eliminate the disease, and it is not uncommon for people with Crohn’s Disease to have more than one operation, as inflammation tends to return to the area next to where the diseased intestine was removed. | ||
===Colectomy=== | |||
*Colectomy is the method of surgery employed. | |||
*Some people who have Crohn’s disease in the [[large intestine]] need to have their entire colon removed in an operation called a [[colectomy]]. | |||
*A small opening is made in the front of the [[abdominal wall]], and the tip of the [[ileum]], which is located at the end of the [[small intestine]], is brought to the skin’s surface. | |||
*This opening, called a [[stoma]], is where waste exits the body. | |||
*The stoma is about the size of a quarter and is usually located in the right lower part of the abdomen near the beltline. | |||
*A pouch is worn over the opening to collect waste, and the patient empties the pouch as needed. The majority of colectomy patients go on to live normal, active lives. | |||
*Rarely only the diseased section of intestine is removed and no stoma is needed. In this operation, the intestine is cut above and below the diseased area and reconnected. | |||
*Because Crohn’s disease often recurs after surgery, people considering it should carefully weigh its benefits and risks compared with other treatments. | |||
==Recommendations of the American Society of Colon and Rectal Surgeons (2015) == | |||
The American Society of Colon and Rectal Surgeons updated their guidelines on the role of surgical intervention in patients with Crohn's disease based on more recent evidence.<ref name="pmid26445174">{{cite journal| author=Strong S, Steele SR, Boutrous M, Bordineau L, Chun J, Stewart DB et al.| title=Clinical Practice Guideline for the Surgical Management of Crohn's Disease. | journal=Dis Colon Rectum | year= 2015 | volume= 58 | issue= 11 | pages= 1021-36 | pmid=26445174 | doi=10.1097/DCR.0000000000000450 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26445174 }}</ref> | |||
The guidelines are as follows: | |||
{| class="wikitable" | |||
!Operative Indication | |||
!Description | |||
!Recommendation | |||
![[ACCP guidelines classification scheme|Quality of Evidence]] | |||
|- | |||
| rowspan="2" |Failed Medical Therapy | |||
|Patients who demonstrate an inadequate response to, develop complications from, or are noncompliant with medical therapy should be considered for surgery. | |||
|Strong recommendation | |||
|1C | |||
|- | |||
| Patients receiving therapy with anti-TNFs, high-dose glucocorticoids, and/or cyclosporine may warrant staged procedures because of concerns about postoperative complications; however, decisions should be individualized based on the patient's risk stratiffication, overal clinical status, and surgeon judgement. | |||
|Weak recommendation | |||
| 2C | |||
|- | |||
|Inflammation | |||
|Patients with acute colitis who have symptoms or signs of impending or actual perforation should typically undergo surgery. | |||
|Strong recommendation | |||
|1C | |||
|- | |||
| rowspan="3" |Stricture | |||
|Endoscopic dilation may be considered for patients with symptomatic small-bowel or anastomotic strictures that are not amenable to medical therapy. | |||
|Strong recommendation | |||
|1C | |||
|- | |||
|Surgery is indicated for patients with symptomatic small-bowel or anastomotic structures that are not amenable to medical therapy and/or dilation. | |||
|Strong recommendation | |||
|1C | |||
|- | |||
|Patients with strictures of the colon that cannot be adequately surveyed endoscopically should be considered for resection. | |||
|Strong recommendation | |||
|1C | |||
|- | |||
| rowspan="3" |Penetrating Disease | |||
|Patients with a free perforation should undergo surgery. | |||
|Strong recommendation | |||
|1B | |||
|- | |||
|Patients with enteroparietal, interloop, intramesenteric, or retroperitoneal abscesses may be managed by antibiotics with or without percutaneous drainage. Surgical drainage with or without resection should be considered when this is not successful. | |||
|Weak recommendation | |||
|2B | |||
|- | |||
|Patients with enteric fistulas and symptoms or signs of localized or systemic sepsis that persists despite appropriate medical therapy should be considered for surgery. | |||
|Strong recommendation | |||
|1C | |||
|- | |||
|Hemorrhage | |||
|Stable patients with significant GI hemorrhage may be evaluated and treated by endoscopic and/or interventional radiological techniques. Unstable patietns should typically undergo operative exploration. | |||
|Strong recommendation | |||
|1C | |||
|- | |||
|Growth Retardation | |||
|Prepubertal patients with significant growth retardation despite appropriate medical therapy should be considered for surgery. | |||
|Strong recommendation | |||
|1B | |||
|- | |||
| rowspan="3" |Neoplasia | |||
|Patients with long-standing Crohn's disease of the ileocolic region or colon should have endoscopic surveillance of the large bowel. | |||
|Strong recommendation | |||
|1B | |||
|- | |||
|Total proctocolectomy should be considered for patients with carcinoma, a nonadenoma-like dysplasia-associated lesion or mass (DALM), high-grade dysplasia, or multifocal low-grade dysplasia of the colon or rectum. | |||
|Strong recommendation | |||
|1B | |||
|- | |||
|Suspicious lesions (i.e. mass, ulcer) identified in patients with Crohn's disease should typically be biopsied, especially when considering a small-bowel strictureplasty. | |||
|Strong recommendation | |||
|1C | |||
|} | |||
==References== | ==References== | ||
{{reflist|2}} | {{reflist|2}} | ||
{{WH}} | |||
{{WS}} | |||
[[Category:Needs overview]] | [[Category:Needs overview]] | ||
[[Category:Disease]] | [[Category:Disease]] | ||
| Line 24: | Line 106: | ||
[[Category:Conditions diagnosed by stool test]] | [[Category:Conditions diagnosed by stool test]] | ||
[[Category:Abdominal pain]] | [[Category:Abdominal pain]] | ||
Latest revision as of 21:10, 29 July 2020
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Crohn's disease |
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Diagnosis |
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Treatment |
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Case Studies |
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Crohn's disease surgery On the Web |
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American Roentgen Ray Society Images of Crohn's disease surgery |
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Risk calculators and risk factors for Crohn's disease surgery |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief: Fahad AlKhalfan, M.D.
Overview
Two-thirds to three-quarters of patients with Crohn’s disease will require surgery at some point in their lives. Surgery becomes necessary when medications can no longer control symptoms. Surgery is used either to relieve symptoms that do not respond to medical therapy or to correct complications such as blockage, perforation, abscess, or bleeding in the intestine. Surgery to remove part of the intestine can help people with Crohn’s disease, but it is not a cure. Surgery does not eliminate the disease, and it is not uncommon for people with Crohn’s Disease to have more than one operation, as inflammation tends to return to the area next to where the diseased intestine was removed.
Surgery
Two-thirds to three-quarters of patients with Crohn’s disease will require surgery at some point in their lives. Surgery becomes necessary when medications can no longer control symptoms. Surgery is used either to relieve symptoms that do not respond to medical therapy or to correct complications such as blockage, perforation, abscess, or bleeding in the intestine. Surgery to remove part of the intestine can help people with Crohn’s disease, but it is not a cure. Surgery does not eliminate the disease, and it is not uncommon for people with Crohn’s Disease to have more than one operation, as inflammation tends to return to the area next to where the diseased intestine was removed.
Colectomy
- Colectomy is the method of surgery employed.
- Some people who have Crohn’s disease in the large intestine need to have their entire colon removed in an operation called a colectomy.
- A small opening is made in the front of the abdominal wall, and the tip of the ileum, which is located at the end of the small intestine, is brought to the skin’s surface.
- This opening, called a stoma, is where waste exits the body.
- The stoma is about the size of a quarter and is usually located in the right lower part of the abdomen near the beltline.
- A pouch is worn over the opening to collect waste, and the patient empties the pouch as needed. The majority of colectomy patients go on to live normal, active lives.
- Rarely only the diseased section of intestine is removed and no stoma is needed. In this operation, the intestine is cut above and below the diseased area and reconnected.
- Because Crohn’s disease often recurs after surgery, people considering it should carefully weigh its benefits and risks compared with other treatments.
Recommendations of the American Society of Colon and Rectal Surgeons (2015)
The American Society of Colon and Rectal Surgeons updated their guidelines on the role of surgical intervention in patients with Crohn's disease based on more recent evidence.[1]
The guidelines are as follows:
| Operative Indication | Description | Recommendation | Quality of Evidence |
|---|---|---|---|
| Failed Medical Therapy | Patients who demonstrate an inadequate response to, develop complications from, or are noncompliant with medical therapy should be considered for surgery. | Strong recommendation | 1C |
| Patients receiving therapy with anti-TNFs, high-dose glucocorticoids, and/or cyclosporine may warrant staged procedures because of concerns about postoperative complications; however, decisions should be individualized based on the patient's risk stratiffication, overal clinical status, and surgeon judgement. | Weak recommendation | 2C | |
| Inflammation | Patients with acute colitis who have symptoms or signs of impending or actual perforation should typically undergo surgery. | Strong recommendation | 1C |
| Stricture | Endoscopic dilation may be considered for patients with symptomatic small-bowel or anastomotic strictures that are not amenable to medical therapy. | Strong recommendation | 1C |
| Surgery is indicated for patients with symptomatic small-bowel or anastomotic structures that are not amenable to medical therapy and/or dilation. | Strong recommendation | 1C | |
| Patients with strictures of the colon that cannot be adequately surveyed endoscopically should be considered for resection. | Strong recommendation | 1C | |
| Penetrating Disease | Patients with a free perforation should undergo surgery. | Strong recommendation | 1B |
| Patients with enteroparietal, interloop, intramesenteric, or retroperitoneal abscesses may be managed by antibiotics with or without percutaneous drainage. Surgical drainage with or without resection should be considered when this is not successful. | Weak recommendation | 2B | |
| Patients with enteric fistulas and symptoms or signs of localized or systemic sepsis that persists despite appropriate medical therapy should be considered for surgery. | Strong recommendation | 1C | |
| Hemorrhage | Stable patients with significant GI hemorrhage may be evaluated and treated by endoscopic and/or interventional radiological techniques. Unstable patietns should typically undergo operative exploration. | Strong recommendation | 1C |
| Growth Retardation | Prepubertal patients with significant growth retardation despite appropriate medical therapy should be considered for surgery. | Strong recommendation | 1B |
| Neoplasia | Patients with long-standing Crohn's disease of the ileocolic region or colon should have endoscopic surveillance of the large bowel. | Strong recommendation | 1B |
| Total proctocolectomy should be considered for patients with carcinoma, a nonadenoma-like dysplasia-associated lesion or mass (DALM), high-grade dysplasia, or multifocal low-grade dysplasia of the colon or rectum. | Strong recommendation | 1B | |
| Suspicious lesions (i.e. mass, ulcer) identified in patients with Crohn's disease should typically be biopsied, especially when considering a small-bowel strictureplasty. | Strong recommendation | 1C |
References
- ↑ Strong S, Steele SR, Boutrous M, Bordineau L, Chun J, Stewart DB; et al. (2015). "Clinical Practice Guideline for the Surgical Management of Crohn's Disease". Dis Colon Rectum. 58 (11): 1021–36. doi:10.1097/DCR.0000000000000450. PMID 26445174.