Surgical Resection of Jejunum for Crohn's Disease?

Surgical Resection of Jejunum for Crohn's Disease? A 50-year-old woman with Crohn´s disease was taken to surgery for multiple strictures of the terminal ileum and jejunum. profAskTheExpert diagnosis,bowell,regional enteritis,large,crohns,crohn`s,chrons,crohn´s´s, surgery,Crohn´s disease,ileitis,intestine,chron´s,chrohns,bowel,small,surgical,crohn, colon,chrohn´s,disorder,dx Wayne Schwesinger, MD, Professor of Surgery and Head of General Surgery Section, Department of Surgery, University of Texas Health Science Center; Director of Surgical Endoscopy, Department of Surgery, University Health System, San Antonio, Texas Medscape Medscape Surgery 05/31/2002 4 1 <h3>Question</h3> A 50-year-old woman with Crohn's disease was taken to surgery for multiple strictures of the terminal ileum causing small bowel obstruction. Proximal to the diseased segment there was another diseased segment in the jejunum. It was not obstructed, but the wall was thickened with fat creeping, and the mesentery was thickened. Should the diseased segment in the jejunum be resected? Aqeel Al-Aqeel, MD, FRCSC <H3>Response</H3> from , 05/31/2002 This question is as difficult as the disease itself is enigmatic. The majority of patients who present with symptoms of intestinal Crohn's disease will eventually require resection and, unfortunately, many will face the prospect of further surgery for recurrence. For this reason, the goals of surgery remain somewhat circumspect; namely, to control the presenting complications and/or symptoms, to prevent or postpone future recurrence, and to preserve the nutritional function of the gut. To accomplish these ends, resections should be tailored to remove only macroscopically diseased bowel; non-resectional surgery (strictureplasty) should be reserved for patients with extensive and/or multiply recurrent disease. In the majority of cases of enteric Crohn's disease, the distal small bowel is the primary site of involvement. Limited ileocolic resection is the preferred operative approach for the management of symptomatic fistulization or obstruction at this site. When multifocal involvement is present, as described in the current case, and includes advanced ileal disease and nonstenotic jejunal disease, the surgical goals remain the same but the optimal approach is indeterminate; in part, this reflects an incomplete understanding of the natural history of early, noncomplicated Crohn's disease of the small bowel. Nevertheless, when found unexpectedly, a diseased segment of jejunum should probably be resected even if not stenotic, because such an approach will presumably interrupt the progression of the inflammatory process and improve the quality of the patient's life. This somewhat aggressive approach may be precluded in patients who require extensive bowel resection(s) for far-advanced disease because of the attendant risk of intestinal failure ("short gut syndrome"). In such a case, an acceptable alternative strategy would be to either leave the jejunum intact or perform a preemptive strictureplasty. Intraoperative endoscopy with aboral passage of an enteroscope or a pediatric colonoscope could be used to clarify the status and extent of the underlying jejunal disease and aid in decision making. Regardless of the approach used, postoperative mesalamine treatment may help to further reduce the risk of relapse. Bernell O, Lapidus A, Hellers G. Risk factors for surgery and postoperative recurrence in Crohn's disease. Ann Surg. 2000;231:38-45. Delaney CP, Fazio VW. Crohn's disease of the small bowel. Surg Clin N Am. 2001;81:137-158. Hurst RD, Michelassi F. Strictureplasty for Crohn's disease: techniques and long-term results. World J Surg. 1998;22:359-363. Sutherland LR, Martin F, Bailey RJ, et al. A randomized, placebo-controlled, double-blind trial of mesalamine in the maintenance of remission of Crohn's disease. The Canadian Mesalamine for Remission of Crohn's Disease Study Group. Gastroenterology. 1997;112:1069-1077.