When is surgery indicated in the management of Crohn disease?

Updated: Jul 26, 2019
  • Author: Leyla J Ghazi, MD; Chief Editor: Praveen K Roy, MD, AGAF  more...
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Answer

Surgery plays an integral role in controlling the symptoms and treating the complications of Crohn disease, but operative resection is not curative. Because of the high rate of disease recurrence after segmental bowel resection, the guiding principle of surgical management of Crohn disease is preservation of intestinal length and function. [1] Recommended indications for surgical intervention include the following [1] :

  • Persistent symptoms despite high-dose corticosteroid therapy

  • Treatment-related complications, including intra-abdominal abscesses

  • Medically intractable fistulae

  • Fibrotic strictures with obstructive symptoms

  • Toxic megacolon

  • Intractable hemorrhage

  • Perforation

  • Cancer

In 2007, the Standards Practice Task Force of the American Society of Colon and Rectal Surgeons (ASCRS) published recommendations for surgery in patients with Crohn disease (see Table 2, below). [7]

Table 2. ASCRS Indications for Surgical Management of Crohn Disease (Open Table in a new window)

Operative Indication

Factors for Considering Surgery

Failed medical therapy

  • Presence of disease-related symptoms not responsive to medical management; condition demonstrates an inadequate response

  • When first- and second-line therapies do not induce remission safely in severe disease

  • Before escalating medical therapy in severe or steroid-dependent disease with limited extent (eg, disease with stricturing behavior, patients who have contraindications or risk factors for further medical therapy)

Perforation

  • Presence of symptoms or signs of free perforation

  • Immediate resection of perforated segment (has a relatively high mortality)

  • After small bowel resection or perforation, other procedures can be performed, as needed (eg, end stoma, diverted or nondiverted anastomosis)

  • When large anteroparietal, interloop, intramesenteric, or retroperitoneal abscesses cannot be or are unsuccessfully managed with antibiotics and percutaneous drainage

  • Perform surgical drainage in such cases, with or without resection

  • Persistent enteric fistulae and symptoms or signs of localized or systemic sepsis despite appropriate medical management

  • Persistent sepsis warrants excision of the diseased bowel, whether or not an abscess is present

For target or “innocent bystander” organs, diseased bowel is typically resected, noninflamed bowel primarily closed, and other internal organs primarily closed or allowed to heal by secondary intention

Note: Operative intervention may be avoided for asymptomatic internal fistulae

Obstruction

  • Presence of symptomatic strictures in regions not amenable or responsive to medical therapy

  • Presence of asymptomatic colonic strictures that cannot be adequately surveyed by biopsy or cytology brushing

Inflammation

  • Presence of acute colitis and symptoms or signs of impending or actual perforation (eg, transverse colon distention > 6 cm on abdominal x-ray or persistent gaseous colonic distention indicate toxic megacolon, pneumatosis coli, evolving local peritonitis, multiple organ failure)

  • Presence of severe or fulminant colitis

  • Worsening acute colitis or failure to significantly improve despite 48-96 hours of appropriate medical therapy

Hemorrhage

  • Presence of massive hemorrhaging of any origin that (1) cannot be or fails to be managed with interventional or endoscopic techniques and (2) occurs in hemodynamically unstable patients

Mesenteric angiography with embolization may be attempted when adequate endoscopic visualization is not possible or when the bleeding source cannot be identified; if this technique is not successful or the patient is hemodynamically unstable, laparotomy with or without intraoperative endoscopy and resection of the responsible bowel segment may be required

Neoplasia

  • Presence of chronic Crohn disease of the ileocolon or colon (endoscopic surveillance)

  • Presence of adenomatous-appearing polyps (excision)

  • Presence of carcinoma, DALM, high-grade dysplasia, multifocal colonic or rectal low-grade dysplasia (resection)

  • Presence of chronic Crohn disease of the terminal ileum, ileocolon, or upper GI region

Growth retardation and EIMs

  • Presence of significant growth retardation in prepubertal patients despite appropriate medical therapy

  • Presence of symptomatic dermatologic, oral, ophthalmologic, or joint disorders refractory to medical therapy (resection of diseased intestine)

ASCRS = American Society of Colon and Rectal Surgeons; DALM = dysplasia-associated lesion or mass; EIM = extraintestinal manifestation; GI = gastrointestinal.

Source:  Strong SA, Koltun WA, Hyman NH, Buie WD, for the Standards Practice Task Force of The American Society of Colon and Rectal Surgeons. Practice parameters for the surgical management of Crohn’s disease. Dis Colon Rectum. 2007;50(11):1735-46. [7]


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