Surgery is generally contraindicated and has not been shown to prevent remission. Adequately controlled, Crohn's disease may not significantly restrict daily living. Certain lifestyle changes can reduce symptoms, including dietary adjustments, elemental diet , proper hydration , and smoking cessation. Diets that include higher levels of fiber and fruit are associated with reduced risk, while diets rich in total fats, polyunsaturated fatty acids, meat, and omega-6 fatty acids may increase the risk of Crohn's. Eating small meals frequently instead of big meals may also help with a low appetite.
A food diary may help with identifying foods that trigger symptoms. Some people should follow a low fiber diet to control acute symptoms especially if fibrous foods cause symptoms. They may have specific dietary intolerances not allergies. Smoking may worsen symptoms, and stopping is recommended. Acute treatment uses medications to treat any infection normally antibiotics and to reduce inflammation normally aminosalicylate anti-inflammatory drugs and corticosteroids.
When symptoms are in remission, treatment enters maintenance, with a goal of avoiding the recurrence of symptoms. Prolonged use of corticosteroids has significant side-effects ; as a result, they are, in general, not used for long-term treatment. Alternatives include aminosalicylates alone, though only a minority are able to maintain the treatment, and many require immunosuppressive drugs.
Medications used to treat the symptoms of Crohn's disease include 5-aminosalicylic acid 5-ASA formulations, prednisone , immunomodulators such as azathioprine given as the prodrug for 6-mercaptopurine , methotrexate , infliximab , adalimumab ,  certolizumab ,  vedolizumab , ustekinumab ,  and natalizumab. The gradual loss of blood from the gastrointestinal tract, as well as chronic inflammation, often leads to anemia, and professional guidelines suggest routinely monitoring for this. Guidelines vary as to how iron should be administered. Besides other, problems include a limitation in possible daily resorption and an increased growth of intestinal bacteria.
Some  advise parenteral iron as first line as it works faster, has fewer gastrointestinal side effects, and is unaffected by inflammation reducing enteral absorption. Other guidelines  advise oral iron as first line with parenteral iron reserved for those that fail to adequately respond as oral iron is considerably cheaper. Blood transfusion should be reserved for those who are cardiovascularly unstable, due to its relatively poor safety profile, lack of long term efficacy, and cost. Crohn's cannot be cured by surgery , as the disease eventually recurs, though it is used in the case of partial or full blockage of the intestine.
After the first surgery, Crohn's usually comes back at the site where the diseased intestine was removed and the healthy ends were rejoined, however it can come back in other locations. After a resection, scar tissue builds up, which can cause strictures , which form when the intestines become too small to allow excrement to pass through easily, which can lead to a blockage.
After the first resection, another resection may be necessary within five years. There is no statistical significance between strictureplasty alone versus strictureplasty and resection in cases of duodenal involvement. Postsurgical recurrence of Crohn's disease is relatively common.
Crohn's lesions are nearly always found at the site of the resected bowel. The join or anastomosis after surgery may be inspected, usually during a colonoscopy, and disease activity graded. The "Rutgeert's score" is an endoscopic scoring system for post-operative disease recurrence in Crohn's disease. Mild postsurgical recurrences of Crohn's disease are graded i1 and i2, moderate to severe recurrences are graded i3 and i4.
Based on the score, treatment plans can be designed to give the patient the best chance of managing recurrence of the disease. Short bowel syndrome SBS, also short gut syndrome or simply short gut is caused by the surgical removal of part of the small intestine. It usually develops in those patients who have had half or more of their small intestines removed. Short bowel syndrome is treated with changes in diet, intravenous feeding, vitamin and mineral supplements, and treatment with medications. In some cases of SBS, intestinal transplant surgery may be considered; though the number of transplant centres offering this procedure is quite small and it comes with a high risk due to the chance of infection and rejection of the transplanted intestine.
Bile acid diarrhea is another complication following surgery for Crohn's disease in which the terminal ileum has been removed. This leads to the development of excessive watery diarrhea. It is usually thought to be due to an inability of the ileum to reabsorb bile acids after resection of the terminal ileum and was the first type of bile acid malabsorption recognized. Crohn's may result in anxiety or mood disorders , especially in young people who may have stunted growth or embarrassment from fecal incontinence.
As of [update] there is a small amount of research looking at mindfulness-based therapies , hypnotherapy, and cognitive behavioural therapy. It is common for people with Crohn's disease to try complementary or alternative therapy. Crohn's disease is a chronic condition for which there is no known cure. It is characterised by periods of improvement followed by episodes when symptoms flare up.
With treatment, most people achieve a healthy weight, and the mortality rate for the disease is relatively low. It can vary from being benign to very severe and people with CD could experience just one episode or have continuous symptoms. It usually reoccurs, although some people can remain disease free for years or decades. Most people with Crohn's live a normal lifespan. The percentage of people with Crohn's disease has been determined in Norway and the United States and is similar at 6 to 7.
Crohn's disease begins most commonly in people in their teens and 20s, and people in their 50s through to their 70s. It usually affects female children more severely than males. The incidence of Crohn's disease is increasing in Europe  and in newly industrialised countries. Later that year, he, along with colleagues Leon Ginzburg and Gordon Oppenheimer, published the case series as "Regional ileitis: a pathologic and clinical entity". However, due to the precedence of Crohn's name in the alphabet, it later became known in the worldwide literature as Crohn's disease.
Some evidence supports the hypothesis that the bacterium Mycobacterium avium subspecies paratuberculosis MAP is a cause of Crohn's disease see also Johne's disease. As a result, researchers are looking at the eradication of MAP as a therapeutic option. Crohn's is common in parts of the world where helminthic colonisation is rare and uncommon in those areas where most people carry worms. Infections with helminths may alter the autoimmune response that causes the disease.
Trials of extracts from the worm Trichuris suis showed promising results when used in people with IBD. Numerous preclinical studies demonstrate that activation of the CB1 and CB2 cannabinoid receptors exert biological functions on the gastrointestinal tract. There is no good evidence that thalidomide or lenalidomide is useful to bring about or maintain remission.
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To prevent this complication, the operation could be performed in multiple stage two or three , to allow anastomoses to heal without important consequences [ 16 , 17 ]. Toxic megacolon — the procedure of choice is open colectomy with ileostomy and closure of the rectum or distal colostomy. The rectum may be resected afterwards with ileal pouch-anal anastomosis. IPAA from the beginning should not be performed because of risk of complications. Hemmorhage — Proctocolectomy, suture of a bleeding ulcer or Hartmann-type colectomy leaving a small stump of distal rectum. Ileal pouch distal rectum anastomosis IPDRA — anastomosis between ileal pouch and distal rectum — easier to perform, better anal sensation and continence especially at night.
Main disadvantage — leaving rectal mucosa behind, that should be avoided in patients with cancer or severe dysplasia in colorectal mucosa, severe extraintestinal manifestations. Advantage — older patients, lack of adequate mobilisation for tension-free anastomosis — ileorectal anastomosis IRA. Medical conditions in which a stoma is relatively contraindicated eg, portal hypertension or ascites ,. The cumulative probability of developing rectal dysplasia at 5, 10, 15, and 20 years was 7, 9, 20, and 25 percent, respectively. The cumulative probability of developing rectal cancer at 5, 10, 15, and 20 years was 0, 2, 5, and 14 percent, respectively.
The cumulative probability of having a functioning IRA at 10 and 20 years was 74 and 46 percent, respectively. Satisfactory rectal function varies greatly depending upon the selections of patients and length of follow-up. The risk is significant considering that most patients are young and have many years to live.
Crohn's disease is not curable by surgery. Therefore, this is actualy reserved for complications or to symptoms refractory to medical therapy [ 20 ]. Surgical decision making in Crohn's disease is driven by anatomic distribution and inflammatory subtype of disease. Surgical intervention is primarily performed for the complications of Crohn's disease: stricture and obstruction, fistula, or medically refractory disease. Surgery should to adress only to segments causing obstruction, bleeding, or perforation.
Resection is performed when there is an abscess or fistula to an adjacent organ.
Indications and Specific Surgical Techniques in Crohn's Disease
The disease-free margins are established by gross inspection, microscopic disease at the margins will not be associated with recurrence. Therefore we should avoid large margins, in the idea of preserving as much as possible of small bowel capital because the patients may need another resection in the future and thus preventing the short bowel syndrome. Ileocolic resections should be followed by a side-to-side anastomosis. A meta-analysis of eight comparative studies found that a side-to-side anastomosis was associated with fewer anastomotic leaks and postoperative complications, a shorter hospital stay and a lower perianastomotic recurrence rates compared to end-to-end anastomosis [ 22 ].
However, the authors suggested that further randomized controlled trials are needed to confirm these associations. Duodenal Crohn's disease very rarely requires surgery.
The major indications for surgery are obstruction and less often perforation or fistula formation. Gastrojejunostomy rather than resection is typically performed. Strictureplasty, duodenojejunostomy, and endoscopic balloon dilation have also been described [ 23 ]. Intraperitoneal abscesses were classically drain by open surgery and were followed by surgical resection of the diseased segment of the bowel.
Progress of interventional radiology, new biologic agents and progress of laparoscopy changed this classic approach [ 24 , 25 ]. Complete drainage of the abscess may necessitate repeated punctures. This attitude allows the patient to be prepared for an elective resection of the bowel after the sepsis resides, after improving nutritional status and decreasing corticosteroids. If percutaneous drainage is unsuccessful, surgical drainage should be performed.
The timing of surgery following percutaneous abscess drainage, when clinically indicated, occurs after clinical resolution of sepsis. Peritonitis is rare in Crohn's disease. Exploratory laparotomy with peritoneal lavage, with construction of a stoma is most commonly required. The decision whether to resect or not the bowel depends upon the operative findings and the patient's condition [ 26 ]. Abdominal wall abscesses psoas and rectus sheath are less common and more difficult to control locally than intra-abdominal abscesses. Fistulas to adjacent organs stomach, duodenum, bladder, vagina, and sigmoid colon are treated by resection and anastomosis of the diseased segment of the bowel and closure of the fistula.
Resection of the adjacent segment is necessary only when it is primarily involved with Crohn's disease. Bypasses should be avoided because persistent disease in the bypassed segment can lead to abscess formation, bleeding, perforation, bacterial overgrowth, and malignancy. Intestinal strictures can be relieved by resection; synchronous small bowel resection in patients with multiple strictures is common [ 27 ].
Strictureplasty or balloon dilation may be a suitable alternative for selected patients. Strictureplasty is performed by longitudinal incision across the stricture and a transversal closure that enlarges the lumen. Indication is represented by the patients that have isolated areas of short stricture and are at risk for short bowel syndrome due to previous surgery or extension of enterectomy. Strictureplasty can relieve obstruction, and is often performed in association with a small bowel resection [ 27 , 28 ].
It can also be performed without excision of bowel [ 29 , 30 ]. It should not be performed in acutely inflamed bowel. Strictureplasty has been associated with excellent results, including relief of obstruction, the ability to withdraw steroids, and improvement in symptoms [ 31 , 33 ] the risk of fistula or recurrent stricture formation is low and comparable to resection.
Whether preservation of diseased bowel increases the long-term risk of malignancy is unknown, although case reports have documented adenocarcinoma arising from sites of previous strictureplasty [ 34 ]. Another study included procedures of strictureplasty performed in patients with a follow-up of 7 years in average [ 35 ]. The major risk factor for reoperation was young age.
The early relaparotomy rate was 8 percent. One patient developed cancer after many years of disease. The authors biopsied suspicious lesions, rather than going for routine biopsy of all lesions. Another method to dilate intestinal strictures is with a hydrostatic balloon Experience is relatively limited compared with strictureplasty or resection, and the long-term efficacy and safety is therefore less well-established.
Couckuyte et al performed 78 dilatation procedures for 59 ileocolonic strictures in 55 patients, all procedures were carried out endoscopically under general anesthesia. In pediatric patients injections of corticosteroids into strictures after balloon dilatations were followed by fewer redilatations than in placebo group. Placement of an expandable metal stent within colonic strictures has been described, but experience is limited, and the safety of this approach is uncertain [ 41 ].
Options for surgery range from temporary diverting ileostomy to resection of segments of diseased colon or even the entire colon and rectum. Same conservative principles applied to disease involving the small intestine should also be applied to the surgical management of Crohn's colitis. The optimal procedure depends in part upon the extent of the disease and the clinical setting:. Segmental colectomy may be adequate for isolated areas of colonic involvement. An Ileorectal anastomosis can be carried out if the rectum is spared. A proctectomy will be required in half of the patients [ 42 ].
While no prospective randomized study has been undertaken to compare segmental colectomy and total colectomy with ileorectal anastomosis, both procedures appear to be equally effective as treatment options for colonic Crohn's disease. However, patients undergoing segmental resection may have earlier recurrence [ 43 ]. The choice of operation depends upon the extent of colonic disease; there may be better outcomes with ileorectal anastomosis in those who have two or more involved colonic segments.
Total proctocolectomy is indicated for patients with extensive, diffuse colorectal disease. An abdominoperineal resection with a permanent end-colostomy is indicated in patients with severe Crohn's disease limited to the anorectum. An intersphincteric proctectomy will minimize the risk of a nonhealing wound and sexual or urinary dysfunction, by avoiding dissection near the hipogastric plexuses. In the presence of anorectal disease and sepsis a Hartmann procedure can be carried out in the first place leaving a small stump of distal rectum, followed by a perineal proctectomy.
The number of Crohn's patients who require surgery has, however, decreased with the advances in medical management. Most of the abscesses are small, difficult to drain and can disappear with antibiotics alone. The antibiotic therapy should associate ciprofloxacin to metronidazole. Greater abscesses can be drained by placement of a seton or by ultrasound or CT guided large bore needle aspiration or drain placement. Treatment of the perianal fistula depends on the type of fistula simple vs. Simple fistulas are intersphincteric or transsphincteric below the dentate line in origin with a single opening and no associated stricture or abscess.
Complex fistulas on the contrary, involve the superficial, transsphincteric, or intersphincteric region below the dentate line, have multiple openings, and can be associated with rectal stricture or rectovaginal fistula. Complex fistulas represent a challenge and require aggressive immunomodulating therapy in combination with surgical therapy. Many patients feel improvement in symptoms with antibiotic therapy ciprofloxacin and metronidazole ; however, symptom relief is transient with recurrence on withdrawal of antibiotics.
Infliximab has proven to be the immunosuppressive drug of choice in treatment of complex perianal fistulas with two randomized trials showing decreased number of fistulas, increased disease-free period, and fewer required hospitalizations and surgeries. Surgical therapy has evolved for complex fistulas as well with the development of less invasive techniques for closure of high fistulas to prevent incontinence associated with damage to the anal sphincters.
Some of the newest approaches use fibrin glue and collagen plugs to occlude fistulous tracts without requiring incision. The review by Lewis and Maron on anorectal Crohn's disease provides an algorithm for management of complex perianal fistulas, stressing that surgical therapy in excess of seton placement should not be attempted during active proctitis due to inflammation [ 50 ]. Postoperative medical treatment for prevention of Crohn's disease recurrence is controversial in light of data supporting increased incidence of complications with preoperative immunosuppressive therapy.
However, a randomized, placebo-controlled clinical trial showed no difference in incidence of adverse events anastomotic leak, wound complications, infection, obstruction, bleeding, death between postoperative patients treated with infliximab within 4 weeks of surgery and those untreated. Bordeianou et al studied the effect of immediate vs. The group found that there was no difference in recurrence rates between patients treated with medication immediately after surgery and those treated based on endoscopic finding, adding to the debate on whether perioperative and postoperative medical suppression is advantageous.
A way to use laparoscopy is only for the mobilization of the colon cecum, ascendent, descendent, sigmoid and to perform the rest of the operation in open but with a smaller incision [ 53 ]. Laparoscopic subtotal colectomy performed in emergency conditions was followed by acceptable outcomes and shorter hospital stay, although in such cases is not usually recommended [ 54 ]. Some authors do that by hand assisted technique. This is a question still under debate. Is laparoscopy superior to open approach? In short term yes — as already proven by comparison between them, with faster recovery including faster ambulation, less postoperative pain, faster return of bowel movement and time to first passage of flatus and feces.
Brown et al compared laparoscopic-assisted restorative proctocolectomy to open approach and found shorter operative time in open group, and similar functional outcome and recovery, only better cosmesis by shorter abdominal scar. The hand-assisted method seems to reduce the operative time with more than 30 minutes [ 58 ]. Laparoscopic approach have the potential of decreasing morbidity, speeding recovery, and reducing costs, while decreasing the incidence of small bowel obstruction and ventral abdominal wall hernias [ 59 , 60 ].
The only benefice was a faster recovery of forced expiratory volume and forced expiratory vital capacity. Maartense et al performed a comparative randomized controlled trial between laparoscopic-assisted ileocolonic resection performed by experienced surgeons in laparoscopy with open resections in Crohn's disease [ 62 ]. Morbidity, hospital stay, and costs were lower in the laparoscopic group, although there were no significant differences in quality-of-life at three months follow-up.
Alves et al found that the need for conversion to an open procedure was predicted by the severity of disease; independent predictors of conversion including a history of recurrent medical episodes of Crohn's disease and the presence of intra-abdominal abscess or fistula at the time of laparoscopy [ 63 ]. Recurrences after laparoscopic surgery were similar after conventional surgery.
In the review by Fichera et al on Crohn's disease, the author highlights three meta-analyses that compared laparoscopic with open ileocolic surgery that demonstrated earlier return of bowel function leading to shorter hospital stay, fewer late small bowel obstructions, and decreased early complications such as wound infections and bleeding with laparoscopic surgery. Two large studies on laparoscopic surgery for isolated colonic disease found similarly good outcomes with fewer complications.
Fifteen percent of laparoscopic cases were converted to open and presence of small bowel disease was the only predictive factor identified, independent of presence of phlegmonous or fistulous disease. Umanskiy et al compared outcomes of patients who underwent laparoscopic vs. The most common procedure in both groups was total proctocolectomy with end ileostomy and the only statistically significant difference in procedures performed applied to completion proctectomies, which were more likely to be open.
Patients in the laparoscopic group had earlier return of bowel function, reduced length of hospital stay, and decreased intraoperative blood loss. Interestingly, the reduced blood loss did not result in fewer transfusions, which were similar in both groups [ 66 ]. There was also no clinical recurrence at 20 months [ 60 ]. Postoperative outcome was better in laparoscopic group [ 68 , 69 ].
Same results were noted by Duepree et al. For Duepree et al costs per case were higher for laparoscopic group. Young-Fadok et al reported an overall cost for laparoscopic cases significantly less than for the open ones [ 60 ]. There is a broad range of conversion rates 1. Most of the series involve relatively small numbers of patients. Laparoscopic surgery is considered to generate less postoperative adhesions and less incisional hernias.
Bergamaschi et al reported the results of a comparative study with long term follow up between laparoscopic and open ileocecal resections. At 5 years, they found a rate of Generally, laparoscopic colectomy is followed by lower incidence of incisional hernia and small bowel obstruction, with significant differences, as reported by Duepree et al [ 70 ]. Functional outcome [ 71 ], quality of life [ 71 ] are similar but cosmetic results [ 71 ] especially for women [ 72 ] are higher after laparoscopy. The most frequent are bowel obstruction, pouch bleeding, pelvic and wound sepsis, transient urinary dysfunction, and dehydration from temporary loop ileostomy with high output.
Surgery is not mandatory in many of those cases. Pelvic abscesses lead to transabdominal or local surgery in most of the cases, failure of pouch in quarter of cases, incontinence, need for constipating or bulking medications was in the patients in whom the reservoir was preserved. There was also a decrease in the quality of life of those patients.
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Portal vein thrombosis can occur after IPAA. Clinical manifestations may include pain, fever, vomiting, leukocytosis, and unexplained postoperative ileus. Diagnose is made with CT-scanner. Treatment with anticoagulation will lead to full resolution. Majority of the pouch related complication can be solved by medical treatment consisting mainly in local measures, surgery being required in a minority. As an example, ileal pouch fistulas and strictures refractory to dilatation are difficult to treat and may require revision of the pouch if Crohn's disease can be excluded.
A transvaginal repair is favored for a pouch-vaginal fistula [ 78 ]. A combined abdominal perineal repair may offer better results compared with a local procedure [ 79 ]. A controlled septic condition does not preclude salvage surgery. Although pouch failure occurs more often than with primary IPAA, high patient satisfaction and quality of life can be achieved [ 80 ]. Furthermore, excision of the pouch is associated with a high risk of complications, especially delayed perineal wound healing [ 81 , 82 ].
A number of unusual late complications have been described including [ 83 , 84 , 85 ]:. The long-term success of surgery depends upon the type of operation, the clinical setting, and surgical expertise. Several studies have suggested that functional results are poor during the long-term follow-up in patients who had adverse personality factors before surgery such as problems with sexual satisfaction, difficulty expressing emotions, perfectionist body ideals, and poor frustration tolerance [ 79 ].
The following results were described in some of the largest series. One series included patients who underwent an ileal pouch-anal anastomosis for ulcerative colitis and were followed for an average of 11 years. The mean number of stools was 5. The incidence of frequent fecal incontinence increased from 5 to 11 percent during the day and from 12 to 21 percent at night. The overall rate of pouch success at 5, 10, 15, and 20 years was 96, 93, 92, and 92 percent, respectively. Quality of life remained unchanged and 92 percent remained in the same employment. In another report that included patients who had undergone proctocolectomy and ileoanal anastomosis for ulcerative colitis or familial adenomatous polyposis, the cumulative probabilities of pouch failure were 1, 5, and 7 percent at 1, 5, and 10 years, respectively [ 87 ] The most common cause of pouch failure was fistula formation.
Tulchinsky et al reported patients who underwent restorative proctocolectomy for IBD. Patients were followed for a mean of 85 months. Failure defined as removal of the pouch or the need for an ileostomy was divided into early occurring within one-year or late occurring more than one-year postoperatively. Three patients died postoperatively while an additional 23 died of a variety of causes during follow-up.
Predictors of failure included a final diagnosis of Crohn's disease, a type J or S reservoir, female gender, postoperative pelvic sepsis, and a one-stage procedure. Anal canal strictures were described in up to 11 percent of patients [ 82 ].
Strictures that were not fibrotic responded well after anal dilation while fibrotic strictures were more commonly associated with intra- or postoperative complications and frequently required surgical therapy. A systematic review of 43 observational studies with a total of patients found a pouch failure rate of 6. Pelvic sepsis occurred in 9. Severe, mild, and urge fecal incontinence was reported in 3. These results suggest that current techniques are associated with non-negligible complication rates and leave room for improvement and continued development of alternative procedures.
Patients should not be discouraged from childbearing because of the pouch. Whether vaginal or cesarean delivery is better for women with a pelvic pouch remains controversial. Satisfactory long-term functional outcome and excellent quality of life have also been described after stapled restorative proctocolectomy.