How do we manage perforated Crohn’s Disease? Daniel von Allmen, MD Cincinnati Children’s Hospital Medical Center Cincinnati, Ohio

Conflict of Interest I have no conflicts to declare

Comparison of evolution of Crohn’s disease behavior between elderly- onset patients (n = 367) and pediatric-onset patients (n = 689) obtained from the EPIMAD registry

Phenotypic Characteristics Pediatric IBD VAN LIMBERGEN et al. 2008

Pediatric vs Adult Behavior VAN LIMBERGEN et al. 2008

Risk for Surgery Gupta et al. 2006

Schaefer et al. CLINICAL GASTROENTEROLOGY AND HEPATOLOGY 2010

Risk of Surgery by Site of Disease Schaefer et al. CLINICAL GASTROENTEROLOGY AND HEPATOLOGY 2010

Time to Surgery Schaefer et al. 2010

Presentation – Is this an emergency? “Free” perforation with peritonitis –Immediate operation, frequent temporary diversion Abscess – Antibiotics, drainage, bowel rest wait Phlegmeon – Antibiotics, bowel rest, wait

Acute Abdomen Resuscitate Antibiotics Open laparotomy Surgical options –Proximal diversion –Resection with diversion –Primary resection with anastomosis

Phlegmon or Contained Abscess Antibiotics Bowel rest Percutaneous drain if defined collection > 2 cm 5-7 days vs 4-6 weeks Resolution vs surgery

Antibiotic Therapy Pfefferkorn et al. JPGN 2013;57: 394–400

Abscess Pfefferkorn et al. JPGN 2013;57: 394–400

CROHN’S DISEASE LAPAROSCOPY Ideal for limited segment disease Ileal or Colonic disease Fistulas or abscess formation do not preclude laparoscopic approach.

LAPAROSCOPY OPEN SURGERY Laparoscopic Assisted Surgery Hand Assisted Laparoscopic Surgery

CROHN’S DISEASE PRIMARY RESECTION DISEASED BOWEL

Laparoscopic Assisted Technique Three ports Extracorporeal stapled anastomosis

INCISIONS FOR LAPAROSCOPIC BOWEL RESECTION (Crohn’s)

Thickened ileum with fat wrapping

Cecal Mobilization

Segmental Ileal Disease

CROHN’S ABSCESS

Surgical Considerations for Surgical Therapy in Crohn’s Disease Open vs Laparoscopy –Faster recovery? –Less pain? –Less ileus? –Better cosmetic result? Hand-sewn vs Stapled Anastomosis –Stapled technically faster –Delayed recurrence? –Fewer leaks?

Improved Cosmesis

Laparoscopic vs Open Surgery

Laparoscopic vs Open Approach Cochrane Analysis 2010 –2 randomized controlled studies analyzed 120 pts –No difference in length of stay –No difference in duration of ileus –Longer OR time for laparoscopic approach –Better cosmesis –More expensive? (increased OR costs)

Complications LaparoscopicOpenp-value Wound Infection2/619/59NS Leak1/610/59NS Abscess0/612/59NS Reoperation (30)1/612/59NS

Hand Sewn vs Stapled Anastomosis McLeod et al –Randomized trial 139 Crohn’s patients –Recurrence rates (sewn vs stapled) Endoscopic 42.5% vs 37.9% Symptomatic 21.9% vs 22.7% Choy et al –Stapled have fewer leaks, otherwise no difference

Is surgery necessary? Wide variation in management Some data suggests no harm in non- operative strategies Prospective studies needed

Medical versus Surgery for Abscess Nguyen et al: CLINICAL GASTROENTEROLOGY AND HEPATOLOGY 2012

Lee et al. Digestive and Liver Disease 2006 Primary Medical Treatment of Perforation

Feagans et al 2011

Summary Medical therapy with abx and drain for perforating disease For stricturing or perforating Crohn’s disease unresponsive to medical therapy - laparoscopic assisted resection with a stapled side to side, functional end to end anastomosis Fistula and phlegmon are not contraindications for laparoscopic procedures