Surgical approach of patients with crhons disease By:Hanaa Tashkandi

Abdominoperineal resection: Anterior resection: anterior proctosigmoidectomy with colorectal anastomosis. *Low anterior resection: resection of the rectum below the peritoneal reflection.

Q: Why the sigmoid is being removed most of the times with the rectum ? A :usually the blood supply to the sigmoid is not adequate to sustain the anastomosis after the IMA is transected.

The anastomosis post resection usually result in a significant alteration in the bowel habit …. WHY ?

Due to loss of normal rectal capacity ..which is called LAR syndrome… Symptoms: frequent small bowel movements”clustering”

How to prevent this?

It can be prevented by designing J-Pouch. as a proximal componant of the anastomosis.. But if the anastomosis above 9 cm from the anal verge , there will be little benefit from the J-pouch compared to end to end anastomosis.

In obese patients or patients with narrow pelvis.. J-pouch is technically difficult because the bulk of the pouch will fit into the pelvis.. so

We can do reservoir with COLOPLASTY.. About 10 cm colotomy ,6 cm from the devided end of the colon.. This colotomy is closed transversely to increase the rectal space.

Right hemicolectomy: resection of few centimeters of the terminal ileum ( 4-6 cm ) and colon up to the division of middle colic vessel into right and left.

Left hemicolectomy: resection from the splenic fexure to the rectosigmid junction

Extended right hemicolectomy: it is used for transverse colon tumors. Division of the right and middle colic arteries at their origin with removal of the right and transverse colon supplied by these vessels.

Sigmoidectomy: removal of the colon between the partially retroperitoneal descending colon and the rectum.

Crohns disease Pattern of the disease: 1-inflammation 2-sticture 3-perforation

Important considerations: -crohns disease is a recurring disorder that can not be cured with surgical resection. -the aim of surgery is palliation. -surgery must strive to alleviate symptoms as effectively as possible without exposing the patient to excessive morbidity.

Non resectional techniques as strictureplasty may be required to avoid excessive loss of the intestine…. Resectional techniques may be necessary to remove only the severely afftected portion of the GIT..leaving the mild asympotomatic diseased parts intact.

Indications for surgery

Failure of medical treatment *symptoms of acute flare do not improve or new complications of crohns develop during optimal treatment *significant side effects related to the treatment. *symptoms may resolve only during systemic steroid therapy and recur with each attempt to withdrow the steroid.

Surgery is indicated if the patient cant be weaned of the steroid within 3-6 months.

Intestinal obstruction Chronic partial obstruction of the small intestine is more common than acute complete obstruction Acute recurrent inflammation leads to bowel thickening and chronic scarring which eventually cause fixed stricture.

So patients with obstructive symptoms that result from fibrotic fixed strictures need surgery.

Enteric fistula Asymptomatic entero enteric fistula don’t require surgical intervention but any why they indicate severe disease. A fistula is an indication for surgery only if: *causing discomfort or embarrasses the patient( enterocutanous or entero vaginal ). *has a potential to induce significant complications.(Enter vesical)

Abscess and inflammatoy mass An abscess from crohns that has been drained percutaneously is very likely to recur or result in enterocutaneous fistula. So surgical resection is advised after successful drainage..

hemorrhage Un common in crohns . But frequent with crohns colitis than small bowel crohns.

perforation Is rare;; Only in 1% of the cases.

Cancer and suspected cancer Crohns patient are at increased risk for adenocarcinoma of the colon and small intestine.. Prevelance 0.3% for small bowel adenoK. 1.8% for large bowel adenoK. Most of the time is multifocal and poorly differentiated.

Growth retardation

Pre op evaluation Small bowel enema. Colonoscopy CT abdomen and pelvis(if suspecting abscess or inflammatory mass ) Fistuloscan. Meticulous mechanical bowel prep even if the procure involving small bowel only.

surgery Abdominal exploration: examination of the whole small bowel which requires release of adhesions. any inflammatory adhesions should be suspected to have a fistulous tract. adhesions that may be result from cancer should be resected in bloc.

resection It should be wide enough to encompass the limits of gross disease.. Wider resection offer no benefit in term of lessening the rate of recurrence. Also the extend of mesenteric resection has no impact on term of recurrence.

Once the resection is completed , the proximal and distal margins of the specimen should be examined to ensure they are free of GROSS disease.

Minimally invasive surgery Laparoscopy. To date ,the largest experience with crohns is ileocecal resection. The cecum and ascending colon are mobilized laparoscopically. Then, a small incision on the abdomen is done ..

Then the mobilized segment of the bowel is exteriorized.. Vision of the bowel and transection of the mesentery is accomplished extracorporeally and a standard anastomosis is done.

Contraindication for lap Criticlly ill pts.who are unable to tolerate a pneumoperitoneum due to hypotention or hypercapnia. Pts with dense adhesions,intra abdominal sepsis or complex fistulation..

strictureplasty Indications: for jejunoileitis with single or multiple fibrotic stricture.. isolated stricture in the duedenum.

contraindications Segment with acute inflmmation or phlegmon. Pt with generalized peritonitis. Long high grade stricture resulting from extremely thickened and rigid intestinal wall as this need resection.

Methods 1- HEINEKE-MICULICZ: Longtudinal enterotomy is done on the antimesenteric side. Which then close transverly ‘’.. Used if the stricure is < 7 cm. Bx should be taken.

2- FINNEY: Used for long stricture up to 15 cm. Result in the formation of divericum. Used less frequantly bec.of its side effects.

3- side to side iso peristaltic stricureplasty.. For multiple stricture with close proximity. It is a recent advance in the surgical management of difficult cases of extensive crohns, Safe and effective in selected patients.

Notes No randomized controlled studies have directly compared recurrence rate after resection vs strictureplasty.. But on observation ,,the rapid recurrence of symptoms following strictureplasty has not proved to be a problem.

Crohns of the colon Segmental colectomy. Ileocecal resection with primary anastomosis. Total abdominal colectomy with ileoproctostomy. Total proctocolectomy with permennat end ileostomy.

Note: Because of the recurrent nature of crohns ,,a restorative procedure as ileal pouch-anal anastomosis is inappropriate.

Ileocolitis: -ileocecal resection with primary anastomosis.. Any why,,disease tends to recur at the anastomotic or pre anastomotic ileum.

Extensive crohns colitis with rectal sparing: -if not responding to medical treatment, total colectomy.. -commenly the rectum is spared and ileorectal anastomosis can be done.. So ,,permenant ileostomy can be avoided or at least delayed..

Unfortunatley,,recurence after total abdominal colectomy with ileorectal anastomosis is common.. Many of these patients ultimatly will require proctectomy with permenant ileostomy’’

Perianal crohns disease Abscess. Fistulae. Fissures. stenosis. Hypertrophied skin tags. ----each one of them is treated accordingly..

Thank you