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

2. Conflict of Interest I have no conflicts to declare

3. 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

4. Phenotypic Characteristics Pediatric IBD VAN LIMBERGEN et al. 2008

5. Pediatric vs Adult Behavior VAN LIMBERGEN et al. 2008

6. Risk for Surgery Gupta et al. 2006

7. Schaefer et al. CLINICAL GASTROENTEROLOGY AND HEPATOLOGY 2010

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

9. Time to Surgery Schaefer et al. 2010

10. 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

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

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

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

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

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

16. LAPAROSCOPY OPEN SURGERY Laparoscopic Assisted Surgery Hand Assisted Laparoscopic Surgery

17. CROHN’S DISEASE PRIMARY RESECTION DISEASED BOWEL

18. Laparoscopic Assisted Technique Three ports Extracorporeal stapled anastomosis

19. INCISIONS FOR LAPAROSCOPIC BOWEL RESECTION (Crohn’s)

20. Thickened ileum with fat wrapping

21. Cecal Mobilization

22. Segmental Ileal Disease

23. CROHN’S ABSCESS

24. 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?

25. Improved Cosmesis

26. Laparoscopic vs Open Surgery

27. 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)

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

29. Hand Sewn vs Stapled Anastomosis McLeod et al. 2007 –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. 2007 –Stapled have fewer leaks, otherwise no difference

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

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

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

34. Feagans et al 2011

35. 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