1. PANEL DISCUSSION SURGERY FOR CROHNS DISEASE

2. AD 24 female Crohns disease since 2001 on penatasa, budesonide, prednisolone needle phobia resolved by psychologist onto azathioprine October 2004 – wt loss, colicky abdominal pain on eating barium meal and follow through

3. AD 24 female

4. Barium Meal and F/T - Featureless terminal ileum over 15cm with a very tight stricture at the ileocaecal valve over a very short distance no previous surgery BMI 18 WHAT NEXT ? AD 24 female

5. LAPAROSCOPIC RESECTION laparoscopic resection – ileocaecetomy 25cm specimen stapled anatomosis postoperative ileus home on day 10 AD 24 female

6. KH 38 female nurse Crohns disease for 17 years involving the terminal ileum managed with azathioprine and steroids August 2003 – IP subacute obstruction

7. KH 38 female nurse BM & F/T “long segment of strictured terminal ileum - ? Early filling of sigmoid and rectum ?? Fistula

8. KH 38 female nurse September 2003 OPD – poor appetite, weight loss, urinary frequency but no pneumaturia. O/E mass in lower abdomen Hb111, Plts 645, Albumin 28g/l, CRP 122 CT Scan – mass of small bowel with local perforation and fistulation into bladder and sigmoid WHAT NEXT ?

9. KH 38 female nurse Medical therapy - ? Infliximab Resection Laparoscopic / Laparotomy Defunction or not ? OPTIONS

10. KH 38 female nurse 20cm mass of fistulating small bowel Crohns fistulation into dome of the bladder multiple complex openings into sigmoid over 8cm LAPAROTOMY 7.11.03 WHAT NEXT ?

11. KH 38 female nurse LAPAROTOMY 7.11.03 WHAT NEXT ? ileocaecectomy broken off dome of the bladder – catheter 10 days sigmoid cannot be repaired, extensive indurated defect

12. KH 38 female nurse LAPAROTOMY 7.11.03 sigmoid resection, on table lavage and left colo- colonic anastomosis in two layers maxon end ileostomy and ascending colon mucous fistula

13. KH 38 female nurse POSTOP. developed heparin induced thrombocytopenia LOS 25 days HISTOLOGY

14. KH 38 female nurse

15. Crohns disease – small bowel adenocarcinoma arising from dysplastic epithelium

16. KH 38 female nurse

17. JH 38 female 9.3.00 perianal Crohns fistula – seton inserted 13.9.01inflamed stricture upper rectum 28.1.02 – white cell scan shows uptake in descending colon and sigmoid 28.11.02 – acute gynae admission with pelvic pain, ultrasound shows complex solid/cystic mass arising from the right ovary

18. JH 38 female 12.11.02 – Gynae Laparotomy inflammed mass involving the sigmoid and the uterus and adenexae. Small amount of pus – colon normal to proximal descending then very abrnormal and thickened.

19. JH 38 female sigmoid separated from the uterus and pelvis washed out. not clear if PID or Crohns so no resection - proximal loop ileostomy brought out. home pod 17

20. JH 38 female gradually improved little in the way of symptoms – attended OPD to reassess pelvis and explore options for re-anastomosis 24.9.03 – CT showed bilateral adnexal fluid collections 27.10.03 – Colonoscopy halted at ulcerated mid-rectal stricture 19.2.04 contrast enema

21. JH 38 female

23. WHAT NEXT ?

24. JH 38 female TAH and BSO Left Hemicolectomy – small abscess around very abnormal proximal rectum, so rectum divided at the pelvic floor. TV colon to distal rectum cross stapled anstomosis loop ileostomy maintained LAPAROTOMY 10.3.05

25. JH 38 female initially good recovery then unwell, low grade pyrexia, superficial wound breakdown CT presacral fluid collection – small amount of contrast in a 2cm cavity adjacent to anstomosis. POSTOP