1. DIFFICULT SMALL BOWEL CROHN’S DISEASE John Northover St Mark’s Hospital, London

3. LOOK BEFORE YOU LEAP

5. Causes of intestinal failure St Mark’s & Hope, 1999-2002

6. Difficult SB Crohn’s Duodenal disease Duodenal disease Multiple strictures Multiple strictures Enterocutaneous fistula Enterocutaneous fistula

7. Duodenal Crohn’s

8. A few facts Rare - <5% Rare - <5% Differential diagnosis Differential diagnosis Rarely sole site Rarely sole site Often overshadowed Often overshadowed

9. Duodenum plus.... D3 stricture D3 stricture Advanced ileal disease Advanced ileal disease

10. Clinical scenarios ‘Peptic ulcer-like’ ‘Peptic ulcer-like’ Obstruction Obstruction Fistula Fistula

11. Patterns of disease *

12. Symptoms ‘Peptic ulcer’ pain 70% ‘Peptic ulcer’ pain 70% Vomiting 50% Vomiting 50% Weight loss 26% Weight loss 26% Diarrhoea 22% Diarrhoea 22% Bleeding 7% Bleeding 7%

13. Investigation Barium studies Barium studies Scanning Scanning Endoscopy Endoscopy

14. Conventional Ba meal Anatomical clarity Anatomical clarity Endoscopy needed Endoscopy needed

15. BaM in D3 obstruction Poor view Poor view No distal information No distal information

16. CT in D4 obstruction

17. Endoscopy Differential diagnosis Differential diagnosis Dilatation Dilatation

18. Treating obstruction Balloon dilatation Balloon dilatation Bypass Bypass Strictureplasty Strictureplasty

19. Balloon dilatation May avoid surgery May avoid surgery Few data Few data Distal disease Distal disease

20. Bypass Check for distal disease Check for distal disease ? need for vagotomy ? need for vagotomy –“4/6 without  re-operation” (Cleveland, ‘83) –“Most re-do surgery after Vx; risk of diarrhoea” (Lahey, ‘89) –“Remains controversial” (B’ham, ‘99)

21. Strictureplasty 13 patients (10 primary) 13 patients (10 primary) 2/10 leaked 2/10 leaked 6 re-strictured  surgery 6 re-strictured  surgery Overall 9/13 re-operated Overall 9/13 re-operated Birmingham, 1999

22. ‘Plasty v Bypass Historical and parallel comparison Historical and parallel comparison Bypass 21; strictureplasty 13 Bypass 21; strictureplasty 13 Same: Same: – Complications (2/21; 2/13) – Recurrence  Re-op. (1/21; 1/13) Cleveland Clinic, 1999

23. Fistulating duodenal Crohn’s Usually secondary Usually secondary To colon or terminal SB To colon or terminal SB Duodenocutaneous rare Duodenocutaneous rare Most OK for oversew Most OK for oversew

24. D2-transverse colic fistula Normal duodenum Normal duodenum Penetrating ulcers Penetrating ulcers Simple closure after colectomy Simple closure after colectomy

26. Multiple strictures

27. Failure to thrive Failure to thrive Obstruction Obstruction

28. Multiple strictures

29. What trouble are they? What trouble are they? Other modalities? Other modalities? Previous surgery? Previous surgery? Is there a ‘dominant’ stricture? Is there a ‘dominant’ stricture? AND ONLY THEN... AND ONLY THEN...

30. Multiple strictures Might surgery help? Might surgery help? If so, what surgery? If so, what surgery? –(Bypass) –Resection –Strictureplasty

31. Multiple strictures Pros and cons of strictureplasty Bowel conservation Bowel conservation Safety Safety Relapse rate Relapse rate

32. Multiple strictures Recurrence avoidance Oxford, 1995

33. Multiple strictures Recurrence avoidance 2006 meta analysis Tekkis et al.

34. Strictureplasty What’s available?

36. What do they achieve?

37. Strictureplasty What’s available?

38. Strictureplasty Beware the occult stricture

39. Strictureplasty Pick ‘n’ Mix...

41. Enterocutaneous fistula

42. Surgery rarely avoided

43. Avoiding re-operation

44. NO UNEXPECTED EXTRA PROCEDURES

45. Avoiding DISASTER DON’T GO IN TOO EARLY

46. Avoiding DISASTER DON’T GO IN TOO EARLY

47. Avoiding DISASTER DON’T GO IN TOO EARLY WAIT!!

48. Avoiding DISASTER DON’T GO IN TOO EARLY WAIT!! and PREPARE

49. Exclude distal obstruction Exclude septic collections Find the optimal entry site Pre-operative preparation

50. Avoiding re-operation ROADMAP ROADMAP Composite image Composite image Pre-operate in head Pre-operate in head

57. DIFFICULT SMALL BOWEL CROHN’S DISEASE John Northover St Mark’s Hospital, London