DIFFICULT SMALL BOWEL CROHN

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DIFFICULTSMALL BOWEL CROHNS DISEASE

• John Northover
• St Marks Hospital, London

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LOOK BEFORE YOU LEAP
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LOOK BEFORE YOU LEAP
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Causes of intestinal failureSt Marks Hope,
1999-2002
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Difficult SB Crohns

• Duodenal disease
• Multiple strictures
• Enterocutaneous fistula

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DuodenalCrohns
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A few facts

• Rare - lt5
• Differential diagnosis
• Rarely sole site
• Often overshadowed

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Duodenum plus . . . .

• D3 stricture
• Advanced ileal disease

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Clinical scenarios

• Peptic ulcer-like
• Obstruction
• Fistula

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Patterns of disease

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Symptoms

• Peptic ulcer pain 70
• Vomiting 50
• Weight loss 26
• Diarrhoea 22
• Bleeding 7

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Investigation

• Barium studies
• Scanning
• Endoscopy

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Conventional Ba meal

• Anatomical clarity
• Endoscopy needed

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BaM in D3 obstruction

• Poor view
• No distal information

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CT in D4 obstruction
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Endoscopy

• Differential diagnosis
• Dilatation

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Treating obstruction

• Balloon dilatation
• Bypass
• Strictureplasty

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Balloon dilatation

• May avoid surgery
• Few data
• Distal disease

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Bypass

• Check for distal disease
• ? need for vagotomy
• 4/6 without?re-operation (Cleveland, 83)
• Most re-do surgery after Vx risk of diarrhoea
  (Lahey, 89)
• Remains controversial (Bham, 99)

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Strictureplasty

• 13 patients (10 primary)
• 2/10 leaked
• 6 re-strictured?surgery
• Overall 9/13 re-operated
• Birmingham, 1999

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Plasty v Bypass

• Historical and parallel comparison
• Bypass 21 strictureplasty 13
• Same
• Complications (2/21 2/13)
• Recurrence?Re-op. (1/21 1/13)
• Cleveland Clinic, 1999

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Fistulating duodenal Crohns

• Usually secondary
• To colon or terminal SB
• Duodenocutaneous rare
• Most OK for oversew

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D2-transverse colic fistula

• Normal duodenum
• Penetrating ulcers
• Simple closure after colectomy

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Multiple strictures
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Multiple strictures

• Failure to thrive
• Obstruction

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Multiple strictures
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Multiple strictures

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

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Multiple strictures

• Might surgery help?
• If so, what surgery?
• (Bypass)
• Resection
• Strictureplasty

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Multiple strictures

• Pros and cons of strictureplasty
• Bowel conservation
• Safety
• Relapse rate

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Multiple strictures

• Recurrence avoidance

Oxford, 1995
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Multiple strictures

• Recurrence avoidance

2006 meta analysis Tekkis et al.
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StrictureplastyWhats available?
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StrictureplastyWhats available?
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StrictureplastyWhats available?
What do they achieve?
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StrictureplastyWhats available?
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StrictureplastyBeware the occult stricture
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StrictureplastyPick n Mix . . .
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Enterocutaneous fistula
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Enterocutaneous fistula
Surgery rarely avoided
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Avoiding re-operation
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Avoiding re-operation
NO UNEXPECTED EXTRA PROCEDURES
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Avoiding DISASTER
DONT GO IN TOO EARLY
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Avoiding DISASTER
DONT GO IN TOO EARLY
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Avoiding DISASTER
WAIT!!
DONT GO IN TOO EARLY
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Avoiding DISASTER
WAIT!! and PREPARE
DONT GO IN TOO EARLY
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Pre-operative preparation
Exclude distal obstruction Exclude septic
collections Find the optimal entry site
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Avoiding re-operation

• ROADMAP
• Composite image
• Pre-operate in head

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DIFFICULTSMALL BOWEL CROHNS DISEASE

• John Northover
• St Marks Hospital, London