Surgical approach of patients with crhons disease

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Surgical approach of patients with crhons disease

• ByHanaa Tashkandi

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

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• 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.

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

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• Due to loss of normal rectal capacity ..which is
  called LAR syndrome
• Symptoms
• frequent small bowel movementsclustering

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• How to prevent this?

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• 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.

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• 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

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• 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.

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• 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.

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

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• 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.

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

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Crohns disease

• Pattern of the disease
• 1-inflammation
• 2-sticture
• 3-perforation

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• 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.

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• 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.

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Indications for surgery
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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.

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

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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.

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

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Enteric fistula

• Asymptomatic entero enteric fistula dont 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)

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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..

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hemorrhage

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

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perforation

• Is rare
• Only in 1 of the cases.

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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.

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Growth retardation
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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.

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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.

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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.

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

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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 ..

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• 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.

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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..

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strictureplasty

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

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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.

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Methods

• 1- HEINEKE-MICULICZ
• Longtudinal enterotomy is done on the
  antimesenteric side.
• Which then close transverly ..
• Used if the stricure is lt 7 cm.
• Bx should be taken.

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

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• 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.

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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.

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Crohns of the colon

• Segmental colectomy.
• Ileocecal resection with primary anastomosis.
• Total abdominal colectomy with ileoproctostomy.
• Total proctocolectomy with permennat end
  ileostomy.

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

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

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• 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..

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

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Perianal crohns disease

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

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Thank you