Crohn Disease Requiring Surgery

Surgery in Crohn disease treats complications rather than curing the disease. Recurrence can occur anywhere in the remaining gastrointestinal tract, so bowel preservation is a central operative principle.

Major indications are:

• Fibrotic obstruction
• Free perforation
• Intra abdominal abscess not controlled nonoperatively
• Symptomatic fistula
• Uncontrolled haemorrhage
• Dysplasia or malignancy
• Medically refractory localised disease with unacceptable symptoms

Elective surgery after optimisation is substantially safer than emergency resection.

The presentation reflects the complication.

Fibrostenotic disease produces recurrent postprandial pain, distension and partial obstruction.

Penetrating disease produces abscesses, phlegmon or internal fistulas.

Free perforation causes peritonitis.

An enterovesical fistula causes pneumaturia, recurrent urinary infection or faecaluria.

Weight loss, anaemia and hypoalbuminaemia frequently indicate significant nutritional compromise before surgery.

MR enterography: preferred for elective mapping of small bowel disease; define the length and number of strictures, penetrating complications and active inflammation.

CT abdomen: preferred in acute sepsis, perforation or obstruction.

Endoscopy should assess colonic and terminal ileal disease when clinically safe and relevant to operative planning.

Preoperative optimisation

Control sepsis before elective resection whenever possible.

Drain accessible intra abdominal abscesses before definitive surgery.

Correct dehydration, electrolyte abnormalities and anaemia.

Malnourished patients should receive nutritional optimisation before elective surgery. Enteral nutrition is preferred when the gut can be used. Parenteral nutrition is reserved for obstruction, severe intolerance, intestinal failure or situations where enteral feeding cannot meet requirements.

Reduce corticosteroid exposure when clinically possible. Prednisolone equivalent at or above approximately 20 mg daily for more than 6 weeks increases postoperative infectious and anastomotic complications and should influence the decision regarding primary anastomosis or temporary diversion.

Operative principles

Use laparoscopy as the preferred approach when technically feasible and experienced expertise is available.

Resect only the diseased bowel necessary to treat the complication. Wide oncological style margins are unnecessary for benign Crohn disease.

For terminal ileal or ileocaecal disease, limited ileocolic resection is standard.

A stapled side to side ileocolic or small bowel anastomosis is a well established reconstruction and is associated with favourable leak and patency outcomes.

Preserve bowel aggressively in patients with multiple previous resections. Strictureplasty is particularly useful for multiple fibrotic small bowel strictures where further resection risks short bowel syndrome.

Temporary diversion should be considered with severe sepsis, poor nutrition, high steroid exposure, gross contamination or questionable tissue quality.

Postoperative recurrence is common. Medical prophylaxis and endoscopic surveillance should be planned rather than waiting for recurrent obstructive symptoms.