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Crohn's Disease

For gastroduodenal Crohn’s disease, which is indeed quite rare, the symptoms of pain, nausea, vomiting and weight loss with studies to confirm upper GI Crohn’s disease with complications, as you see here, in obstruction, fistula and hemorrhage. The surgery for gastroduodenal Crohn’s disease is fortunately rare but consists really of only bypass and strictureplasty.

What about disease-free margins in small-bowel Crohn’s disease? Just briefly, there are studies that show with normal and disease margins no difference in the rate of cumulative recurrence rate over an eight year period of time.  In work from our own institution we would say that gross residual disease, in the orange line, has a much higher rate of recurrence than in the overall group of patients without gross residual disease. So what our practice is - at least mine is - is to approach the patient with small-bowel Crohn’s disease, resect that to non-diseased margins and do the anastomosis. If indeed the pathologist tells us that the margin is involved, I’ll go back slightly again - maybe 2 or 3 more centimeters - and do the anastomosis.

But I will not resect and resect apparently normal bowel if the disease margin is … if the margin is microscopically diseased only. Perhaps I can answer questions about that in a few minutes.

What about strictureplasty? I think all of you have surgeons who are interested in doing strictureplasty on patients. The rationale for strictureplasty, at least in their minds, is shown here. That indeed the disease involves the whole intestine. It is obviously impossible to cure Crohn’s disease by mere excision alone, and all diseased bowel does not need excision. So if the main problems the patients are having are stenotic in nature, then these can be relieved usually without excising the bowel.

Ileorectostomy is an operation we perform often for patients with colonic Crohn’s disease but in whom the rectum must be normal, or very minimally involved, and you can tell that by inflating air into the rectum and seeing if it blows up normally. If it doesn’t, then the surgeon would be anastomosing the small bowel to a rigid pipe of rectum, which is totally unacceptable.

What about this change in intrarectal Crohn’s? Well in Crohn’s disease of the anus it is surprising how often this is misdiagnosed when patients come to us. It’s really pretty simple. If the patients have huge skin tags, fissures, big ulcers in the anal canal -often not uncomfortable - there is a blue discoloration, cyanotic hue to the perianal area. That they are stricturing, that as you do a digital you can barely get your finger in, it’s a circumferential stricture at the top of the anal canal, or they have fistulas in funny locations. I mean, it’s obvious that this patient … and they have the symptoms of internal inflammatory bowel disease.

What are we doing today? Well, thanks to - at least at our institution - our gastroenterologists are aggressively treating patients with anal Crohn’s disease, and the role of the surgeon has changed a little bit. We are still draining abscesses, placing setons as drains through complex fistulas to keep them drained so that they don’t form abscesses, and we medicate - in this era of anti-TNF alpha - we medicate these people aggressively. We will take them back to the operating room as necessary and the goal is to dry up the perianum. I think if you watch the literature for the next several months and years, that I think this is a rational approach in patients - particularly in younger patients - before we even think about having to excise the perianum.