Role of Surgery in The Management of Crohn - S Disease PDF

Current Problems in Surgery 55 (2018) 162–187
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Current Problems in Surgery
journal homepage: www.elsevier.com/locate/cpsurg
Role of surgery in the management of Crohn’s

disease
Alessandro Fichera, MD, FACS, FASCRS a,∗,
Francisco Schlottmann, MD b, Mukta Krane, MD c,
Greta Bernier, MD c, Erin Lange, MD, MSPH d
Introduction
Over the last 2 decades the management of Crohn’s disease has changed substantially. Very
effective medical and surgical options have become available, changing the characteristics of our
patients when they are eventually referred for surgery. Although the indications for surgery re-
main the same, we are definitely operating on patients that are immunocompromised, often
malnourished, and more prone to infectious postoperative complications. We have evolved our
surgical approach toward minimally invasive options and bowel and sphincter saving procedures.
In addition to the differences associated by more effective and aggressive medical therapy, some
of the changes in management have been dictated by a better understanding of the pathophys-
iology of the disease, the natural history of recurrence, and by the significant improvement in
medical strategies to control the disease and induce remission. Another important factor to in-
clude in the comprehensive management of patients with Crohn’s disease is the perception of
quality of life that must be balanced with patient expectations and disease characteristics and
progression. Putting it all together in a multidisciplinary treatment plan requires specific exper-
tise and the involvement of multiple specialties. This is a lifelong chronic and often recurrent
disease and has a significant impact on the patient and the family’s well-being, especially when
diagnosed during childhood and the teenage years. The first priority of the medical team is to
gain the trust of the patient and the family. Patient and family involvement in the treatment
plan is paramount to achieve optimal results.
In this review we will not discuss current medical options for treatment of primary dis-
ease and only briefly mention medical strategies to prevent recurrence after surgical remission.
We will focus instead on surgical management, including indications for surgery, preoperative
From the a University of North Carolina Medical Center, Chapel Hill, NC; b Hospital Alemán of Buenos Aires, Buenos Aires,
Argentina; c University of Washington, Seattle, WA; and d Northwest Hospital, University of Washington, Seattle, WA
∗
Corresponding author: Alessandro Fichera, MD, FACS, FASCRS, University of North Carolina Medical Center, 4035
Burnett Womack Building, Chapel Hill, NC 27599-7081.
E-mail address: alessandro_fichera@med.unc.edu (A. Fichera).
https://doi.org/10.1067/j.cpsurg.2018.05.001
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A. Fichera et al. / Current Problems in Surgery 55 (2018) 162–187 163
evaluation and optimization, the different surgical approaches, and the surgical prophylaxis of
recurrence. As we discuss only surgical management it is important for the readership to keep
in mind the critical value of multidisciplinary discussion and comanagement with our gastroen-
terology colleagues to be able to offer the right operation, at the right time, to the right patient,
performed by the trained and experienced surgeon.
Indications for surgery
Although medical therapy continues to advance and improve the quality of life for Crohn’s
patients, progressive disease and complications can lead to refractory symptoms or acute clin-
ical presentations that require surgical intervention throughout the gastrointestinal (GI) tract.1
Close partnership between gastroenterologists and surgeons can lead to optimized outcomes for
patients. Although the generic “failure of medical management” is the most common and im-
portant indication for surgery, which can provide a clinical reset, specific disease patterns across
the GI tract also demand the surgeon’s close attention.2
Foregut
Intestinal Crohn’s disease often manifests with a combination of acute and chronic inflamma-
tory elements, including fistulae, abscesses, and strictures. Over time, these features can result in
persistent symptoms, including abdominal pain, diarrhea, and bleeding, whose lack of response
to medical therapy pushes patients to seek surgical attention.3
Fistulizing disease develops in one-third of Crohn’s patients, and requires surgical interven-
tion when it leads to refractory secondary symptoms—functional bypass of a major intesti-
nal segment resulting in malabsorption and diarrhea; communication with the genitourinary
tract with repeated urinary tract infections (UTIs), or discomfort and/or social embarrassment
from enterocutaneous and enterovaginal fistulae. Certain fistulae—cologastric, enteroduodenal,
and enterosigmoid—often need to be repaired surgically.4
Most abdominal abscesses represent sealed bowel perforations, and can be treated with per-
cutaneous drainage and antibiotics.5 However, subsequent resection is often required due to re-
current infection or development of an enterocutaneous fistula. A recent prospective series with
long follow-up showed that even in patients that initially remain asymptomatic the risk of dis-
ease recurrence is such that subsequent elective surgical resection is indicated.6 In some cases,
image-guided drain placement may not be feasible (eg, loculated fluid collections, interloop ab-
scesses, or inflammatory phlegmon) thus requiring surgical intervention.
Stricturing disease is a common small bowel phenotype, leading to obstructive symptoms.
Although the terminal ileum is the most common site of small bowel stricture, it is important to
use imaging guided enterography (eg, barium studies, magnetic resonance enterography [MRE],
or computed tomography enterography [CTE]) to evaluate the entire small bowel when operative
intervention is considered.7 By establishing a “road map,” the surgeon is less likely to miss “skip
lesions” and can plan for the possibility of multiple targets for intervention. A combination of
resection and stricturoplasty may be required to achieve symptomatic relief while maximizing
functional bowel length.
Patients with Crohn’s disease carry an increased risk of small bowel adenocarcinoma, al-
though it is diagnosed in less than 1% of all patients. Malignant masses and/or strictures can
be difficult to distinguish from inflammatory disease due to lack of accessibility by endoscopic
techniques and similarities on axial imaging. Most cases (73%) are identified on pathologic anal-
ysis, rather than diagnosed preoperatively. Defunctionalized or bypassed intestinal segments are
at increased risk of malignancy and should be either excised or restored to continuity in a timely
fashion.8
Inadequate control of intestinal disease in children can result in growth retardation in 10% to
40% of Crohn’s patients, despite appropriate medical and nutritional therapy.9 Surgery is needed
164 A. Fichera et al. / Current Problems in Surgery 55 (2018) 162–187
in these situations to prevent permanent developmental changes, and in particular, can facilitate
“catch up growth” in prepubertal children in the 6 months following surgery.10
Hindgut
Similar to small bowel Crohn’s disease, colonic Crohn’s can manifest with fistulae, abscesses,
and strictures. Most colonic fistulae—colocutaneous, cologastric, and rectovaginal—require op-
erative correction, and often arise as a complication of prior surgery.11 Abscesses are initially
drained via percutaneous approach, with subsequent resection strongly considered to avoid pos-
sible fistula development.6
Strictures raise concerns both for symptomatic obstruction and for the possibility of missed
dysplasia or cancer. Progressive obstruction secondary to inflammatory stricture can lead to re-
fractory pain, postobstructive diarrhea, or perforation. Crohn’s colitis poses a significantly higher
risk of colorectal cancer compared to the general population (4-20 times higher), with incidence
correlated to the activity, duration of disease, and extent of colonic involvement. Although ad-
vancements in endoscopic technique, including use of chromo endoscopy, have allowed for close
surveillance of selected patients with dysplasia, formal colon resection is indicated for multi-
focal dysplasia irrespective of degree and biopsy-proven high-grade dysplasia. Other indications
include stenosis, pseudopolyp burden not manageable by endoscopic surveillance, or defunction-
alized rectum without plans for restoration of function due to the risk of neoplastic degenera-
tion.12,13
Refractory GI bleeding is a rare but clear indication for surgical intervention.14 Acute bleeding
occurs in approximately 0.9% to 6% of Crohn’s patients, generally secondary to severe inflamma-
tion rather than other focal sources such as diverticula or arteriovenous malformations. In situa-
tions where bleeding persists despite medical management, including resuscitation, transfusion,
and targeted therapy for the underlying inflammation, surgical resection should be pursued. Ad-
equately localized bleeding can be addressed with segmental colectomy, whereas more diffuse
involvement will require a total abdominal colectomy.15 Decisions regarding primary anastomo-
sis versus diverting stoma should be made with consideration for the patient’s clinical status,
prior surgical history, and extent of anorectal disease.
Although surgeons generally have an opportunity to evaluate and optimize a patient prior to
proceeding to the operating room, urgent intervention can be required for toxic megacolon or
perforation secondary to refractory stricture. Free perforation is an absolute indication for surgi-
cal intervention.5 Toxic megacolon, or the presence of segmental or total colonic nonobstructive
dilation with associated systemic toxicity, can manifest from infectious or inflammatory underly-
ing sources (Clostridium difficile, cytomegalovirus, ulcerative colitis [UC], and Crohn’s disease).16
Judicious investigation, including stool studies, computed tomography scan, and possible low-
insufflation endoscopy, should be undertaken to allow targeted therapy. In the setting of Crohn’s
disease, progressive dilation, peritonitis, or systemic toxicity despite maximal medical therapy
may serve as an indication for surgical intervention in order to avoid perforation.17 Patients in
this situation generally receive a subtotal colectomy with end ileostomy, with choice of closed
distal stump versus mucus fistula depending on the clinical picture and surgeon’s preference.18
Perineum
Anorectal Crohn’s disease is a complex constellation of clinical features most frequently seen
in patients with concurrent colitis or proctitis. These patients often suffer from significant symp-
tom burden, leading 25% to 34% to require surgical intervention. In principle, these operations
focus on relieving sepsis and pain, while minimizing permanent impact on sphincter function.
The tendency toward poor healing can limit the use of certain surgical strategies. Proctectomy
often serves as the intervention of last resort for unrelenting perianal symptoms.19
Anal stenosis, either from poor controlled inflammation or prior surgical intervention, is man-
aged with dilation in mild cases, and diverting ileostomy or proctectomy in more severe cases.
It is mandatory in long-standing cases to rule out malignancy in strictures refractory to dilation.
Patients with fissures must be evaluated cautiously for possible cancer or immunodeficiency,
with biopsies performed in cases of multiple fissures and/or atypical locations (off midline).
Therapeutic interventions should be limited to medical strategies to avoid potential inconti-
nence.
Abscesses and fistulae are a common presentation in Crohn’s disease, with 20% to 50% of pa-
tients developing perianal pathology in their lifetime.19 These issues have a high negative impact
on quality of life. Abscesses should be managed with incision and drainage, with seton place-
ment if a fistula is identified. Fistulae themselves may arise secondary to rectal inflammatory
disease, or be cryptoglandular in origin. Medical therapy with biologic agents is the mainstay
of therapy, with long-term seton placement for recalcitrant or complex fistulae to avoid future
infectious complications. Superficial fistulotomy can be considered for distal submucosal or in-
tersphincteric fistulae, although extreme care should be taken to avoid sphincter injury in this
population. Severe cases may require consideration of diverting colostomy with or without proc-
tectomy, with low likelihood of future restoration of continence. Rectovaginal fistula can be a
troubling complication for women with distal Crohn’s disease which is initially addressed with
a draining seton, followed by mucosal advancement flap after medical optimization.
Preoperative evaluation and medical optimization
Despite significant advances in the medical management of Crohn’s disease, approximately

80% of patients will still need surgical intervention in their lifetime. Patients undergo surgery
either due to a failure of medical management or as a result of disease related complications.
Their presentations run the gamut from simple fibrostenotic strictures in the terminal ileum
to complex multifocal disease to fulminant colitis where patients may present in shock. The
severity of disease will often define the urgency of an operation, but consideration should always
be made for preoperative planning to ensure optimal timing of surgery and appropriate medical
optimization, if possible.
Preoperative evaluation
Preoperative evaluation consisting of a detailed history and physical examination, radiologic

imaging, and endoscopy can assist in making the diagnosis of Crohn’s disease, delineating the
distribution and severity of disease, and detecting complications. Information obtained from the
preoperative evaluation and adherence to the basic tenets of Crohn’s disease surgery will often
guide the surgeon in deciding the extent of resection, surgical approach, and management of the
patient’s nutritional status and medications.
History and physical exam
Evaluating a patient with Crohn’s disease begins with a complete and detailed history and
physical examination. Questions should focus on the patient’s symptoms, current and past sites
and severity of disease, dietary restrictions, surgical and medication history, smoking status,
and comorbidities. Previous endoscopy, operative, and pathology reports should be obtained and
pathology slides should be re-reviewed by a pathologist specializing in inflammatory bowel dis-
ease (IBD). A thorough physical examination should be conducted paying close attention to the
vital signs, abdominal examination (particularly assessing for pain, distention, and previous sur-
gical scars), and perineal and digital rectal examination noting the presence of an abscess, fistula,
fissure, skin tag, rectal mass and bleeding, or anal stenosis.
Imaging
Radiologic assessment for a patient with Crohn’s disease may begin with a plain abdominal
radiograph particularly in critically ill patients where dilated loops of bowel or free air on an
upright film will indicate an obstruction or perforation, respectively. Serial plain radiographs may
also serve as an adjunct to abdominal examinations in patients being followed for small bowel
obstruction or colonic dilation. However, plain abdominal radiographs do not provide detailed
information or make the diagnosis of Crohn’s disease and therefore may be skipped in favor of
more accurate imaging including contrast fluoroscopy and cross-sectional imaging.
Cross-sectional imaging
Cross-sectional imaging including CTE and magnetic resonance imaging (MRI) and/or MRE
has become the mainstay in the radiologic evaluation of Crohn’s disease and can provide de-
tailed examination of the entire length of the intestinal tract and visualization of extra-enteric
complications including: abscesses, fistulas, strictures, obstruction, and perforation. CTE and MRE
are indicated for the diagnosis, identification of disease related complications, disease monitor-
ing in response to medical management, and evaluation of disease recurrence. Cross-sectional
imaging is particularly helpful in assessing small bowel disease as this area can be difficult to
access endoscopically and the inflammatory process may penetrate beyond the lumen of the
bowel. Drawbacks of these imaging modalities include inability to detect early mucosal changes
associated with Crohn’s disease and difficulty is distinguishing lesions secondary to other causes
of inflammation or malignancy.20
Although the exact protocols vary by institution, in general performing a CTE or MRE involves
consumption of a large volume of neutral or low-density oral contrast to ensure adequate lumi-
nal distention and administration of intravenous contrast to optimize bowel wall enhancement.
Reduction of peristalsis may be achieved with the administration of spasmolytics.
Manifestations of acute Crohn’s disease include: “cobblestoning,” the transverse and longi-
tudinal distribution of ulcerations with surrounding islands of edematous mucosa, mucosal hy-
perenhancement, and increased bowel wall thickening if inflammation is transmural (Fig 1).21
Differential enhancement of the bowel wall (enhancement of mucosal and muscular layers with
intervening nonenhancement of submucosal layer) gives pathologic segments a stratified appear-
ance known as a “target sign” or “double halo sign” (Fig 2) which may also be visualized with
active disease.22 Engorgement of the vasa recta (“comb sign”) and increased attenuation of the
mesenteric fat secondary to edema are extra-intestinal signs of acute inflammation but not as
sensitive as luminal manifestations.23,24 Mucosal fat deposition, fibrofatty proliferation, strictur-
ing without mucosal hyperenhancement, and presence of sacculations due to asymmetric fibro-
sis of the mesenteric side of the bowel are signs of chronic disease.21 Being able to distinguish
between these 2 processes has important implications for therapy since chronic fibrostenotic
disease reflects permanent change and is best treated with surgical resection whereas active
inflammation may respond to more aggressive medical management.
Systematic reviews have found that MRE and CTE are comparable for diagnosing small bowel
Crohn’s disease although rates are lower for detection of early disease.25,26 Pooled sensitivity
and specificity are 88% and 81%, respectively, for MRE and 86% and 84%, respectively, for CTE,
which was not significantly different. CTE and MRE also have similar rates for the detection
of complications associated with Crohn’s disease and therefore are the tests of choice if one is
suspected. Diagnosis of stenosis, which is visualized as an enhanced and thickened segment of
bowel proceeded by a dilated segment (Fig 3), has a sensitivity and specificity of 88% and 95%,
respectively.27 An enhanced sinus tract between adjacent loops of bowel (Fig 4) or a convergence
of inflamed loops of bowel that are interconnected (“star sign”) may represent fistulas whereas
abscesses are often seen as rim enhancing collections of fluid and air.27,28 Detection of abscesses
or fistulas has a pooled sensitivity of 86% and specificity of 93%.28,29
CTE and MRE are validated imaging techniques when compared to endoscopic, pathologic,
and clinical methods.30–32 Seastedt and colleagues recently evaluated the accuracy of CTE and
MRE in the preoperative detection of surgical Crohn’s disease lesions when compared with
Fig. 1. (A) Increased bowel wall thickening of a loop of distal ileum due to transmural inflammation. (B) Thickening and hyperenhancement of the left colon.
Fig. 2. “Target sign” due to differential enhancement of the bowel wall.
Fig. 3. Stricture with proximal small bowel dilation.
intra-operative findings.33 Seventy-six patients underwent a surgical procedure for Crohn’s dis-
ease after having undergone preoperative CTE (47%) and/or MRE (57%). The accuracy of CTE for
the detection of stenosis, fistula, and abscess was 76%, 79%, and 90%, respectively. For MRE, the
accuracy was 78% for stenosis, 85% for fistula, and 95% for abscess. Higher rates of accuracy of
CTE and MRE to predict the operative approach for patients with Crohn’s disease were reported
by Malgras and colleagues.34 In this study, 52 patients with Crohn’s disease were evaluated; 26
underwent preoperative imaging with CTE and 26 underwent preoperative imaging with MRE.
MRE had 100% sensitivity in detecting the presence of lesions and CTE had a sensitivity of 93%.
Moreover, in 94% of patients, the estimation of disease forecasted by preoperative imaging pro-
vided an exact prediction of the operative approach. In other studies, use of CTE and MRE has
reportedly altered therapeutic management in 50% to 61% of patients with Crohn’s disease.35
The choice of CTE versus MRE remains controversial and a number of factors should be con-
sidered before selecting a particular modality. Advantages of MRE include superior soft tissue
contrast resolution and diffusion-weighted imaging allowing better delineation between acute
and chronic inflammation, superior evaluation of perineal disease, and the ability to obtain dy-
namic images. It is particularly useful when assessing perineal abscesses/fistulas or response to
medication.36,37 The sensitivity and specificity of MRI for the detection of perianal fistula tracks
were 100% and 86%, respectively, when compared with surgical examination under anesthesia.38
In fact, the surgical procedure was modified as a result of information obtained from the MRI
in 40% of patients with perineal Crohn’s disease. MRE is also the study of choice for patients
Fig. 4. Linear rim enhancing areas between the terminal ileum and more proximal distal ileum, suggestive of an en-
teroenteric fistula.
with renal impairment, contrast allergy, and those who may be pregnant. Quickness and ease
of acquisition, greater accessibility, lower expense of equipment, and absence of the expertise
needed to interpret MRI may make CTE preferable, particularly in patients presenting with sep-
sis or peritonitis. CTE is also preferred in patients with a history of claustrophobia or those
with implantable devices. However, the cumulative dose of radiation that accompanies CTE may
pose a risk of radiation-induced cancer and therefore should generally be avoided, particularly
in younger patients if MRE is available.
Although CTE is still the diagnostic modality most employed worldwide due to accessibility,
there has been a steady increase in the utilization of MRE over the last several years. This has led
to the development of the magnetic resonance index of activity. The magnetic resonance index
of activity is calculated based on a formula incorporating wall thickness, ulceration, edema, and
relative enhancement of each segment of bowel. Recent studies have demonstrated a significant
correlation with the Crohn’s disease endoscopic index of severity and a sensitivity of 81% and
95% for detection of disease and detection of ulcerative lesions, respectively, which may lead to
improvements in inter-observer variability.39,40
Contrast fluoroscopy
Cross-sectional imaging has largely replaced contrast fluoroscopy in many inflammatory
bowel disease (IBD) centers due to the ability to assess extraluminal disease and ease of per-
forming the studies. However contrast fluoroscopy, including upper GI with small bowel follow-
through (SBFT) and contrast enema, provide the ability to obtain dynamic images and have supe-
rior spatial resolution, and therefore continue to play a role in the evaluation of complex Crohn’s
disease, and in particular for delineating complications of Crohn’s disease including strictures,
fistulas, and mesenteric inflammation.
Prior to obtaining fluoroscopic examination, it is important to inform the radiologist if an
obstruction or perforation is suspected. A detailed history and physical examination will enable
Fig. 5. Barium Study showing multiple strictures (“skip lesions”) with intervening normal mucosa.
the radiologist to determine the type of study and contrast material to use. If the patient has
recently received oral contrast from a different study, a plain radiograph should be obtained to
ensure that no residual contrast remains.
An upper GI with SBFT is a useful study in patients with esophageal, gastric, or small bowel
disease. It can serve as an adjunct to upper endoscopy in evaluating the mucosa and document-
ing stricturing or fistulizing disease. Early manifestations of Crohn’s disease include: alterations
of the intestinal fold pattern, loss of mucosal integrity, mural thickening, and the appearance of
aphthous ulcers. As the disease progresses, a cobblestone appearance of the mucosa may be-
come evident. Creeping mesenteric fat or transmural inflammation with intestinal wall thicken-
ing, which accompanies severe disease or acute inflammation, can be identified by the presence
of an abnormal separation between loops of bowel.
With more severe Crohn’s disease, complications may become evident. Luminal narrowing
secondary to a fibrostenotic stricture or inflammatory stenosis may be visualized by the “string
sign.” Strictures separated by intervening normal lengths of small bowel will result in skip le-
sions (Fig 5). An advantage of contrast fluoroscopy is that dynamic imaging of luminal distensi-
bility can often reveal the etiology of the stenosis. Luminal distention is often lost with a fibrotic
stricture but is at least partially intact when the narrowing is inflammatory in nature. Fistula
tracts or sinuses seen with transmural extension can be detected with SBFT which is often in-
strumental in operative planning.
Focused evaluation of a particular loop of bowel can also be obtained fluoroscopically with
retrograde enema if a patient has an ileostomy or a fistulogram in the presence of an enterocuta-
neous fistula. Barium enema may be used in patients with colonic Crohn’s disease to determine
the extent of disease and location of strictures.
Studies comparing the use of SBFT to MRE have demonstrated that both modalities have
similar diagnostic yield when identifying small bowel Crohn’s disease. A prospective comparison
of 30 patients with recurrent Crohn’s disease conducted by Bernstein and colleagues revealed
similar diagnostic accuracy of both MRE and SBFT. SBFT demonstrated complications related to
Fig. 6. Early Crohn’s disease: small, punched out ulcerations surrounds by normal mucosa.
Crohn’s disease including fistula and strictures in 4 additional patients compared to MRE, but
MRE provided superior assessment of bowel wall enhancement. The authors concluded that on
the basis of cost and accessibility, SBFT may be a reasonable initial study, but with greater iden-
tification of active inflammation and extra-intestinal manifestation and the lack of radiation ex-
posure, MRE should be considered when available.41
Endoscopy
Given the clinical complexity of Crohn’s disease, operative planning often requires the use of
several diagnostic modalities, with endoscopy serving as the cornerstone of pre-operative eval-
uation. Not only can it help determine the severity and distribution of disease but also by vi-
sual appearance and pathological assessment it may help differentiate Crohn’s disease from UC,
which has significant implications in surgical decision-making. Endoluminal evaluation may in-
clude: colonoscopy with ileal intubation, esophagogastroduodenoscopy (EGD), enteroscopy, and
capsule endoscopy, depending upon the nature and extent of disease.
Colonoscopy with ileoscopy (ileocolonoscopy) enables direct visualization and, via biopsy,
histological assessment of the mucosa of the entire colon and terminal ileum and therefore plays
a primary role in the initial diagnosis of Crohn’s disease. As Crohn’s disease often manifests with
terminal ileal disease, ileal intubation should always be attempted and is successful in approx-
imately 75% of patients.42 Biopsies of the terminal ileum and throughout the colon should be
obtained even if the mucosa appears normal by visual inspection. In addition, strictures or areas
that appear suspicious should be biopsied to rule out malignancy. Characteristic Crohn’s disease
usually appears as sections of inflamed mucosa separated by areas of normal tissue (skip lesions)
and inflammation is usually visualized on the anti-mesenteric aspect of the bowel. Early Crohn’s
disease may be demonstrated by the appearance of small, punched out ulcerations surrounded
by normal mucosa (Fig 6). These aphthous ulcers coalesce creating stellate ulcers, which along
with cobblestoning due to progressive submucosal edema and tissue damage, is characteristic
of moderate Crohn’s disease. As the disease progresses, large linear and deep serpiginous ulcers
may become apparent (Fig 7). Severe colonic Crohn’s disease can be difficult to distinguish from
UC and it is therefore essential to assess the terminal ileum. Factors that are more indicative
of Crohn’s disease include: rectal sparing, involvement of the upper GI tract or small bowel, and
anal or perineal disease. Patients with strictures or fistulas also more likely have Crohn’s disease,
but these complications can be seen in either Crohn’s disease or UC patients with a concurrent
malignancy. As with radiologic imaging, the extent and severity of disease as determined by
endoscopy can be classified using a number of validated scoring systems including the Crohn’s
Fig. 7. Large linear and deep serpiginous ulcers indicative of severe Crohn’s disease.
disease endoscopic index of severity, the Rutgeerts’ score, and the simple endoscopic index of
severity.
Complications of colonoscopy including bleeding and perforation occur in patients with IBD
at a similar rate to the general population.43 Patients with high-grade obstruction or severe col-
itis are at higher risk for perforation but can still safely undergo colonoscopy. However, con-
sideration should be paid with high-risk patients as to whether the information obtained from
endoscopy will change surgical management.
EGD should be performed in all Crohn’s disease patients with upper GI symptoms and biop-
sies should be performed in any areas of inflammation or abnormal appearing mucosa.
A challenge of endoluminal evaluation has always been the ability to assess areas of the
small bowel that are traditionally inaccessible by standard endoscopy. Recently, the introduction
of deep enteroscopy and small bowel video capsule endoscopy (SBCE) has allowed visualization
of an increased length of small bowel.
Deep enteroscopy, first described in 2002, includes balloon assisted and spiral enteroscopy
and can assist in the evaluation of the small bowel from both an oral antegrade and retrograde
approach via the rectum. Balloon-assisted enteroscopy uses a standard endoscope with an over-
tube to increase the stiffness of the scope reducing excess looping and a balloon at the distal
end of the scope to stabilize it in the small bowel. A single or double balloon technique may be
employed. Spiral enteroscopy uses an overtube with a helical thread at the distal end allowing
for a rotational technique.44 There have been no randomized controlled trials comparing the 3
different types of enteroscopy, but a recent meta-analysis of 375 patients found similar depth
of insertion, procedure times, diagnostic and therapeutic yield, and complication rates for sin-
gle balloon and double balloon enteroscopy.45 However, a similar meta-analysis did show that
double balloon enteroscopy had a higher rate of complete small bowel enteroscopy.46
SBCE is a relatively recent addition to the repertoire of modalities used to diagnose Crohn’s
disease. It is a noninvasive method of assessing the small bowel mucosa particularly when stan-
dard endoscopic or radiologic techniques are inadequate. Multiple studies have found that SBCE
can visually confirm mucosal changes, such as erosions, structures, and ulcers consistent with
Crohn’s disease in 43% to 65% of patients with negative colonoscopies and small bowel imag-
ing.47–49 Solem and colleagues compared SBCE with CTE, SBFT, and ileocolonoscopy in 41 pa-
tients. Each patient underwent all 4 tests on consecutive days and SBCE had the highest sensi-
tivity at 83% but the difference did not reach statistical significance; the specificity was reported
at 53%.50 Although SBCE has high diagnostic yield for nonstricturing small bowel Crohn’s disease,
biopsies cannot be performed thereby making it difficult to rule out other sources of inflamma-
tion. The major risk associated with SBCE is capsule retention, which occurs in 5% to 13% of
patients with Crohn’s disease. Capsule retention is more likely in patients with luminal narrow-
ing which may be due to inflammation or fibrosis. The risk may be mitigated with the use of a
patency capsule prior to capsule endoscopy.
Preoperative optimization
Nutritional assessment and supplementation

There is a longstanding association between malnutrition and poor surgical outcomes. Al-
though a number of different markers of nutrition such as weight loss, serum albumin, and
protein depletion have been linked to poor nutrition and postoperative complications, no single
assessment is reliable by itself. In clinical practice, therefore, the combination of a number of pa-
rameters should be considered including unintentional weight loss exceeding 10% of total body
weight, body mass index <18.5 kg/m2 , and severe hypoalbuminemia. It has been estimated that
between 65% and 80% of patients with Crohn’s disease will have some degree of malnutrition,
underscoring the importance of preoperative nutritional assessment and optimization.51
Ideally, nutritional supplementation occurs via an enteral route. Li and colleagues, retrospec-
tively studied the benefit of 3 months of enteral nutrition in 55 patients with Crohn’s disease
requiring surgery compared to 68 matched controls who maintained their normal diet prior to
surgery. After 3 months, the patients in the enteral nutrition group had higher body mass in-
dexes, greater improvement in serum albumin levels, and a rate of 3.6% for intra-abdominal
septic complications compared to 17.6% in the control group (p < 0.05). Larger studies must be
done to determine the indications and ideal duration of enteral nutrition.
Although enteral nutritional supplementation is generally preferred, in some Crohn’s disease
patients, severe obstruction, localized perforation, or an enterocutaneous fistula may prohibit
oral intake and total parenteral nutrition (TPN) should be considered. Small cases series have
supported the use of TPN in the weeks preceding surgical intervention to decrease the com-
plication rate in patients with Crohn’s disease. One study evaluated 78 patients with penetrat-
ing Crohn’s disease who underwent ileocecal resection. Sixty-eight percent (50/78) of these pa-
tients had required nutritional supplementation, with the majority receiving TPN. Use of TPN
was associated with fewer postoperative complications and a higher rate of primary anastomo-
sis without diverting stoma. Another study matched 15 patients with Crohn’s disease undergo-
ing bowel resection who received preoperative TPN to 105 historical controls and found that
patients given TPN had significantly improved nutritional parameters and no postoperative com-
plications within 30 days as opposed to a 27.6% complication rate in the matched controls (p <
0.05). However, larger studies including a more heterogeneous surgical population have shown
no significant benefit to preoperative TPN. In addition, administration of TPN is not without risk.
Patients may suffer a number of access related, liver, and metabolic complications. Therefore, it
is recommended that all patients with Crohn’s disease undergoing surgical resection should un-
dergo nutritional assessment with enteral or parental supplementation reserved for those with
evidence of malnutrition.
Medication management
Many patients with Crohn’s disease are on immunomodulatory therapy during the periopera-
tive period. The potential for postoperative complications associated with medical therapy is de-
pendent on the type of medication and the dosage/bioavailability. Although there is concern that
immunosuppressive therapy may be associated with an increased risk of postoperative compli-
cations, it must be balanced with the potential benefits of continuing therapy and in some cases
initiating therapy preoperatively to try and control acute inflammation.
Corticosteroids have been associated with an increased risk of postoperative complications
including sepsis, anastomotic leak, and suppression of the hypothalamus-pituitary axis. A re-
cent meta-analysis of 11 studies found an increased risk of postoperative infections (odds ratio
[OR] 1.74, 95% confidence interval [CI] 1.11-2.71) and complications (OR 1.46, 95% CI 1.05-2.31)
with the use of steroids preoperatively. The greatest risk was observed in patients on a dose of
>40 mg daily and the risk of postoperative sepsis appeared to be dose dependent. In a meta-
analysis of data pooled from 71 controlled clinical trials, Stuck and colleagues, found that the
overall rate of infectious complications was 12.7% in the 2111 patients selected to receive sys-
temic corticosteroids as opposed to 8.0% in the 2087 control patients (relative risk 1.6%; 95%
CI 1.3-1.9; p < 0.001).52 The rate of complications increased with increased dosages of steroids.
However, not all studies have demonstrated a significant increase in complications due to pre-
operative steroid use. Bruewer and colleagues, examined the effects of steroids by stratifying
379 patients with Crohn’s disease who underwent bowel resection into groups based on steroid
usage for at least a month prior to surgery and found no significant difference in complications
between the groups.53
The data are mixed as well regarding the degree that anti-tumor necrosis factor alpha (TNFα )
medications contribute to postoperative complications. Appau and colleagues found that a co-
hort of 389 Crohn’s disease patients who underwent ileocolic resection and had been treated
preoperatively with infliximab, had a higher rate of intra-abdominal abscess, sepsis, and read-
mission compared to a group of matched controls.54 However, in a study by Kunitake and col-
leagues, evaluating postoperative outcomes in 413 IBD patients, the complication rate was not
higher in those who have received infliximab preoperatively.55 In our own patient population
we found that of 518 IBD patients who had undergone elective laparoscopic bowel resection,
142 patients had been treated with infliximab during the month prior to surgery. Patients on
infliximab were also more likely to have been receiving steroids preoperatively (73.9 vs 58.8%,
p = 0.002) but incurred no greater risk for anastomotic leak (2.1% vs 1.3%, p = 0.81), infections
(12% vs 11.2, p = 0.92), or thrombotic complications (3.5% vs 5.6%, p = 0.46).56 Recently, studies
have been conducted to examine the risks associated with some of the newer medications in-
cluding vedolizumab and ustekinumab, with variable results.57–59
Medical management is often first line treatment for patients with Crohn’s disease and many
are on combination therapy. Although these medications may cause an increase in postopera-
tive complications, in many circumstances stopping them preoperatively would risk operating
on a patient during an active flare or worsening of their Crohn’s disease related complication.
Therefore, in our practice we advocate using steroids and biologics as needed to treat acute in-
flammation but with tailoring the dosage and timing of surgery to try and mitigate the risk.
Smoking
Smoking is a known risk factor for clinical and surgical recurrence of Crohn’s disease and
cessation should be strongly encouraged in this patient population. In addition, smoking is as-
sociated with higher risks of pulmonary and intra-abdominal septic complications after bowel
resection for Crohn’s disease.60 Recent studies have found that even a 50% reduction of smok-
ing within 6 to 8 weeks prior to surgery reduces the risk of cardiovascular and wound-related
complications.61
In summary, surgery for patients with Crohn’s disease should ideally be delayed until ap-
propriate preoperative evaluation and optimization can be performed. The initial consultation
should focus on an assessment of the patient’s medical/surgical history, nutritional parameters,
and smoking status and obtaining up to date radiologic and endoscopic studies. Cross-sectional
imaging, contrast fluoroscopy, and endoscopy should be used in conjunction to define the na-
ture and severity of disease and assess for Crohn’s disease related complications. If possible, the
evaluation should be reviewed and a plan of care formulated in a multidisciplinary team.
Attempts should be made at correcting malnutrition and downstaging inflammation with a
combination of dietary supplementation and medical management. Enteral nutrition is preferred,
with TPN reserved for situations in which patients either do not tolerate or are not candidates
for oral intake or when enteral feeds alone are not providing adequate support. The lowest dose
of immunosuppression needed to control acute inflammation should be initiated and, if possible,
the timing of surgery should be coordinated based on the last dose of anti-TNFα agents. In
addition, all patients should be encouraged to stop smoking to decrease the risk of postoperative
complications and disease recurrence. If surgery must be done urgently or the patient cannot
Table 1
Golden rules of Crohn’s management.62
1. Crohn’s disease is a pan-intestinal disease with intermittent activity and the potential of focal exacerbations
throughout the patient’s life.
2. It is impossible to cure Crohn’s disease by excision. The surgeon is required only to treat the complications.
3. The essence of surgical treatment is to make the operation as safe as possible. If the operation becomes safe
and patients survive, they will inevitably have recurrences and so repeated operations may be required.
Therefore, it is important to conserve as much gut as possible.
4. All diseased bowel needs not be excised, only the part with complications.
5. If only stenotic complications are being treated, perhaps the stenosis can be simply widened by strictureplasty
or dilation.
be appropriately optimized, then performing the operation as a staged procedure or placing a

diverting stoma may be necessary.
Surgical procedures
In 1987, Drs. Alexander-Williams and Haynes outlined the golden rules for surgical manage-
ment of Crohn’s disease, which have guided us over the last 3 decades62 (Table 1). Indications for
surgery include obstruction, fistula, abscess, perforation, bleeding, malignancy, failure of medical
management, toxic colitis, and growth retardation. Given that Crohn’s disease cannot be cured
with surgical management, we must be cognizant of remaining bowel quality and length when
making decisions regarding surgical management. In addition, the management will vary de-
pending on location in the intestinal tract and underlying disease process.
Abdominal operations
The first component of any abdominal operation for Crohn’s disease is a complete exploration
of the intestinal tract for additional disease and evidence of prior surgical intervention. Dis-
eased bowel will appear hypervascular, thickened, and may have areas of stenosis. The mesen-
tery should be examined for thickness, friability, and creeping fat. Small bowel length may be
measured and documented, particularly if the patient has undergone prior small bowel resec-
tions.
Laparoscopic vs open surgical approach

Laparoscopic colorectal surgery has been widely shown to have benefits over open surgery,
including faster recovery, shorter hospital length of stay, decreased pain, and reduced risk of
surgical site infection.63–67 Given the possibility of extensive inflammation, fistulas, abscesses,
multifocal disease, multiple organ involvement, thickened bowel, and friable mesentery associ-
ated with Crohn’s disease, there is reasonable concern regarding the safety and efficacy of the
laparoscopic approach in these patients. There have been several nonrandomized studies that
support the safety of laparoscopy in Crohn’s disease, but these are likely biased toward noncom-
plex Crohn’s disease. Collectively, they show that operative length is increased with laparoscopy,
however there is a decrease in length of stay, more rapid return of bowel function, decreased
rate of postoperative bowel obstruction, and shorter time to tolerance of oral intake.68,69 To date
there have been 2 randomized controlled trials comparing laparoscopic to open approach for
Crohn’s ileocolic resections. Milsom and colleagues randomized 60 patients to laparoscopic ver-
sus open ileocolic resections and found a decreased rate of minor complication and shorter hos-
pital length of stay in the laparoscopic group.70 There was no difference in major complication,
postoperative pain, or return of bowel function. Long-term outcomes from this study after mean
follow-up of 10.5 years were not statistically different in terms of incidence of anorectal dis-
ease/surgery, endoscopic, radiologic or surgical recurrence, or medication use.71 Maartense and
colleagues similarly randomized 60 patients to laparoscopic versus open approach to ileocolic
resection for Crohn’s disease and again showed lower complication rate and shorter hospital
length of stay with the laparoscopic group.72 Long-term follow-up (median 6.7 years) revealed
similar rates of surgical recurrence and non-disease related complication.73 Overall, these studies
indicate that laparoscopy is as safe and effective as the open approach. Each surgeon must use
his own judgement and individualize decisions based on their skill level and patient character-
istics, such as history of multiple abdominal operations, hemodynamic instability, and inability
to tolerate pneumoperitoneum.
Stapled versus hand-sewn anastomosis

Recurrent disease after resection is of great concern; risk factors include smoking, history of
prior resection, penetrating disease, and extent of disease (>50 cm).74 Additional factors include
fecal stasis and subsequent bacterial overgrowth and local ischemia. Because of this risk of re-
currence, many have investigated any potential differences between the hand sewn end-to-end
anastomosis (HSA) and stapled side-to-side functional end-to-end anastomosis (SSSA). The sta-
pled anastomosis is widely employed in other colorectal resections and saves time as compared
to hand-sewn anastomoses. Munoz-Juarez and colleagues performed a case control comparative
analysis of Crohn’s patients who underwent ileocecectomy and found decreased recurrence rates
(28% vs 12%, p = 0.0041) and decreased need for reoperation (6% vs 0%, p = 0.017) at one year in
SSSA patients as compared to those with a HSA.75 In 2009 McCleod and colleagues performed a
randomized controlled trial of 139 patients randomized to SSSA or HSA. At the 12-month follow-
up point, endoscopic recurrence (HSA 42%, SSSA 37.9%) and symptomatic recurrence (HSA 21.9%,
SSSA 22.7%) were not statistically different.76 A recent Cochrane review (2011) investigated out-
comes of HSA and SSSA in those with ileocecectomy and identified a decreased leak rate with
stapled anastomosis.77 An additional meta-analysis by He and colleagues (2014) that compared
SSSA and HAS identified an overall lower complication rate (OR 0.54, 95% CI 0.32-0.91, p = 0.03),
anastomotic leak rate (OR 0.45, 95% CI 0.20-1.00, p = 0,05), rate of recurrence (OR 0.2, 95% CI
0.07-0.55, p = 0.002), and reoperation for recurrence (OR 0.18, 95% CI 0.07-0.45, p = 0.0 0 02)
in favor of the SSSA.78 These studies indicate that the 2 anastomotic types are at least equiva-
lent with respect to recurrence rates, with the SSSA potentially having an improved incidence of
recurrence. All studies indicate an improved complication rate with SSSA over HSA.
Small bowel disease

Operative interventions of the small intestine are focused on locoregional management of
the diseased segment. The most common indications include obstruction from fibrostenotic dis-
ease and infection from fistula, abscess, or perforation. Fibrostenotic disease can be treated with
strictureplasty and therefore preserve bowel length by avoiding resection. There is concern for
increased recurrence at areas of strictureplasty, as the diseased segment is left in place. Ya-
mamoto and colleagues performed a meta-analysis of 1112 patients who underwent 3259 stric-
tureplasties without resection.79 They identified a 5-year recurrence rate of 28%, however 90%
of patients recurred at non-strictureplasty sites, yielding a site-specific recurrence rate of 3%.
An additional meta-analysis by Reese and colleagues of 688 patients compared those with stric-
tureplasty alone to those with resection with/without strictureplasty.80 Their findings revealed a
decreased complication rate and increased rate of recurrence with strictureplasty alone as com-
pared to resection, however these were not significant.80 The current general consensus is to
perform resection for more significantly diseased pieces of bowel and reserve strictureplasty for
less diseased bowel (Table 2).81 Some advocate for biopsy of each stricture site to rule out un-
derlying malignancy and marking with clips such that the appropriate site can be identified if
there are multiple strictureplasty sites.
Short segment strictures (<10 cm) are best managed with standard Heineke-Mikulicz stric-
tureplasty. In this standard technique, the bowel is incised longitudinally to the extent of the
stenosis. The resulting enterotomy is closed transversely, yielding an increase in luminal diam-
eter. Medium length strictures (12-20 cm) are more often treated with a Finney strictureplasty.
The initially described Jaboulay procedure was simply a side-to-side bypass of the strictured seg-
ment. This technique, however, yielded complications of the diverted segment, therefore Finney
Table 2
Contraindications to strictureplasty.81
• Excessive tension due to rigid and thickened bowel segments

• Intestinal perforation
• Fistula or abscess formation at the planned strictureplasty site
• Hemorrhagic strictures
• Malnutrition/Hypoalbuminemia (<2.0)
• Suspicion of cancer at the planned strictureplasty site
described extension of the 2 enterotomies to create a single u-shaped enterotomy along the
length of the stricture. This is then sutured closed approximating the posterior and anterior
walls and creating a diverticulum. These are at risk for complications of enteric stasis if the
resulting diverticulum is too large. Lastly, long length strictures are treated with side-to-side
isoperistaltic strictureplasties, such as the Michelassi or Poggioli strictureplasty. In the Michelassi
strictureplasty the bowel is transected at the mid-point of the stricture and each side is opened
longitudinally to the extent of the stricture. The 2 spatulated limbs of bowel are anastomosed to
one another in an isoperistaltic fashion. Poggioli suggested a modification to transect the bowel
at one end of the stricture and spatulate the stenosis as well as the equivalent length of nor-
mal bowel across from the transection point. This would be potentially beneficial in that healthy
bowel is included in the anastomosis, however it creates a much longer anastomosis and there-
fore risk of increased bowel loss if a complication arises.
For diseased small bowel requiring resection, the surgeon need only resect macroscopically
involved bowel. There is no difference in recurrence rates when more radical resections are per-
formed either for wider macroscopic margin or to microscopically negative margins.82–84
Special considerations—terminal ileal disease. Terminal ileal disease, specifically, is the most com-
mon indication for surgeon referral in Crohn’s disease.85,86 As with other sites in the small
bowel, this region can be affected by fistulizing disease, abscess, perforation, and obstruction.
Given involvement of the ileocecal valve, disease in this region is treated almost exclusively with
resection, rather than strictureplasty. As with other sites of resection, macroscopically normal
margins are all that is required.
Special considerations—gastroduodenal disease. Gastroduodenal disease is an uncommon mani-

festation of Crohn’s disease, with duodenal stricture being the most common type.87,88 Given
the need to preserve the pancreaticobiliary structures, segmental resection is often not feasi-
ble depending on the duodenal portion involved. Additional options include balloon dilation,
strictureplasty and gastrojejunal bypass.89 Observational studies do not reveal a clear preferred
technique.90,91
Colon and rectald

Similar to the small intestine, the colon may require operative intervention for obstruction,
fistula or perforation. Additional indications for surgery include toxic colitis and acute or chronic
failure of medical therapy. Unlike small bowel disease, operative intervention for Crohn’s colitis
generally involves removal of the entire organ. In the acute setting with a toxic or severely ill pa-
tient, the most appropriate operation is a total abdominal colectomy with Hartman’s pouch and
end ileostomy. Many also advocate for techniques to decrease the risk of Hartman’s pouch blow
out, including oversewing the staple line, leaving a rectal drain or maturing the staple line to the
abdominal wall as a mucous fistula. After the patient recovers from the acute illness, then surgi-
cal options include completion proctectomy with perineal resection or “micro-Hartman’s pouch”
or ileorectal anastomosis, depending on the prior presence of rectal involvement or perianal dis-
ease. Patients with ileorectal anastomosis are at high risk of complication including anastomotic
leak, recurrence, and need for reoperation.92–97 Despite these risks, the literature reports a 48%
to 86% rate of functioning ileorectal anastomosis at 10 years, which continues to support this as
an appropriate option for some patients.
Patients who present for nonemergent surgery may be candidates for total proctocolectomy
at the initial operation depending on the degree of rectal inflammation identified intraopera-
tively. These patients will typically undergo end ileostomy. Ileal-pouch anal anastomosis is not
recommended for Crohn’s disease, however this is offered in some select high volume centers.
Perineal disease
Patients may suffer from external tags, fissures, fistulas, abscess, ulcers, and strictures. The
overriding principles of surgical management of perianal Crohn’s disease are to control infec-
tion with drainage and possible seton or drain placement and avoid damage to the perianal
tissues and sphincter complex. Once infection is controlled, medical therapy should be initiated
including antibiotics and Crohn’s directed therapies. After appropriate medical therapy, setons
and drains may be removed with good results and no need for subsequent fistula operation. If
the fistula remains symptomatic or an abscess recurs, then sphincter sparing operations should
be used such as ligation of intersphincteric fistula tract, endorectal advancement flap, fibrin glue,
or fistula plug. Fistulotomy should be avoided due to increased risk of incontinence and nonheal-
ing wound.
Noninfectious manifestations of Crohn’s disease such as skin tags or hemorrhoids should be
managed expectantly with dietary changes and perianal hygiene. Anal fissures may be “atypical”
in location and should also be treated nonoperatively with a good bowel regimen and topical
medications such as calcium channel blocker or nitroglycerin. If the fissure persists, Botulinum
toxin may be used for chemical sphincterotomy, and surgical sphincterotomy should be avoided.
Chronic ulcerations, fissures, or wounds should be biopsied due to risk of malignancy.
In instances when perianal disease is debilitating and not responding to medical therapy, a
proctectomy with permanent end colostomy may be warranted. Alternatively, a diverting loop
ileostomy or colostomy may help with infection control, however patients should be counseled
that this may be a permanent stoma if the infection does not resolve.
Asymptomatic anal strictures can be watched without intervention. Once symptomatic they
can be treated with serial dilation (digital, balloon, or Hegar). Unfortunately, one half of these
patients will ultimately require proctectomy.94
In summary, surgical management of Crohn’s disease should be individualized for each pa-
tient depending on the degree of illness, location of disease in the intestinal tract, type of dis-
ease, and prior surgical history.
Surgical prophylaxis of Crohn’s disease recurrence
Despite the advances in medical therapy, approximately 80% of patients with Crohn’s disease
will require an intestinal resection for complications related to stricturing or penetrating dis-
ease during their lifetime.98,99 Surgical therapy is not curative and addresses complications and
disease-related symptoms. Unfortunately, postoperative surgical recurrence is still a common oc-
currence. In fact, endoscopic recurrence has been observed in up to 70% of patients within 1 year
of the operation,100 and almost one third of the patients who underwent an intestinal resection
will require a second operation.101
Previous studies have evaluated the efficacy of medical therapy on preventing postoperative
recurrence. Although nitroimidazole antibiotics showed clinical benefits, endoscopic recurrence
rates remain high after 1 year of treatment.102,103 Similarly, thiopurine analogues, such as aza-
thioprine or 6-mercaptopurine, have failed to prevent postoperative recurrence and are associ-
ated with significant adverse events.104–106 In 2009, a randomized controlled trial evaluated the
effectiveness of infliximab, a monoclonal antibody to human TNFα , in preventing Crohn’s disease
recurrence after ileal resection. Compared to the placebo group, patients receiving infliximab
had significantly lower rates of endoscopic recurrence (9.1% vs 84.6%) and histologic recurrence
(27.3% vs 84.6%) at 1 year.107 The subsequent Infliximab for Prevention of Recurrence of Post-
Surgical Crohn’s Disease Following Ileocolic Resection, however, found that although infliximab
reduced the endoscopic recurrence, patients receiving infliximab and placebo had similar clinical
recurrence rates at 76 weeks (12.9% vs 20.0%).108
Overall, current level I data suggest that medical therapy does not prevent surgical recur-
rence in patients with Crohn’s disease. Therefore, efforts should be made to optimize surgical
technique and offer the best possible operation at the right time to the right patient.
Anastomotic site: the Achilles’ heel
Endoscopic recurrence has been observed in up to 60% of patients who underwent ileocolonic
resection at 6 months. Anastomosis and recurrence are intrinsically related. Postoperative recur-
rence typically occurs at the anastomotic site or in the neoterminal ileum in patients with pre-
vious ileal involvement.109 Moreover, the risk of recurrence is extremely low in patients with
permanent end ileostomies.110 Hence, the sole presence of an anastomosis could predispose in
different ways to disease recurrence. Functional obstruction, reflux of colonic contents into the
neoterminal ileum, and fecal stasis after ileocolic anastomoses are likely to play a role in the
pathogenesis of Crohn’s disease recurrence.111 Remarkably, D’Haens and colleagues112 showed
that the infusion of intestinal luminal contents into excluded segments of ileums triggered lo-
cal inflammation and postoperative recurrence of Crohn’s disease. In addition, a previous study
demonstrated that suture materials could impair the macrophage’s function in the proximity of
an anastomosis and this could also influence the risk of local recurrence.113
Microvascular injury and local ischemia are also factors associated with anastomotic recur-
rence. The bowel’s blood flow is significantly decreased in patients with Crohn’s disease.114 Blood
supply is likely to be even more compromised at the anastomotic site. In an animal model, Os-
borne et al.115 found that ischemic insults at the anastomosis could produce a pattern of intesti-
nal inflammation similar to that seen in patients with anastomotic recurrence. Angerson and
colleagues116 used endoscopic laser Doppler flowmetry to measure neoterminal ileal blood flow
after ileocolic resection for Crohn’s disease, and found that flow measurements were inversely
correlated with the endoscopic recurrence grade.
Wide-lumen side-to-side versus end-to-end anastomosis
Theoretically, an end-to-end anastomosis could predispose to recurrence by creating a func-

tional obstruction at the site of the anastomosis with proximal fecal stasis and reduction of
blood supply to the proximal bowel due to increased intraluminal pressure. Therefore, many
surgeons advocated the use of a wide-lumen side-to-side anastomosis.
In 1996, Caprilli and colleagues117 reviewed data on 110 patients enrolled in a multicen-
ter trial looking at the effectiveness of 5-aminosalicylic acid in the prevention of postoperative
Crohn’s disease recurrence. The authors found that patients with end-to-end anastomoses had a
risk of recurrence more than 3 fold higher than those with other types of anastomosis (relative
risk 3.40). Subsequently, Hashemi and colleagues118 stated that stapled wide-lumen side-to-side
anastomoses after resection for Crohn’s disease were associated with fewer complication rates
than sutured end-to-end anastomoses and delayed reoperations for symptomatic recurrences.
The authors believe that the difference is due to the anatomic configuration (side-to-side vs
end-to-end) and not the anastomotic technique (stapled vs hand sewn).
In 2001, Muñoz-Juárez and colleagues75 compared the results of 69 patients with wide-lumen
stapled side-to-side anastomoses and 69 patients with handsewn end-to-end anastomoses. Clini-
cal recurrence occurred in 16 (24%) of the wide-lumen anastomosis group and in 39 (57%) of the
end-to-end anastomosis. The cumulative reoperation rate at 5 years was 11% after wide-lumen
anastomosis and 20% after conventional end-to-end anastomosis (p = 0.017). These promising re-
sults suggested that the wider diameter of the anastomosis could decrease the ischemia-induced
recurrence rates, reduce the occurrence of proximal fecal stasis with the resulting modification
of the local microbiome, and delay the recurrence of symptoms.
A meta-analysis comprising 8 studies with 661 patients who underwent 712 anastomoses
compared the outcomes between end-to-end anastomoses (53.8%) and other types of anasto-
motic configurations (46.2%), including stapled side-to-side in the vast majority. Overall post-
operative complications and postoperative hospital stay were significantly reduced in the side-
to-side anastomosis group. However, there were no significant differences between the groups
regarding anastomotic recurrence and reoperation needed because of anastomotic recurrence.119
In 2009, the results of the CAST trials were released. In this trial, patients with Crohn’s dis-
ease who underwent ileocolic resection were randomized to either side-to-side anastomosis or
end-to-end anastomosis. A total of 139 patients were included and after a mean follow-up of
11.9 months, the endoscopic recurrence rate was 37.9% in the side-to-side anastomosis group and
42.5% in the end-to-end anastomosis group (p = 0.55). The symptomatic recurrence rate was also
similar between the 2 groups (22.7% vs 21.9%, p = 0.92).76 This study represents the only level
1 evidence comparing these 2 types of anastomosis and questions the benefits of wide-lumen
stapled anastomoses in preventing recurrence of disease.
Kono-S anastomosis
In 2003, Kono and colleagues from the Asahikawa Medical University Hospital in Japan de-
veloped a unique antimesenteric functional end-to-end handsewn anastomosis to prevent anas-
tomotic recurrence in Crohn’s Disease.120
Surgical technique
Step 1—Mesentery and bowel division: Once the intestinal segment to be resected is iden-
tified (Fig 8), a small window in the mesentery is created at the proximal and distal re-
section margins. The mesentery is divided at the mesenteric edge of the bowel wall with a
vessel-sealing device. This step is critical in order to avoid unnecessary devascularization and
Fig. 8. The intestinal segment to be resected is identified. In this cartoon represented by a stricture with moderate
amount of mesenteric inflammation. Drawing by Shiori Kono.
Fig. 9. The bowel is then transected transversely with linear stapler sutures placing the staplers perpendicular to the
intestinal lumen and mesentery. The mesentery is divided close to the bowel. Drawing by Shiori Kono.
Fig. 10. Corners of the staple lines are reinforced with sutures. Drawing by Shiori Kono.
denervation of the residual bowel. The bowel is then transected transversely with linear stapler
sutures placing the staplers perpendicular to the intestinal lumen and mesentery (Fig 9).
Step 2—Creation of the supporting column: Corners of the stump are reinforced with su-
tures (Fig 10) and the 2 stapled lines are then sewn together with interrupted sutures spaced
apart in order to create the “supporting column” (Fig 11). If the caliber of the 2 intestinal seg-
ments differs significantly (eg, small bowel to colon anastomosis), the sutures are spaced in
order to evenly distribute the surplus of tissue of the larger segment and obtain good approxi-
mation and stable support for the anastomosis.
Fig. 11. The two stapled lines are then sewn together with interrupted sutures spaced apart in order to create the
“supporting column”. Drawing by Shiori Kono.
Fig. 12. An antimesenteric longitudinal enterotomy and colotomy are performed starting at no more than 1 cm from
the staple line and extending it to allow a transverse lumen of 7 cm on the small intestine and close to 8 cm on the
large intestine. Drawing by Shiori Kono.
Step 3—Creation of the anastomosis: An antimesenteric longitudinal enterotomy (or colo-

tomy) is performed on each stump starting at no more than 1 cm from the staple line and
extending it to allow a transverse lumen of 7 cm on the small intestine and close to 8 cm on
the large intestine (Fig 12). The anastomosis is performed by closing the longitudinal opening
transversely either in a single layer Gambee manner or in 2 layers with running and interrupted
sutures. The result is a wide lumen anastomosis with complete exclusion of the mesentery and
preservation of innervation and vascularization with a stable posterior supporting column that
prevents distortion of the fecal stream (Fig 13).
Fig. 13. Wide lumen anastomosis with complete exclusion of the mesentery with a stable posterior supporting column.
Drawing by Shiori Kono.
Advantages of Kono-S anastomosis

There are several advantages of the Kono-S anastomosis. First, the mesentery is divided as
close as possible to the bowel wall preserving the blood supply and innervation, which are cru-
cial during the healing process of the anastomosis and to further prevent endoscopic recurrence.
Second, the mesentery is completely excluded from the anastomotic lumen. Both primary and
recurrent Crohn’s disease originates from the mesenteric side of the bowel wall. The mesenteric
adipose tissue clearly plays a role in disease progression and excluding it from the anastomotic
lumen has theoretical advantages. Third, the supporting column is located immediately behind
the posterior wall of the anastomosis, preventing flow limiting alteration of the fecal stream and
maintaining the orientation and the large diameter of the anastomosis. Fourth, the functional
end-to-end anastomosis with “trumpet” shape allows successful postoperative endoscopic ob-
servation and treatment (ie, balloon dilatation). Finally, since the mesentery is divided close to
the intestinal wall, closure of the mesentery is usually not necessary.
Results of Kono-S anastomosis

Kono and colleagues first reported the outcomes of this novel technique comparing 69 pa-
tients after Kono-S anastomosis with 73 patients who underwent conventional anastomosis
(handsewn end-to-end, handsewn side-to-side, or stapled functional end-to-end). The median
endoscopic recurrence score (Rutgeerts score) at 5 years was significantly lower after the Kono-
S anastomosis (2.6 vs 3.4, p = 0.008). Surgical recurrence was also significantly less likely with
this new anastomosis (0% vs 15%, p = 0.0013).120
The Kono-S anastomosis was rapidly adopted in other medical centers. In our own experi-
ence121 we followed 44 patients after 46 Kono-S anastomoses and reported no surgical recur-
rences during the study period and an average Rutgeerts score of 0.722 at a mean follow-up of
6.8 months. Similarly, Katsuno and colleagues122 evaluated 30 consecutive patients who under-
went Kono-S anastomosis and reported no anastomotic leakages or surgical recurrences during a
median follow-up period of 35 months. Endoscopic surveillance evidenced an average Rutgeerts
score of 0.78 at a mean of 14.5 months postoperatively.
In 2016, an international multicenter study conducted at 5 hospitals (four in Japan and 1
in the United States) analyzed 187 patients who underwent Kono-S anastomosis for Crohn’s
Disease. In the Japanese cohort (144 patients), surgical recurrence occurred only in 2 patients,
with a 5-year recurrence-free survival rate of 98.6%. In the American group (43 patients), no
surgical recurrences occurred during the follow-up period of 32 months.123 Currently a multi-
center prospective randomized trial is underway in the United States comparing the Kono-S to
conventional side-to-side anastomosis.
In summary, surgical recurrence of Crohn’s disease is still a common occurrence and most
often is noted at the anastomotic site after bowel resection. Anti-TNF therapy has not yet been
proven to prevent surgical recurrence and the cost-benefit ratio of such an approach still re-
mains to be determined. Therefore, it is of paramount importance to offer the operation with
the lowest proven recurrence risk to Crohn’s disease patients. The Kono-S anastomosis is a safe
and feasible anastomotic technique suitable for both the small and large intestine. Current data
suggest that the Kono-S anastomosis is associated with very low rates of surgical recurrence.
Randomized trials are underway to confirm the benefits and value of this anastomotic technique
in reducing surgical recurrence in Crohn’s disease.
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Current Problems in Surgery 55 (2018) 162–187

Contents lists available at ScienceDirect

Current Problems in Surgery

journal homepage: www.elsevier.com/locate/cpsurg

Role of surgery in the management of Crohn’s

Indications for surgery

Preoperative evaluation and medical optimization

Despite signiﬁcant advances in the medical management of Crohn’s disease, approximately

Preoperative evaluation consisting of a detailed history and physical examination, radiologic

History and physical exam

Fig. 2. “Target sign” due to differential enhancement of the bowel wall.

Fig. 3. Stricture with proximal small bowel dilation.

Nutritional assessment and supplementation

be appropriately optimized, then performing the operation as a staged procedure or placing a

Laparoscopic vs open surgical approach

Stapled versus hand-sewn anastomosis

Small bowel disease

• Excessive tension due to rigid and thickened bowel segments

Special considerations—gastroduodenal disease. Gastroduodenal disease is an uncommon mani-

Colon and rectald

Surgical prophylaxis of Crohn’s disease recurrence

Anastomotic site: the Achilles’ heel

Wide-lumen side-to-side versus end-to-end anastomosis

Theoretically, an end-to-end anastomosis could predispose to recurrence by creating a func-

Step 3—Creation of the anastomosis: An antimesenteric longitudinal enterotomy (or colo-

Advantages of Kono-S anastomosis

Results of Kono-S anastomosis

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