Surgical approach of

patients with crhons

disease
By:Hanaa Tashkandi
 Abdominoperineal resection:
 Anterior resection:

anterior proctosigmoidectomy with

colorectal anastomosis.
*Low anterior resection:
resection of the rectum below the
peritoneal reflection.
 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.
 The anastomosis post resection usually
result in a significant alteration in the
bowel habit …. WHY ?
 Due to loss of normal rectal
capacity ..which is called LAR syndrome…
 Symptoms:
 frequent small bowel
movements”clustering”
 How to prevent this?
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.
 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
 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.
 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.
Left hemicolectomy:
 resection from the splenic fexure to the
rectosigmid junction
 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.
Sigmoidectomy:
 removal of the colon between the
partially retroperitoneal descending colon
and the rectum.
Crohns disease

 Pattern of the disease:

 1-inflammation
 2-sticture
 3-perforation
 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.
 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.
Indications for surgery
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.
 Surgery is indicated if the patient cant be
weaned of the steroid within 3-6 months.
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.
 So patients with obstructive symptoms that
result from fibrotic fixed strictures need
surgery.
Enteric fistula
 Asymptomatic entero enteric fistula don’t 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)
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..
hemorrhage
 Un common in crohns .
 But frequent with crohns colitis than small
bowel crohns.
perforation
 Is rare;;
 Only in 1% of the cases.
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.
Growth retardation
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.
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.
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.
 Once the resection is completed , the
proximal and distal margins of the
specimen should be examined to ensure
they are free of GROSS disease.
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 ..
 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.
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..
strictureplasty
 Indications:
 for jejunoileitis with single or multiple
fibrotic stricture..
 isolated stricture in the duedenum.
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.
Methods
 1- HEINEKE-MICULICZ:
 Longtudinal enterotomy is done on the
antimesenteric side.
 Which then close transverly ‘’..
 Used if the stricure is < 7 cm.
 Bx should be taken.
 2- FINNEY:
 Used for long stricture up to 15 cm.
 Result in the formation of divericum.
 Used less frequantly bec.of its side effects.
 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.
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.
Crohns of the colon
 Segmental colectomy.
 Ileocecal resection with primary
anastomosis.
 Total abdominal colectomy with
ileoproctostomy.
 Total proctocolectomy with permennat end
ileostomy.
 Note:
 Because of the recurrent nature of
crohns ,,a restorative procedure as ileal
pouch-anal anastomosis is inappropriate.
 Ileocolitis:
 -ileocecal resection with primary
anastomosis..
 Any why,,disease tends to recur at the
anastomotic or pre anastomotic ileum.
 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..
 Unfortunatley,,recurence after total
abdominal colectomy with ileorectal
anastomosis is common..
 Many of these patients ultimatly will
require proctectomy with permenant
ileostomy’’
Perianal crohns disease
 Abscess.
 Fistulae.
 Fissures.
 stenosis.
 Hypertrophied skin tags.
 ----each one of them is treated accordingly..
Thank you