more commonly seen in ulcerative colitis or diverticular disease. Each of these will be outlined in the

following sections. Despite improvements in medical therapy, over 70% of all Crohn patients will

require surgery at some point in their lives, with almost half of those undergoing one operation

requiring additional procedures. Therefore, having a firm understanding of the general principles and

technical specifics is important to surgeons who care for these patients.

General Principles

3 While Crohn disease can affect the entire GI tract from mouth to anus, certain overriding principles

can help guide the planning and operative management. First, Crohn disease is a process marked by

lifelong potential for recurrence; therefore, preservation of bowel when possible and consideration of

future function are paramount concerns during the planning phase.74 Next, the extent of resection

required is dependent on multiple factors, including location and duration of disease, ability to exclude

malignancy, and prior resections that may have resulted in shortened small bowel. In addition, as the

stools tend to be loose, consideration must be given to rectal compliance and sphincter function during

surgical planning to avoid a “perineal colostomy,” whereby in-continuity management is preserved but

the patient has no control. Furthermore, unlike ulcerative colitis, segmental resection for both small and

large bowel is common with ileocolonic, colo-colonic, and rectal anastomoses all playing a role in

avoiding a permanent stoma while maximizing functional bowel.75 Crohn patients with pancolitis may

undergo a total abdominal colectomy with ileorectal anastomosis (for those with rectal-sparing) or total

proctocolectomy with end ileostomy.76 Total proctocolectomy with ileal pouch-anal anastomosis is

typically discouraged, and is normally the result of an initial misdiagnosis of ulcerative colitis.

4 Technical tips also come into play when planning for Crohn resections. For example, when

performing a proctectomy, it is important to consider the potential for a delayed or nonhealed perineal

wound. An intersphincteric dissection, which maximizes the amount of healthy muscle/tissue remaining,

facilitates closure in attempt to avoid this complication. Some patients will require more extensive

procedures such as flaps that utilize adjacent tissues (i.e., gracilis, bulbocavernosus), and may require

plastic surgeon involvement.77 In addition, as in the small bowel, length of resection margins does not

influence the risk of relapse with segmental resections, and only grossly normal bowel is all that is

required.78 Finally, diversion may be more commonly used due to both the presence of active disease as

well as the potential negative healing effects of the Crohn medications.

ABDOMINAL FISTULAS

Intra-abdominal fistulas may arise from either the small or large bowel and affect nearly every adjacent

structure. Similar to any fistula, it is important to determine the site of origin of the fistula, as this

section of bowel will typically require a formal resection when symptomatic (Fig. 50-14). On the other

hand, a section of bowel may simply be involved in the process secondarily as a “bystander,” and the

preferred treatment is to take the fistula down and primarily repair the site. It is important to ensure

there is no significant active disease at the closure site, as this may predispose to healing problems and

a subsequent leak. In this case, the preferred strategy would be to perform a segmental resection.79

Transmural bowel inflammation and communication can also occur more commonly with the skin,

bladder, or vagina. Once again, the bowel is the offending organ and should be resected, while ligation

of the fistula and closure of the secondarily involved organ is adequate treatment. In certain cases, the

inflammatory process is so intense, or there is a concern for concomitant malignancy, that the entire

process should be resected en bloc. When an abscess is present, it is often preferable to percutaneously

drain the abscess and ensure adequate medical therapy (that often includes biologics), prior to

embarking on abdominal exploration.80 Finally, asymptomatic entero-enteric or entero-colonic fistulas

are often best left alone and treated medically, especially with the relative success of anti-TNF agents.81

1300

Figure 50-14. Entero-enteric-colonic fistula.

OBSTRUCTION AND STRICTURE

Strictures in Crohn disease most commonly occur in the terminal ileum, but may arise anywhere along

the GI tract (Fig. 50-15). Due to the transmural inflammation, it is not uncommon to have luminal

narrowing within the bowel especially with repeated flares. However, the underlying pathophysiology

may be from a phlegmonous/inflammatory process or secondary to the fibrostenotic pattern of disease.

In the former, medical management may be successful, decreasing the inflammation and resolving the

intrinsic or extrinsic “compression” on the bowel wall. On the other hand, patients with fibrotic

strictures typically have little to no response to medical management (including anti-TNF agents) and

most often require surgery.82–84 Emerging evidence suggests early treatment of strictures with

aggressive biologic therapy may aid in preventing the onset of fibrosis, especially in patients under 40,

prior to the onset of the irreversible cascade of fibrosis where surgery becomes inevitable.85

Figure 50-15. Endoscopic balloon passing through the ileocecal valve to dilate a stricture.

Strictures also differ somewhat based on their location. The rate of colonic strictures has been

reported to be as high as 7% to 17%.86 In general, these benign strictures are responsive to medical

management as well as endoscopic dilation for moderate-to-high–grade stenosis. Complicating the

situation, malignancy has been shown to be present in ∼7% of all colonic strictures,87 and Crohn

disease carries an increased risk of colorectal cancer above the general population. Furthermore, it is

very difficult to differentiate malignant from benign strictures on strictly clinical basis. Therefore all

colonic strictures should undergo endoscopic evaluation and biopsy. If malignancy is detected (or the

lesion appears worrisome and remains indeterminate on work-up), a standard oncologic resection

should normally be performed. For those that are clearly benign and nonresponsive to medical

management, endoscopic dilation has been shown to provide symptomatic relief. Technical success

occurs in ∼70% to 90%, and provides initial symptomatic resolution in over 80% of patients.88

Unfortunately, most patients with colonic strictures require repeated dilations. The procedure is

generally safe, with hemorrhage and perforation occurring in <5%, and most often occur when balloon

sizes over 25 mm are used. Although concomitant direct injection of the stricture with steroids or

treatment with systemic steroids immediately after dilation have both demonstrated some success in

1301

case series, the true effect of this remains uncertain.

Strictures of the small bowel have been reported in 20% to 40% of Crohn patients.89 Treatment

typically consists of medical management, though depending on the severity, many patients will require

intervention. Small bowel strictures are often amenable to dilation via double-balloon enteroscopy,

especially in the 10- to 20-mm range, though perforation is a known risk.90,91 Symptomatic relief occurs

in ∼75% to 90% following the first dilation, while approximately 30% to 40% will require repeated

intervention over the next 3 years. For those with initial success, the cumulative dilation-free rate at 3

years is ∼40% to 50%.92 Overall complications occur in ∼10% to 15% (<5% major complications),

and include pain, fistula, fevers, bleeding, and perforation.93 Despite this success, many will require

operative intervention when symptoms fail to resolve, repeated bouts occur, or when a stricture is

associated with a nonresolving inflammatory process, malnutrition, immunosuppression or fistula.

Options then include strictureplasty (see below) or resection.

Strictureplasty preserves bowel length by avoiding resection altogether. The Heineke–Mikulicz

method involves a longitudinal incision along the antimesenteric border of the bowel with a transverse

closure, and is useful for shorter segments of bowel. Additional techniques include the Finney

strictureplasty, classically used for longer strictures of 7 to 15 cm in length, where the diseased segment

is opened longitudinally, the bowel is folded upon itself, and a full-thickness anastomosis is formed. In

another method, an isoperistaltic strictureplasty is constructed such that the narrowed diseased portion

of the bowel is anastomosed to the dilated segment of an adjacent loop in a side-to-side manner.

Complications have been reported in 4% to 15% in large series, and include obstruction, bleeding,

sepsis, perforation, and death.94,95 Overall, 5-year recurrence rates for strictureplasty in jejunoileal and

ileocolonic locations have been reported between 25% and 30%, including an ∼3% site-specific

recurrence. Similar to endoscopic dilation, malnutrition, presence of a phlegmon/perforation/fistula at

the site, multiple strictures within a small segment, and suspicion of a malignancy are all

contraindications to strictureplasty.96

Strictures at prior anastomotic sites may occur from recurrent disease or secondary to technical

problems. They are often amenable to dilation,97 yet they are often fibrotic in nature and

nonresponsive, thus requiring resection for symptomatic strictures. To prevent this, evidence from

systematic reviews and meta-analyses suggests that side-to-side stapled anastomoses in Crohn patients

undergoing an ileocolonic resection have a decreased rate of postoperative complications (OR = 0.54),

leak (OR = 0.45), recurrent (OR = 0.2), and reoperation (OR = 0.18) when compared to hand-sewn

end-to-end anastomoses.98,99

MALIGNANCY

5 Historically, the risk of malignancy with Crohn disease was felt to be only slightly higher than the

general population and significantly lower than the risk of patients with ulcerative colitis.100 More

recently, population-based data suggest that the cancer risk with long-standing Crohn’s is ∼4- to 20-fold

above that of the average population, and equivalent to patients with ulcerative colitis. Known risk

factors for malignancy include pancolitis (at least one-third) and a disease duration of >8 years.101–103

Endoscopic surveillance strategies to detect malignancy have had to date mixed results.104 Data from a

large meta-analysis found that surveillance colonoscopy has not shown to effect survival in these

patients, though lesions are typically detected earlier.105,106

The optimal surveillance strategy for patients with Crohn disease has not been determined. As such,

most recommendations favor mimicking surveillance for ulcerative colitis in patients with Crohn colitis.

In this algorithm, surveillance colonoscopy begins 8 years after disease onset for pancolitis and 15 years

for patients with left-sided disease, and is repeated every 1 to 2 years. In addition, the American Society

for GI Endoscopy, American College of Gastroenterology, and American Gastroenterological Association

were unable to draw conclusions regarding the benefit or need to perform random surveillance

biopsies.107–109 Treatment for malignancy in the Crohn patient is similar to that of the general

population, with resection following standard oncologic principles. As synchronous and metachronous

lesions have been reported in up to 10%, consideration should be given to a subtotal colectomy with

ileorectal anastomosis in the absence of rectal lesions.

While most evidence is from patients with ulcerative colitis, a polyp in a setting of colitis

(nonadenoma dysplasia–associated lesion or mass-DALM) has traditionally felt to carry a significant risk

of malignancy and is a strong indication for a formal resection.101,110–113 While these nonadenoma-like

1302

DALMs should typically undergo a colectomy, more recent evidence suggests that complete endoscopic

excision of an adenoma-like DALM (i.e., a sporadic adenoma occurring in a patient with colitis with or

without active disease) may be safely undergo a surveillance protocol.114 Low-grade dysplasia outside

the setting of a nonadenoma-like DALM, and even in areas flat mucosa, warrants close follow-up,

although the need for follow-up resection remains unproven.101,113

HEMORRHAGE

Patients with Crohn may complain of bloody stools, however, frank hemorrhage in Crohndisease is

fairly uncommon. Possible sources include deep ulcerations, toxic colitis, an underlying mass, or

concomitant diverticular bleed. Significant upper GI bleeding is also rare, and likely from a secondary

source other than Crohn’s (e.g., ulcer, varices, esophageal tear, malignancy). Similar to any other

patient with a significant GI hemorrhage, patients require continued resuscitation, correction of any

coagulopathy, and transfusion as indicated. Adjunctive measures such as intravascular vasopressin and

infliximab have also been described,115,116 though should not be considered first-line agents. Endoscopy

is the most useful diagnostic and therapeutic maneuver for bleeding from either an upper or lower

source. When endoscopy or medical therapy is unsuccessful or bleeding recurs, segmental resection is

preferred when the source is localized in the large or small bowel. In the setting of unlocalized disease,

every effort should be made to identify the source of bleeding, including upper and lower endoscopies,

nuclear medicine scans, angiography, and small bowel evaluation (push endoscopy, video capsule

endoscopy, or small bowel follow-through). However in the unstable or nonlocalizable lower source, a

subtotal colectomy with end ileostomy may be required.117 In the case of upper GI bleeding, the source

may be localized and controlled with endoscopy or may require a resection or ligation as in patients

without Crohn disease depending on the underlying pathology.

SPECIFIC CONSIDERATIONS

Gastroduodenal Disease

As stated, gastroduodenal disease occurs in 0.5% to 4% of all Crohn patients. The most common

indications likely to require advanced or surgical intervention involve stricture/obstruction, fistula or

bleeding. Isolated gastric disease is even more rare,118 as the stomach will hardly ever be the sole

source for the patient’s complaints. It is important to exclude H. pylori infection, gastritis (NSAIDs),

ulcers, and malignancy in the absence of disease elsewhere in the GI tract. Most patients will respond to

medical management, especially with the anti–TNF-α therapy.119 Gastric outlet obstruction at the level

of the pylorus and first portion of the duodenum is often amenable to endoscopic balloon dilation, with

avoidance of surgery in approximately half of patients.120

Duodenal strictures are more frequent with disease in this location, and case series have demonstrated

successful amelioration of symptoms with endoscopic dilation.121 More often, symptomatic duodenal

strictures nonresponsive to medical therapy will be managed by strictureplasty, resection, or to a lesser

extent, bypass (i.e., gastrojejujostomy). As previously noted, the type of strictureplasty will depend on

the location, status of the surrounding tissues (i.e., ability to mobilize), and length of the stricture.122

Fistulas typically arise from disease located more distally in the small bowel, and therefore require

resection of the primary site with closure of the stomach or duodenum. Occasionally the upper tract is

the original of the fistula and resection or bypass is required. With appropriate expertise, a laparoscopic

approach has been associated with fewer complications and improved recovery. If bypass is performed,

vagotomy is not needed; however, every effort should be made to avoid bypass if possible, as this is

associated with worsening diarrhea and nutritional abnormalities.123 For those cases where resection or

closure of the duodenum is required, a jejunal serosal patch or Roux-en-Y duodenojejunostomy may help

minimizing wound breakdown and recurrent fistulas.124

Small Bowel Disease

Most small bowel disease is amenable to surgical resection and primary anastomosis. As stated,

strictureplasty is another option for those patients with short bowel, multiple sites of noncontiguous

disease, and early recurrence – especially for those with noninflammatory patterns. Following resection,

consideration should be given to the nutritional status of the patient, medications, and overall

1303