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home - IBD - Surgery - Crohns Surgery Written by Dr Sebastian Zeki
Knowledge

Knows the criteria for assessing the severity and extent of IBD, in
particular recognition of acute severe colitis. Knows treatment options
including aminosalicylates, corticosteroids, and steroid sparing
therapies.

Knows differing methods of delivery for therapy.
Skills
Selects of appropriate treatment for extent and severity of disease,
including timing of immunomodulator therapy and referral for surgery.

Behaviours
Recognises the urgency of treating acutely sick patients, including
multidisciplinary team early, particularly surgeons. Clearly explains
the clinical situation and treatment options to patient and family.
Involves patient and family in decision making about treatment
options.

also....
Knows the complications of IBD including stricturing, fistulae,
extraintestinal manifestations, colon cancer and special situations
such as pregnancy.

Skills
Able to recognise potential complications and take appropriate action
to investigate and alter treatment as necessary including referral for
surgery and involvement of other healthcare professionals

Behaviours
Works with patient to explain complications and options for treatment
Involves the multidisciplinary team especially IBD nurse and surgeon
in management, and tailors treatment to the needs of the patient.
Discusses with colleagues early and appropriately

Also...

Knowledge


Understands the indications for surgery in active disease and for
complications including structuring and fistulising disease

Understands different surgical approaches in particular methods of
bowel-preserving surgery in Crohn’s disease and long term options
for surgery in UC

Recognises that early liaison with surgeons is important in high
quality patient management

Skills
Has appropriate discussions with surgeons when patients are
admitted with active disease

Involves surgeons early in patients with difficult chronically active
disease or with complications

Is able to explain clearly to patients and relatives the role of the
surgeon and possible surgical approaches to treatment
PS
Behaviours
Shows willingness to liaise appropriately with surgical teams
Explains clearly to patients and relatives the involvement of the
surgical teams and their importance and possible outcomes

Also...

Knowledge


Knows the pathogenesis and complications of fistulising Crohn’s
disease including perianal enteroenteric enterocutaneous
colovesical and rectovaginal fistulae

Understands the different treatment modalities available for treatment
of fistulae including antibiotics immune modulators biologics
surgical drainage and the possible combinations that may be
required

Is aware of the importance of joint medical-surgical management of
complex fistulae and of nutritional support for high output fistulae

Skills
Able to detect the possibility of fistulising disease and to perform
appropriate investigations

Can liaise with surgical colleagues to define the most appropriate
management plan

Behaviours
Can make an appropriate of fistulae including deciding a
long term management strategy

Can provide an appropriate explanation of the problem to the patient PS
Involves all relevant health professionals and patient in deciding the
appropriate treatment strategy

Crohns Surgery

Surgery in Crohn's 70-80% have operation Limited resection rather than left hemi for TI/ascending colonic Small intestinal strictures: Stricturoplasty i) Usually for strictures <10 cm in length, but can be for longer ii) A phlegmon in the bowel wall, carcinoma, or active bleeding mucosal disease are contraindica - tions Where there are multiple strictures in a short segment and where bowel length is sufficient to avoid short bowel syndrome, resection may be preferable Localised ileal or ileocaecal disease (<40cm affected with CDAI >220Jury’s out on what to doIf have surgery, 50% chance of no further operationIf steroids, will need surgery sooner or later Concomitant abscess Usually drain and consider surgery later However, most series favour a delayed resection, although opinions varyAnastomotic technique Stapling vs hand-sewn- Difference in anastomotic recurrence unclear ‘‘Coincidental’’ ileitis If ileitis at appendicectomy, remove appendix and leave ileum,- if more experienced surgeon, can do primary resection if typical for Crohn‘s Laparoscopic resection Usefullness in Crohn’s not fully established Surgery and medicationIFX is not a risk factor for surgical complications.The optimal time span between treatment with IFX and abdominal surgery is unclear.IFX hangs around for 8 weeks.Corticosteroids is a risk factor for postoperative complications. >20 mg prednisolone for 6 weeks do have an increased risk for surgical complications.Thiopurines dont increase the risk of surgical complications. Dilatation of strictures Dilatation is an accepted technique for the management of mild to moderate stenosing diseaseOutcomes suggest a short to mid-term benefitColonic stricturoplasty Not an option. Also increased cancer risk in a stricture Localised colonic disease Limited colonic CD treated by limited resection gives a higher rate of recurrence than a proctocolectomyBut avoidance of a permanent stoma usually outweighs the increased risk of recurrence Multi-segment colonic diseaseJury’s out on segmental resection + two anastomoses vs subtotal colectomy with an ileorectal anastomosis should be performed when macroscopic disease affects the ascending and the whole of the sigmoid colon Endoscopic 70% recurrence within 12 months/ 100% within 3 years without treatment Fistulas-if simple for fistulating/draining Setons or diversion procedures Small intestine strictures-stricturoplasty Ileorectal anastomosis: if rectum is spared Split ileostomy and Hydrocortisone in distal limb heals resistant perianal/colonic disease Ileo pouch-anal anastomosis (IPAA) Can be used if no small bowel/ perianal disease but not recommended Failure rate can be as much as 50% (only slightly more in CD vs UC End to end anastomosis preferable to bypass Need a well nourished strong patient Start Mesalazine 3g before leaving hospital after first small bowel resection Start Azathioprine after second or extensive (more than 1m) resection General Issues Op Pre-op Treatment:Mesalazine >2 g daily recommended after small bowel resection.Imidazole antibiotics-effective after ileocolic resection.Other drugs including azathioprine/6-mercaptopurine - these should be considered as first line therapy in high risk patients.It is recommended to start 2 weeks post op and prophylaxis should last 2 years. Surgery after IFX Steroids Azathioprine Risk factors for Recurrence:Absence of prophylactic treatment.Smoking.Disease location.Disease extent. Written by Dr Sebastian Zeki

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