Surgical Planning in Penetrating Abdominal Crohn's Disease

Abstract

Crohn's disease (CD) is increasing globally, and the disease location and behavior are changing toward more colonic as well as inflammatory behavior. Surgery was previously mainly performed due to ileal/ileocaecal location and stricturing behavior, why many anticipate the surgical load to decrease. There are, however, the same time data showing an increasing complexity among patients at the time of surgery with an increasing number of patients with the abdominal perforating disease, induced by the disease itself, at the time of surgery and thus a more complex surgery as well as the post-operative outcome. The other major cause of abdominal penetrating CD is secondary to surgical complications, e.g., anastomotic dehiscence or inadvertent enterotomies. To improve the care for patients with penetrating abdominal CD in general, and in the peri-operative phase in particular, the use of multidisciplinary team discussions is essential. In this study, we will try to give an overview of penetrating abdominal CD today and how this situation may be handled. Proper surgical planning will decrease the risk of surgically induced penetrating disease and improve the outcome when penetrating disease is already established. It is important to evaluate patients prior to surgery and optimize them with enteral nutrition (or parenteral if enteral nutrition is ineffective) and treat abdominal sepsis with drainage and antibiotics.

Keywords: Crohn's disease; complications; optimisation; perforating disease; surgery.

Figure 1

Abdominal fistulizing Crohn's disease may develop due to penetrating disease but more often due to surgical complications. With increasing non-responsive attempts with medical therapies (e.g., steroids, immunomodulators, and/or biologicals) patients may develop clinical impairment with an increasing number of surgical risk factors like weight loss, hypo-albuminemia, or penetrating disease. Before deciding on a primary anastomosis or not the risk of anastomotic dehiscence should be evaluated as well as if the patient is fit enough to survive such complication or not. The patient must be fully aware of such risks as there is a risk of severe post-operative morbidity and mortality. In a patient deemed not suitable for surgery with primary anastomosis pre-operative optimization (e.g., enteral or parenteral nutrition, drainage of collections, and antibiotics) may change this and otherwise patients should be advised toward two-stage surgery with two-barrel stoma (of the future anastomosis) or possibly a covering stoma.

Figure 2

Example of pre-operative optimization components.