[Surgical concepts in Crohn disease of the terminal ileum and colon]

Abstract

Most patients with Crohn's disease have to be operated on. Necessity to loose some amount of the intestine and time-point of the surgical intervention may be derived from the irreversible cascade of the inflammatory process and the limitations of the conservative treatment. In ileocecal disease indications for surgery are represented by stenotic and/or penetrating complications of the inflamed bowel, whereas in Crohn's colitis acute or terminal medical refractority is predominating. Standard-procedures result from constantly definable patterns of the disease manifestation: ileocecal resection and colectomy/-proctocolectomy. In segmental colitis sometimes "resections within Crohn's" may be adequate in a first attempt to avoid anticipating the natural course by surgical means. In these cases the further prognosis depends on the treatment possibilities of the remaining colon. In contrast, true recurrence is a new inflammation of the neoterminal ileum and may indicate repeated resections. The frequence decreases with the number of resections. Nevertheless nutritional status is restored even by multiple resections, whereas specific functional sequelae of the resection--distal resection- and dehydration syndromes--are well treatable mostly. In the case of appropriate timing of the operation and the reoperation operative morbidity and mortality are remarkable low today resulting in an almost normal life expectancy. Most important as negative prognostic factor remains sepsis resulting from pre-existing or postoperative infectious complications. Keeping this in mind experimental pharmaco-therapy to delay the operation and not profoundly substantiated tendencies to minimize surgery are to be considered only with critical scepticism. At the moment, future research is thought to be more successful in focussing prophylaxis of ileal recurrence than avoiding surgery.