Crohn’s Disease: Surgical Management [sounds like]
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Crohn’s Disease: Surgical Management- Key Concepts
- Introduction
- Changing Trends in the Surgical Management of Crohn’s Disease
- Indications for Surgery
- Failed Medical Therapy
- Bowel Obstruction
- Perforation
- Penetrating Disease: Fistula and Abscess Formation
- Cancer and Dysplasia
- Toxic Colitis
- Bleeding
- Surgical Considerations
- Overview of Operative Considerations
- Minimally Invasive Surgery
- Enhanced Recovery Pathways
- Perioperative Medical Management
- Anastomotic Type
- Disease Recurrence Trends and Surveillance
- Operative Considerations for Specific Locations
- Gastroduodenal Disease
- Upper Small Bowel Disease
- Colonic and Rectal Disease
- Ileal Pouch-Anal Anastomosis in Crohn’s Disease
- Special Considerations
- Conclusion
- References
Benign Disease- A 48-year-old woman with Crohn’s disease presents to the clinic for evaluation of right lower quadrant abdominal pain. Her surgical history is significant for proctocolectomy with end ileostomy. What began as a small pustule adjacent to her ileostomy has rapidly progressed into a painful 1-cm ulcer (Figure). Physical examination demonstrates peristomal ulcerations with serpiginous, irregular, and violaceous borders. The most appropriate management for this patient is:
- A 23-year-old man who is being treated with infliximab for ileocolonic Crohn’s disease presents with a large left perianal abscess. Operative drainage reveals a perianal abscess and a superficial transsphincteric fistula involving the posterior anal canal at the dentate line. Inspection of the rectum reveals proctitis. What is the best next step in management?
- A 25-year-old man presents to the emergency department with worsening intermittent, colicky abdominal pain of 1 week’s duration. He has experienced several weeks of irregular bowel habits and loose stools. Examination reveals right lower quadrant tenderness without guarding or rebound; his white blood cell count is 20,000/µL (20109/L) with 80% polymorphonuclear leukocytes. Computed tomography reveals marked edema of the terminal ileum with a comb sign, a loss of fat planes, and narrowing of the lumen. The appendix is not seen. What is the best next step in management?
- You are consulted on a 43-year-old woman with Crohn’s disease, who underwent a balloon dilation procedure for an ileocolic stricture 4 months ago. She is now admitted to the hospital with complaints of right lower quadrant pain that radiates through her right lower extremity, diarrhea, and abdominal distention. Her white blood cell count is 15,000/µL (15109/L), and examination reveals right lower quadrant tenderness without peritonitis. She is currently receiving prednisone and biologic therapy for her Crohn’s disease. Imaging is shown (Figure). In addition to intravenous antibiotics, what is the most appropriate next step in management?
- A 35-year-old woman is taken to the operating room for a proctocolectomy with end ileostomy for Crohn’s disease–related colonic dysplasia. What is the most appropriate surgical management of the perineal dissection?
- Anorectal Crohn’s Disease
Benign Disease- A 56-year-old man with a remote history of uncomplicated sigmoid diverticulitis presents with pneumaturia, fecaluria, and frequent urinary tract infections. Colonoscopy showed sigmoid diverticulosis. Computed tomography (CT) of the abdomen and pelvis showed air in the bladder. Cystoscopy showed 1.5 cm defect in the bladder. The best next step in the management of this patient is
- A 30-year-old patient with a history of ileal Crohn’s disease undergoes drainage of a perirectal abscess with placement of seton. Flexible sigmoidoscopy at the time shows proctitis. The most appropriate next treatment is
- A 43-year-old woman presents to the emergency room with 24 hours of nausea, vomiting, and bloating. She has history of Crohn’s disease with no prior surgery and is currently not taking any medications. She smokes one pack of cigarettes per day. Computed tomography (CT) is obtained (see figure below). Magnetic resonance enterography (MRE) shows mucosal edema and hyperenhancement. She is treated with intravenous (IV) fluid resuscitation, bowel rest, and nasogastric decompression. Inpatient colonoscopy performed 4 days later demonstrates inflamed ileal mucosa and narrowed lumen. What is the best next step in this patient’s management?
- A 23-year-old woman with a longstanding history of fistulizing Crohn’s disease reports diarrhea and abdominal pain. Computed tomography (CT) enterography shows an ileosigmoid fistula. After medical optimization, the fistula persists. Sigmoid colon mucosa is unremarkable on colonoscpy. What is the best next step in management?
- A 33-year-old woman has ileal Crohn’s disease refractory to medical management. With respect to postoperative recurrence, which of the following strategies is recommended?
Complex Anorectal Crohn's Disease- Anorectal Disease
- A 32-year-old woman with a history of Crohn’s disease presents with pain of 3 days’ duration and swelling in the perianal region. Computed tomography confirms an ischiorectal abscess with transsphincteric fistula. In addition to draining the abscess, what is the best next step in management?
- A 40-year-old woman with a history of Crohn's disease presents to your office with quiescent proctitis and a 4-mm rectovaginal fistula just above the anorectal ring. There is no appreciable sphincter defect. What is your best recommendation for repair?
- A 27-year-old woman presents with a grade 4 perineal laceration 2 weeks after vaginal delivery. At the time of delivery, a repair was attempted. She presents today reporting passage of flatus and stool from the vagina. On examination under anesthesia, the patient is found to have a low rectovaginal fistula. What is the next step in management?
- A 25-year-old woman with perianal Crohn’s disease reports increased perianal pain and drainage. Over the past year, she had 4 setons placed for perianal fistulizing disease. She is receiving optimal biologic dual therapy. On examination, she has increased erythema and 4 draining setons. What is the best next step in management?
- A 45-year-old woman presents with induration and chronic draining sinuses in the perineum, axilla, and groin. She underwent a screening colonoscopy 2 years ago, the result of which was normal. What is the best long-term management strategy to prevent recurrence?
- A 28-year-old woman with perianal Crohn’s disease is referred for evaluation for perianal itching. On examination, she has large bilateral anal skin tags that are painless to palpation. What is the most appropriate treatment?
- Comprehensive Approaches to Perianal Crohn's Disease Working Together With The GI Colleagues
- About ASCRS Textbook of Colon and Rectal Surgery
- Hemorrhoids
- Abdominal Crohn’s Disease
- Medical Therapy for Crohn’s Disease
Management of Anorectal Abscess, Fistula-in-Ano, and Rectovaginal Fistula (2022)- Rectovaginal Fistula
- Anal Fissure and Anal Stenosis
- Surgical Management of Ulcerative Colitis (2021)
- Surgical Management of Crohn's Disease (2020)
- Cryptoglandular Abscess and Fistula
- Complications of the Pelvic Pouch
- ASCRS Webinars
- Anorectal Disease
- Ulcerative Colitis: Surgical Management
- Preoperative Evaluation in Colorectal Patients
- Perioperative
- Infectious Colitis
- Malignancy
- Management of Anal Fissures (2023)
- Pediatric Colorectal Disorders
- Management of Fecal Incontinence (2023)
- Rectourethral and Complex Fistulas: Evaluation and Management