From Extended to Minor Resections Evolution in the Approach to CD

In the past, CD surgery entailed resection of all diseased segments and the creation of anastomosis on the healthy tissue. Major intestinal resections were then carried out, all with a radical intent. At the beginning of the 1980s, Krause, reporting results achieved in a retrospective study with a long follow-up in which he compared minor and extended resections [19], stated that it was necessary to extend resection margins up to 10-20 cm from the margins of the diseased segment. In time, though, it became obvious that this principle was not only wrong, because the rate of CD relapses was not at all influenced by extension of the resection, but it exposed patients to a high risk of malabsorption comparable with short-bowel syndrome.

The first data proving how inappropriate wide resections were came from a study showing that the presence of disease at the resection margins (macroscopically healthy) did not affect the rate of relapse [20]. Another study proved that the use of intraoperative frozen section did not allow reduction of resection extension [21]. In 1996, Fazio published a prospective randomised study with a good sample where he compared patients operated with resection performed 2 or 12 cm from the apparently healthy margin [22]. In this study, the main outcome was defined as the need to perform surgery again. The results (median follow-up 56 months) showed a rate of relapse not statistically significant between the two groups (25% in the group with a 2-cm margin, 18% in the group with a 12-cm margin). This work definitively proved how the approach toward minor resections, with margins a few centimetres from the diseased segment, is the appropriate one.

What are the indications for resective surgery? Using Wien's classification [23], Poggioli [24] suggests that, schematically, penetrating manifestations are likely to undergo resective surgery whereas fibrostenotic manifestations (with the exception of that involving the terminal ileum) are an indication for strictureplasty only in the case of a non-active disease. This division, even if partly overcome by Poggioli himself (as we will see when addressing stricturoplasty), is a good starting point. Fistulous tracts certainly are a high risk for non-resective surgery. Resections in this case must be minor. It must be remembered that resective surgery and stricturo-plasty can and must integrate with each other. The presence of localised areas of peritonitis away from other injuries susceptible of stricturoplasty seems to be not an absolute contraindication even if there is still an agreement yet. They certainly are difficult situations, however, in which there is no consensus as yet and the surgeon's expertise is essential. Other rather difficult cases are active and diffused diseases, which are always difficult to approach. From the surgeon's point of view, wide resections give greater safety in comparison with strictureplasty on inflammatory tissues; however, we must take into account the problems connected with absorption. In these patients, considering the inflammatory processes, absorption ability is not exclusively connected with the length of intestine left but also with the structural and functional features.

"Classic" CD, terminal ileitis, has always represented the most common indication for a resection, especially in the case of initial manifestation of the disease. This operation can be mostly performed with laparoscopy.

In literature, there are several studies comparing the results of end-to-end or end-to-side anastomosis or comparing the methodology for performing the anastomosis (either conventional or stapled). The theoretic premise was the hypothesis that the cul-de-sac ensuing from an end-to-side anastomosis could make relapse of the disease easier. The results obtained were not univocal [25-27].

Our experience suggests that anastomosis must be wide and tension free. We believe that the best alternatives are the conventional sutured end-to-end anastomosis with a longitudinal excision along the antimesenteric margin of the ileum (to allow enlargement plasty) (Fig. l) or the use of a stapled functional end-to-end anastomosis.

Fig. 1. Ileo-colic anastomosis with single layer suture

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