Indications for Surgery

The majority of patients with inflammatory changes limited to the right colon are subject to surgery due to obstruction, intra-abdominal abscesses, internal fistulae; and less frequently due to chronic increasing anaemia or bleeding from digestive tract [24]. When the descending or sigmoid colon is affected, symptoms are similar to diverticulitis with the subsequent obstruction and pericolonic abscess. Indications for elective surgery may also include stenosis after failure of endoscopic dilatation, persistent diarrhoea resistant to conservative treatment and bleeding [25]. According to the course of the disease indications for the operation can be divided into urgent and elective. Indications for emergency surgery:

- Toxic colitis (toxic megacolon);

- Intestinal perforation;

- Peritoneal abscess;

- Extensive haemorrhage;

- Obstruction.

Types of surgical procedures performed in emergency cases:

- Colectomy with ileostomy;

- Restorative proctocolectomy;

- Segmental resection of the colon.

Despite the fact that colectomy with ileostomy is the most frequently performed type of procedure, restorative proctocolectomy finds increasingly more advocates. In a selected group of patients with no changes in the rectum, this type of surgery offers the chance of avoiding intestinal diversion. In severe stages of Crohn's disease, the risk of performing restorative proctocolectomy is very high with a complication rate reaching 56% of patients. Fisher et al. [22] reported that 64% of patients who have undergone restorative proctocolectomy had complications of a fistula, pouch stenosis and/or pelvic abscess. The same complications occurred only in 22% of patients with ulcerative colitis treated with this surgical modality. Pouch failure was reported in 56% of Crohn's disease patients, and was dramatically lower in a group of patients with ulcerative colitis, reaching only 6%. The major goal of the ileo-rectal anastomosis is to preserve the continuity of the physiological tract but may not be connected with the high risk of complications. Additionally results of the studies on the quality of life of patients who have undergone proctocolectomy with ileostomy show a good adaptation to a stoma [26]. In the case of large-bowel bleeding that cannot be managed with the use of endoscopy or in cases when pathological changes affect only a short part of the large bowel, segmental resection seems to be a good alternative to more extensive procedures. Colectomy with ileostomy remains the gold standard in surgical treatment of severe Crohn's disease of the large bowel.

Indications for elective surgical treatment of Crohn's disease of the large bowel:

- Surgical treatment of intestinal, intestinovesical, intestinovaginal, and intestinocutaneal fistulae

- Treatment of stenosis after endoscopic failure

- Disease refractory to medical management.

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