Surgical Indications in Crohns Disease and Preoperative Preparation

Table 1 summarises indications for surgical treatment in Crohn's disease [4, 12, 13]. Surgery may be either scheduled or urgent. The subdivision into absolute and relative indications is partly arbitrary. Regardless of CD, intestinal perforation is considered to require urgent surgical treatment, but determining

Table 1. Indication for surgical therapy

Absolute indication

Fulminant form of the disease

Intestinal obstruction (especially terminal ileum) Intestinal perforation

Complication of the disease process Intestinal bleeding

Recalcitrant sepsis Fistulae (?) Abscess (?)

Failure of medical therapy

Complications of steroids or other medical therapy Growth failure

Controversial indications Series of subileus

Recurrences subsiding after conservative treatment where the therapy failed is sometimes very difficult. Many cases also require careful consideration by the gastroenterologist. A recurring event in clinical practice that is a common experience for many individuals treating this type of patients is to define, in some cases, clear definition between a pattern of subocclusion due to inflammatory oedema (that can respond to therapy) or to fibrosis (that cannot respond to therapy but to surgery only). Some preoperative care and attention, if permitted by the clinical situation, should always be used.

The patient should be operated only after a thorough study [14]. The single-contrast gastrointestinal (GI) series with small-bowel follow-through represents, presently, an examination with a good cost/benefit ratio and that, in many important cases, gives information regarding intestinal transit and the presence of stenosis [15]. On many occasions, in urgent cases especially, enteroclysis with computed tomography (CT] and double-contrast evaluation provides information on the presence of peritoneal abscesses or on fistulae. Ultrasonography with or without Doppler as well as magnetic resonance imaging (MRI) [16] can be used for monitoring disease activity and response to therapy or when the use of ionising radiation is contraindicated (e.g. pregnancy or childhood). Even if surgical exploration allows visualisation of the intra-abdominal state, the possibility of planning the surgical approach is essential and supportive in the search for any fistulous tracts, which are often difficult to find.

An essential aspect, which is often overlooked, is preoperative marking the stoma. Creation of a temporary stoma takes place frequently, especially during urgent surgery. The most frequent indications are postoperative dehiscences, presence of major perianal fistulae, intra-abdominal sepsis (which makes creation of the anastomosis unsafe) or a serious colonic disease. Proper positioning of the stoma allows patients to not only manage it easily but to accept it [17]. It must remembered, moreover, that, as Post [18] wrote, approximately 20% of "temporary" stomas become definitive if the indication is postoperative complications; this percentage increases up to 60% if the indication is rectal stenosis or perianal fistulae.

Appropriate treatment during the postoperative period must include an antithrombotic prophylaxis and antibiotic administration. The latter will need to be broad spectrum for some days in the case of abscesses, fistulae or perforations, or just a single dose given within 30 min of skin incision (repeated if the operation lasts longer than 3 h) in the case of noncontaminated operations (the so-called short-term prophylaxis).

Another important aspect is nutritional support. A state of malnutrition is rather frequent in these patients, and it may be worsened by poor control of the disease or by the presence of infection or fistulae. Restoring electrolyte balance is essential. Caloric support may be achieved through a total parenteral nutrition or, if possible and the patient tolerates it, through enteral nutrition, which has lower costs and complications.

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