THE SURGICAL MANAGEMENT OF IBO Crohn ' s disease : The benefits of extensive surgery

BG WOLFF. Crohn's disease: The benefits of extensive surgery. Can} Gastroenterol 1993;7(2):250-253. Crohn's disease is frequently discussed as a surgically incurahle disease. Because of this, an atmosphere of surgical nihilism permeates many J1scussions about appropriate surgery for Crohn's disease. Even though minimal surgery is often most appropriate for certain situations, more extensive surgery clearly has a place in other situations. Among these situations are extensive perianal Cmhn 's disease with or without colonic involvement. Proctocolec.tomy and Brooke ileostomy m this setting has a much lower rec.urrcncc rate than ileorcctostomy or diversion procedures. Rectovaginal fistulas frequently can be m.magcd with less extensive surgery, but proctocolectomy is curative of this particular condition. More extensive surgery is indicated for toxic megacolon, as well as for children with Crohn's coliti1:, who fail to thrive. There i~ considcrnhle controversy about di~easc involvement at surgical margins before anastomosis; however, there is considerable data to support the practice of trying to achieve at least grossly free margins in patients with a single short segment of isolated Crohn's disease. While the fear of short bowel syndrome from radical resection remains, the thoughtful surgeon can appropriately tailor a more extensive operatton in certain circumstances that may save the patient a quick reopcration or multiple future procedures in a misguided attempt to preserve dysfunctional bowel

S IXTY YEARS AFfER TIIE DESCRll'- tion of regional ileitis or C rohn's disease, there has been relac1vcly little progress in establishing an etiology fo r this frustrating and debilitating disease or of determining appropriate surgical management.While almost all surgeons agree on a more limited resection than in the past, radical resections arc rarely performed.The question of disease-free margins an<l their association with decreased recurrence rates, together with the question of radical resection for Crohn's colius remains unsettled and contested in the literature.In spite of the controversy, it is clear that many patients have benefi ted from limited anJ extensive surgery for Crohn's disease and it remains a question of applying the approrriate operation to the individual patient's disease.
In general, surgery is most advantageous in case~ of C rohn's dbease that arc mtractable to medical management.C hron ic o bstruction, enteroenteric fistulas, and chronic anemia fro m bleeding are also indications for elective surgical treatment of Crohn's disease.Perforation and tox ic megacolon hea<l the list of complications along with the rare occurrence of mas-plus libcrale prcsente p,irfo1s tres ccrtamemcm des ,wantages.Parm1 ccs situa tions, mentionnnns la maladic dc Crohn pcrianale, avcc ou sans atteinte cohqtw.
,ive hemorrhage for cmL'rgcncy opcrarion.Failure to thrive and malnourishmem 1s the primary ind1cat1on for surgery 111 children.
Havmg stated the~e indications, the literature over the past 50 years indicates that: half the patients wtth lim1tcd uwolvement of C'rohn's disease who undergo operation m,l\' ne\•cr have a recrudescence; pattents who do have a recrudescence may nnt necessarily need <1 further procedure and may have many years of a disease-and medication-free life preceding the recrudescence; the surgical mnrtalirv from operations of C'rohn \ d t,l',hC 1s low; and the area of rcsecu on 1s large ly nnn-funct1onal from a nutritive standpoint.
Othl•r, have advocated an even larger margm of 15 to 20 cm nf hnwd ahovc tht• 11wnlvcd area along with h1srolngic cxammat1nn nf the margms dunng the opcratum O ).In our own 1983 ,cudy (12), we found an extrl•mely high rate of recur rc11Le in N paucnts who had micro scopic evidence of disease ,It the anastrnnotlC margin with reuirrcncc documented at the ,mastomotic site.
A ll of tlw margins 111 queslllm werl' reviewed ,md werL confirmed as havmg e\'1dence of Crnhn\ d isease nn the original spec imen.We fell thm micro-,cop1calh J1,L',ise-free margms ,houlJ he ohtamed from ,\ patient with an 1so la ted segmen t of Crnhn\ disease, but not ar the cost of removing excessive a1rn1unts nf norma l small howt•I.More recently, a simila r study from the C leveland C linic (I~) found no d1ffl'n.'nLem recurrence ratt: hetwcen patients who had h1stnl,1gical ev1denCL' lif Crohn's d isease and rho,e who did not ThP, study confirmed an earlier study by Pcnnmgtnn ct al (14).A ll of the,c ,rud1cs suffer fmm the fact that they arc not populat 1,m h,bl'll.and all for the most part havl' been performed in referral lentrcs \\ 1th the aclompanymg rekrral h1.1s.All have l>eL•n Jone as rct rnspcctive reviews and there arc ,lssumpnons ahout rl•currence that werl' erroneous.
In one study of 89 patients with (. 'rohn's disease who h,1d heen treated l>r 1leal rcsellllll1 ,tnd were fo llowed prospectively ( 15), 73'\1 developed en-doscopic evidence of recurrent lesions just proximal to the anastomosis within one year, ailhough only 20% of these patients had symptoms.Another prospective study c losely followed Crohn's disease patients for recurrence ( 16).To date, 50 patients (32%) have symptomatic Jiscasc while another 34 (22%) have a~ymptomatic disease.Thu~. the symptomatic recurrence rates at one anJ two years arc 19 and 31 % respectively while the total (symptomatic and asymptomc1tic) rates arc 23 anJ 52%, respectively.Patiems with margins equal to or greater than 5 cm showed a decreased recurrence rate nf l Oto 15%, as opposed to those who haJ a surgical margin less than 5 cm.However, these darn arc preliminary and a final multivanate analysi~ will need to be made before any definite conclu~ions can he Jrawn.
Sachar ( 17) proposed that two factors seem to exert particularly strong influence on postoperative recurrence rates.One is the surgical proceJure itself, with recurrences appearing earlier and more frequently after howcl anastomosis than after ileostomies.The seconJ is the behaviour of the underlying disease, with the aggressive fistulizmg form of Crohn\ disease returning patients to surgery earlier than the more indolent obstructive form.

CROHN'S COLITIS
One area in which more extensive surgery, namely proctocolectomy, is effective, is for colonic Crohn's Jisease.
Several studies (18)(19)(20) have shown that the recurrence rate after proctocolectomy is much lower than that for colectomy and ileorectal anastomosis.Segmental colectomy also has a high recurrence rate for Crohn's colitis (21 ), hut one can make the argument that this is at a cost of a permanenr ileostomy anJ loss of normal bowel function.Treatment of rerianal disease with temporary diversion has not heen successful in our own series (22).Ilcorcctnstomy clearly has a hetter chance of success if there 1s mtnimal or no perianal anJ rectal Jisease, if the patient has an adequate reservoir remaining after the anastomosis, and if the patienr's sphincter function b good.There is also no evidence that proximal resection of bowel involved with Crohn':disease leads to amelioration of anorcctal disease except on a temporary hasis (23).

TOXIC MEGACOLON OR FULMINANT COLITIS
More extensive surgery for toxic mcgacol,m clearly has a hcncfit 111 patients with known Crnhn's colitis, who should undergl1 rrocwcolcctomy with Brooke ileostmny as a ~ingle procedure.l f there is douht as to the diagnosis and distinction between ulcerative colitis and Crnhn's colitis, then a subtotal colectomy with a Hartmann procedure o r mucous fisrula, as described by McLeoJ and associates (24), should he performed.Only 111 the rare mstance of extreme dilation and friability of the bowel wall should the hlow-holc procedure, popularized hy Turnbull, be performed (25).

PEDIATRIC SURGERY
In one study of pediatric paricnrs who underwent surgery fo r Crnhn 's Jisease Juring childhood (26) Gastrnenrcmlogy 1971 ;61: 75 l-6.8. Karescn R. ~erch-1 lanssen A, on long term follow-up.In aJditton, an increase m growth rate was observed during the first year after operation in 89°/o of 40 children studied.Improved growth is clearly an early benefit of surgery in this group of patients.Six of seven patients haJ staged colonic resections with a primary anasromosis relapse, as did rhree of four patients given a loop ileostomy ro divert fecal flow.ln another study (27), 38 children with Crohn's colitis were followed after su rgery, and 53% eventually underwent proccocolectomy.Again, in this group, resection of active mtra-abJominal Jisease was not necessarily followed h) resolution of perianal lesions, and defunctionali:ing rhe rectum diJ not appear to alter or prevent the progression of pcrianal disease.

CONCLUSIONS
In summary, there are henefirs for extensive surgery for Crnhn 's di~easc.partiu1larly111 Crohn's colitis with proccocolectomy and 1leostomy yiclJing a much lower recurrencl' rate than ~ubtotal cokctomy and tleorectostom) or segmental colcctomy.Proctocolectomy c learly has substantial benefits 111 c1 setting of toxtc megacolon with Crohn\ colitis.The data arc less clear