Treatment of Crohn’s disease should be primarily medicinal. Surgical interventions are reserved for complications. Guidelines:
- Complex surgery for Crohn’s disease should be performed by CED-experienced surgeons in centers. (II, ↑ , consensus).
- In patients with a refractory course, the indication for surgery should be reviewed early. This is especially true for children and adolescents with growth retardation and/or delayed puberty. (III, ↑↑ , strong consensus).
- Colon stenoses (strictures in the colon) of unclear dignity (biological behavior of tumors; that is, whether they are benign (benign) or malignant (malignant)) require surgery. (PPP, strong consensus)
- Abdominal abscesses should be treated with antibiotics, taking into account the history (esp. antibiotic history) and local resistance, in combination with interventional or surgical drainage treatment. (II, ↑ , strong consensus).
- Short-stretch, reachable stenoses can be dilated; longer-stretch (≥ 5 cm) stenoses should be operated on (IV), with stricturoplasty (see below) and resection being equivalent (II). ( ↑ , strong consensus).
- Laparoscopic ileocecal resection (ileocecal valve: functional closure between the large and small bowel) should be preferred over the conventional approach in appropriate cases. (I, ↑ , strong consensus).
- In patients with Crohn’s colitis, ileopouchanal anastomosis (IPAA, ” pouch” ) can be considered only if there is no perianal (“around the anus“) or small bowel involvement (II, ↓ ). The patient should be educated about the increased risk of chronic pouchitis and the long-term increased risk of pouch failure (II, ↑↑ ). (Consensus)
- Prednisolone doses greater than 20 mg/day or equivalent for longer than 6 weeks should be reduced preoperatively on an interdisciplinary basis if clinically possible. (II, ↑ , strong consensus).
- Asymptomatic perianal fistulas should be treated surgically only in exceptional cases. (IV, ↑ , strong consensus).
Within 15 years of disease, surgery is required in 70% of cases, due to complications. Because repeated surgical procedures are often required, they should be minimally invasive and bowel-preserving techniques should be preferred [minimally invasive surgery (MIS); gold standard].
Stricturoplasty
Stricturoplasty is a surgical procedure to widen a stricture (high-grade narrowing) in the small intestine. It preserves the small bowel and avoids short bowel syndrome. Main indications (indications for use)
- Rapid disease recurrence with obstruction.
- Multiple strictures with diffuse involvement of the small intestine
- Previous extensive resections (> 100 cm) of the small intestine.
- Strictures (constrictions) at preexisting anastomoses (connection of two parts of the intestine), especially in the ileorectal (small intestine-rectum connection) or ileocolic (small intestine-colon connection) area
- Short bowel syndrome (clinical picture resulting from resection (surgical removal) of large parts of the small intestine; symptoms are massvie diarrhea (diarrhea), fatty stools, deficiency, etc.).
- Duodenal strictures (constrictions in the duodenum).
Contraindications
- Intestinal perforation (intestinal rupture) with or without peritonitis (peritonitis).
- Stricture at a short distance from the resection site.
- Multiple strictures over short sections of bowel
- Malnutrition (malnutrition) with an albumin (blood protein) level < 2.0 g/l
The recurrence rate is independent of the surgical procedure. Preference is given to limited resection, in which the most severely diseased portions of the bowel are removed, and alternatively to stricturoplasty. Stricturoplasty preserves the small bowel and avoids short bowel syndrome.In irreversible intestinal failure as well as in short bowel syndrome, if necessary, small bowel transplantation is an option because of the ever-improving survival rates.
