A study reviewed literature dealing with surgical management of small bowel, large bowel and perianal Crohn’s disease (CD) to identify those cases in which surgery is the best option, and found surgery overall, and especially minimally invasive surgery, to be safe. But, they cautioned, surgical rates for this patient population remain high.
The review, “Indications and surgical options for small bowel, large bowel, and perianal Crohn’s disease,” published in World Journal of Gastroenterology, was conducted by researchers at Concord Repatriation General Hospital and other institutions in Australia.
Chronic inflammation of the colon and small intestine, generally known as inflammatory bowel disease (IBD), is managed by various means, including medications like immunomodulators and biological agents. But a large number of patients, including those showing signs of perforation, toxic megacolon, or major gastrointestinal tract (GIT) bleeding, will eventually require surgery at least once. One-third of Crohn’s patients will undergo multiple operations, the researchers reported.
The team looked through available literature to identify major indications for surgery, and its timing and role in improving patient outcomes and lowering rates of repeat surgeries.
Researchers searched two databases, MEDLINE and Embase, from 2010-2016, and identified 510 studies, and an additional 189 studies using hand-searching references. The abstracts were then reviewed and analyzed.
The results suggested that improvements in medications were changing the requirement for surgical interventions. As a result, surgery is generally indicated for severe cases of obstruction from stricturing (narrowing) disease, followed by abscesses and fistulae.
Although the risk of gastrointestinal bleeding because of these diseases is high, such bleeding does not necessarily require surgery as it often resolves spontaneously.
Data also showed that the risk of colorectal cancer associated with these gastrointestinal diseases is moderate, while current surgical guidelines recommend a total removal of the rectum and all or part of the colon. Researchers suggested, based on their analysis, that “a reasonable” option for this cancer might be “subtotal colectomy or segmental colectomy with endoscopic surveillance.”
Finally, the data revealed that an estimated 20 to 40 percent of CD patients will require perianal surgery during their lifetime.
“The management strategies of CD are largely dependent on phenotypic classification and indication. Advances in surgical management has reduced perioperative [surgical] mortality rates to < 1%, with minimally invasive surgery shown to be safe in CD,” the researchers concluded.
“However, unfortunately, improvements in surgical techniques have only been accompanied by modest improvements in surgical rates, recurrences and overall mortality,” they added.