Northeast Florida Medicine Journal, Winter 2015

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Northeast Florida Medicine

Vol. 66, No. 4 2015

Inflammatory Bowel Disease

by administering TPN for about five days. In a moderately

nourished patient, TPN use is controversial. Immunosup-

pressive agents should be stopped. However, studies suggest

that patients treated with biologicals within two months do

not have an increased risk of complication.

7,8

Steroids should

be administered if the patient has received steroids in the

past six months. Bowel preparation and antibiotics should

be given according to the individual institution’s protocol.

Institutions have varying protocol for cleaning the colon.

Options include giving an enema, Golytely, Miralax and

some other available agents.

Operative Procedures and Techniques:

If the abdomen is explored for Crohn’s disease, a physician

must examine the entire intestine, as there may be other

areas affected by the disease. Sometimes this can be a very

challenging task, especially in a patient who has undergone

multiple previous surgeries.

Laparoscopic or Open Technique:

The most common laparoscopic procedure performed in

Crohn’s disease is surgery of the ileocolic segment. Laparo-

scopic procedures in general have been shown to have better

cosmetic results, less post-operative pain and fewer adhesions

leading to less recurrence of obstruction, shorter post-oper-

ative ileus, a faster return to work and fewer post-operative

pulmonary complications. The duration of the hospital stay

depends on the extent and severity of the disease. However,

most of the studies prove that duration of the stay is short-

er with laparoscopic technique.

Hand assist devices have

further facilitated laparoscopic procedures. There are some

limiting factors for laparoscopic surgery.These include dense

adhesions, complex fistulas and abscesses, and severely ill and

unstable patients. Laparoscopic procedures do take longer

operative time. Surgeons experienced in laparoscopic surgery

have used single incision laparoscopic colectomy, as well. In

single incision procedures, ergonomics aremore difficult and

depend upon the surgeon’s level of training and confidence.

Obstruction:

The most common cause of obstruction is stricture for-

mation. In repeat surgery, adhesions can also be a factor. For

long or multiple strictures in close proximity, the choice of

procedure is resection and primary anastomosis. However,

in patients with short bowel syndrome, even with a long

stricture, a strictureplasty should be considered. Stricture-

plasty should also be considered if the patient has repeat

and frequent episodes of bowel obstruction. Short strictures,

even if multiple, can also be treated with strictureplasty. The

technique requires dividing the stricture area longitudinally

for about one to two centimeters proximal and distal to the

stricture and closing it transversely. Another technique is to

perform Finney type repair, in which a long incision is made

at the long segment of the stricture. This is then closed by

bringing the open loop in U shape and anastomosing the

opening in U shape.

A physician can use the Jaboulay type technique if the

stricture area is too long. This is to bring the large loop of

stricture area in U shape. Then making an opening just

proximal and distal to the stricture area and anastomosing

these side by side.

A third technique is a side-to-side isoperistalticMichelassi

strictureplasty. This is performed if there are multiple stric-

tures in a long segment. With this technique the diseased

bowel segment is isolated, a proximal loop is placed on top

of the distal loop in a side-to-side fashion, and they are

anastomosed in two layers. Balloon dilatation with balloon

catheter has sometimes been proven to be helpful in patients

with short bowel. Balloon dilatation has better outcomes in

patients with stricture fromprevious anastomosis. However,

balloon dilatation carries a risk of perforation, bleeding and

stricture reoccurrence. Recurrence, even after resection, can

be 30 percent at 10 years and can reach up to 50 percent over

a 15 year period.

Stricture can occur at a different location

and not at the site of previous strictureplasty.

Conservative resection is the norm. Even in involvement

of the colon, a physician should perform conservative

resection so that ideally the patient can be colostomy free

for many years. Margins of resection do not have to be

microscopically disease free, so long as macroscopically it

appears to be disease free. There have been several studies

debating the anastomosis technique.

The anastomosis can

be hand sewn or stapled. It can be side-to-side, end-to-side

or end-to-end. There is the same recurrence rate irrespective

of anastomosis technique. However, in a severely diseased

segment or if there is marked luminal discrepancy, a hand

sewn anastomosis ensures a smaller chance of complication.

When meticulously performed, a strictureplasty has the

same incidence of recurrence as that of resection.

One

must be aware that an albumin level below 2.0 can result in

infectious complications and non-healing. The stricture site

should not have active infection at the site of obstruction.

In such cases it would be best to divert the flow via a stoma.

There have been reports of cancer developing at the site of

stricture. Therefore, in suspicious areas, a biopsy should

be performed. If there is even dysplasia, a resection must

be carried out. Strictureplasty should not be attempted in

the presence of infection, perforation, abscess, presence of

phlegmon, dysplasia, any internal or external fistula and

severe hypoalbuminemia, such as less than 2.0 g/dL.

short segment of intestine with single or multiple strictures

and colonic strictures is best treated with resection. In rare

cases a duodenal stricture will present as high grade upper GI