Transcript PREVENTION OF RECURRENCE IN CROHN’S DISEASE

DIFFICULT
SMALL BOWEL
CROHN’S DISEASE
John Northover
St Mark’s Hospital, London
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Causes of intestinal failure
St Mark’s & Hope, 1999-2002
70
Hope
St Mark's
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30
20
10
0
Difficult SB Crohn’s
• Duodenal disease
• Multiple strictures
• Enterocutaneous fistula
Duodenal
Crohn’s
A few facts
• Rare - <5%
• Differential diagnosis
• Rarely sole site
• Often overshadowed
Duodenum plus . . . .
• D3 stricture
• Advanced ileal
disease
Clinical scenarios
• ‘Peptic ulcer-like’
• Obstruction
• Fistula
Patterns of disease
*
Symptoms
• ‘Peptic ulcer’ pain
70%
• Vomiting
50%
• Weight loss
26%
• Diarrhoea
22%
• Bleeding
7%
Investigation
• Barium studies
• Scanning
• Endoscopy
Conventional Ba meal
• Anatomical clarity
• Endoscopy needed
BaM in D3 obstruction
• Poor view
• No distal information
CT in D4 obstruction
Endoscopy
• Differential diagnosis
• Dilatation
Treating obstruction
• Balloon dilatation
• Bypass
• Strictureplasty
Balloon dilatation
• May avoid surgery
• Few data
• Distal disease
Bypass
• Check for distal disease
• ? need for vagotomy
– “4/6 withoutre-operation”
(Cleveland, ‘83)
– “Most re-do surgery after Vx; risk
of diarrhoea” (Lahey, ‘89)
– “Remains controversial” (B’ham, ‘99)
Strictureplasty
• 13 patients (10 primary)
• 2/10 leaked
• 6 re-stricturedsurgery
• Overall 9/13 re-operated
Birmingham, 1999
‘Plasty v Bypass
• Historical and parallel comparison
• Bypass 21; strictureplasty 13
• Same:
– Complications (2/21; 2/13)
– RecurrenceRe-op. (1/21; 1/13)
Cleveland Clinic, 1999
Fistulating duodenal Crohn’s
• Usually secondary
• To colon or terminal SB
• Duodenocutaneous rare
• Most OK for oversew
D2-transverse colic fistula
• Normal duodenum
• Penetrating ulcers
• Simple closure
after colectomy
Multiple
strictures
Multiple strictures
• Failure to thrive
• Obstruction
Multiple strictures
Multiple strictures
• What trouble are they?
• Other modalities?
• Previous surgery?
• Is there a ‘dominant’ stricture?
• AND ONLY THEN . . .
Multiple strictures
• Might surgery help?
• If so, what surgery?
– (Bypass)
– Resection
– Strictureplasty
Multiple strictures
Pros and cons of strictureplasty
• Bowel conservation
• Safety
• Relapse rate
Multiple strictures
Recurrence avoidance
Oxford, 1995
Multiple strictures
Recurrence avoidance
2006 meta analysis
Tekkis et al.
Strictureplasty
What’s available?
Strictureplasty
What’s available?
Strictureplasty
What’s available?
Strictureplasty
What’s available?
Strictureplasty
Beware the occult stricture
Strictureplasty
Pick ‘n’ Mix . . .
Enterocutaneous
fistula
Enterocutaneous fistula
Avoiding re-operation
Avoiding re-operation
NO
UNEXPECTED
EXTRA
PROCEDURES
Avoiding DISASTER
Avoiding DISASTER
Avoiding DISASTER
WAIT!!
Avoiding DISASTER
WAIT!!
and PREPARE
Pre-operative preparation
Exclude distal obstruction
Exclude septic collections
Find the optimal entry site
Avoiding re-operation
• ROADMAP
• Composite image
• Pre-operate in head
DIFFICULT
SMALL BOWEL
CROHN’S DISEASE
John Northover
St Mark’s Hospital, London