Crohn's disease : current surgical treatment

Surgical treatment of Crohn's disease (CD) is purely symptomatic In addition, medical therapy always precedes surgery and almost always continues afterwards. The indications for surgical treatment are failure of medical treatment and progressive complications such as chronic bowel obstruction and occlusion, internal abscesses and fistulae, and recurrences. Between 70 and 80% of patients with CD will undergo surgical treatment at some time, mainly reflecting the very high frequency of recurrences (50% at 10 years). Laparoscopic surgery has many advantages in this setting, except for urgent interventions. In the last 30 years, segmental small-bowel resection has followed precise technical intestine-saving rules. Widening enteroplasty ("stricturoplasty") must replace resection for patients with staged CD and multiple foci, and must be used for patients who have already had mutilating resections for multiple recurrences, in order to avoid the "short bowel" syndrome. In severe acute colitis, early surgery is indicated if short-term resuscitation fails : the operation is always subtotal colectomy with double stomy of the ileum and of the sigmoid colon. In chronic and scalable colorectal attacks, the choice of technique depends on the location and severity of the lesions. Conserving the distal colon is justified if the lesions are moderate : this saves natural transit for a time, which is important for young adults. At least half of these conservative treatments eventually fail. Progressive pancoloproctitis complicated by anoperineal lesions that compromise continence is usually treated by total coloproctectomy with final ileostomy. Sphincter conservation by ileoanal anastomosis is only possible in rare patients with colorectal CD.