| Abstract|| |
The aim: The study aims to evaluate the clinical presentation and surgical management of small bowel Crohn's disease (CD) at a tertiary referral center in the Kingdom of Saudi Arabia (KSA).
Patients and methods: A retrospective review of the medical records of all patients with the diagnosis of small bowel CD from March 1999 up to December 2003. The records of 28 patients were reviewed for demographic data, clinical presentation, preoperative investigations, indications of surgery, surgical procedures, postoperative complications and follow-up. The final diagnosis of CD was based on paraffin section histopathology reports.
Results: The mean age was 34 years, female to male ratio was 1:2.1. The medical treatment was offered to 22 patients in whom the diagnosis of CD was established after investigations or they were known to have CD before admission. Thirteen patients (46.4%) responded to medical treatment, whereas 15 patients (53.6%) required surgery. The indications for surgery were intestinal obstruction (seven patients), right iliac fossa mass lesion of uncertain nature (three patients), enterocutaneous fistula and pelvic collection (one patient), failure of medical treatment (two patients), and acute abdomen (two patients). The surgical procedures carried out were limited right hemicolectomy in ten patients, segmental bowel resection (two patients) and stricturoplasty of the stenosed segment (three patients).
Conclusion: Crohn's disease is not uncommon in KSA. It is a disease of young patients, half of patients needed surgery at some stage. Intestinal obstruction remains the most common indication of surgery. The surgery of CD needs a good cooperation between the surgeon, radiologist and gastroenterologist
Keywords: Crohn′s disease, small bowel, surgery.
|How to cite this article:|
Al Salamah SM. Surgery for small bowel Crohn's disease: Experience of a tertiary referral center. Saudi J Gastroenterol 2005;11:85-92
Crohn's disease is a focal, transmural granulomatous inflammation affecting the gastrointestinal tract with potential for systemic and extra-intestinal manifestations  . It usually affects the terminal ileum and cecum, but small bowel alone is affected in 30-35% of the cases and isolated colon involvement is reported in 25-35%  . Crohn's disease is a chronic lifelong condition with an unpredictable course. The cure is not yet established by available medical or surgical therapy. Only 20% of the patients remain asymptomatic 10 to 20 years after the initial episode and surgical intervention becomes necessary for most patients , . This study aims to evaluate the experience of the University Unit of the Department of Surgery, Riyadh Medical Complex in the management of small bowel CD.
| Patients and Methods|| |
The medical records of all patients diagnosed with CD of small bowel, from January 1999 up to December 2003 were retrospectively reviewed for age, sex, clinical presentation, duration of symptoms, diagnostic work up, management and outcome. Preoperative diagnostic investigations included abdominal ultrasonogram, computed axial tomogram (CT), small bowel enema, and colonoscopy. Multiple biopsies were obtained, either from the ileocecal junction or teniiinal ileum in all patients who underwent colonoscopy. The indications for surgery were persistent symptoms despite adequate medical treatment, intestinal obstruction, massive lower GI bleeding, enterocutaneous fistula, right iliac fossa masses of uncertain diagnosis and incidental findings in patients operated for acute appendicitis. Various surgical procedures included limited right hemicolectomy, with additional extended ileal resection depending upon the extent of ileal disease, for CD involving the terminal ileum or ileocecal junction and segmental small bowel resection for lesions limited to the small bowel with severe narrowing or obstruction of the lumen. Stricturoplasty was reserved for involvement of short segments (< 5 cm) of the small bowel.
The final diagnosis of CD was confirmed on paraffin sections, where endoscopic biopsies were available. The patients were reviewed for intra and postoperative complications and outcome of medical therapy. Hospital mortality was defined as death within 30 days after surgery. Patients were discharged when they were in good general status, tolerating sufficient oral intake, afebrile, self ambulating, and had adequate control of pain on oral analgesics. All patients were followed up in the surgical and gastroenterology outpatient clinics two weeks after discharge and then every three months for first year and every six months thereafter.
| Results|| |
Of the twenty-eight patients with the diagnosis of small bowel CD, there were nine females and 19 male (female to male ratio 1:2.1). The mean age was 34 years (range 23-47 years). There were 23 Saudis (82%) and five non Saudis (18%). Only six patients (21%) were above 40 years of age. Acute on chronic abdominal pain was the commonest symptom observed in 13 patients (46%) followed by diarrhea in 12 patients (43%). Two patients presented with acute abdominal features suggestive of acute appendicitis and the diagnosis of CD was initially made intraoperatively. Subacute intestinal obstruction was the major presenting feature in nine patients (32%), four patients (14%) presented with right iliac fossa (RIF) mass, whereas intermittent lower GI bleeding and recurrent perianal disease (fistula) were observed in two patients (7%) each. One patient presented with enterocutaneous fistula and RIF collection. The duration of symptoms varied from 1 week to nine years (mean = 3.9 years). Five patients had previous abdominal surgery, two had appendectomy (mean post-appendicectomy interval = 1.65 years) and three had laparotomy and segmental bowel resection for small bowel CD. Ten patients (36%) were on medical treatment before admission (meslazine, corticosteroids) and were under regular follow up by gastroenterologist.
The abdominal ultrasonogram done in six patients, detected RIF mass in four of them. Abdomen CT was performed in 24 patients (86%), detected segmental thickening of small bowel in 13 (54%) patients, and RIF mass in ten (41.6%). Enterocutaneous fistulae with pelvic and RIF collectionswere reported in one more patient. CT scan was able to identify strictures in the distal ileum in ten out of 24 patients (41.6%) and proximal ileum in three (12.5%). Lower GI endoscopy was performed in 22 patients (79%) and multiple biopsies from the terminal ileum and cecum were obtained in 20 patients (71%). Histopathological result of colonoscopic biopsies was diagnostic in 14 out of 20 patients (70%) and suggestive of CD in six (30%). Small bowel enema was performed in 14 patients (50%) and a narrowing of the lumen with features suggestive of CD was reported in 11 (78.5%) patients. Nine of these patients demonstrated lesions in the terminal ileum whereas two patients had multiple lesions in the small bowel.
The medical treatment was offered to 22 patients (79%) in whom the diagnosis of CD was established after various investigations or they were known to have CD before admission. Nine patients admitted with subacute bowel obstruction received total parenteral nutrition in addition to medical treatment in order to achieve complete bowel rest. Thirteen (59%) of 22 patients responded to medical treatments and were discharged on maintenance therapy. Fifteen (54.5%) patients underwent surgery for various indications. The mean time interval from the first presentation to surgery was 13 months (range 2 days to 19 months). Five of these patients had second surgery (three following previous segmental resection, one following enterocutaneous fistula after appendicectomy, and- one following recurrent bowel obstruction after appendicectomy). Meantime interval between two surgeries was eight months. One patient had surgery for three times on account of recurrent bowel obstruction (mean interval 5 days) following appendicectomy elsewhere. The indications of surgery were as follows: seven patients operated for persistent intestinal obstruction, three patients due to RIF masses of uncertain nature (possibility of malignancy), one patient was operated because of enterocutaneous fistula after drainage of RIF collection, whereas two patients were referred by gastroenterologist because of persistent bowel symptoms despite adequate medical treatment. Two patients were initially operated for acute appendicitis and the diagnosis of CD was suspected intraoperatively. Both patients had limited right hemicolectomy and diagnosis of CD was subsequently confirmed on histopathology. Of the 15 operated patients, 10 (66.6%) underwent limited right hemicolectomy, with resection of 15-30 cm of terminal ileum. Seven of these patients had end-to-end ileoascending anastomosis, whereas three had side-to-side ileo-transverse anastomosis.
One of these patients had additional covering ileostomy in order to avoid anastomotic leakage due to extensive contamination caused by terminal ileum perforation and pelvic collection. Two patients had segmental small bowel resection and primary anastomosis, and three had stricturoplasty of the stenosed segment. The diagnosis on the operated patients was confirmed on paraffin section from the resected specimen and biopsies from the site of stricturoplasty.
Overall operative morbidity was 27%. Chest infection, necessitating antibiotics, was the most common general complication observed in four (26.6%) patients. Significant procedure-related complications were pelvic collection in two patients (responded to conservative treatment), wound infection (necessitating open drainage) in two, and recurrent adhesive bowel obstruction in one patient. One of the operated patients (6.6%) died of massive aspiration pneumonia leading to respiratory failure after having limited right hemicolectomy. All patients who underwent surgery were put on maintenance medical treatment (Meslazine), with or without steroids, and are being followed in surgical and gastroenterology clinics. [Table I] summarizes the characteristics, clinical presentation, diagnosis and management outcome of 28 patients with small bowel CD. Of the 14 patients who were discharged home after surgery, the mean follow up was 2.8 years (range 8 months to 5 years). Two (14.2%) patients were readmitted with adhesive subacute bowel obstruction after a mean interval of 13 months. Both were successfully managed with conservative treatment. One patient developed incisional hernia but was not keen to have any more surgical procedure. No patients required surgery for recurrent symptoms or progressive disease.
| Discussion|| |
In the KSA, there are few available reports about CD. Mokhtar and Khan reported the first two cases of CD in Saudis in Jeddah in 1982  . That CD is not uncommon in this region of the world was first observed by Al-Nakib and associates  . El Sheikh et al reported three cases of CD from Riyadh Armed Forces Hospital in 1987  . Hossain et al reported further seven cases (three Saudis) from Riyadh  . Isbister and Hubler reviewed 101 patients with inflammatory bowel disease in Saudi Arabia, out of which 28 had CD  . Makanjuola studied the radiological findings of gastrograffin studies in 18 patients with CD from 1976 to 1994  . Satti and colleagues reported 12 cases of CD colitis among 1297 colonoscopic biopsies (0.80%) over 11 year-period in the Eastern region  . The incidence and prevalence of CD in the United States has been observed similar to other "Westernized" countries and is estimated at 5/100,000 and 50/100.0000 respectively  . In a recent report of 77 patients reviewed from 1983 through 2002 in King Khalid University Hospital, Riyadh, Al-Ghamdi and colleagues reported a mean annual incidence of 0.94:100,000 over a 20 years period  . The authors observed an actual increase in the incidence of the disease in the KSA during the last decade.
This study aimed to highlight the outcome of surgery for small bowel CD in a tertiary referral center in the Central region of Saudi Arabia. Crohn's disease usually affects the terminal ileum and cecum, but small bowel alone is affected in 30-35% and colon alone in another 25-35% of affected patients  . The ileocecal region was the most common site of CD in this study (46%). This is consistent with most of reports from the Western literature ,. Approximately 40% of all patients undergoing surgery for CD have a disease in the ileocecal region  . Sixty-six percent of the patients in the present study underwent limited right hemicolectomy with or without additional extensive resection of the distal ileum due to high incidence of involvement of the terminal ileum and ileocecal junction.
Surgery for CD cannot be regarded as curative and is usually reserved for patients whose disease is refractory to aggressive medical therapy or who develop complications of the disease (small bowel obstruction, perforation and abscess collection), or treatment (steroids). One third of the patients with CD require surgery for partial or complete intermittent, episodic or persistent acute or subacute bowel obstruction  . Failure of medical management to reduce persistent disease activity (patients with persistent symptoms despite aggressive therapy for several months or for relapse whenever aggressive therapy is tapered or if the symptoms worsen during therapy) is another indication of surgery. Inflammatory masses and abscess caused by fistulization are frequent complications occurring in 20% of the patients with CD ,, Less common complications requiring surgical intervention are acute gastrointestinal hemorrhage and the development of a malignancy. Fulminant colitis or toxic megacolon are among other indications for surgery occurring in 20% of the patients with colonic CD  . Patients with CD can present with right sided lower quadrant abdominal pain mimicking appendicitis. In this report, 20% of our patients presented with RIF masses whereas two patients were operated with provisional diagnosis of acute appendicitis and found to have Crohn's disease on exploration. These figures are similar to earlier published reports ,,, Intestinal obstruction remained the major indication of surgery in this study (46%).
Resection is typically the procedure of choice for patients with CD especially when it is the first surgery for the disease. Right hemicolectomy is usually carried out when the ileocecal region is involved. Resection lines may be guided by palpation of the mesenteric margin of the bowel wall  . Earlier reports suggested that wide resection margins might reduce the recurrence rates , . However, more recent studies reported no increased recurrence rates even with narrower resection margins , . Furthermore, many studies showed that microscopic examination of resection margins had no added advantage, making frozen-section studies of limited values ,, . The primary anastomosis is usually preferred after resection but ileostomy is occasionally indicated in patients with intra-abdominal sepsis or an enterocutaneous fistula  . In this study, the ileocecal resection with primary anastomosis was performed in 66% of patients owing to cecum and terminal ileum involvement. Covering ileostomy was needed in one patient, where the primary anastomosis alone was considered unsafe due to extensive peritoneal contamination and pelvic abscess. Stricturoplasty was initially described in 1982  . It is useful for patients with extensive disease with fibrotic strictures who had undergone previous resections and are susceptible for short-bowel syndrome  . However, the stricturoplasty is contraindicated inpatients with active sepsis or fistula or when the closure is vulnerable to leakage. Three patients in this study had isolated small bowel segment involvement. Two of them had previous small bowel resections and a stricturoplasty was performed in order to avoid further small bowel resection and short bowel syndrome. Ten years after surgery. 30% of the patients with distal ileal disease needed more than one resection and 5% needed more than three resections  . The incidence of short-bowel syndrome has been reported in 1.5-12.6% of cases in various studies ,
Laparoscopic resection of ileocecal Crohn's disease has the advantages of short mean hospital stay and reduced hospital cost, which are significantly less than the open surgical procedures. Laparoscopic resections have a conversion rate of 14% and a significant increase of operation time , . In a recent comparative study, Shore and colleagues treated 20 patients with laparoscopic resection compared to 20 conventional surgery, the conversion rate was 5% only  . The laparoscopic group had less blood loss during surgery and the mean operative time was 145.0 minutes vs. 133.5 minutes for open procedures. The bowel function returned more quickly and the hospital stay was significantly shorter (4.25 days vs. 8.25 days). The mean hospital cost was significantly less than the conventional group. The authors concluded that laparoscopic surgery for resection of CD is safe and successful and should be considered as the preferred operative approach for primary resection  .
Conclusion: Crohn's disease is no more uncommon in KSA. It is a disease of relatively young population and about half of patients require surgery at some stage. The intestinal obstruction is the most common indication of surgery. The resectional surgery may be recommended as initial procedure, whereas stricturoplasty should be reserved for short stenotic lesions and to prevent short bowel syndrome in those with extensive bowel involvement. A close cooperation and follow up by the surgeon, gastroenterologist, pathologist and radiologist as a team is recommended for successful outcome.
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Saleh Mohammed Al Salamah
P 0 Box 31168, Riyadh 11497
Source of Support: None, Conflict of Interest: None
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