Review
Copyright ©The Author(s) 2016. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Oct 28, 2016; 22(40): 8892-8904
Published online Oct 28, 2016. doi: 10.3748/wjg.v22.i40.8892
Indications and surgical options for small bowel, large bowel and perianal Crohn's disease
James WT Toh, Peter Stewart, Matthew JFX Rickard, Rupert Leong, Nelson Wang, Christopher J Young
James WT Toh, Peter Stewart, Matthew JFX Rickard, Christopher J Young, Department of Colorectal Surgery, Concord Repatriation General Hospital, NSW 2139, Australia
James WT Toh, South Western Sydney Clinical School, University of New South Wales, Liverpool Hospital, NSW 2170, Australia
James WT Toh, School of Medicine, Western Sydney University, Liverpool Hospital, NSW 2170, Australia
James WT Toh, Ingham Institute of Applied Research, Liverpool Hospital, NSW 2170, Australia
Christopher J Young, Department of Colorectal Surgery, Royal Prince Alfred Hospital, NSW 2050, Australia
James WT Toh, Matthew JFX Rickard, Nelson Wang, Christopher J Young, Discipline of Surgery, Sydney Medical School, the University of Sydney, NSW 2006, Australia
Rupert Leong, Department of Gastroenterology, Concord Repatriation General Hospital, NSW 2139, Australia
Author contributions: The manuscript was prepared by Toh JWT and was reviewed and revised by Stewart P, Rickard MJFX, Leong R, Wang N and Young CJ.
Conflict-of-interest statement: The authors have no conflicts of interest to declare (refer to signed statement by the corresponding author).
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Dr. James WT Toh, BSc, MBBS (UNSW), FRACS, Department of Colorectal Surgery, Concord Repatriation General Hospital, Hospital Rd, Concord, NSW 2139, Australia. james.toh@unsw.edu.au
Telephone: +61-404-006271
Received: July 14, 2016
Peer-review started: July 16, 2016
First decision: August 19, 2016
Revised: August 26, 2016
Accepted: September 28, 2016
Article in press: September 28, 2016
Published online: October 28, 2016
Processing time: 104 Days and 6.5 Hours
Abstract

Despite advancements in medical therapy of Crohn’s disease (CD), majority of patients with CD will eventually require surgical intervention, with at least a third of patients requiring multiple surgeries. It is important to understand the role and timing of surgery, with the goals of therapy to reduce the need for surgery without increasing the odds of emergency surgery and its associated morbidity, as well as to limit surgical recurrence and avoid intestinal failure. The profile of CD patients requiring surgical intervention has changed over the decades with improvements in medical therapy with immunomodulators and biological agents. The most common indication for surgery is obstruction from stricturing disease, followed by abscesses and fistulae. The risk of gastrointestinal bleeding in CD is high but the likelihood of needing surgery for bleeding is low. Most major gastrointestinal bleeding episodes resolve spontaneously, albeit the risk of re-bleeding is high. The risk of colorectal cancer associated with CD is low. While current surgical guidelines recommend a total proctocolectomy for colorectal cancer associated with CD, subtotal colectomy or segmental colectomy with endoscopic surveillance may be a reasonable option. Approximately 20%-40% of CD patients will need perianal surgery during their lifetime. This review assesses the practice parameters and guidelines in the surgical management of CD, with a focus on the indications for surgery in CD (and when not to operate), and a critical evaluation of the timing and surgical options available to improve outcomes and reduce recurrence rates.

Keywords: Surgery; Crohn’s disease; Major abdominal surgery; Perianal; Inflammatory bowel disease; Colon cancer

Core tip: Despite significant advances in the medical management of Crohn’s disease (CD), most patients will still need surgery during their lifetime, with a third requiring multiple surgeries. It is important to optimise the surgical management of CD in order to reduce rates of emergency surgery, surgical recurrence and intestinal failure. Surgical options depend on the phenotype of CD. The most common indications for surgery include stricturing disease, fistulae and abscesses whereas surgery for bleeding and cancer associated with CD is less common. It is vital to understand the role and timing of surgery, and the best surgical options in the management of CD.