Docstoc

PREVENTION OF RECURRENCE IN CROHN'S DISEASE

Document Sample
PREVENTION OF RECURRENCE IN CROHN'S DISEASE Powered By Docstoc
					   DIFFICULT
 SMALL BOWEL
CROHN’S DISEASE

     John Northover
St Mark’s Hospital, London
                                                 % patients
  Cr
    oh




                                   0
                                       10
                                            20
                                                  30
                                                       40
                                                              50
                                                                           60
                                                                                  70
          n's
                 dis
                      ea
                            se
               Va
                      scu
   Su                    l   ar
        rgi
           c   al
                     co
                          mp
 Mo
    t ilit                   s
           y   di s
Ra                   ord
  di a                     ers
         tio
             n   en
                      ter
                         i   tis
       Sc
              ler
                 o   de
Fa                        rm
     mi
        lia                  a
              l po
                     lyp
                           os
                             is
          Ma
             lig      na
                           nc
                             y
                                                                                       St Mark’s & Hope, 1999-2002




                      Ot
                                                                           Hope




                         he
                               r
                                                               St Mark's
                                                                                                                     Causes of intestinal failure
  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

				
DOCUMENT INFO
Shared By:
Categories:
Tags:
Stats:
views:11
posted:10/5/2011
language:English
pages:57