Surgical treatment of Crohn's disease

In clinical practice surgery in patients with Crohn's disease is usually applied in the absence of the effect of conservative therapy, in cases strictly local lesions, often in combination with certain complications (perforation, obstruction, fistulas, and so on).
Along with this, the operation is performed in patients with so-called acute ileotomy, clinically resembling acute appendicitis.
If the diagnosis of acute illness is not in doubt, the operation should not be, and should be conservative treatment for bed. However, many patients may be at laparotomy about suspected acute appendicitis. In such cases, if the wall blind gut thickened and inflammatory modified, the appendectomy should not be, for it is fraught with the aggravation of the process, the emergence of external fistula. Resection of the affected area ileum is also considered to be contraindicated. I. D. Klepov (1959) recommends that in most of these cases to investirovat mesentery solution penicillin-procaine (to 200 ml 0.25% novokaina solution is added to 500 UNITS of penicillin) and layers tightly to sew up the abdominal cavity.
The cases with the defeat of the gastro-duodenal zone is usually treated conservatively and only when signs of stenosis recommended surgery (resection of the stomach, gastroenterostomy). In view of the rarity of such localization process, the final decision of the question about the tactics of these patients is obviously premature (Duprey and others, 1970).
Indications for surgery for chronic regional ileitis are usually subacute intestinal obstruction, chronic forms, not amenable to therapy, and is complicated by the occurrence of fistula and abcesses. Apply 2 main types of surgery: surgery "off" part of the intestine with ileo-colostomy and resection of the affected segment with the imposition of anastomosis, is preferable to the "end to end". Operation "off" finds the number of supporters, as this remains the primary pathological focus and a potential source of fistula. Along with this modern operational techniques and anesthesia let succesfully produce a bowel resection with a significant reduction in the percentage of deaths during the operation (Jones and others, 1968).
When conducting resection ileum simultaneously usually produce the right hemicolectomy. Lapeyrere and others (1967) are supporters of extended resection with excision of the mesentery, similar to those with cancer of the small intestine. According to their data, such transactions reduce the number of relapses.
Edwards (1964) to establish the level of resection considered it necessary to use fresh frozen slices of the intestinal wall, received at the operating table, to determine the boundaries of normal and abnormal areas. You must cross the intestine within the normal areas. Often, however, and histologically normal wall has struck and wounded lymphoid follicles, which can cause a relapse. The latter, according to the materials Schofield (1965), usually more often in common granulomatous lesions than with limited processes.
In Crohn's disease of the colon often indications to surgery is the lack of effect of drugs. Uses 2 types of surgery: "drainage" of feces (original variant operation "off" with carrying out a colostomy or ileostomy) and resection of the affected areas in a particular volume.
Recently Burman and others (1969) have traced the fate of 24 patients with Crohn's disease, subjected to the first of the type of transaction during 12-200 months and in any case not watched the termination of activity of the pathological process in the "desfunktionalnom" section of the intestine. 12 patients subsequently underwent resection of the affected segments. Obviously, the "rejection" of feces is not effective operational intervention in Crohn's disease.
When segmental granulomatous colitis has been used successfully economical resection with anastomosis. In case of injury of the right half of the colon and intact rectum suitable overlay ileorectal anastomosis. When lesions of the anus and rectum good results excision last, followed by a colostomy.
In total colitis is proctocolectomy, which, according to Jones and others (1966), gives a good therapeutic effect. It is significant that after this operation, rarely relapse of the disease in the ileum, which confirms the radical nature of the intervention.
For all types of operations in half of the cases, relapse of the disease, requiring a conservative treatment, as many patients - re-intestinal resections.
Lennard-Jones and Stalder (1967) among the 78 patients undergoing surgical treatment regarding regional ileitis, during 10 years of follow-up to 50% of installed relapses, and 1/4 cases - indications for repeated operations. On materials of Barter and others (1963), 26.5% of cases in 10 years after resection there was a need for a second surgery. Similar results were also obtained for the granulomatous colitis. So, Tarkunde and Patankar (1969) was observed in 50% of patients relapse after surgery, and in 65% of them - in the first 2 years, 85% - within 5 years of observation. Described cases of relapse 20 years after the operation.
The most effective was the surgical treatment of the distal lesions of large intestine, where relapses were observed only rarely.
One should agree with the opinion Tarkunde and Patankar (1969), stating that until the etiology and pathogenesis of Crohn's disease but will be found out, treatment of this disease will remain essentially a purely empirical.