PANEL DISCUSSION SURGERY FOR CROHNS DISEASE. AD 24 female Crohns disease since 2001 on penatasa, budesonide, prednisolone needle phobia resolved by psychologist.

PANEL DISCUSSION

SURGERY FOR CROHNS DISEASE

AD 24 female

• Crohns disease since 2001

• on penatasa, budesonide, prednisolone

• needle phobia resolved by psychologist onto azathioprine

• October 2004 – wt loss, colicky abdominal pain on eating

• barium meal and follow through

AD 24 female

Barium Meal and F/T - Featureless terminal ileum over 15cm with a very tight stricture at the ileocaecal valve over a very short distance

• no previous surgery

• BMI 18

WHAT NEXT ?

AD 24 female

LAPAROSCOPIC RESECTION

• laparoscopic resection – ileocaecetomy 25cm specimen

• stapled anatomosis

• postoperative ileus

• home on day 10

AD 24 female

KH 38 female nurse

• Crohns disease for 17 years involving the terminal ileum managed with azathioprine and steroids

•August 2003 – IP subacute obstruction

KH 38 female nurse

• BM & F/T “long segment of strictured terminal ileum - ? Early filling of sigmoid and rectum ?? Fistula

KH 38 female nurse

• September 2003 OPD – poor appetite, weight loss, urinary frequency but no pneumaturia.

•O/E mass in lower abdomen

•Hb111, Plts 645, Albumin 28g/l, CRP 122

•CT Scan – mass of small bowel with local perforation and fistulation into bladder and sigmoid

WHAT NEXT ?

KH 38 female nurse

• Medical therapy - ? Infliximab

• Resection

• Laparoscopic / Laparotomy

• Defunction or not ?

OPTIONS

KH 38 female nurse

• 20cm mass of fistulating small bowel Crohns

• fistulation into dome of the bladder

• multiple complex openings into sigmoid over 8cm

LAPAROTOMY 7.11.03

WHAT NEXT ?

KH 38 female nurse

LAPAROTOMY 7.11.03

WHAT NEXT ?

• ileocaecectomy

• broken off dome of the bladder – catheter 10 days

• sigmoid cannot be repaired, extensive indurated defect

KH 38 female nurse

LAPAROTOMY 7.11.03

• sigmoid resection, on table lavage and left colo-colonic anastomosis in two layers maxon

• end ileostomy and ascending colon mucous fistula

KH 38 female nurse

POSTOP.

• developed heparin induced thrombocytopenia

• LOS 25 days

• HISTOLOGY

KH 38 female nurse

KH 38 female nurse

Crohns disease – small bowel adenocarcinoma arising from dysplastic epithelium

KH 38 female nurse

JH 38 female

• 9.3.00 perianal Crohns fistula – seton inserted

• 13.9.01inflamed stricture upper rectum

• 28.1.02 – white cell scan shows uptake in descending colon and sigmoid

• 28.11.02 – acute gynae admission with pelvic pain, ultrasound shows complex solid/cystic mass arising from the right ovary

JH 38 female

• 12.11.02 – Gynae Laparotomy

• inflammed mass involving the sigmoid and the uterus and adenexae. Small amount of pus – colon normal to proximal descending then very abrnormal and thickened.

JH 38 female

• sigmoid separated from the uterus and pelvis washed out.

• not clear if PID or Crohns so no resection - proximal loop ileostomy brought out.

• home pod 17

JH 38 female

• gradually improved little in the way of symptoms – attended OPD to reassess pelvis and explore options for re-anastomosis

• 24.9.03 – CT showed bilateral adnexal fluid collections

• 27.10.03 – Colonoscopy halted at ulcerated mid-rectal stricture

• 19.2.04 contrast enema

JH 38 female

JH 38 female

JH 38 female

WHAT NEXT ?

JH 38 female

• TAH and BSO

• Left Hemicolectomy – small abscess around very abnormal proximal rectum, so rectum divided at the pelvic floor.

• TV colon to distal rectum cross stapled anstomosis

• loop ileostomy maintained

LAPAROTOMY 10.3.05

JH 38 female

• initially good recovery

• then unwell, low grade pyrexia, superficial wound breakdown

• CT presacral fluid collection – small amount of contrast in a 2cm cavity adjacent to anstomosis.

POSTOP