SURGICAL TREATMENT IN FISTULOUS CROHN’S DISEASE Ethem Geçim,MD Colorectal Surgeon Professor of Surgery Ankara University School of Medicine
SURGICAL TREATMENT IN FISTULOUS CROHN’S
DISEASE
Ethem Geçim,MDColorectal Surgeon
Professor of SurgeryAnkara University School of Medicine
How Big Is The Problem?
• Currently 600 000 CD patients are affected within theUS. Roughly 150 000 pts in Turkey?
• 20 000 new cases a year. 1• Surgery eventually complicates 2/3rds of the entire
patient population.2• Racial differences in prevalance?
1. Loftus EV, Schoenfeld P, Sandborn WJ. The epidemiology and natural history of Crohn’s disease in population-based patients cohort from North America:a systematic review. Aliment Pharmacol Ther2002;16:51-60.
2. Dhillon S, Loftus JrEV, Tremaine W et al The natural history of surgery for Crohn’s disease in a population-based cohort from Olmsted County Minnesota. Am J Gastroenterol 2005;100;S305.
Risk Factors for Early Surgery
• Younger age of onset• Smoking• Necessity of Corticosteroids to control the
disease• CBir1 serologic marker positivity• Penetrating disease
Why do patients require surgery?
• Bowel Malignancy(x2 colon,X40-50SB)• Stricturing disease• Fistulizing disease• Refractory disease
What Type of Surgery
• 60% of patients undergo bowel resectionwithin 30 years after the initial diagnosis
• 8% LOA within 20 years after surgery• 18 % perianal surgery within 30 years after
the diagnosis
Dhillon S, Loftus JrEV, Tremaine W et al The natural history of surgery for Crohn’s disease in a population-based cohort from Olmsted County Minnesota. Am J Gastroenterol 2005;100;S305.
Long Term Outcome• Long term remission is rare regardless to the
treatment.• Strictures or penetrating complications increase
to 70 % by the end of 20 years.
Silverstein MD, Loftus JrEV, Sandborn WJ,Tremaine W et al Clinical courseand costs of care for Crohn’s disease.Markov model analysis of a population-based cohort. Gastroenterology 1999;117:49-57.
CosnesJ, Catta S, Blain A et al. Long term evolution of disease behaviour of Crohn’s disease. Inflamm. Bowel Dis 2002;8:44-50.
Perforating Complications
• Intraabdominal penetrating disease 50 % over20 years
• Perianal disease 26 % over 20 years
CosnesJ, Catta S, Blain A, Beaugerie L, Cabonnel F, Parc R, Gendre JP. Longterm evolution of disease behaviour of Crohn’s disease. Inflamm. Bowel Dis2002;8:44-50.
• Another enterocutaneous fistula pt
• An enterovesical fistula pt
Another example : What happens if we do not stop the
ongoing pathology
Medically Refractory Disease• Initial response to corticosteroids can only be
maintained in some portion of patients after thecessation the treatment.
• Only half of the patients will achieve long termremission without corticosteroids and with any of the conventional Crohn’s medications.
Hanauer SB et al. Gastroenterolgy 2004;127:723-9.Hanauer SB et al.Lancet 2002;359:1541-9.Leman M et al. Gastroenterology 2005;128:1812-8.Feagen BG et al. New Eng J Med 1995;332;292-7.Feagen BG et al. New Eng J Med 2000; 342:1627-32.
Shortened colon with a stricturesteroid dependent and can not tolerate
steroid cessation
Crohn’s colitis
Crohn’s Colitis- Multiple Strictures
Has Medical Therapy Altered TheNatural Course?
• The French studies comparing eras withand without immunosuppressives, do not suggest an improvement in rates of surgical interventions (Cosnes et al.Gut 2005;54:237-41.)
• Infliximab maintenance however, mayreduce hospitalizations, surgeries andprocedures in fistulizing disease and childpatients. (Hanauer SB et al.Lancet 2002;359:1541-9. Lichtenstein GR et al. Gastroenterology;2005:128:862-9. Markowitz J et al. Clin Gastroenterol Hepatol
2006;4:1124-9. )
COMMENT
• Less # surgical cases– More serious complications (intraabdominal
abscess,enterovesical etc.)– Cost of Care?– QOL
COMMENT
• Era’s of Medical Treatment– Before Infliximab– After Biological Therapy
Conclusion
• Collaborative management of cases withColorectal Surgeons andGastroenterologistis required for optimal outcome.