DIFFICULT SMALL BOWEL CROHN’S DISEASE

1. DIFFICULTSMALL BOWEL CROHN’S DISEASE John Northover St Mark’s Hospital, London

3. LOOK BEFORE YOU LEAP

4. LOOK BEFORE YOU LEAP

5. Causes of intestinal failureSt Mark’s & Hope, 1999-2002

6. Difficult SB Crohn’s • Duodenal disease • Multiple strictures • Enterocutaneous fistula

7. DuodenalCrohn’s

8. A few facts • Rare - <5% • Differential diagnosis • Rarely sole site • Often overshadowed

9. Duodenum plus . . . . • D3 stricture • Advanced ileal disease

10. Clinical scenarios • ‘Peptic ulcer-like’ • Obstruction • Fistula

11. Patterns of disease *

12. Symptoms • ‘Peptic ulcer’ pain 70% • Vomiting 50% • Weight loss 26% • Diarrhoea 22% • Bleeding 7%

13. Investigation • Barium studies • Scanning • Endoscopy

14. Conventional Ba meal • Anatomical clarity • Endoscopy needed

15. BaM in D3 obstruction • Poor view • No distal information

16. CT in D4 obstruction

17. Endoscopy • Differential diagnosis • Dilatation

18. Treating obstruction • Balloon dilatation • Bypass • Strictureplasty

19. Balloon dilatation • May avoid surgery • Few data • Distal disease

20. 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)

21. Strictureplasty • 13 patients (10 primary) • 2/10 leaked • 6 re-stricturedsurgery • Overall 9/13 re-operated Birmingham, 1999

22. ‘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

23. Fistulating duodenal Crohn’s • Usually secondary • To colon or terminal SB • Duodenocutaneous rare • Most OK for oversew

24. D2-transverse colic fistula • Normal duodenum • Penetrating ulcers • Simple closure after colectomy

26. Multiple strictures

27. Multiple strictures • Failure to thrive • Obstruction

28. Multiple strictures

29. Multiple strictures • What trouble are they? • Other modalities? • Previous surgery? • Is there a ‘dominant’ stricture? • AND ONLY THEN . . .

30. Multiple strictures • Might surgery help? • If so, what surgery? • (Bypass) • Resection • Strictureplasty

31. Multiple strictures Pros and cons of strictureplasty • Bowel conservation • Safety • Relapse rate

32. Multiple strictures Recurrence avoidance Oxford, 1995

33. Multiple strictures Recurrence avoidance 2006 meta analysis Tekkis et al.

34. StrictureplastyWhat’s available?

35. StrictureplastyWhat’s available?

36. StrictureplastyWhat’s available? What do they achieve?

37. StrictureplastyWhat’s available?

38. StrictureplastyBeware the occult stricture

39. StrictureplastyPick ‘n’ Mix . . .

41. Enterocutaneous fistula

42. Enterocutaneous fistula Surgery rarely avoided

43. Avoiding re-operation

44. Avoiding re-operation NO UNEXPECTED EXTRA PROCEDURES

45. Avoiding DISASTER DON’T GO IN TOO EARLY

46. Avoiding DISASTER DON’T GO IN TOO EARLY

47. Avoiding DISASTER WAIT!! DON’T GO IN TOO EARLY

48. Avoiding DISASTER WAIT!! and PREPARE DON’T GO IN TOO EARLY

49. Pre-operative preparation Exclude distal obstruction Exclude septic collections Find the optimalentry site

50. Avoiding re-operation • ROADMAP • Composite image • Pre-operate in head