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.