| Despite improvement in medical management of Crohn’s disease there has not been a significant reduction in surgery. The indications for surgery remain unchanged with failure of medical management as the most common, both primary non response or loss of response in patient on biologic agents. When planning surgery the multidisciplinary team has to evaluate the overall picture. Often these patients are malnourished, immunosuppressed and septic. Every effort should be made to optimize their conditions before surgery whenever possible. The choice of surgical approach should be decided based on patient, disease and surgical related factors. Furthermore this decision should be timed with the patient, family and support system, gastroenterology team, nutritionist and stoma therapist. Historic data on postoperative clinical and endoscopic recurrence showed a concerning rate of endoscopic recurrence at 1 year after ileocecectomy of approximately 80%. Studies have shown that that endoscopic recurrence will eventually translate in surgical recurrence in up to 50% of the total group. Clearly the scenario is different now given the availability of more aggressive medical therapy shown to be effective not only in inducing remission, but also in preventing endoscopic, clinical and surgical recurrence. The right balanced between risk of complications, cost of therapy and risk of recurrence when recommending postoperative medical prophylaxis of Crohn’s disease recurrence is a topic of intense debate. Risk stratification based on known prognostic indicators of disease severity in Crohn’s disease is far from being an exact science. Early colonoscopic surveillance, when feasible based on location of disease, has been used as a tool to titrate medical therapy in the postoperative setting. The surgeon however can also play a major role in prevention of postoperative endoscopic, clinical and surgical recurrence. Data in the literature suggest that a wide lumen anastomosis is effective in preventing postoperative surgical recurrence. It is the configuration and the size of the anastomotic lumen rather than the technique (i.e. stapled versus handsewn) that impacts on the risk of recurrence. The importance of stasis of enteric flow at the anastomosis with the associated local modification of microbiota is currently actively investigated. Dr. Toru Kono has recently described a wide lumen antimesenteric end to end handsewn anastomosis with very promising long-term reduction in surgical recurrence. The Japanese experience has been replicated in the US by our group. We are awaiting longitudinal prospective data. |
