Surgical management and strategy in classical Crohn's disease

Surgical treatment for Crohn's disease of the small bowel or ileocecal region consists of resection. Surgery is not for cure but rather to relieve symptoms. In this respect resectional surgery has proved to be superior to present day medical management. The main arguments against resectional surgery are that it causes a fair amount of operative morbidity and mortality. However, these hazards can be reduced by recommending surgery at an earlier stage of the disease before the onset of complications. Furthermore it should be followed by a high incidence of recurrence of the disease, amounting to about 50% by 10 years. However, recurrences can be excised with no increased likelihood of further recurrence, and by a combination of resection and reresection as required, most patients can be afforded prolonged periods of symptomatic relief; limited resections are recommended with removal of macroscopically diseased bowel. And last that intestinal absorption is grossly impaired, especially after major or repeated resections of the small bowel. However, ileal resection causes a characteristic malabsorption pattern, qualitatively and quantitatively related to the extent of resection. The consequences such as diarrhea and possible hematological and nutritional disturbances and a predisposition to the formation of biliary and urinary calculi can be successfully prevented and/or managed by medical support and dietary restrictions. Even a loss of up to 50% of the entire small intestine is often compatible with a reasonably good state of general health, particularly if most of the colon has been preserved. Fortunately, such extensive intestinal losses are rare, even after 2 or 3 resections.