Perforating Crohn's disease: conservative and surgical treatment

Surgery is a part of the clinical history of patients with Crohn's disease (CD) since nearly all the patients receive at least one surgical procedure. The main indication for surgery is obstruction, but 50-60% of patients present a concomitant perforating disease at surgery, and 10% of patients have a primary indication for abscess or fistula. Generally, fistulas are classified on an anatomical basis, indicating the site of origin followed by the target (i.e. ileocolic, ileovesical, etc.). Enteroenteric fistulas are frequently asymptomatic and are not always considered an indication for surgery. However, in case of bypass with severe malnutrition or bacterial overgrowth (i.e. duodenal involvement), surgery is the only option. Enterovesical, enteroureteral and enterobiliary fistulas, due to their potential for septic complications, are a definite indication for surgery. Enterogenital fistulas have an indication mainly for their impact on the quality of life. Enterocutaneous fistulas are, in most cases, a late surgical complication, and the indication and timing for treatment are due to their output volume. Abscesses may be present alone or in association with enteric fistulas. The initial approach is conservative, and a percutaneous drainage should be a good treatment or a bridge to elective surgery. Since a modern surgical approach to CD has to be minimally invasive and highly conservative whenever possible, the presence of perforating disease should be well characterized in order to plan a laparoscopic approach and to reduce the amount of resected bowel, in case combining resection and strictureplasty. Perforating CD necessitates a multidisciplinary approach involving, behind the gastroenterologist and the surgeon, the radiologist, the urologist, the gynecologist and the nutritionist in order to obtain the best tailored treatment.