Therapeutic strategies in Crohn’s disease in an emergency surgical setting

Abstract

Crohn’s disease (CD) remains a chronic, incurable disorder that presents unique challenges to the surgeon. Multiple factors must be considered to allow development of an appropriate treatment plan. Medical therapy often precedes or complements the surgical management. The indications for operative management of CD include acute and chronic disease complications and failed medical therapy. Elective surgery comes into play when patients are refractory to medical treatment if they have an obstructive phenotype. Toxic colitis, acute obstruction, perforation, acute abscess, or massive hemorrhage represent indications for emergency surgery. These patients are generally in critical conditions and present with intra-abdominal sepsis and a preoperative status of immunosuppression and malnutrition that exposes them to a higher risk of complications and mortality. A multidisciplinary team including surgeons, gastroenterologists, radiologists, nutritional support services, and enterostomal therapists are required for optimal patient care and decision making. Management of each emergency should be individualized based on patient age, disease type and duration, and patient goals of care. Moreover, the recurrent nature of disease mandates that we continue searching for innovative medical therapies and operative techniques that reduce the need to repeat surgical operations. In this review, we aimed to discuss the acute complications of CD and their treatment.

Keywords: Crohn’s disease; Intestinal obstruction; Free perforation; Intra-abdominal sepsis; Perineal sepsis; Acute bleeding

Core Tip: Crohn’s disease remains a chronic and incurable disorder. Multiple factors must be considered to allow the development of an appropriate treatment. The indications for operative management of Crohn’s disease include acute and chronic disease complications and failed medical therapy. Progression into a complicated phenotype can be characterized by the formation of stenosis or abscesses/fistulas. Elective surgery comes into play when patients are refractory to medical treatment if they have an obstructive phenotype. Indications for emergency surgery include intestinal obstruction, abdominal and perineal sepsis, toxic colitis, or massive hemorrhage.