PANEL DISCUSSION

SURGERY FOR CROHNS DISEASE

AD 24 female

• Crohns disease since 2001

• on penatasa, budesonide, prednisolone

• needle phobia resolved by psychologist onto azathioprine

• October 2004 – wt loss, colicky abdominal pain on eating

• barium meal and follow through

AD 24 female

Barium Meal and F/T - Featureless terminal ileum over 15cm with a very tight stricture at the ileocaecal valve over a very short distance

• no previous surgery

• BMI 18

WHAT NEXT ?

AD 24 female

LAPAROSCOPIC RESECTION

• laparoscopic resection – ileocaecetomy 25cm specimen

• stapled anatomosis

• postoperative ileus

• home on day 10

AD 24 female

KH 38 female nurse

• Crohns disease for 17 years involving the terminal ileum managed with azathioprine and steroids

•August 2003 – IP subacute obstruction

KH 38 female nurse

• BM & F/T “long segment of strictured terminal ileum - ? Early filling of sigmoid and rectum ?? Fistula

KH 38 female nurse

• September 2003 OPD – poor appetite, weight loss, urinary frequency but no pneumaturia.

•O/E mass in lower abdomen

•Hb111, Plts 645, Albumin 28g/l, CRP 122

•CT Scan – mass of small bowel with local perforation and fistulation into bladder and sigmoid

WHAT NEXT ?

KH 38 female nurse

• Medical therapy - ? Infliximab

• Resection

• Laparoscopic / Laparotomy

• Defunction or not ?

OPTIONS

KH 38 female nurse

• 20cm mass of fistulating small bowel Crohns

• fistulation into dome of the bladder

• multiple complex openings into sigmoid over 8cm

LAPAROTOMY 7.11.03

WHAT NEXT ?

KH 38 female nurse

LAPAROTOMY 7.11.03

WHAT NEXT ?

• ileocaecectomy

• broken off dome of the bladder – catheter 10 days

• sigmoid cannot be repaired, extensive indurated defect

KH 38 female nurse

LAPAROTOMY 7.11.03

• sigmoid resection, on table lavage and left colo-colonic anastomosis in two layers maxon

• end ileostomy and ascending colon mucous fistula

KH 38 female nurse

POSTOP.

• developed heparin induced thrombocytopenia

• LOS 25 days

• HISTOLOGY

KH 38 female nurse

KH 38 female nurse

Crohns disease – small bowel adenocarcinoma arising from dysplastic epithelium

KH 38 female nurse

JH 38 female

• 9.3.00 perianal Crohns fistula – seton inserted

• 13.9.01inflamed stricture upper rectum

• 28.1.02 – white cell scan shows uptake in descending colon and sigmoid

• 28.11.02 – acute gynae admission with pelvic pain, ultrasound shows complex solid/cystic mass arising from the right ovary

JH 38 female

• 12.11.02 – Gynae Laparotomy

• inflammed mass involving the sigmoid and the uterus and adenexae. Small amount of pus – colon normal to proximal descending then very abrnormal and thickened.

JH 38 female

• sigmoid separated from the uterus and pelvis washed out.

• not clear if PID or Crohns so no resection - proximal loop ileostomy brought out.

• home pod 17

JH 38 female

• gradually improved little in the way of symptoms – attended OPD to reassess pelvis and explore options for re-anastomosis

• 24.9.03 – CT showed bilateral adnexal fluid collections

• 27.10.03 – Colonoscopy halted at ulcerated mid-rectal stricture

• 19.2.04 contrast enema

JH 38 female

JH 38 female

JH 38 female

WHAT NEXT ?

JH 38 female

• TAH and BSO

• Left Hemicolectomy – small abscess around very abnormal proximal rectum, so rectum divided at the pelvic floor.

• TV colon to distal rectum cross stapled anstomosis

• loop ileostomy maintained

LAPAROTOMY 10.3.05

JH 38 female

• initially good recovery

• then unwell, low grade pyrexia, superficial wound breakdown

• CT presacral fluid collection – small amount of contrast in a 2cm cavity adjacent to anstomosis.

POSTOP