Pre-operative management improves Crohn's surgery outcomes
MedWire News: A systemic pre-operative management program for Crohn's disease patients undergoing first ileocecal resection (ICR) offers a low rate of postoperative morbidity and fecal diversion, conclude French researchers.
Patient who have abdominal surgery for penetrating Crohn's disease experience a high rate of postoperative complications, with a two-stage procedure including a temporary diverting stoma required in up to 51% of patients.
Philippe Serbib, from Hôpital Claude Huriez in Lille, and colleagues studied the records of 78 patients who underwent first ICR between 1997 and 2007. Their procedure was performed after the institution had implemented a systematic pre-operative management program for penetrating Crohn's disease, consisting of bowel rest, nutritional therapy, intravenous antibiotics, weaning off steroids, and percutaneous drainage of abscesses.
In 64% of patients, pre-operative total parenteral nutrition or enteral nutrition was performed for 23 days, and 29.7% of 37 patients with abscesses had percutaneous scan or surgical drainage in association with antibiotic therapy. Thirty-five patients were on steroids, immunosuppressants, or anti-tumor necrosis factor alpha therapy at admission and were weaned off the drugs at the time of surgery.
Forty-five per cent of the patients underwent laparoscopic, as opposed to open, ICR, of whom 31.4% were converted to an open approach. A temporary diverting stoma was performed in 7.7% of patients due to the presence of a residual abscess at the time of surgery or complex ileo-sigmoid fistula requiring a large sigmoidectomy.
There was no postoperative deaths. There were three grade I, seven grade II, one grade IIIa, and three grade IIIb postoperative morbidities. The postoperative course was uneventful in 74.0% of patients.
The team concludes that pre-operative management for patients with penetrating Crohn’s disease led to a dramatic decrease in the rate of fecal diversions compared with those previously reported for ICR.
While acknowledging that the pre-operative management may result in a longer hospital stay and higher overall costs, the researchers say that "this needs to be balanced with a low rate of fecal diversion which is associated with decrease of quality of life and iterative hospitalizations, and the low rate of postoperative morbidity with no need for readmissions."
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By Liam Davenport