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  • Title: [Surgical treatment of Crohn disease based on the inflammatory pattern].
    Author: Lindemann W, Hönig A, Feifel G, Ecker KW.
    Journal: Zentralbl Chir; 1998; 123(4):344-51. PubMed ID: 9622892.
    Abstract:
    286 patients with Crohn's disease were classified on the basis of the inflammatory pattern at their first operation as type 1 (Ileitis: n = 116), type 2a (segmental colitis: n = 60), and type 2b (total colitis: n = 108); 2 patients remained unclassified. At the same age at operation of 31.9 +/- 10.7 yrs symptoms were known in type 1 for 3.4 +/- 3.9 yrs, but for 7.5 +/- 5.7 yrs in type 2b. Main indication in type 1 was stenosis (56.9%), whereas in type 2b intractabilitiy (68.5%) predominated. Type 2a was intermediate concerning duration of symptoms and relationship of indications including fistulas. Standard-procedures were ileocecal resection (92.2%) in type 1, and colectomy (90.7%) in type 2b. In type 2a ileocolic resections and partial colectomies were mostly done. During the following 3.9 +/- 3.8 yrs reoperation rate due to disease progression was 13.6% in type 1, 25.5% in type 2a and 18.5% in type 2b. The cumulative risk of ileal resection at ten years due to new inflammation was significantly (p < 0.01) higher in the case of ileocolic/ileorectal anastomosis than of ileostomy (38% vs. 11%). In contrast, cumulative probability of a colorectal resection was significantly (p < 0.05) higher in type 2 (16%) when compared to type 1 (1.5%). Primary ileal loss was significantly (p < 0.01) higher in type 1 (37 +/- 23 cm) compared with type 2a (25 +/- 28 cm) and type 2b (17 +/- 21 cm). Loss of continence occurred in 0%, 3.3% and 53.7% respectively. With reoperations additional loss of ileum decreased in all types, whereas in type 2 loss of anorectal function increased. Including reoperations the rate of major complications was 9.8% and lethality was 0.8% (3/386). Resections in Crohn's disease are unavoidable due to shrinking therapeutical alternatives in the course of the disease. Owing to limited resections, loss of bowel may not exceed ileum in type 1, whereas the same resectional policy cannot avoid the total loss of the colorectum eventually in type 2. Both limited surgery and repeated resections help to maintain function as long as possible. Due to the high safety-standard the number of operations does not impair the success of the surgical concept.
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