P440 Staged surgical management of complicated ileo-colonic Crohn’s Disease
A. P. Mishreki*, F. G. Bergin
Royal Victoria Infirmary, Colorectal Surgery, Newcastle Upon Tyne, United Kingdom
Surgical management options for patients presenting with complicated ileo-colonic Crohn’s disease that is, fistulation/perforation with or without abscess formation, is complex. There is limited evidence in the literature as to how these patients should best be managed, and the potential beneficial role of a staged surgical approach to these patients remains unclear.
We identified patients in our unit in whom a staged surgical strategy has been adopted, with appropriate control of sepsis/fistulation, establishment of satisfactory nutrition, and ultimately reconstruction with excellent outcomes. We analysed surgical details, lengths of stay(s), complications related to surgery, need for nutritional support, and prior treatment. We also reviewed outcome data to include stoma requirement (looking for complete reversal), independence, nutritional recovery, and follow-up data from a medical gastroenterology status.
We found 15 patients who had been managed in this manner. Age range varied from 17 to 64 years, and all but 1 patient had a pre-existing diagnosis of Crohn’s disease, with 80% on medical therapy at presentation. Admission body mass index (BMI) ranged from 16 to 24.8, with a mean of 19.5, and 60% needed nutritional supplementation. Initial surgery was a proximal defunctioning loop ileostomy, performed on all patients after drainage of any abscesses as required. A period of nutritional correction, treatment of ongoing sepsis, and weaning off steroids and immunosuppression then took place, before re-staging of the disease extent. All patients then went on to have repeat imaging and planned definitive surgeries. All patients were followed-up and were independent with a full nutritional recovery.
Our results suggest that patients presenting with complicated, fistulating ileo-colonic Crohn’s disease may be better managed with a staged surgical intervention. Patients with perforated and/or fistulating disease often present with a large inflammatory mass, varying degrees of sepsis, and/or abscess formation. Further, these patients can have severe nutritional compromise and often have had extensive steroid and/or immunosuppressive treatment. We advocate a staged approach, and our data suggest excellent results, with reduction of extent of resection, reduced overall length of stay, and ultimately reconstruction with nutritional independence, free of surgical disease.