Crohn Disease Clinical Practice Guidelines (2019)

European Crohn’s and Colitis Organisation (ECCO)

This is a quick summary of the guidelines without analysis or commentary. For more information, go directly to the guidelines by clicking the link in the reference.

December 03, 2019

The European Crohn's and Colitis Organisation (ECCO) published its guidelines on the surgical management of Crohn disease (CD) in November 2019.[1]

Complex Perianal Fistula

Medical therapy and surgical drainage

No prospective study directly compares medical or surgical treatment of complex perianal CD fistulae either in isolation or in combination with both modalities. Observational studies support a combined medical/surgical approach to control sepsis and luminal activity.

Surgical techniques

For patients with CD and complex perianal fistulae:

  • Advancement flaps are a therapeutic option.

  • Ligation of the intersphincteric fistula tract is an option.

  • Fibrin glue may be a potential treatment with limited efficacy.

Do not routinely consider anal fistula plugs for closure of anoperineal fistulas in CD, as seton removal alone is equally effective.

Ano- and rectogenital fistulae related to CD are very complex and rare; thus, treatment should involve an experienced multidisciplinary team.

Stem cell therapy

Allogeneic adipose-derived stem cell (ASC) therapy could be an effective and safe treatment for complex perianal fistulae in patients with CD.

Autologous ASCs may have a positive effect for patients with CD and complex perianal fistulae, with good tolerability and safety.

Refractory Pelvic Sepsis

Pelvic sepsis and symptoms from complex perineal CD refractory to medical or surgical interventions can be controlled by a diverting stoma, but with limited rates of fistula healing and stoma closure.

Surgical Management of Abdominal CD

Approach to intra-abdominal abscess

The recommended primary approach is percutaneous image-guided drainage of well-defined accessible intra-abdominal abscesses.

Following successful image-guided drainage of an intra-abdominal abscess, medical management without surgery may be considered. A low threshold for surgery is recommended if medical management is not successful.

Preoperative Optimization

Perform preoperative nutritional assessment for all patients with CD who need surgery. Preoperative nutritional optimization with enteral or parenteral nutrition is recommended for patients with nutritional deficiencies.

Preoperative corticosteroid use is associated with an increased risk of postoperative complications. Preoperative reduction of corticosteroid doses may reduce postoperative complications but should be monitored carefully to avoid increasing the disease burden.

Current evidence suggests that preoperative treatment with anti-tumor necrosis factor (TNF) therapy, vedolizumab, or ustekinumab does not raise the risk of postoperative complications in patients with CD having abdominal surgery. Preoperative cessation of these medications is not mandatory.

Preoperative control of sepsis is recommended prior to abdominal surgery for CD.

Small-Bowel Obstruction

Deferred surgery is the preferred option in adult patients with CD who present with acute small-bowel obstruction without bowel ischemia or peritonitis.

Endoscopic balloon dilatation or surgery are both suitable treatment options for patients with short (<5 cm) strictures of the terminal ileum in CD. Local expertise and patient preference guide the treatment selection.

Strictureplasty is a safe option to treat small bowel strictures related to CD. Strictureplasty may be preferable to resection of long segments of bowel, with a potential reduction in surgical recurrence rates.

Surgical Techniques for Abdominal CD

Laparoscopic surgery should be offered as the first-line approach in surgery for CD, depending on the presence or availability of appropriate expertise.

Consider a temporary stoma if steroids cannot be withdrawn or significantly reduced prior to surgery.

Primary anastomosis may safely be performed in the presence of anti-TNF therapy, vedolizumab, and ustekinumab, as long as other risk factors have been taken into account.

A reasonable alternative to infliximab therapy is laparoscopic resection in patients with limited, nonstricturing, ileocecal CD (diseased terminal ileum <40 cm).

Stapled small-bowel or ileocolic side-to-side anastomoses are associated with lower rates of postoperative complications than end-to-end anastomoses in CD.

Segmental colectomy is appropriate for patients with a single involved colonic segment in CD.

A defunctioning stoma for non-acute refractory Crohn colitis may delay or avoid the need for colectomy.

Restorative proctocolectomy with ileal pouch-anal anastomosis can be considered in selected patients with refractory pancolonic CD without a history of perianal disease, taking into account the high risk of pouch failure.

For more information, please go to Crohn Disease and Crohn Disease Pathology.

For more Clinical Practice Guidelines, please go to Guidelines.

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