Clinical Practice Guidelines on the Surgical Management of Crohn Disease (ASCRS, 2020)

American Society of Colon and Rectal Surgeons

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.

July 28, 2020

In July 2020, the American Society of Colon and Rectal Surgeons published clinical practice guidelines on the surgical management of Crohn disease.[1]

Medically refractory disease

Surgery should be considered for patients in whom the response to medical therapy is inadequate or who develop complications from or are nonadherent to such treatment.

Inflammation

Surgery should be performed when patients with severe acute colitis have an inadequate response to medical therapy or when signs or symptoms of impending or actual perforation exist.

Stricture

Patients with short-segment, noninflammatory, symptomatic small-bowel or anastomotic strictures may be considered for endoscopic dilation.

When medical therapy and/or endoscopic dilation are not feasible for symptomatic small-bowel or anastomotic strictures, surgery is indicated.

Resection should be considered when strictures of the colon cannot be adequately surveyed endoscopically.

Penetrating disease

A free perforation should be managed via surgical resection of the perforated segment.

Antibiotics, with or without drainage, can be used to manage penetrating Crohn disease with abscess formation, with subsequent treatment performed via interval elective resection or medical therapy, depending on the clinical situation and patient preferences.

Surgery should be considered when enteric fistulas persist despite appropriate medical treatment.

Hemorrhage

Endoscopic and/or interventional radiologic techniques may be used for the evaluation and treatment of stable patients with gastrointestinal hemorrhage. Operative exploration should typically be used in unstable patients, despite resuscitation efforts.

Colorectal dysplasia and cancer

Endoscopic surveillance performed at regular intervals should typically be employed in patients with long-standing Crohn colitis involving at least one-third of the colon or more than one segment.

Typically, endoscopic surveillance should be used in patients with visible dysplasia who have undergone complete endoscopic excision. Total colectomy or total proctocolectomy is typically recommended if such excision is not feasible, if the dysplasia also exists in the surrounding flat mucosa or is multifocal, or if colorectal adenocarcinoma is diagnosed.

In patients with invisible, indefinite dysplasia, referral should typically be made to an experienced endoscopist for repeat colonoscopy; enhanced imaging should be employed, with repeat random biopsies within 3-12 months.

A finding of invisible, low- or high-grade dysplasia on routine surveillance colonoscopy should typically prompt referral to an experienced endoscopist for high-definition colonoscopy with chromoendoscopy, with repeat random biopsies within 3-6 months. Total colectomy or proctocolectomy should typically be performed when invisible, low- or high-grade dysplasia has been found via high-definition colonoscopy with chromoendoscopy.

Biopsy suspicious lesions (eg, mass, ulcer) in patients with Crohn disease, especially when small-bowel or colonic strictureplasty is being considered.

Site-specific surgery

Endoscopic dilation, bypass, or strictureplasty should typically be considered for patients who, despite medical therapy, are suffering from symptomatic disease of the stomach or duodenum.

Medically refractory disease isolated to the jejunum, ileum, or ileocolon in the absence of existing or anticipated short-bowel syndrome should typically be addressed via escalation of medical therapy or resection of the affected bowel, ideally, as determined by a multidisciplinary team. Strictureplasty should be considered for patients with multifocal disease who are undergoing surgery.

In Crohn colitis, a total abdominal colectomy with end ileostomy is the procedure of choice for emergency surgery.

Segmental colectomy for single-segment disease or total colectomy for more extensive disease can be performed in cases of colonic disease and rectal sparing if the patient proceeds to elective surgery.

Total proctocolectomy with end ileostomy or proctectomy with creation of a colostomy should typically be carried out when elective surgery for rectal disease is performed.

In selected patients with Crohn disease in whom perianal or small-bowel disorders are absent, restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) may be offered.

Preoperative considerations

The postoperative infectious complication risk is increased by the administration of preoperative high-dose glucocorticoids; prior to surgery, attempts should typically be made to wean patients from glucocorticoids.

In patients with Crohn disease, smoking cessation may lead to a reduction in postoperative morbidity.

Operative considerations

In Crohn disease surgery, a minimally invasive approach should typically be considered.

When patients with Crohn disease who have multiple risk factors are undergoing ileocolectomy, a diverting ileostomy should be considered.

Following ileocecal resection, it is reasonable to perform reconstruction using, according to surgeon preference and experience, side-to-side, side-to-end, or end-to-end handsewn or stapled anastomosis.

Postoperative considerations

Medical therapy to treat residual active disease or to maintain disease remission should be considered following Crohn disease surgery.

For more information, please go to Crohn Disease.

For more Clinical Practice Guidelines, please go to Guidelines.

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