Introduction
Crohn’s disease is a chronic, granulomatous, inflammatory bowel disease which can affect the entire gastrointestinal tract and extraintestinal organs. Patients typically present with transmural, penetrating disease of the terminal ileum or colon. Crohn’s disease has the highest incidence and prevalence rates in western countries, with a peak incidence in adolescence and young adulthood [1]. Over the past decades, incidence and prevalence rates have been increasing most in newly industrialised countries [2-4]. This suggests that the still unclear aetiology is related to industrialisation and (western) lifestyle. Since Crohn’s disease is known for its intermittent and relapsing course and the extensive impact on patient’s quality of life, many different therapies have been studied. Usually, medical therapy is started as first line of treatment, whereas surgery was considered a last treatment resort when medical therapy had failed. Over the past decades, it became apparent that earlier surgery can be applied for certain disease variants and in patients with severe disease, especially now that surgical procedures are becoming more minimally invasive. Extensive small bowel resections resulting in short bowel syndrome, and permanent stomata should of course be avoided. Nowadays, around 3 out of 4 Crohn’s patients will undergo surgery during the course of their lives [5]. Especially patients with small bowel disease, perianal fistulas or diagnosed between the age of 45 to 59 years appear to have an increased risk of surgery [5]. Up to date, multiple surgical techniques have been reported for the various Crohn’s disease locations and disease behaviour.
According to the Montreal classification (based on the formerly used Vienna classification), Crohn’s disease location can be divided into ileal (L1), colonic (L2), ileocolonic (L3) and isolated (L4) upper disease (which can also be added to the first three when concomitant), and behaviour can be divided into non-stricturing and non-penetrating (B1), stricturing (B2) and penetrating (B3) types with or without perianal disease [6, 7]. Both disease location and behaviour are most important to evaluate when determining appropriate treatment strategies. Fistulas for example often arise from abscesses caused by perforating disease activity, although abscesses can also arise from an existing fistula if the drainage is blocked. Asymptomatic fistulas are usually not surgically treated, whereas enterovaginal and enterovesical fistulas are always treated surgically, and symptomatic perianal fistulas require seton drainage before initiating (or optimising) medical therapy or surgery aiming at closure as well.
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In this state-of-the-art review, we aim to report beyond what has been published in the ECCO guidelines on the surgical management of Crohn’s disease [8] and will address current research questions relevant for the surgical management. A literature search was therefore performed in MEDLINE (PubMed) using the following search terms: ‘Surgery’ and ‘Crohn’. Relevant articles were reviewed for current treatment strategies. Different current surgical treatment strategies and considerations are discussed based on disease location, from top to bottom.
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