The clinical presentations of Crohn disease of the small bowel vary from low to high complexity. Understanding the complexity of Crohn disease of the small bowel is important for the surgeon and the gastroenterologist caring for the patient and may be relevant for clinical research as a way to compare outcomes. Here, we present a categorization of complex small bowel Crohn disease and review its surgical treatment as a potential initial step toward the establishment of a definition of complex disease.
The complexity of small bowel Crohn disease can be sorted into several categories: technical challenges, namely, fistulae, abscesses, bowel or ureteral obstruction, hemorrhage, cancer and thickened mesentery; extensive disease; the presence of short gut; a history of prolonged use of medications, particularly steroids, immunomodulators, and biological agents; and a high risk of recurrence.
Although the principles of modern surgical treatment of Crohn disease have evolved to bowel conservation such as strictureplasty techniques and limited resection margins, such practices by themselves are often not sufficient for the management of complex small bowel Crohn disease. This manuscript reviews each category of complex small bowel Crohn disease, with special emphasis on appropriate surgical strategy.
Crohn disease of the small bowel presents with protean manifestations and may pose a challenge even to the most experienced surgeon due to the extent of disease, the severity of complications, the presence of short bowel, the presence of complications from prolonged medical treatment, and the likelihood of future recurrences. In this article, we review the surgical management of complex small bowel Crohn disease.
From the Department of Surgery, New York-Presbyterian Hospital, Weill Cornell Medical College, New York, NY.
Reprints: Fabrizio Michelassi, MD, Department of Surgery, New York-Presbyterian Hospital, Weill Cornell Medical College, 525 East 68th St, Box 129, New York, NY 10065. E-mail: email@example.com.
Disclosure: The authors declare no conflicts of interest.