Management of Crohn’s Disease in Adults

- Recommendations

Section 1: Operative indications:

1.     Medically refractory disease:

·       Surgical treatment for CD must consider disease location, severity of symptoms, clinical manifestations, and nutritional status. The decision must be the result of a common agreement between gastroenterologists, surgeons, and patients, (Good practice statement).

·       We recommend surgical treatment for patients who demonstrate an inadequate response to, develop complications from, or are non-adherent with medical therapy, (Strong recommendation, low certainty evidence, ⁽¹⁾).

·       We advise performing a de-functioning stoma for non-acute refractory CD colitis, to delay or avoid the need for colectomy, (Good practice statement).

·       We advise conservative treatment following successful percutaneous, image-guided drainage of an intra-abdominal abscess in carefully selected cases, (Conditional recommendation, low certainty evidence, ⁽⁸⁾).

2.     Inflammation:

·       We recommend for patients with severe acute colitis who do not adequately respond to medical therapy or who have signs or symptoms of impending or actual perforation to undergo surgery, (Strong recommendation, low certainty evidence, ⁽¹⁾).

·       In localized ileocaecal CD, we advise performing surgical treatment as a therapeutic option, (Conditional recommendation, low certainty evidence, ⁽⁹⁾).

·       In cases of recurrent ileocaecal CD after initial treatment with steroids and/or immunosuppressants, surgical resection is recommended, (Strong recommendation, low certainty evidence, ⁽⁹⁾).

·       In cases of recurrent ileocaecal CD after initial treatment with steroids and/or immunosuppressants, biological therapy is an alternative option, (Conditional recommendation, low certainty evidence, ⁽⁹⁾).

3.    Stricture: 

·       We advise performing endoscopic dilation for patients with short-segment, non-inflammatory, symptomatic small bowel or anastomotic strictures when feasible, (Conditional recommendation, low certainty evidence, ⁽¹⁾).

·       We recommend surgical intervention for patients with symptomatic small-bowel or anastomotic strictures that are not amenable to medical therapy and/or endoscopic dilation, (Strong recommendation, low certainty evidence, ⁽¹⁾).

·       We recommend surgical resection for patients with strictures of the colon that cannot be adequately surveyed endoscopically, (Strong recommendation, low certainty evidence, ⁽¹⁾).

4.    Penetrating disease:

·       We advise the use of cross-sectional imaging tests when CD complications result in abdominal abscess formation, especially when the condition is complex, recurrent, or associated with previous surgery. For these cases, magnetic resonance imaging (MRI) is better, due to its sensitivity and specificity, (Conditional recommendation, low certainty evidence, ⁽⁹⁾).

·       We recommend surgical resection of the perforated segment for patients with a free perforation, (Strong recommendation, moderate certainty evidence, ⁽¹⁾).

·       We advise managing of patients with penetrating Crohn’s disease with abscess formation with antibiotics with or without drainage followed by interval elective resection or medical therapy depending on the clinical situation and patient preferences, (Conditional recommendation, moderate certainty evidence, ⁽¹⁾).

·       We recommend surgical intervention for patients with enterocutaneous fistulas with short tracts and high output. However, proper timing of surgery must be decided after full preoperative optimization, including nutritional status. Caution must be taken in patients previously submitted to small bowel resection(s) because of the risk of intestinal failure, (Strong recommendation, low certainty evidence, ⁽⁹⁾).

5.    Hemorrhage:

·       We recommend for stable patients with gastrointestinal hemorrhage to be evaluated and treated by endoscopic and/or interventional radiologic techniques. Unstable patients, despite resuscitation efforts, should typically undergo operative exploration, (Strong recommendation, low certainty evidence, ⁽¹⁾).

6.     Colorectal dysplasia and cancer:

·       We recommend endoscopic surveillance at regular intervals for patients with long-standing Crohn’s colitis involving at least one-third of the colon or more than 1 segment, (Strong recommendation, moderate certainty evidence, ⁽¹⁾).

·       We recommend endoscopic surveillance for patients with visible dysplasia that is completely excised endoscopically. If dysplasia is not amenable to endoscopic excision, is also found in the surrounding flat mucosa, or is multifocal, or if colorectal adenocarcinoma is diagnosed, total colectomy or total proctocolectomy is typically recommended, (Strong recommendation, moderate certainty evidence, ⁽¹⁾).

·       We recommend for patients with invisible, indefinite dysplasia, they should typically be referred to an experienced endoscopist for repeat colonoscopy using enhanced imaging with repeat random biopsies within 3 to 12 months, (Strong recommendation, low certainty evidence, ⁽¹⁾).

·       We advise for patients with invisible, low- or high-grade dysplasia on routine surveillance colonoscopy, to be referred to an experienced endoscopist for high-definition colonoscopy with chromoendoscopy with repeat random biopsies within 3 to 6 months. Patients found to have invisible, low- or high-grade dysplasia at the time of high-definition colonoscopy with chromoendoscopy should typically undergo total colectomy or proctocolectomy, (Conditional recommendation, moderate certainty evidence, ⁽¹⁾).

·       We recommend biopsy from any suspicious lesions (eg, mass, ulcer) identified in patients with Crohn’s disease, especially when considering small-bowel or colonic strictureplasty, (Strong recommendation, low certainty evidence, ⁽¹⁾).

Section 2: Site specific operations:

·       We recommend for patients with symptomatic disease of the stomach or duodenum despite medical therapy to consider for endoscopic dilation, bypass, or strictureplasty, (Strong recommendation, low certainty evidence, ⁽¹⁾).

·       We advise performing strictureplasty for stenosis of the second and third duodenal portions, as it has better outcomes. Duodenal resection or pancreatoduodenectomy are options used as a last therapeutic resource, (Conditional recommendation, low certainty evidence, ⁽⁹⁾).

·       We recommend for patients with medically refractory disease isolated to the jejunum, ileum, or ileocolon without existing or anticipated short-bowel syndrome, to undergo escalation of medical therapy or resection of the affected bowel, ideally, as determined by a multidisciplinary team, (Strong recommendation, low certainty evidence, ⁽¹⁾).

·       We recommend strictureplasty for patients undergoing an operation with multifocal disease, (Strong recommendation, low certainty evidence, ⁽¹⁾).

·       We recommend performing a total abdominal colectomy with end ileostomy, as the procedure of choice, for emergency surgery in Crohn’s colitis, (Strong recommendation, low certainty evidence, ⁽¹⁾).

·       For patients with colonic disease and rectal sparing who proceed with elective surgery, we recommend performing segmental colectomy for single-segment disease or total colectomy for more extensive disease, (Strong recommendation, moderate certainty evidence, ⁽¹⁾).

·       For patients undergoing elective surgery for rectal disease, we recommend performing total proctocolectomy with end ileostomy or proctectomy with creation of a colostomy, (Strong recommendation, low certainty evidence, ⁽¹⁾).

Section 3: Preoperative considerations:

·       We recommend elective bowel resection over emergency surgery in patients with CD, (Strong recommendation, high certainty evidence, ⁽⁸⁾).

·       We recommend control of sepsis prior to abdominal surgery for CD, (Strong recommendation, moderate certainty evidence, ⁽⁸⁾).

·       Preoperative high-dose glucocorticoids increase the risk of postoperative infectious complications and we recommend weaning glucocorticoids before surgical intervention. Other immunomodulators are not associated with increased risk of postoperative infectious complications and do not typically need to be held before surgery, (Strong recommendation, low certainty evidence, ⁽¹⁾).

·       Preoperative nutritional support for patients with malnutrition may decrease postoperative morbidity and pre-operative optimization is advised, followed by re-assessment of the patient for surgical intervention, (Conditional recommendation, low certainty evidence, ⁽¹⁾).

·       Smoking cessation is recommended to reduce postoperative morbidity in patients with Crohn’s disease, (Strong recommendation, low certainty evidence, ⁽¹⁾).

Section 4: Operative considerations:

·       We advise performing CD surgery in high-volume tertiary centers, (Conditional recommendation, moderate certainty evidence, ⁽⁸⁾).

·       Laparoscopy is the preferred option, particularly for primary procedures for ileocolonic CD. Nevertheless, it may not always be feasible in patients with recurrent or complex disease, (Conditional recommendation, moderate certainty evidence, ⁽⁹⁾).

·       We advise performing a de-functioning stoma for non-acute refractory CD colitis, to delay or avoid the need for colectomy, (Good practice statement).

·       We recommend a diverting ileostomy when performing ileocolectomy in patients who have Crohn’s disease with multiple risk factors, (Strong recommendation, moderate certainty evidence, ⁽¹⁾).

·       We advise performing stapled side-to-side anastomoses in small bowel or ileocolic resections for CD, (Conditional recommendation, moderate certainty evidence, ⁽⁸⁾).

·       We advise performing the Kono-S anastomosis as an alternative surgical approach to other types of anastomoses after ileocaecal resection, (Conditional recommendation, moderate certainty evidence, ⁽⁸⁾).

·       We recommend strictureplasty as an alternative treatment option to resection in small-bowel CD, (Strong recommendation, high certainty evidence, ⁽⁸⁾).

·       We advise performing segmental colectomy in selected cases of colonic CD, (Conditional recommendation, low certainty evidence, ⁽⁸⁾).

Section 5: Postoperative considerations:

·       After surgery for CD, patients are recommended to be on medical therapy to treat residual active disease or to maintain disease remission, (Strong recommendation, moderate certainty evidence, ⁽¹⁾).

·       We recommend endoscopic surveillance within 6–12 months after surgical resection in CD, (Strong recommendation, high certainty evidence, ⁽⁸⁾).

·       We recommend thromboembolism prophylaxis following hospital discharge after CD surgery, (Strong recommendation, high certainty evidence, ⁽⁸⁾).

Section 6: Perianal Crohn’s disease:

•        We recommend management of symptomatic anorectal fistula associated with Crohn’s disease,   with a combination of surgical and medical approaches, (Strong recommendation, moderate certainty evidence ^{(10, 11)}).

•        We recommend against surgical treatment of asymptomatic fistulae in patients with Crohn’s disease, (Strong recommendation, low certainty evidence ^{(10, 11)}).

•        We recommend draining Setons in the multimodality therapy of fistulizing anorectal CD and may be used for long-term disease control, (Strong recommendation, moderate certainty evidence ^{(10, 11)}).

•        Endorectal advancement flaps and the LIFT procedure are recommended to treat fistula-in-ano associated with CD, (Strong recommendation, moderate certainty evidence ^{(10, 11)}).

•        We advise to treat symptomatic, simple, single, low anal fistulae in patients with Crohn’s disease, by lay-open fistulotomy, (Conditional recommendation, low certainty evidence ^{(10, 11)}).

•        Fecal diversion or proctectomy, is recommended for patients with uncontrolled symptoms from complex anorectal fistulizing CD, (Strong recommendation, moderate certainty evidence ^{(10, 11)}).