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      Indications and surgical options for small bowel, large bowel and perianal Crohn's disease

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          Abstract

          Despite advancements in medical therapy of Crohn’s disease (CD), majority of patients with CD will eventually require surgical intervention, with at least a third of patients requiring multiple surgeries. It is important to understand the role and timing of surgery, with the goals of therapy to reduce the need for surgery without increasing the odds of emergency surgery and its associated morbidity, as well as to limit surgical recurrence and avoid intestinal failure. The profile of CD patients requiring surgical intervention has changed over the decades with improvements in medical therapy with immunomodulators and biological agents. The most common indication for surgery is obstruction from stricturing disease, followed by abscesses and fistulae. The risk of gastrointestinal bleeding in CD is high but the likelihood of needing surgery for bleeding is low. Most major gastrointestinal bleeding episodes resolve spontaneously, albeit the risk of re-bleeding is high. The risk of colorectal cancer associated with CD is low. While current surgical guidelines recommend a total proctocolectomy for colorectal cancer associated with CD, subtotal colectomy or segmental colectomy with endoscopic surveillance may be a reasonable option. Approximately 20%-40% of CD patients will need perianal surgery during their lifetime. This review assesses the practice parameters and guidelines in the surgical management of CD, with a focus on the indications for surgery in CD (and when not to operate), and a critical evaluation of the timing and surgical options available to improve outcomes and reduce recurrence rates.

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          Most cited references112

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          The risk of cancer in patients with Crohn's disease.

          The risk of cancer in patients with Crohn's disease is not well defined. Using meta-analytical techniques, the present study was designed to quantify the risk of intestinal, extraintestinal, and hemopoietic malignancies in such patients. A literature search identified 34 studies of 60,122 patients with Crohn's disease. The incidence and relative risk of cancer were calculated for patients with Crohn's disease and compared with the baseline population of patients without Crohn's disease. Overall pooled estimates, with 95 percent confidence intervals, were obtained, using a random-effects model. The relative risk of small bowel, colorectal, extraintestinal cancer, and lymphoma compared with the baseline population was 28.4 (95 percent confidence interval, 14.46-55.66), 2.4 (95 percent confidence interval, 1.56-4.36), 1.27 (95 percent confidence interval, 1.1-1.47), and 1.42 (95 percent confidence interval, 1.16-1.73), respectively. On subgroup analysis, patients with Crohn's disease had an increased risk of colon cancer (relative risk, 2.59; 95 percent confidence interval, 1.54-4.36) but not of rectal cancer (relative risk, 1.46; 95 percent confidence interval, 0.8-2.55). There was significant association between the anatomic location of the diseased bowel and the risk of cancer in that segment. The risk of small bowel cancer and colorectal cancer was found to be higher in North America and the United Kingdom than in Scandinavian countries with no evidence of temporal changes in the cancer incidence. The present meta-analysis demonstrated an increased risk of small bowel, colon, extraintestinal cancers, and lymphoma in patients with Crohn's disease. Patients with extensive colonic disease that has been present from a young age should be candidates for endoscopic surveillance; however, further data are required to evaluate the risk of neoplasia over time.
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            Practice parameters for the management of perianal abscess and fistula-in-ano.

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              Risk factors for surgery and postoperative recurrence in Crohn's disease.

              To assess the impact of possible risk factors on intestinal resection and postoperative recurrence in Crohn's disease (CD) and to evaluate the disease course. The results of previous studies on possible risk factors for surgery and recurrence in Crohn's disease have been inconsistent. Varying findings may be explained by referral biases and small numbers of patients in some studies. Data on initial intestinal resection and postoperative recurrence were evaluated retrospectively in a population-based cohort of 1,936 patients. The influence of concomitant risk factors was assessed using uni- and multivariate analyses. The cumulative rate of intestinal resection was 44%, 61%, and 71% at 1, 5, and 10 years after diagnosis. Postoperative recurrences occurred in 33% and 44% at 5 and 10 years after resection. The relative risk of surgery was increased in patients with CD involving any part of the small bowel, in those having perianal fistulas, and in those who were 45 to 59 years of age at diagnosis. Female gender and perianal fistulas, as well as small bowel and continuous ileocolonic disease, increase the relative risk of recurrence. Three of four patients with CD will undergo an intestinal resection; half of them will ultimately relapse. The extent of disease at diagnosis and the presence of perianal fistulas have an impact on the risk of surgery and the risk of postoperative recurrence. Women run a higher risk of postoperative recurrence than men. The frequency of surgery has decreased over time, but the postoperative relapse rate remains unchanged.
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                Author and article information

                Journal
                World J Gastroenterol
                World J. Gastroenterol
                WJG
                World Journal of Gastroenterology
                Baishideng Publishing Group Inc
                1007-9327
                2219-2840
                28 October 2016
                28 October 2016
                : 22
                : 40
                : 8892-8904
                Affiliations
                James WT Toh, Peter Stewart, Matthew JFX Rickard, Christopher J Young, Department of Colorectal Surgery, Concord Repatriation General Hospital, NSW 2139, Australia
                James WT Toh, South Western Sydney Clinical School, University of New South Wales, Liverpool Hospital, NSW 2170, Australia
                James WT Toh, School of Medicine, Western Sydney University, Liverpool Hospital, NSW 2170, Australia
                James WT Toh, Ingham Institute of Applied Research, Liverpool Hospital, NSW 2170, Australia
                Christopher J Young, Department of Colorectal Surgery, Royal Prince Alfred Hospital, NSW 2050, Australia
                James WT Toh, Matthew JFX Rickard, Nelson Wang, Christopher J Young, Discipline of Surgery, Sydney Medical School, the University of Sydney, NSW 2006, Australia
                Rupert Leong, Department of Gastroenterology, Concord Repatriation General Hospital, NSW 2139, Australia
                Author notes

                Author contributions: The manuscript was prepared by Toh JWT and was reviewed and revised by Stewart P, Rickard MJFX, Leong R, Wang N and Young CJ.

                Correspondence to: Dr. James WT Toh, BSc, MBBS (UNSW), FRACS, Department of Colorectal Surgery, Concord Repatriation General Hospital, Hospital Rd, Concord, NSW 2139, Australia. james.toh@ 123456unsw.edu.au

                Telephone: +61-404-006271

                Article
                jWJG.v22.i40.pg8892
                10.3748/wjg.v22.i40.8892
                5083794
                27833380
                8a69cfa3-8a58-46d7-96ac-0319d92664c0
                ©The Author(s) 2016. Published by Baishideng Publishing Group Inc. All rights reserved.

                This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial.

                History
                : 14 July 2016
                : 26 August 2016
                : 28 September 2016
                Categories
                Review

                surgery,crohn’s disease,major abdominal surgery,perianal,inflammatory bowel disease,colon cancer

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