Crohn’s disease surgeries make steady advances

Thousands of Americans suffering from the chronic inflammatory bowel condition known as Crohn’s disease are leading longer, healthier lives due to innovative new surgeries, according to experts at New York-Presbyterian Hospital/Weill Cornell Medical Center.

"Four out of five Crohn’s patients will require some kind of surgery at some point during their lives, but these advanced, often minimally invasive techniques are sparing precious bowel tissue while improving quality of life," says senior author Dr Fabrizio Michelassi, Lewis Atterbury Stimson Professor and chairman of the Department of Surgery at Weill Cornell Medical College and surgeon-in-chief at New York-Presbyterian Hospital/Weill Cornell Medical Center.

He and co-author Dr Sharon L. Stein, assistant professor of surgery at Weill Cornell Medical College and colorectal surgeon at New York-Presbyterian Hospital/Weill Cornell Medical Center, wrote a "state of the science" review in a recent issue of the journal Practical Gastroenterology.

As many as 500,000 people in the US suffer from Crohn’s disease, which triggers inflammation along the gastrointestinal tract, most typically in the lower bowel. Certain drugs can help ease symptoms, but there is no cure for this chronic illness. Some of the more severe complications of Crohn’s disease include strictures (narrowing of the bowel), abscesses, perforations, fistulas (abnormal, obstructive connections between tissues), haemorrhage and even cancers. These types of complications often require surgical intervention.

"In the past, this was limited to complex, invasive surgeries that required the removal of whole sections of the affected bowel. But over the past two decades, advances in surgery have changed that paradigm," Dr. Stein notes.

Some of the innovations outlined in the review include:

• Laparoscopic surgery: "Patients – especially younger patients – prefer laparoscopic surgery because the small incision involved leaves little external scarring, even after repeat procedures," Dr Michelassi notes. These minimally invasive techniques also lead to fewer surgery-linked internal tissue adhesions. Laparoscopic procedures do tend to require more training on the part of surgeons, and they can take longer to perform than conventional surgery. "However, they also lead to shorter hospital stays, saving money and getting patients home faster," Dr Stein notes.
• Strictureplasty: This technique has revolutionised bowel surgery, the experts say. "In the past, surgeons would cut out whole sections of diseased bowel, shortening the organ and thereby limiting gastrointestinal function," explains Dr Michelassi, a world-renowned pioneer in the technique. With strictureplasty, surgeons leave the affected length of bowel in place but widen it, "much like letting out the seams on a pant-leg," he says. This spares bowel tissue while "restructuring" it, so that intestinal contents can safely pass through.
• Fistula plugs: Fistulas can be both painful and dangerous, causing intestinal contents to diverge from the anal canal. This often leads to anal incontinence, abscesses and, most seriously, systemic infection. Certain surgeries can drain the fistula tract but for more difficult lesions a new surgical anal plug – made from grafted porcine tissue – is placed over the fistula. The plug triggers the growth of local fibrotic tissue that then closes off the fistula tract. "In studies, this approach has proven successful in up to half of Crohn’s patients," Dr Stein says.

These and other surgical advances are giving patients valuable new options against a relentless disease, Dr Michelassi says.

"In our work here at New York-Presbyterian/Weill Cornell, we’re learning that we can do so much more than we thought we could, reducing surgical risks, sparing bowel and helping patients have better outcomes," he says.

Dr Stein agrees. "As we learn more, and become more comfortable with these techniques, our success emboldens us to reach for the next generation of advances. Year by year, it’s making a real difference in patients’ lives."

(Source: New York-Presbyterian Hospital/Weill Cornell Medical Center: New advances in surgical treatment of Crohn’s disease. Practical Gastroenterology: November 2008)