[When is it too early or too late for surgery in Crohn's disease? ].
The surgical boarding of Crohn's disease (CD) admitted as a last effort of treatment against behavior in those the therapy prescribes it has failed, it supposes a loss on perspective that can postpone the delay in the recovery of patients and it retracts them of a better quality of life when it is considered that 50% of patients maintain inactive illness during years after selected surgical procedures; some rate no reached by the most effective treatments. The risk to specify surgical procedure in the course of CD rises to 75% of payees, more than 50% in the first year from the diagnosis, and practically 100% patients in the evolution when it is contemplated to attend perianal lesions. Therefore gastroenterologist should be trained in the selection who, when and why these patients should be operated. To retard the surgery to advanced illness phases increases morbidity, and if it is certain that the new biological therapy allow induction of remissions it is also it that to increase the duration of the process and the patient s age and contributes to face bigger surgical risk and worse perspectives in the treatment of their acute complications and also chronic manifestations often clinically inconsiderate as: Retractile mesenteritis, the states of hipercoagulability and the appearance of malignizations phenomena. Saving absolute indications for initial selective surgery in management of CD patient like: Massive intestinal bleeding, toxic megacolon or free perforation, other surgical conditions they should be reevaluated on light of our current knowledge. Patient s genotyping constitutes a clinical element that contributes to the identification of its specific risks and it facilitates the therapeutic selection. Unfortunately until these analyses can be routinely used the precocious employment of CD surgery it will be based on the consideration clinical data: The patient age, its nutritional state, smoking, and the necessities of steroids. To differ among inflammatory or fibrous stenosis is crucial for the election of their treatment, because the therapeutic employment of surgery it supposes to accept its irreversibility and makes indispensable to conjugate clinical manifestations of chronic obstruction: Pain, distension bacterial overgrowth and hipoalbuminemia with demonstration of their aperistaltic character, local hipovascularity or the submucosae muscularization submucosa in the stenosis. On the other hand, the medical treatment of fistulous behaviors CD in proximal gastrointestinal tracts offers results that they cannot be considered valid and this condition should be assumed as absolute indication for the surgical treatment. The image methods diagnoses also they don't offer absolute effectiveness in the characterization on penetrating modalities in which the effectiveness of the new ones biological it is controversial to recommend its therapeutic handling for what the surgical option seems to acquire a high-priority significance under conditions as coloenteric and colovesical fistulae. The under anesthesia surgical exam for anatomical characterization of lesions in perineal CD it demands a surgical attendance precociously carried out and it is constituted in the gold standard for definition that can be supplemented with image techniques. After characterization perianal CD they should be attended considering the presence or absence of proctitis and the phenotype of underlying illness. Some authors had intended to stratify the patients as: Simple fistula without proctitis; Affections with simple fistula associated to rectal illness; or associated complex fistulae. The first group they will be candidates to an antibiotic therapy and immunosupressors in the beginning, the second group to protocols for biological therapy added to the previous program, and the third group to previous surgical exploration to any later medical performance. The cumulative relative risk to the ten years from the diagnosis gives the CD it is relatively low (3%) for the development he/she gives a cancer colorrectal. But it ascends until 33.2% (15.9-60.9) on the small intestine, with rate no modified in the last 30 years that accentuate the necessity of screening programs or indication for surgery against their mere suspicion the poor later presage he/she gives these patient.
Fernández-Blanco Hernáiz
J I
JI
Servicio de Cirugía General, Hospital Universitario La Paz, Madrid. fernandezblanco@telefonica.net
Monturiol Jalón
J M
JM
D001004:Anus Diseases / Q000209:etiology; D003424:Crohn Disease / Q000150:complications / Q000601:surgery*; D006801:Humans; D007412:Intestinal Fistula / Q000209:etiology; D007415:Intestinal Obstruction / Q000209:etiology; D013997:Time Factors