title: Surgical management and outcomes of patients with duodenal Crohn's disease.
abstract: BACKGROUND
  Duodenal Crohn's disease (DCD) has been reported to occur in 0.5% to 4% of patients with Crohn's disease. When patients fail to respond to conservative therapy or severe narrowing of the duodenum develops, operation is required. The recent literature is limited in description of surgical treatment of such patients. We reviewed our experience with surgical management and outcomes in patients with DCD, including outcomes of laparoscopic bypass procedures.
  
  
  METHODS
  A retrospective review was undertaken of all patients who underwent surgical intervention for DCD between 1995 and 2006. Data collected included demographics, clinical presentation, operative and hospital course, and postoperative followup.
  
  
  RESULTS
  Thirty patients had surgical intervention for DCD during the selected period. Four patients had duodenoenteric fistulas, resulting from complications of their disease in the distal gastrointestinal tract. Operations done for intrinsic DCD were: open bypass (n = 11), laparoscopic bypass (n = 13), and stricturoplasty (n = 2). Only one vagotomy was done. Mean followup was 58 months (range 6 to 144 months). Patients resumed oral diet 3.0 days after laparoscopic bypass, with mean discharge of 6.9 days, as compared with 4.4 days and 12.2 days after open bypass, respectively. In the early postoperative period (0 to 30 days), six major complications (n=5, 19%): persistent obstruction, anastomotic leak, small bowel obstruction, anastomotic bleeding (two patients), and respiratory failure, developed in four patients in the open (36%) and one patient in the laparoscopic (8%) bypass group. There were two more complications during longterm followup, for an overall major morbidity rate of 27%. Two patients experienced recurrence requiring revision (one in the open group and one in the laparoscopic group). Gastroduodenal ulcers requiring operation did not develop in any of the patients.
  
  
  CONCLUSIONS
  Surgery is a viable and safe option for patients with intractable duodenal Crohn's disease. The laparoscopic approach during a bypass procedure, as opposed to an open bypass, may result in faster recovery, less morbidity, and comparable recurrence rate. There is no role for vagotomy in bypass procedures.
authors.affiliation: Department of Surgery, The Mount Sinai Medical Center, New York, NY, USA.
authors.forename: Mark
authors.initials: M
authors.lastname: Shapiro
authors.forename: Alexander J
authors.initials: AJ
authors.lastname: Greenstein
authors.forename: John
authors.initials: J
authors.lastname: Byrn
authors.forename: Jacqueline
authors.initials: J
authors.lastname: Corona
authors.forename: Adrian J
authors.initials: AJ
authors.lastname: Greenstein
authors.forename: Barry
authors.initials: B
authors.lastname: Salky
authors.forename: Michael T
authors.initials: MT
authors.lastname: Harris
authors.forename: Celia M
authors.initials: CM
authors.lastname: Divino
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000714:Anastomosis, Surgical; D003424:Crohn Disease / Q000601:surgery*; D004378:Duodenal Diseases / Q000601:surgery*; D004386:Duodenum / Q000601:surgery; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007081:Ileostomy; D007582:Jejunostomy; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications; D012189:Retrospective Studies; D016896:Treatment Outcome