Surgical treatment of Crohn's colitis

About 20-25% of patients with Crohn's disease have involvement of the large intestine, Crohn's colitis (CC). Surgical treatment of CC is indicated when conservative treatment fails or for complications of the disease. Chronicity of the disease without accompanying dysplasia is not an indication for surgery. The initial surgical procedures of choice in CC are total proctocolectomy with ileostomy, or total colectomy with ileorectal anastomosis, or ileostomy. The choice between these options depends on the presence of anorectal disease, and the general status of the patient. In patients with poor general status, the preferred approach is colectomy with retention of the rectal stump. In 30-50% of patients with CC the initial evaluation reveals involvement of the rectum and a by-pass procedure or proctocolectomy is performed. In 25-50% of patients with CC and no involvement of the rectum ileorectal anastomosis is an option; 70% of these patients have significant rectal disease postoperatively, but only half of them will need additional proctectomy. Total proctocolectomy is effective in the avoidance of disease recurrence in the large intestine but not in the small intestine, where recurrence usually occurs within 60 cm of the ileostomy. In selected cases, good results are achieved from segmental and isolated resection of the involved part of the intestine. Diversion ileostomy has been successfully replaced nowadays by subtotal colectomy. Proctocolectomy and ileoanal anastomosis with pouch construction have no place in CC, due to frequent complications and recurrence in the pouch.