The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Surgical Management of Crohn’s Disease

The American Society of Colon and Rectal Surgeons (ASCRS) is dedicated to ensuring high-quality patient care by advancing the science, prevention, and management of disorders and diseases of the colon, rectum, and anus. The Clinical Practice Guidelines Committee is composed of Society members who are chosen because they have demonstrated expertise in the specialty of colon and rectal surgery. This committee was created to lead international efforts in defining quality care for conditions related to the colon, rectum, and anus and develop clinical practice guidelines based on the best available evidence. While not proscriptive, these guidelines provide information on which decisions can be made and do not dictate a specific form of treatment. These guidelines are intended for the use of all practitioners, health care workers, and patients who desire information about the management of the conditions addressed by the topics covered in these guidelines. These guidelines should not be deemed inclusive of all proper methods of care nor exclusive of methods of care reasonably directed toward obtaining the same results. The ultimate judgment regarding the propriety of any specific procedure must be made by the physician in light of all of the circumstances presented by the individual patient. STATEMENT OF THE PROBLEM Crohn’s disease (CD) is an idiopathic, incurable chronic inflammatory disease of the GI tract, which affects over one million people in the United States and continues to increase in incidence for unknown reasons.1 The characteristic transmural inflammation of CD can occur anywhere along the GI tract, resulting in an inflammatory, fibrostenotic, or penetrating phenotype. Although the degree of symptoms is variable and may wax and wane throughout the disease course, patients can require chronic immunosuppression and operations to treat the disease symptoms, but both are unable to cure the disease. Monoclonal antibodies have become the cornerstone of medical therapy for moderate-to-severe disease; however, their utility is limited by primary and secondary loss of response and the risk of serious opportunistic infection with anti-tumor necrosis factor (TNF) medication.2–9 Although the rate of surgical intervention for medically refractory disease has decreased over the past 6 decades and less emergent surgery is being performed, a meta-analysis of population-based studies reported that rates of surgical intervention for medically refractory disease remain high at 16%, 33%, and 47% at 1, 3, and 5 years from diagnosis.10,11 After resection, because surgery is not curative, 70% to 90% of patients will have endoscopic recurrence by 1 year and up to 35% of patients will have a repeat intestinal resection within 10 years.12–14 Given the typical complexity of patients with CD requiring surgical intervention, multidisciplinary care with gastroenterologists, surgeons, radiologists, pathologists, and other ancillary team members is critical for optimizing patient care. Because the management of patients with CD involves different medical disciplines working in conjunction with one another, these guidelines must be viewed in that context and represent only a portion of the treatment necessary for the optimal care of these patients. This clinical practice guideline will focus on the surgical management of patients with CD. METHODOLOGY This clinical practice guideline is based on the previous ASCRS Clinical Practice Guideline for the Surgical Management of Crohn’s Disease that was published in 2015.15 Bowel preparation, enhanced recovery pathways, prevention of thromboembolic disease, and the management of perianal disease, although relevant to the management of patients with CD, are beyond the scope of this guideline and are addressed in other ASCRS clinical practice of and the of limited to the was from 1, 1, The is in necrosis and or or or or or or or or or or or or or of a of from a directed of in from the The of the to the of After a of the a of chosen for of the was on and practice guidelines. studies and studies was The was for the the was and a treatment guideline was by the for this The of and of for the of and was regarding the or treatment from the committee and the of the ASCRS Clinical Practice Guidelines Committee in of these guidelines from to by the by the Clinical Practice Guidelines members of the ASCRS Bowel Disease and The guideline was by of the Colon and the guideline was by the ASCRS ASCRS Clinical Practice Guideline is 5 was for this guideline and the have related this This guideline to the of Guidelines and The Disease who an response develop or are with medical therapy should be for surgery. of based on The of medical treatment of CD are to with endoscopic in patients with disease and in with disease. are clinical is within of therapy and within to of treatment with are a a in of clinical symptoms is demonstrated within to the of therapy with an or a to of therapy is to to these is in the of is a in an to the in this a limited of about 5 to is to the response of Surgical intervention may be in patients who are unable to medical therapy because of are to medical or have medically refractory disease to primary or secondary loss of may be in patients who are of disease because of the of chronic resection a therapy in the of limited disease inflammatory, with who do not to medical therapy or who have or symptoms of or should surgery. of based on Because of the limited specific to CD, the management of in patients with CD is based on of this in patients with that the of and Crohn’s to medical therapy with a response to in and of patients and to in and of and are that to patients with and inflammatory response The degree of can be or the and with and at one of the rate or a is colon in the of is Crohn’s is of should be with studies and endoscopic and may be to and and for can the response to Given the of patients are with to the of or and these may to be not clinical treatment of of limited use of and and of on is because is a risk factor for this and are not a response to therapy or of the a in and clinical patients do not within about a therapy an or should be response to or in this should occur within about 5 to medical treatment or colon with is may be for patients with or of based on CD can anywhere along the intestinal and are inflammatory or in The degree of inflammation the can be of an inflammatory and chronic is typical of a these are not exclusive because intestinal is a and inflammation and can within the same or and can with a high of and guidelines for to and inflammatory the from that may be a relevant in patients who an may be in inflammatory, and obtaining an a has is not because of the of these therapy with or the treatment for with an inflammatory endoscopic or surgical therapy is for The typical for endoscopic therapy is a in the of penetrating disease and may be with endoscopic The is a variable although a of has not The of endoscopic is about and occur in to of After of a primary repeat endoscopic is in to of patients for up to 5 and recurrence rates are at in to of in in the of CD has with the best of the is not to 5 years endoscopic of primary or surgical intervention is in about of is for patients with or that are not to medical therapy endoscopic of based on or is for and medical endoscopic are or a is to be and in and not to medical resection is performed, the of resection should only about of and to the because is to obtaining or of Although limited the practice these the of a resection is being and is or both for in this and the use of a are in this an to resection, is in to and is the for patients with by of in in patients who are at risk for may be for resection but should be in the of inflammatory or to of is with resection to disease The of is based on the of the and the of the is for can 10 to in and is for about of have reported in to of patients in and surgical in of and or at the of are risk for are at a risk for in is to patients a recurrence rate in and of to that a recurrence the of develop in intestinal from After for disease has reported in and of patients and 10 with of the colon that be should be for of based on occur in to of patients with CD and are at a although may be can be in to symptoms with rates to is to that to of CD or but is to from by clinical with patient of disease, and of should be with endoscopic and to for a be to a resection should be Although has this is to a of about being in Disease with a should surgical resection of the of based on of the in patients with CD is with a reported incidence of to with all a of the of the is over because of the high rate and risk of with primary with penetrating Crohn’s disease with may be with with or by resection or medical therapy on the clinical and patient of based on in patients with CD from a penetrating disease with an and can have an inflammatory that affects other of the Although can be with are with and that has a rate of studies and and surgery for in patients with CD that and of in to of recurrence is surgical intervention with disease, and that are or a to resection with resection in decreased for and and in rates of and with and the of a meta-analysis of patients who have CD with the rate was in patients who by surgical intervention surgical intervention at these circumstances should and resection, because the of can lead to or of therapy in the of an inflammatory with a a risk and of the Although studies have the treatment of by therapy may resection in up to of with that medical therapy should be for surgery. of based on the of penetrating disease with should be and The to of a penetrating resection of the a of patients with CD a but a all patients with therapy with or a and surgery was in of this the surgery rate was and 47% at 1, 3, and 5 years from the of and not by surgery was in over of patients. 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to their risk of recurrence risk surgery for of disease less and disease or high risk or for penetrating disease with or perianal patients CD, is not or can be for prevention of clinical with this endoscopic recurrence and patients risk from the use of these use should be limited to about these 6 patients should with a in the to recurrence based on the and of at the and with from to inflammation with patients with a should repeat an in 1 to the is an other the patient response or should be with or a The patients with CD to or and that the treatment endoscopic recurrence but the clinical recurrence rates the meta-analysis of 10 CD recurrence and that therapy was with the in clinical and endoscopic of for a that and and have not in the of patients with disease surgery or in patients who are high risk for treatment or on the can within to with from and with an with or a is should 6 to disease and for of medical this treatment clinical and endoscopic recurrence are with