Severe Gastroduodenal Crohn's Disease: Surgical Treatment

Crohn's disease can involve any portion of the gastrointestinal tract from the mouth to the anus. Gottlieb and Alpert (1) described the first case of duodenal involvement in 1937. The estimated prevalence varies between 0.5% and 4% if clinical symptoms and barium radiographs are used for diagnosis. (2,3,4). The incidence increases dramatically if upper endoscopy is used as the diagnostic modality. In some series, gastroduodenal involvement is as high as 60%. There is essentially an equal distribution of males and females. The first line of treatment is medical, and most patients have mild disease, which responds nicely to management with a variety of antiulcer regimens (proton pump inhibitors or H2-blockers). There has been some interest in endoscopic dilation and local steroid injection for intestinal strictures and in those patients with peptic esophageal narrowing (5). There is very little data on its use in gastroduodenal Crohn's, and its efficacy here is unknown. However, when the inflammatory process is severe with narrowing of the duodenum, obstructive symptoms require surgery as the best option for management. There are many reports documenting the efficacy of traditional (open) surgery in the treatment of gastroduodenal Crohn's disease. There are only case reports on treatment with laparoscopic surgery. This review will detail the author's experience utilizing laparoscopic surgery for this disease. The diagnosis of obstructive duodenal Crohn's disease is suspected by the clinical signs of vomiting (post-prandial), bloating, abdominal pain, and weight loss. A succusion splash is usually present in those patients with gastric outlet obstruction. Anemia is also common in these patients, but massive hemorrhage is rare. Free perforation is also very uncommon (6). It is distinctly uncommon to have obstructive duodenal Crohn's disease without terminal ileal involvement. Therefore, a high index of suspicion should be present. Depending of the extent of intestinal involvement, laparoscopic resection of the diseased bowel can be accomplished at the same time. However, these are independent variables, and the decision to resect must be based on the intestinal symptoms. This has been reported previously (7,8). Confirmation of duodenal involvement is by endoscopy. Granulomas are present in less than 50% of biopsy specimens. A barium upper gastrointestinal radiograph is required before surgery is undertaken. It is important to know extent of involvement, the amount of gastric outlet obstruction present, and whether there are “skip” lesions in the proximal jejunum. This can best be ascertained by barium study (Fig. 1). The indications for surgery revolve around patients' symptoms. Vomiting and weight loss are the most common indications for surgical treatment. If signs of gastric outlet obstruction are present (succusion splash), this author prefers preoperative nasogastric decompression before operative intervention. One or two days of decompression are usually all that is needed. This will decrease the incidence of postoperative gastric “ileus,” and thereby shorten the total hospitalization. There is no agreement on the continuation of proton pump inhibitors once bypassed, but the trend is for continued treatment. There is conflicting data on the addition of truncal vagotomy with bypass, and I have not used it. There also has been interest in the performance of duodenal stricturoplasty in selected cases, but conflicting data on potential benefit to patients. Worsey et al. (9) reported equal rates of reoperative surgery with stricturoplasty (selected cases) as compared with bypass, but Yamamoto et al. (10) reported higher reoperative rates with stricturoplasty compared with bypass. The presence of duodenal-colonic fistula is almost always secondary to primary colonic disease (11). Primary duodenal disease as a cause of fistulization is rare. Upper gastrointestinal barium radiograph demonstrating distal gastric and duodenal Crohn's disease. Note the typical “cobblestone” appearance of the second portion of the duodenum. Image courtesy of Daniel H. Present. A posteriorly placed, retrocolic gastrojejunostomy is constructed via four small incisions. The longest is 1/2 inch in length. This explains the decrease in pain and more rapid return to normal activities compared with traditional open surgery. Length of stay has averaged three days, and the majority of patients are back to normal activities in 10 days. In a matched group of patients at our institution, the length of stay for open gastrojejunostomy is 7.5 days. From 1994 through 2002, 12 patients have undergone laparoscopic gastrojejunostomy for obstructive duodenal Crohn's disease. The mean age was 28 years, and there were an equal number of males and females. This represents seven percent of the patients (175) with Crohn's disease undergoing laparoscopic surgery by the author. Five of the twelve patients presented with a succusion splash. Two patients underwent a concomitant laparoscopic assisted ileocolic resection for stenotic ileal disease. This delayed discharge from hospital one day in each patient. Eleven of the patients have done well with resolution of symptoms. The mean follow-up is 4.2 years. One patient required reoperation within the first month for a malfunctioning anastomosis. There was a misplaced gastrojejunostomy in this patient, and the operation was performed in a traditional manner by another surgeon. This complication occurred early in the author's laparoscopic experience. This patient continues to do well. Two patients had previous traditional surgery for ileal Crohn's disease, and the previous surgery did not influence the laparoscopic gastrojejunostomy. There were no infectious complications or other morbidity. At present, the operative time is down to 70 minutes, which compares favorably to open surgery. The indications for laparoscopic bypass in obstructive, gastroduodenal Crohn's disease are the same as in traditional surgery. The advantages of a minimally invasive approach have been realized in this small group of patients. Compared with traditional surgery, the length of stay and recovery are much shorter. The cosmetic differences have been dramatic especially considering the young age of the patients. Morbidity has been nil in this series. Laparoscopic gastrojejunostomy is considered an advanced procedure, and, therefore, certain laparoscopic skills must be in place. The most important is suturing and knot tying (two-handed technique). One patient in this series required open surgery to correct a wrongly placed anastomosis. This attests to the complex nature of this type of surgery. In those patients with a succussion splash, preoperative decompression via a nasogastric tube is important to decrease the incidence of gastric ileus. The addition of other laparoscopic surgery did not adversely affect outcome in this series, although hospitalization was prolonged in the two patients with concomitant laparoscopic ileocolectomy. Laparoscopic gastrojejunostomy is considered the primary approach to gastroduodenal Crohn's disease. Open surgery is reserved for those patients in whom laparoscopic surgery is not possible.