Abstract
Radical excision of the small bowel and affected lymph nodes was originally advocated for Crohn's disease of the small bowel. Subsequently, intestinal bypass became popular, either in continuity or by exclusion of the diseased segment. Bypass in turn was superseded by limited resection, which remains the procedure of choice in most patients. Recognition that Crohn's disease is both panintestinal in nature and incapable of surgical cure has led to increasingly conservative operations aimed solely at overcoming the complications of the disease. Balloon catheters have been used to assess luminal stenosis in 20 patients and to undertake dilatation of strictures between 20 and 25 mm in diameter. Tighter strictures have been treated by strictureplasty. In 3 years, 37 patients have had 43 operations and 106 strictureplasties. Rates for anastomotic leakage episodes of pain and fever and overt wound infection have all been below 10%. Six patients have required reoperation, usually for strictures elsewhere.
Résumé
L'exérèse de l'intestin et des ganglions afférents a constitué le traitement initial de la maladie de Crohn du grÊle. Ultérieurement, le court-circuit anastomotique lui fut préféré qu'il ait été réalisé en continuité ou en excluant le segment intestinal intéressé. De nouveau la résection limitée lui est à l'honneur car elle représente le meilleur traitement pour la majorité des malades. Le fait que la maladie de Crohn est une affection qui intéresse la totalité de l'intestin et qu'ainsi elle est impossible à guérir par la chirurgie explique l'expansion du traitement chirurgical conservateur dont le but est seulement de contrôler les complications de l'affection. La dilatation par des cathéters à ballon a été employée pour agir chez 20 malades qui présentaient des sténoses de 20 à 25 mm de diamètre. Les sténoses plus sévères ont été traitées par des plasties du rétrécissement. En 3 ans, 37 malades ont été soumis à 43 opérations et à 106 plasties de la sténose. Les taux de fièvre et de douleur ainsi que d'infection pariétale provenant d'une fuite de la suture ont été inférieurs à 10%. Six malades ont dû Être réopérés habituellement pour des sténoses d'un autre siège.
Resumen
La resección radical del intestino delgado y de los ganglios linfáticos afectados fue el procedimiento originalmente propendido para la enfermedad de Crohn del intestino delgado. Más tarde la derivación (“bypass”) intestinal se hizo popular, en continuidad o con exclusión del segmenta afectado. La derivación fue luego superada por la resección limitada, procedimiento que sigue siendo el de escogencia en la mayoría de los casos. El reconocimiento de que la enfermedad de Crohn es de naturaleza panintestinal y no susceptible a la curación por medios quirÚrgicos, ha resultado en una tendencia hacia operaciones conservadoras dirigidas sólo a corregir las complicaciones de la enfermedad. Se han utilizado catéteres de balón para determinar el grado de estenosis en 20 pacientes, y para emprender la dilatación de estrecheces de 20–25 mm de diámetro. Estrecheces más pronunciadas han sido tratadas mediante “estenoplastia.” En un periodo de 3 años 37 pacientes han sido sometidos a 43 operaciones y a 106 “estenoplastias.” Las tasas de episodios de escape anastomótico, de dolor y de fiebre, y de clara infección de la herida, han sido consistentemente menores de 10%. Seis pacientes han requerido reoperación, generalmente debido a la presencia de un área de estenosis en un lugar diferente.
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Alexander-Williams, J., Haynes, I.G. Conservative operations for Crohn's disease of the small bowel. World J. Surg. 9, 945–951 (1985). https://doi.org/10.1007/BF01655400
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DOI: https://doi.org/10.1007/BF01655400