Surgical Treatment of Crohn’ s Disease Alessandro Fichera & Fabrizio Michelassi Published online: 19 January 2007 # 2007 The Society for Surgery of the Alimentary Tract Keywords Crohn’ s disease . Surgical treatment . Minimally invasive approach Introduction Crohn’ s disease is an entity which comprises a heteroge- neous spectrum of intestinal and extraintestinal manifes- tations, each one requiring individual approaches for diagnosis and management. Medical management has evolved greatly during the last decade: innovations have included the introduction of new therapeutical agents for prophylaxis and for management of complications. Yet, the introduction of new biologic agents, such as anti-TNF antibody, 1,2 or immunomodulators, such as azathioprine/6 mercaptopurine, 3 has not significantly changed the long- term prognosis and natural history of patients with Crohn’ s disease. 4,5 Patients with Crohn’ s disease still tend to require surgery as time progresses, and the timing of surgery is critical. This review article will focus on the indications for surgical treatment, on the preoperative evaluation of Crohn’ s patients, on surgical options specific to different gastrointestinal locations affected by the disease, and on new minimally invasive approaches to this disease. Indications for Surgery in Crohn’s Disease The chronic and unrelenting nature of Crohn’ s disease brings these patients to the attention of the gastroenterologist during the early phases. 6 The initial management is medical until treatment fails or a complication arises. Failure to respond to medical treatment or the inability to tolerate effective therapy (Table 1) are the most common indications for surgical treatment of Crohn’ s disease. 7,8 Some patients may respond to the initial medical therapy only to have the symptoms rapidly recur with the tapering of the medical treatment. For example, some patients respond well to steroid therapy but become steroid- dependent as tapering of the steroid dose results in recurrent symptoms. Due to the severe complications that are virtually inevitable with prolonged steroid treatment, surgery is warranted if the patient cannot be weaned from systemic steroids within 3 to 6 months. The occurrence of complications related to the medical treatment or the progression of disease while on maximal medical treatment represent additional indications to surgical treatment. More than one in five Crohn’ s patients present to the surgeon with worsening obstipation. 9 Symptoms are pre- cipitated by a single (Fig. 1) or multiple strictures (Fig. 2) or a lengthy disease segment and differ depending on the location of the disease in the gastrointestinal tract. Even a complete obstruction in Crohn’ s disease tends to resolve with nasogastric decompression, intravenous hydration, and medical therapy, and surgery should be postponed until resolution of the clinical picture allows for a definitive procedure. Intestinal fistulae occur in one-third of Crohn’ s disease patients. 10 Intestinal fistulae, however, are the primary indication for surgery in only a minority of patients. Thus, the presence of an intestinal fistula is not in and of itself an indication for surgery. 11 In general, intestinal fistulae are the primary indication to surgical treatment if they connect J Gastrointest Surg (2007) 11:791–803 DOI 10.1007/s11605-006-0068-9 A. Fichera Pritzker School of Medicine, University of Chicago, Chicago, IL, USA F. Michelassi (*) Department of Surgery, Weill Medical College of Cornell University, 1300 York Avenue, Room F-739, New York, NY 10021, USA e-mail: Fam2006@med.cornell.edu