[Crohn's disease: current surgical treatment]. / Maladie de Crohn: état actuel du traitement chirurgical.

Surgical treatment of Crohn's disease (CD) is purely symptomatic. In addition, medical therapy always precedes surgery and almost always continues afterwards. The indications for surgical treatment are failure of medical treatment and progressive complications such as chronic bowel obstruction and occlusion, internal abscesses and fistulae, and recurrences. Between 70 and 80% of patients with CD will undergo surgical treatment at some time, mainly reflecting the very high frequency of recurrences (50% at 10 years). Laparoscopic surgery has many advantages in this setting, except for urgent interventions. In the last 30 years, segmental small-bowel resection has followed precise technical intestine-saving rules. Widening enteroplasty ("stricturoplasty") must replace resection for patients with staged CD and multiple foci, and must be used for patients who have already had mutilating resections for multiple recurrences, in order to avoid the "short bowel" syndrome. In severe acute colitis, early surgery is indicated if short-term resuscitation fails: the operation is always subtotal colectomy with double stomy of the ileum and of the sigmoid colon. In chronic and scalable colorectal attacks, the choice of technique depends on the location and severity of the lesions. Conserving the distal colon is justified if the lesions are moderate: this saves natural transit for a time, which is important for young adults. At least half of these conservative treatments eventually fail. Progressive pancoloproctitis complicated by anoperineal lesions that compromise continence is usually treated by total coloproctectomy with final ileostomy. Sphincter conservation by ileoanal anastomosis is only possible in rare patients with colorectal CD.

[Familial adenomatous polyposis: long term follow-up of patients after surgical treatment. Prognostic factors]. / Devenir à long terme des patients opérés pour une polypose adénomateuse familiale. Facteurs du pronostic.

The purposes of this study are: 1) to evaluate if recent progresses (knowledge of natural history, genetic diagnosis and surgical treatment) have an impact upon the long term follow up of familial adenomatous polyposis (FAP); 2) to assess the prognosis factors that are relative to recent progresses in diagnosis and treatment procedures. A retrospective study of 51 cases was carried out in July 2002 to analyse the following characteristics: phenotype, treatment, operative mortality and morbidity, late complications, especially rectal stump cancer after ileo-rectal anastomosis, duodenal adenomatosis and desmoid tumors. Twenty seven men and 24 women underwent surgery: 11 colo-rectal cancers were present at first step. Initial surgical procedures included 39 total colectomies with ileo-rectal anastomosis (IRA), 6 coloproctectomies with ileo-anal anastomosis (IAA) and 6 coloproctectomies with permanent ileostomy. Operative mortality was nil. Operative morbidity affected 11 patients. The rectum had to be secondary removed in 11 patients with convert in IAA. Duodenal adenomatosis required surgery in 10 patients: 5 surgical local excisions, 4 duodenopancreatectomies and 1 palliative by-pass. Six desmoid tumors were noted during the follow-up. On the whole 3 patients were lost of sight. Nine patients died (19.1%), 4 deaths were in relation with the disease: 1 rectal cancer, 2 duodenal cancers, 1 desmoid tumor necrosis. At the end of the follow up (mean duration: 17 years) 26 IRA and 17 IAA are present with good functional results. This study, according to already published data, suggests that today the risk of death related to colorectal cancer is becoming lower than the risk of death from duodenal cancer and desmoid tumor evolution, particularly since the introduction of the restorative proctocolectomy. The genetic diagnosis is useful in order to determine the choice of surgical procedures.

Crohn's colitis: experience with segmental resections; results in a series of 84 patients.

BACKGROUND: Colonic Crohn's disease can be treated surgically by total colonic resection or by segmental colonic resection. The aim of this study was to analyze the outcomes of patients treated by segmental colectomy for colonic Crohn's disease. STUDY DESIGN: Among 413 patients undergoing operations for Crohn's disease, 84 had a segmental colectomy (cases of terminal ileitis with limited cecal involvement were not included). Postoperative complications, mortality, recurrence, and functional results were studied. RESULTS: Eighty-four patients (51 women, 33 men), with a mean age of 34 years, underwent operation (right segmental colectomy: 55%; left segmental colectomy: 40%; associated right and left colectomy: 5%). A stoma was established in 27 patients (32%). Operative mortality was zero. Twelve patients (14%) had postoperative complications (including six cases of anastomotic leakage). The mean and median followup times were 111 and 104 months, respectively (range: 15 to 276 months) for the 82 patients with followup available. Thirty-six patients had to undergo reoperation, and the mean time to reoperation was 4.5 years. Twenty-six of these patients suffered colonic recurrence and were treated by total colectomy (n = 9) or new segmentary resection (n 17). The only factor that correlated with the risk of recurrence was youth. At the end of the study, 13 patients still had a stoma. Seventy-five percent of the patients without stoma had less than three bowel movements per day, and 80% were fully satisfied or satisfied, CONCLUSIONS: There is no evidence of a higher risk of postoperative complications, surgical recurrence, or the requirement of a permanent stoma in patients suffering from colonic Crohn's disease who are treated according to a "bowel-sparing policy" compared with patients treated with more extensive resections published in the literature. Prospective randomized studies are needed to validate this observation.