Intrapperative and endoscopic surveillance after surgery in Chron's disease

Abstract: Crohn's disease is a chronic inflammatory bowel disease. There is no cure and the disease progresses to severe intestinal inflammation and stricture fonnation. Most patients will require intestinal resection of diseased bowel segments, but this is frequently followed by recurrent inflammation and symptoms.The study was undertaken to investigate a possible role for intraoperative endoscopy of the bowel in the surgical management of Crohn's disease, and to investigate various aspects of recurrent intestinal inflammation by colonoileoscopic surveillance after surgery. During surgery the relationship between intraoperative endoscopy of the bowel, transmural histopathology, and exterior inflammatory bowel wall changes, traditionally used to decide the extent of intestinal resection, were investigated, as was the influence intraoperative endoscopic findings had on surgical decision·making. At follow-up after surgery, the reliability of endoscopy was evaluated by studying the interobserver variation of endoscopic findings and the relationship between endoscopic inflammatory lesions and symptoms were investigated.Ileal ulcerations appeared soon after ileocolic resection, within three months, and with a high frequency. The lesions showed a time·related progression from aphthous ulcers to larger ulcers and stricture and excellent interobserver agreement was seen with some well· defined inflammatory lesions, even when investigator experience was limited. Ileal ulcers appeared prior to symptoms. Luminal pus and anastomotic stricture were related to symptoms and a stricture frrst produced symptoms when the diameter was less than 10 mm. The length of intestinal resection was as much related to symptoms as any endoscopically visualized inflammatory lesion. Endoscopically viewed inflammation correlated with bowel wall histopathology, whereas exterior bowel wall lesions, i.e. mural thickening, fat wrapping and serositis, had poorer correlation to both histology and endoscopy, the difference being attributable to cases with previous resection, fistula or abscess which causes exterior bowel wall changes mimicking Crohn's disease.In conclusion, intraoperative endoscopy offers better guidance as regards intestinal resection and selection of strictures for treaunent, and intraopemtive endoscopic findings intluenced surgical decision·making in the majority of the cases mainly by limiting intestinal resection. The findings underline the chronicity of Crohn's disease. This and the association of intestinal resection with symptoms emphasize the advisability of conservative surgery in Crohn's disease, which requires accurate intraoperative decisions. Intraoperative endoscopy enables more precise surgery.