Overview
Definition:
Ileocecal resection is a surgical procedure involving the removal of the terminal ileum, cecum, and often a portion of the ascending colon
It is a common intervention for Crohn's disease affecting the terminal ileum, characterized by chronic transmural inflammation, skip lesions, and potential for stricturing, fistulizing, or perforating complications
The goal is to resect diseased bowel while preserving length and function.
Epidemiology:
Crohn's disease affects approximately 1.4 to 1.7 million people in the US and is increasingly prevalent worldwide
The ileocecal region is the most commonly affected site, occurring in about 50% of patients
Surgery is required in up to 70-80% of patients with Crohn's disease at some point in their lives, with ileocecal resection being the most frequent surgical procedure
Peak incidence is in young adults (15-35 years), with a slight female predominance.
Clinical Significance:
Ileocecal resection is critical for managing symptomatic terminal ileitis refractory to medical therapy or complicated by obstruction, fistula, abscess, or perforation
Effective surgical management improves quality of life, resolves acute complications, and is often necessary to control disease activity, although it does not represent a cure for Crohn's disease
Understanding the indications, surgical techniques, and potential complications is vital for surgical residents preparing for DNB and NEET SS examinations.
Indications
Surgical Indications:
Failure of optimal medical therapy with persistent symptoms
Complications of disease including: Small bowel obstruction (SBO) secondary to strictures
Enteroenteric or enterocutaneous fistulas
Intra-abdominal abscess
Perforation
Hemorrhage unresponsive to conservative measures
Dysplasia or malignancy in the setting of long-standing Crohn's disease
Growth failure in pediatric patients.
Medical Refractory Disease:
Persistent, debilitating symptoms such as abdominal pain, diarrhea, weight loss, and fatigue despite adequate medical management with corticosteroids, immunomodulators, or biologics
Significant impairment of quality of life.
Acute Surgical Emergencies:
Signs of acute peritonitis suggesting perforation
Sepsis secondary to an intra-abdominal abscess
Intractable symptoms of bowel obstruction that fail to resolve with nasogastric decompression and bowel rest.
Preoperative Preparation
Medical Optimization:
Nutritional assessment and support to correct malnutrition and hypoproteinemia
Correction of anemia with iron or blood transfusions
Management of electrolyte imbalances
Optimization of inflammatory markers if possible
Empiric antibiotics to cover gut flora, particularly Gram-negative rods and anaerobes.
Bowel Preparation:
Mechanical bowel preparation with polyethylene glycol or sodium phosphate solutions the day before surgery
Clear liquid diet 24-48 hours prior to surgery
Prophylaxis against deep vein thrombosis (DVT) with subcutaneous heparin or low molecular weight heparin, and mechanical compression devices.
Imaging And Assessment:
Endoscopic evaluation (colonoscopy with biopsy) to assess extent of disease, rule out dysplasia/malignancy, and confirm diagnosis
Imaging studies including CT enterography or MR enterography to delineate the extent of disease, identify complications (strictures, fistulas, abscesses), and plan the surgical approach
Barium studies can also be useful in specific scenarios.
Surgical Management
Surgical Approaches:
Laparoscopic approach is preferred when feasible, offering reduced pain, shorter hospital stay, and quicker recovery
Open laparotomy is reserved for cases of significant adhesions, extensive disease, or intra-abdominal sepsis/abscess that preclude safe laparoscopic dissection.
Anastomotic Techniques:
Side-to-side stapled anastomosis (e.g., using EEA stapler) is the most common technique for ileocolic reconstruction, preserving luminal diameter and reducing tension
Hand-sewn anastomosis may be used in specific situations, but carries a higher risk of stricture
Careful assessment of bowel viability and tension-free anastomosis are paramount.
Resection Margins:
Macroscopic margins should be clear of gross disease
Microscopic assessment of margins is often not routinely performed intraoperatively but is confirmed on final pathology
The goal is to resect all visibly diseased bowel while preserving as much healthy bowel as possible to prevent short bowel syndrome.
Drainage And Diversion:
Peritoneal drains may be placed selectively if significant contamination or abscess cavity is present
Ostomy (ileostomy) is typically avoided in elective resections unless the anastomosis is concerning, the patient is severely malnourished, or there is significant distal disease
Diverting ileostomy may be considered in emergent situations or for very high-risk anastomoses.
Postoperative Care
Pain Management And Monitoring:
Adequate analgesia, often multimodal (opioids, NSAIDs, acetaminophen), with careful titration
Close monitoring of vital signs, urine output, and abdominal examination for signs of complications
Nasogastric tube management for ileus or if a diverting ostomy is present.
Fluid And Nutritional Support:
Intravenous fluid resuscitation and electrolyte correction
Gradual reintroduction of oral intake as bowel function returns, starting with clear liquids
Parenteral nutrition may be required in patients with prolonged ileus or significant malnutrition
Early mobilization is encouraged to prevent VTE and pneumonia.
Ambulation And Discharge:
Early ambulation within 24-48 hours post-surgery
Gradual increase in oral intake
Discharge criteria typically include tolerating a regular diet, absence of significant pain, ability to ambulate, and no signs of surgical complications
Follow-up appointments are crucial for monitoring recovery and disease status.
Complications
Early Complications:
Anastomotic leak (0-5% depending on technique and patient factors)
Intra-abdominal abscess
Postoperative ileus
Bleeding
Wound infection
DVT/PE
Urinary tract infection
Fistula formation.
Late Complications:
Stricture formation at the anastomosis or within the remaining bowel
Recurrence of Crohn's disease in the neoterminal ileum or elsewhere
Small bowel obstruction from adhesions
Incisional hernia
Short bowel syndrome if excessive bowel is resected.
Prevention Strategies:
Meticulous surgical technique, including tension-free anastomosis and assessment of bowel viability
Appropriate bowel preparation and perioperative antibiotics
Judicious use of drains
Early mobilization and prophylaxis for DVT
Careful patient selection and preoperative optimization.
Prognosis
Recurrence Rates:
Recurrence of Crohn's disease after ileocecal resection is common, with approximately 50% of patients experiencing endoscopic recurrence within 1 year and clinical recurrence within 5-10 years
Factors influencing recurrence include disease phenotype, extent, smoking, and adherence to medical therapy.
Functional Outcomes:
Most patients experience significant symptomatic improvement after resection
However, quality of life can be impacted by long-term disease activity, need for re-operation, or complications
Preservation of bowel length is critical for long-term functional outcomes and avoiding short bowel syndrome.
Long Term Follow Up:
Regular clinical assessment and laboratory monitoring for disease activity (CRP, ESR)
Periodic endoscopic surveillance (colonoscopy with biopsies) to detect recurrence early, particularly in patients at higher risk
Optimization of medical therapy is essential to prevent or delay recurrence.
Key Points
Exam Focus:
Indications for surgery in Crohn's disease are disease complications and failure of medical management
Laparoscopic ileocecal resection is the preferred approach
Side-to-side stapled anastomosis is common
High recurrence rate post-surgery necessitates long-term medical management and surveillance.
Clinical Pearls:
Always assess for abscess formation preoperatively
Ensure adequate nutritional status before elective surgery
Meticulous surgical technique to create a tension-free anastomosis is crucial
Early recognition and management of anastomotic leak are critical for patient survival.
Common Mistakes:
Performing resection for active inflammation without prior medical optimization
Inadequate resection of diseased bowel
Creating a tensioned or narrow anastomosis
Failing to counsel patients on high recurrence rates and the need for lifelong medical follow-up
Inappropriate management of intra-abdominal abscesses.