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Phillip Fleshner, MD Shierley , Jesslyne , and Emmeline Widjaja Chair in Colorectal Surgery

Clinical Debate A patient with severe Crohn's disease, an ileal stricture and proximal dilation on CTE should have an ileocolonic resection first. S. C. Cedars-Sinai Medical Center Los Angeles, California. Phillip Fleshner, MD

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Phillip Fleshner, MD Shierley , Jesslyne , and Emmeline Widjaja Chair in Colorectal Surgery

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  1. Clinical Debate A patient with severe Crohn's disease, an ileal stricture and proximal dilation on CTE should have an ileocolonic resection first S C Cedars-Sinai Medical Center Los Angeles, California Phillip Fleshner, MD Shierley, Jesslyne, and Emmeline Widjaja Chair in Colorectal Surgery Program Director, Colorectal Surgery Residency Clinical Professor of Surgery UCLA School of Medicine

  2. Therapeutic Alternatives to Treat CD Strictures • Additional medical therapy • Endoscopic dilation • Surgery

  3. Why Medical Therapy Not Useful • Expensive • When do you stop, ? lifetime exposure • QOL issues in partial responders • IV steroids frequently used to assess response Steroids associated with development of stenosis Steroids associated with postoperative morbidity • Aggressive medical therapy ↑ surgical morbidity • Prestenotic dilation is a negative prognostic factor Disease assessment scores Clinical studies

  4. Lehman Score • Score measuring the progressive nature or cumulative structural bowel damage, independent of the current and fluctuating disease activity • A longitudinal tool currently being developed and validated prospectively Pariente B, et al., IBD 2011

  5. Prestenotic Dilation and Clinical Response in CD % “Patients with intestinal narrowing and prestenotic dilatation … were less likely to respond to medical therapy” (OR = 7.85, 95% CI 1.73-35.6,p= 0.008) Lawrance IC, et al., WJG 2009

  6. Why Medical Rx Is Not UsefulExpert Consensus Opinion

  7. Why Medical Rx Is Not UsefulExpert Consensus Opinion

  8. Laparoscopic IleocolicResection • Short term outcomes Minimal scarring Enhanced cosmesis Fast surgical recovery Fast restoration of QOL Complications are low (<10%) Medication can be stopped or limited in prevention mode Small bowel loss is generally small (usually 20–25 cm) • Long term outcomes Lower incisional hernia Less adhesions, possibly less SBO

  9. Endoscopic Dilation vsLaparoscopic Surgery

  10. Endoscopic Dilation vsLaparoscopic Surgery

  11. Severe CD, Ileal Stricture and Proximal Dilation

  12. Is Endoscopic Dilation Ever Preferable to Surgery? • Multicentricdisease • Multiple prior resections Adhesions Loss of bowel → short bowel syndrome • Poor surgical risk • Initial presentation of the disease • Stricture location Gastroduodenal Rectosigmoid

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