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## Complete Summary

#### GUIDELINE TITLE

Practice parameters for the surgical management of Crohn\'s disease.

#### BIBLIOGRAPHIC SOURCE(S)

Strong SA, Koltun WA, Hyman NH, Buie WD, Standards Practice Task Force
of The American Society of Colon and Rectal Surgeons. Practice
parameters for the surgical management of Crohn\'s disease. Dis Colon
Rectum 2007 Nov;50(11):1735-46. \[155 references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=17690937)

#### GUIDELINE STATUS

This is the current release of the guideline.

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Crohn\'s disease of the terminal ileum, colon, ileocolon, and upper
gastrointestinal tract

**Note**: The management of perianal Crohn\'s disease is not discussed
in this guideline.

#### GUIDELINE CATEGORY

Management\
Treatment

#### CLINICAL SPECIALTY

Colon and Rectal Surgery\
Gastroenterology

#### INTENDED USERS

Health Care Providers\
Patients\
Physicians

#### GUIDELINE OBJECTIVE(S)

To provide practice parameters for the surgical management of Crohn\'s
disease

#### TARGET POPULATION

Adults and children with Crohn\'s disease

#### INTERVENTIONS AND PRACTICES CONSIDERED

**Management/Treatment**

1.  Assessment of need for surgery over medication

2.  Antibiotics and percutaneous drainage

3.  Surgical drainage with or without resection

4.  Computed tomography (CT) or magnetic resonance enterography

5.  Interventional radiologic and/or endoscopic techniques

6.  Endoscopic surveillance for dysplasia or neoplastic transformation

7.  Resection with end stoma, diverted anastomosis, or nondiverted
    anastomosis

8.  Strictureplasty with biopsy of lesions suspicious for cancer

9.  Assessment of growth patterns in prepubertal children

10. Assessment of extraintestinal manifestations (EIMs)

11. Laparoscopic versus open surgery

12. Bypass surgery (gastrojejunostomy and duodenojejunostomy)

13. Endoscopic dilatation of affected area

14. Subtotal or total colectomy with end ileostomy

15. Segmental or total colectomy with or without a primary anastomosis

16. Total proctocolectomy or proctectomy with creation of a stoma

#### MAJOR OUTCOMES CONSIDERED

-   Change in disease-related symptoms

-   Morbidity and mortality from surgery

-   Relapse rate

-   Rate of progression to cancer

-   Rate of involvement of contiguous organs

-   Growth patterns of prepubertal patients

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

Not stated

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Weighting According to a Rating Scheme (Scheme Given)

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

**Levels of Evidence**

I.  Meta-analysis of multiple well-designed, controlled studies,
    randomized trials with low false-positive and low false-negative
    errors (high power)

II. At least one well-designed experimental study; randomized trials
    with high false-positive or high false-negative errors or both (low
    power)

III. Well-designed, quasi-experimental studies, such as nonrandomized,
     controlled, single-group, preoperative-postoperative comparison,
     cohort, time, or matched case-control series

IV. Well-designed, nonexperimental studies, such as comparative and
    correlational descriptive and case studies

V.  Case reports and clinical examples

Adapted from Cook DJ, Guyatt GH, Laupacis A, Sackett DL. Rules of
evidence and clinical recommendations on the use of antithrombotic
agents. Chest 1992;102(4 Suppl):305S--11S. Sacker DL. Rules of evidence
and clinical recommendations on the use of antithrombotic agents. Chest
1989;92(2 Suppl):2S--4S.

#### METHODS USED TO ANALYZE THE EVIDENCE

Review of Published Meta-Analyses\
Systematic Review

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

Not stated

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Not stated

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

**Grades of Recommendations**

A.  Evidence of Type I or consistent findings from multiple studies of
    Type II, III, or IV

B.  Evidence of Type II, III, or IV and generally consistent findings

C.  Evidence of Type II, III, or IV but inconsistent findings

D.  Little or no systematic empirical evidence

Adapted from Cook DJ, Guyatt GH, Laupacis A, Sackett DL. Rules of
evidence and clinical recommendations on the use of antithrombotic
agents. Chest 1992;102(4 Suppl):305S--11S. Sacker DL. Rules of evidence
and clinical recommendations on the use of antithrombotic agents. Chest
1989;92(2 Suppl):2S--4S.

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

Not stated

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

Not applicable

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

The levels of evidence (**I-V**) and the grades of recommendations
(**A-D**) are defined at the end of the \"Major Recommendations\" field.

**[Operative Indications]{.underline}**

**Failed Medical Therapy**

1.  Patients with disease-related symptoms who suffer from medically
    unresponsive disease, demonstrate an inadequate response, manifest
    medication-related complications, or appear noncompliant with
    medication should be considered for operation. **Level of Evidence:
    II; Grade of Recommendation: B.**

> Surgical treatment is warranted if first-line and second-line
> therapies fail to induce remission safely in severe disease states,
> but surgery also should be considered before escalating medical
> therapy for patients with severe or steroid-dependent disease that is
> limited in disease extent, particularly in individuals with
> stricturing behavior or those with contraindications or risk factors
> for further medical therapy.

**Perforation**

1.  Patients with symptoms and/or signs of free perforation should
    undergo operation. **Level of Evidence: III; Grade of
    Recommendation: B.**

> Immediate resection of the perforated segment is preferred over simple
> suture closure because of a relatively high mortality rate associated
> with the latter. After resection of a small-bowel perforation, an end
> stoma, diverted anastomosis, or nondiverted anastomosis can be
> performed depending on the presentation and operative findings.
> Colorectal perforations are more commonly resected in combination with
> a proximal stoma and mucous fistula or Hartmann\'s closure of the
> distal bowel; alternatively, a diverted anastomosis can be considered.

2.  Patients with large anteroparietal, interloop, intramesenteric, or
    retroperitoneal abscesses may be managed by antibiotics and
    percutaneous drainage. If this approach is unavailable or
    unsuccessful, the patient should undergo surgical drainage with or
    without resection. **Level of Evidence: III; Grade of
    Recommendation: B.**

3.  Patients with enteric fistulas and symptoms or signs of localized or
    systemic sepsis that persist despite appropriate medical therapy
    should be considered for operation. Asymptomatic patients with
    internal fistulas do not typically require surgery. **Level of
    Evidence: III; Grade of Recommendation: B.**

> Fistulas originating in diseased bowel and secondarily involving other
> intra-abdominal organs or the skin are not usually associated with
> localized or systemic sepsis. If sepsis is present, the patient should
> be started on broad-spectrum antibiotics and imaging studies should be
> performed to exclude a concomitant abscess, which should be drained.
> Regardless of whether an abscess is present, persistent sepsis usually
> warrants excision of the diseased bowel. Management of the target or
> \"innocent bystander\" organ is based on whether it is diseased bowel,
> noninflamed bowel, or another internal organ. Diseased bowel is
> generally resected, noninflamed bowel can be primarily closed, and
> other internal organs (e.g., bladder, vagina) can be primarily closed
> or left to heal by secondary intention. Surgery is usually not
> necessary if sepsis and symptoms are absent.

**Obstruction**

1.  Patients with symptomatic strictures in any location that do not
    appear amenable or responsive to medical therapy should undergo
    operation. **Level of Evidence: III; Grade of Recommendation: B.**

> The incidence of fibrostenosing lesions in patients with Crohn\'s
> disease increases with longer disease duration, and this behavior is
> most commonly seen in patients with upper gastrointestinal disease
> involvement. Computed tomography and magnetic resonance enterography
> can sometimes help discern whether these areas of narrowing have an
> inflammatory component that might respond to medical therapy. If the
> patient is symptomatic and the stricture appears fibrotic with minimal
> inflammation, or if medical therapy fails to adequately improve the
> symptoms, surgery is generally warranted.

2.  Patients with asymptomatic strictures of the colon that cannot be
    adequately surveyed by biopsy and/or cytology brushing should be
    considered for operation. **Level of Evidence: III; Grade of
    Recommendation: B.**

> Approximately 7 percent of large bowel strictures in patients with
> Crohn\'s disease are malignant and should be surveyed for neoplastic
> transformation. This is usually performed with multiple biopsies and
> cytologic brushing. If the stricture cannot be appropriately surveyed
> or if neoplastic changes are identified, resection is usually
> warranted.

**Inflammation**

1.  Patients with acute colitis and symptoms or signs of impending or
    actual perforation should undergo operation. **Level of Evidence:
    III; Grade of Recommendation: B.**

> Although supporting evidence is limited, severe or fulminant colitis
> should be treated in the same way, regardless of the underlying
> inflammatory bowel disease. An abdominal film that reveals transverse
> colon distention \>6 cm or persistent gaseous distension in a colonic
> segment indicates toxic megacolon and suggests that the patient is at
> risk for perforation. Persistent or progressing colonic dilatation,
> pneumatosis coli, evolving local peritonitis, and multiple organ
> failure also are evidence of impending or actual perforation and
> surgery is warranted.

2.  Patients with acute colitis whose condition worsens despite
    appropriate medical therapy or fails to significantly improve after
    48 to 96 hours of medical therapy should be considered for
    operation. **Level of Evidence: III; Grade of Recommendation: B.**

**Hemorrhage**

1.  Patients with massive hemorrhage originating from any location may
    be managed by interventional radiologic and/or endoscopic
    techniques. If the patient is too unstable for this, or if this
    approach is unavailable or unsuccessful, the patient should undergo
    operation. **Level of Evidence: III; Grade of Recommendation: B.**

> Massive gastrointestinal hemorrhage is an uncommon event in patients
> with Crohn\'s disease. Other common etiologies of gastrointestinal
> hemorrhage, such as peptic ulcer disease and gastritis, should be
> excluded. If the hemorrhage is a direct consequence of Crohn\'s
> disease, it most commonly occurs from an ulcer that has eroded into a
> submucosal vessel. If the patient is stable and the source of bleeding
> can be endoscopically identified, local measures can be used to halt
> the bleeding. If the bleeding is too brisk to permit adequate
> endoscopic visualization or the source of hemorrhage cannot be
> identified, mesenteric angiography can be attempted and the bleeding
> site might be embolized. Patients who are hemodynamically unstable or
> fail to respond to these measures usually require laparotomy,
> sometimes with intraoperative endoscopy, and resection of the
> responsible bowel segment.

**Neoplasia**

1.  Patients with long-standing Crohn\'s disease of the ileocolon or
    colon should undergo endoscopic surveillance. **Level of Evidence:
    III; Grade of Recommendation: B.**

> Patients with colitis often are advised to undergo a screening
> colonoscopy after eight to ten years of disease symptoms, and
> surveillance endoscopy every one to two years thereafter. Ideally,
> surveillance colonoscopy should be performed when the disease is in
> remission to minimize confusion interpreting neoplastic changes. Four
> quadrant random biopsies at 10-cm intervals along the colon and rectum
> may be obtained, as well as biopsies of any strictures, lesions, or
> mass; pseudopolyps that do not appear suspicious need not be sampled.
> Adenomatous-appearing polyps should be removed if possible, and the
> adjacent flat mucosa should be biopsied to exclude associated
> dysplasia.

2.  Patients with carcinoma, dysplasia-associated lesion or mass (DALM),
    high-grade dysplasia, or multifocal, low-grade dysplasia of the
    colon or rectum should undergo resection. **Level of Evidence: III;
    Grade of Recommendation: B.**

> The appropriate extent of the resection is unclear and could range
> from a limited segment that includes only the inflamed bowel to the
> entire colon and rectum.

3.  Patients with long-standing Crohn\'s disease of the terminal ileum,
    ileocolon, or upper gastrointestinal locations should undergo biopsy
    of suspicious lesions at the time of strictureplasty. **Level of
    Evidence: III; Grade of Recommendation: B.**

> Small-bowel adenocarcinoma has been reported at the site of previous
> strictureplasty, and consequently the stricture site should be
> carefully inspected and any suspicious areas should be biopsied.

**Growth Retardation and Extraintestinal Manifestations**

1.  Prepubertal patients with significant growth retardation despite
    appropriate medical therapy should be considered for operation.
    **Level of Evidence: IV; Grade of Recommendation: C.**

2.  Patients with symptomatic disorders of the skin, mouth, eye, or
    joints who fail to respond to medical therapy should be considered
    for operation. **Level of Evidence: IV; Grade of Recommendation:
    C.**

> Extraintestinal manifestations (EIMs) of Crohn\'s disease occur in up
> to 30 percent of patients. The presence of one EIM sometimes
> predisposes an individual to the development of others. Some EIMs are
> temporally related to intestinal disease activity, whereas others
> occur independently. Erythema nodosum, oral aphthous ulcers,
> episcleritis, and some types of peripheral arthritis tend to parallel
> the intestinal disease activity, whereas pyoderma gangrenosum,
> uveitis, spondyloarthropathy, and primary sclerosing cholangitis do
> not. For the former group, therapy for the EIM focuses on treatment of
> the underlying intestinal disease, and medical management is usually
> sufficient. Nevertheless, if medical therapy fails to adequately
> control these manifestations, resection of the diseased intestine is
> warranted. For the group of EIMs that behave independently of the
> intestinal disease, surgery has no role in the management of the EIM.

**[Site-Specific Operations]{.underline}**

**Terminal Ileum, Ileocolon, and Upper Gastrointestinal Tract**

1.  Patients who require surgery for disease of the jejunum, proximal
    ileum, terminal ileum, or ileocolon without existing or impending
    short-bowel syndrome should usually undergo resection of the
    affected bowel. **Level of Evidence: III; Grade of Recommendation:
    B.**

> Most patients with penetrating or inflammatory disease of the terminal
> ileum or ileocolon can undergo resection of the offending bowel
> without significant risk to nondiseased bowel, superior mesenteric
> vessels, or retroperitoneal structures. Nevertheless, in rare cases
> when there is concern about damage to these structures, the diseased
> segment may be bypassed by using an ileocolostomy or proximal loop
> ileostomy. At the same time, any septic focus should be drained.
> Definitive resection at a later date is recommended, because the
> bypassed segment is at risk for recurrent disease and later
> adenocarcinoma. The subsequent operation should be delayed for several
> months to allow resolution of the inflammatory process and a safer
> excision.

2.  Patients who require surgery for nonphlegmonous strictures of the
    jejunum, ileum, or ileocolon, and existing or impending short bowel
    syndrome should typically undergo strictureplasty. **Level of
    Evidence: III; Grade of Recommendation: B.**

> Strictureplasty should be strongly considered in patients with
> multiple strictures of the jejunum, proximal ileum, or terminal ileum.

3.  Patients with symptomatic disease of the stomach or duodenum should
    be considered for bypass of the affected area or strictureplasty.
    **Level of Evidence: III; Grade of Recommendation: C.**

> Bypass options for refractory obstruction or pain secondary to
> gastroduodenal Crohn\'s disease include gastrojejunostomy and
> duodenojejunostomy. Truncal vagotomy with gastrojejunostomy may
> decrease the risk of marginal ulceration but increases the likelihood
> of diarrhea. Highly selective vagotomy may avoid these problems.
>
> Symptomatic strictures of the distal stomach or duodenum can be
> treated with bypass; nonperforated, nonphlegmonous stenotic lesions in
> this region also can be safely managed by strictureplasty.

4.  Patients with symptomatic, accessible strictures of the intestinal
    tract can be considered for endoscopic dilatation of the affected
    area. **Level of Evidence: II; Grade of Recommendation: C.**

> Mild-to-moderate stricturing disease of the terminal ileum, colon, or
> duodenum can be safely and effectively treated by endoscopic
> dilatation with or without concomitant steroid injection. The
> procedure allows surgery to be postponed or avoided in many patients
> with Crohn\'s disease and short intestinal strictures. However,
> recurrent symptoms frequently necessitate a repeat procedure, and a
> dilatation should not be performed unless surgical services are
> available to intervene if perforation occurs.

**Colon**

1.  Patients with disease of the colon that requires emergency or urgent
    surgery should typically undergo subtotal or total colectomy with
    end ileostomy. **Level of Evidence: III; Grade of Recommendation:
    B.**

> This approach removes most of the inflamed intestine with a relatively
> simple operation that avoids a pelvic dissection and an anastomosis
> and can be performed through a laparoscopic or open approach.

2.  Patients with disease of the colon that requires elective surgery
    may undergo segmental or total colectomy with or without a primary
    anastomosis. **Level of Evidence III; Grade of Recommendation: B**

> Total colectomy with ileoproctostomy is preferable if two or more
> colonic segments are affected, because this subgroup has a higher
> recurrence rate when segmental resections are performed.

3.  Patients who require surgery for disease of the rectum may undergo
    total proctocolectomy or proctectomy with creation of a stoma.
    **Level of Evidence: III; Grade of Recommendation: C.**

> Usually the entire rectum should be excised because cancer has been
> found in patients with even a short Hartmann\'s remnant.

**[Definitions]{.underline}**:

**Levels of Evidence**

I.  Meta-analysis of multiple well-designed, controlled studies,
    randomized trials with low false-positive and low false-negative
    errors (high power)

II. At least one well-designed experimental study; randomized trials
    with high false-positive or high false-negative errors or both (low
    power)

III. Well-designed, quasi-experimental studies, such as nonrandomized,
     controlled, single-group, preoperative-postoperative comparison,
     cohort, time, or matched case-control series

IV. Well-designed, nonexperimental studies, such as comparative and
    correlational descriptive and case studies

V.  Case reports and clinical examples

**Grades of Recommendations**

A.  Evidence of Type I or consistent findings from multiple studies of
    Type II, III, or IV

B.  Evidence of Type II, III, or IV and generally consistent findings

C.  Evidence of Type II, III, or IV but inconsistent findings

D.  Little or no systematic empirical evidence

#### CLINICAL ALGORITHM(S)

None provided

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of supporting evidence is identified and graded for each
recommendation (see \"Major Recommendations\" field).

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

Appropriate surgical management of Crohn\'s disease

#### POTENTIAL HARMS

-   Morbidity or mortality from surgery

-   Requirement for a stoma

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

-   These guidelines are inclusive and not prescriptive. Their purpose
    is to provide information on which decisions can be made, rather
    than dictate a specific form of treatment.

-   It should be recognized that these guidelines should not be deemed
    inclusive of all proper methods of care or exclusive of methods of
    care reasonably directed to obtaining the same results. The ultimate
    judgment regarding the propriety of any specific procedure must be
    made by the physician in light of all of the circumstances presented
    by the individual patient.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Getting Better\
Living with Illness

#### IOM DOMAIN

Effectiveness\
Timeliness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Strong SA, Koltun WA, Hyman NH, Buie WD, Standards Practice Task Force
of The American Society of Colon and Rectal Surgeons. Practice
parameters for the surgical management of Crohn\'s disease. Dis Colon
Rectum 2007 Nov;50(11):1735-46. \[155 references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=17690937)

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

2007 Nov

#### GUIDELINE DEVELOPER(S)

American Society of Colon and Rectal Surgeons - Medical Specialty
Society

#### SOURCE(S) OF FUNDING

American Society of Colon and Rectal Surgeons

#### GUIDELINE COMMITTEE

Standards Practice Task Force of The American Society of Colon and
Rectal Surgeons

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Authors*: Scott A. Strong, MD; Walter A. Koltun, MD; Neil H. Hyman, MD;
W. Donald Buie, MD

*Task Force Members*: C. Neal Ellis, MD; Ravin Kumar, MD; Steven Mills,
MD; Graham Newstead, MD; Paul Shellito, MD; Elin Sigurdson, MD; Scott
Steele, MD; Joe Tjandra, MD

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Not stated

#### GUIDELINE STATUS

This is the current release of the guideline.

#### GUIDELINE AVAILABILITY

Electronic copies: Available in Portable Document Format (PDF) from the
[American Society of Colon and Rectal Surgeons Web
site](http://www.fascrs.org/gedownload!/chrons.pdf?item_id=680001&version_id=680002).

Print copies: Available from the ASCRS, 85 W. Algonquin Road, Suite 550,
Arlington Heights, Illinois 60005.

#### AVAILABILITY OF COMPANION DOCUMENTS

None available

#### PATIENT RESOURCES

None available

#### NGC STATUS

This NGC summary was completed by ECRI Institute on July 7, 2008.

#### COPYRIGHT STATEMENT

This NGC summary is based on the original guideline, which is subject to
the guideline developer\'s copyright restrictions.

### DISCLAIMER

#### NGC DISCLAIMER

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Date Modified: 11/3/2008