A patient with Crohn's disease has multiple skip lesions in the terminal ileum, with stricturing disease and a penetrating fistula between two adjacent loops of small bowel (enteroenteric fistula). She has had two prior small bowel resections (total resected = 180 cm). What is the most important surgical consideration?
- A Bowel-sparing strictureplasty to preserve intestinal length and prevent short bowel syndrome ✓
- B Definitive ileocecal resection with primary anastomosis
- C Total proctocolectomy with permanent ileostomy
- D Anti-TNF therapy first; surgery should be avoided in all penetrating Crohn's
Explanation
In patients with Crohn's disease who have had prior extensive small bowel resections, preservation of intestinal length is the critical surgical principle to prevent short bowel syndrome (SBS), which requires parenteral nutrition when residual small bowel < 100–150 cm. Strictureplasty (Heineke-Mikulicz for short strictures < 10 cm; Finney or side-to-side isoperistaltic for longer segments) allows correction of obstructing strictures without resection, maintaining bowel length. The enteroenteric fistula may be resected with the diseased segment if short; the remainder managed with strictureplasty. Total proctocolectomy is for colonic Crohn's, not small bowel disease.
Reference: Bailey & Love's Short Practice of Surgery, 27th ed.
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Written and medically reviewed by the StethoPrep medical team.