Diagnosis and Surgical Treatment of Complicated Forms of Crohn's Disease

The research is dedicated to developing a comprehensive approach to the diagnosis and surgical treatment of complicated forms of Crohn's disease. The study analyzes modern diagnostic methods, including radiographic, ultrasonic, endoscopic, and morphological investigations, and develops optimal surgical tactics and endolymphatic therapy techniques. Special attention is given to the two-stage surgical approach for colonic obstruction and endolymphatic antibiotic administration for treating intra-abdominal abscesses and infiltrates.

The relevance of the problem of Crohn's disease at the beginning of the twenty-first century is determined by the increase in the frequency of this disease, especially among young people. The highest disease frequency is observed among individuals aged 20-29 years. This trend has persisted for 40 years. Crohn's disease is observed in women somewhat more frequently than in men (ratio 1:1.12). This ratio does not depend on age or the extent of damage at the time of diagnosis. (Fellows I.W., Freeman J.G., 1990; Langholz et al., 1991).

According to the results of epidemiological studies conducted in Great Britain, Sweden, the United States, and Germany, the prevalence of Crohn's disease ranges from 34 to 146 patients per 100,000 persons. The average disease frequency is 5.9 cases per 100,000 population per year. Thanks to these studies, a significant increase in morbidity is visible at the beginning of the 1970s. (Ekbom A. et al. 1991; Goebdl Н. et al. 1994; Lee F.I. Nguyen-Van-Tarn J.S., 1991).

Acute forms of Crohn's disease are observed less frequently today, which can be explained by improved diagnosis and increased effectiveness of conservative treatment. However, the number of chronic forms with continuous course of the process in the intestine, extraintestinal manifestations, and complications has increased (Kirsner J.B., 1999).

Thus, the relevance of the dissertation topic is determined by the increase in morbidity from Crohn's disease, insufficient study of its complications, and the absence of a comprehensive approach to diagnosis and treatment of complicated forms.

All of the above determined the relevance of this topic and served as the basis for conducting this research.

The goal of this work is to develop, based on clinical-instrumental research methods, the most effective methods for early diagnosis and surgical treatment of complicated forms of Crohn's disease.

In accordance with the stated goal, the following tasks were set:

1. To determine the role of modern research methods (radiological, ultrasonographic, endoscopic, and morphological) in the early diagnosis of complicated forms of Crohn's disease.

2. To study morphological changes in the intestinal wall in Crohn's disease.

3. To develop an optimal variant of surgical treatment for complicated forms of Crohn's disease.

4. To evaluate the role and place of endolymphatic administration of antibiotics in complex treatment of the disease.

Scientific novelty.

The high informativity of modern radiological methods for diagnosing complications of Crohn's disease has been proven. It has been established that the most informative method for early diagnosis of Crohn's disease is overview abdominal radiography with study of barium passage through the intestine (when the lesion is localized in the terminal ileum) and enteroclysis (when the lesion is localized in the colon). The high sensitivity of modern ultrasonographic investigation allows early recognition of intestinal lumen stenosis and detection of signs of forming intestinal obstruction.

It has been shown that fistulography is the most informative diagnostic method for clarifying the localization of fistulas. Internal fistulas are detected by means of oral enterography. For diagnosing abscesses and infiltrates of the abdominal cavity, ultrasonography, endoscopic ultrasonography, and computed tomography are most valuable.

It has been proven that the most effective method for treating colonic obstruction is a two-stage method consisting of placing a decompressing colostomy with endolymphatic therapy at the first stage, resection of the affected intestinal segment, and restoration of continuity after 2-3 months at the second stage of treatment.

It has been determined that endolymphatic antibiotic therapy is a highly effective method for treating Crohn's disease complicated by intra-abdominal abscesses and infiltrates; it allows suppression of the acute inflammatory process within the first 3 days of the disease by creating a high and long-lasting concentration of antibiotics in the blood serum and inflamed tissues. The importance of lymphangiography for diagnosing the extent of damage in Crohn's disease has been proven.

Practical significance.

The clinical significance of overview abdominal radiography with study of barium passage through the intestine, enteroclysis, and endoscopic investigation of the digestive tract when Crohn's disease is suspected has been demonstrated. To clarify the localization and configuration of external fistulas, fistulography is necessary. For internal fistulas, enterography is indicated.

A new method for the prevention and treatment of infiltrates and abscesses in Crohn's disease by endolymphatic administration of antibiotics into the drained inguinal lymph node has been developed.

A differentiated approach to operative treatment of complicated forms of Crohn's disease has been worked out. When the lesion is localized in the terminal ileum and fistulas are present, the optimal extent of surgery is resection of the affected segment with the creation of a small bowel-to-colon anastomosis. For Crohn's disease complicated by colonic obstruction, a two-stage treatment is indicated: the first stage is colostomy placement with endolymphatic drug therapy, and the second stage is performed after 2-3 months and consists of resection of the affected segment and restoration of colon continuity.

Thesis statements for defense:

1. The decisive significance in establishing the diagnosis of Crohn's disease lies in the combination of "traditional" and modern examination methods for patients (radiological, ultrasonographic, endoscopic, and morphological).

2. The developed program for prevention and treatment of Crohn's disease complicated by intra-abdominal abscesses and infiltrates, using endolymphatic administration of medicinal substances, allows improvement of the immediate results of operative treatment of such patients.

3. The basis of the differentiated surgical tactics for complicated forms of Crohn's disease lies in the developed algorithm of comprehensive diagnosis, which allows, even during preoperative examination of the patient, to individualize the presumed extent of operative intervention.

4. The extent of the operation in complicated forms of Crohn's disease depends, first and foremost, on the localization of the disease process. When the process is localized in the terminal ileum and fistulas are present, the optimal extent of the operation is resection of the affected segment with the creation of a primary small bowel-to-colon anastomosis. For Crohn's disease complicated by colonic obstruction, a two-stage treatment is indicated: at the first stage, colostomy placement is performed against the background of endolymphatic antibiotic therapy, and at the second stage (after 2-3 months), resection of the affected segment with restoration of colon continuity is performed.

Implementation in practice.

The results of the investigation have been applied in the practical work of surgical clinics of the Military Medical Academy, the Department of Surgical Gastroenterology of the St. Petersburg Research Institute named after I.I. Janelidze, the 442nd Military Hospital named after Z.P. Solovyov of the Leningrad Military District, as well as in pedagogical work at the Department and Clinic of General Surgery, the 2nd Department and Clinic (Surgery for Advanced Training of Physicians).

Defense of the work.

The main provisions of the dissertation were reported and discussed at the scientific conference "Actual Questions of Clinical Practice, Diagnosis, and Treatment" (Saint Petersburg, 2002), the All-Russian conference "Gastro-2002" (Saint Petersburg, 2002) and the 5th Slavic-Baltic Forum "Gastro-2003" (Saint Petersburg, 2003), at "Gastro-2006" (Saint Petersburg, 2006), at the VI All-Russian Scientific and Practical Conference dedicated to the 300th anniversary of Saint Petersburg and the 205th anniversary of the Military Medical Academy "Actual Questions of Clinical Practice, Diagnosis, and Treatment in a Multidisciplinary Institution" (Saint Petersburg, 2003), the II All-Russian Conference of General Surgeons (Rostov-on-Don, 2004), the jubilee conference "Modern Radiological Diagnosis in a Multidisciplinary Medical Institution" dedicated to the 75th anniversary of the Department of Radiology and Radiation Therapy of the Military Medical Academy (Saint Petersburg, 2004).

Nine printed works have been published on the topic of the dissertation.

Volume and structure of the work.

The dissertation consists of an introduction, 4 chapters, a conclusion, conclusions, and practical recommendations. The work is presented across 135 pages, contains 31 figures and 9 tables. The bibliography includes 209 sources, of which 76 are domestic and 133 are foreign.