Background
Crohn's disease, one of chronic autoimmune disease, is typically characterized by intestinal transmural damage. The key features for diagnosing CD comprises a combination of radiographic, endoscopic and pathological findings demonstrating focal, asymmetric, transmural or granulomatous features. Intestinal lesions include hyperplasia, stenosis, ulcerative bleeding, transmural perforation, etc. Crohn's disease, is usually complicated with obstruction, especially chronic incomplete obstruction, which required surgical operation. The perioperative principle of Crohn's disease is different from the enhanced recovery after surgery or fast track surgery of general gastrointestinal tumors. If there are no life-threatening complications, the operation should not be performed too hasty. Because of persistence of intestinal lesions and the incurability of surgery, the preoperative optimization strategy is expected to reduce postoperative complications, preserve intestinal segments, solve the complications of Crohn's disease, avoid the risk of short bowel syndrome, achieve the purpose of remission, improve nutritional status, reduce drug dependence, and improve the quality of life [
1].
Surgical operation should be avoided at the active stage of Crohn's disease. During the perioperative period, they should withdraw steroid dependence as much as possible and ablate the use of hormones, immunosuppressor and other drugs. If the disease condition is stable, and the Crohn's disease activity index score(CDAI) is less than 150, qualitative surgical treatment can be carried out [
2].
The perioperative strategy of incomplete obstruction need stop using the medication that can control Crohn's activity, relieve the obstruction as soon as possible, improve the nutritional status of patients, and provide surgical conditions for the optimization of surgery. Conservative management is the preferred option in the absence of peritonitis, including bowel rest, intravenous fluid therapy,and gastric decompression [
3]. The nasogastric decompression tube can only be placed in the stomach and has no direct decompression effect on the contents of the small intestine, so it can not achieve the ideal remission effect [
4]. Transnasal intestinal obstruction tube is a new method for rapid relief of intestinal obstruction in Crohn's disease complicated with small intestinal obstruction. In contrast to nasogastric decompression tube, the complete decompression site of the transnasal intestinal obstruction tube is directly above the obstruction plane of the proximal small intestine. Inhalation and decompression of gas and intestinal contents at the obstruction site can quickly alleviate the symptoms of small intestinal obstruction [
5]. Resection and anastomosis of obstructive lesions can be successfully performed on most patients after preoperative preparation through catheter [
6,
7]. This study describes the treatment, that is, surgical procedure on the basis of transnasal ileus tube insertion, of 6 cases of Crohn's complicated with small intestinal obstruction.
Discussion
The benefits of surgical treatment of Crohn's disease have been greatly improved. However, it remains challenging for surgeons because gastrointestinal surgery is still a high-risk operation for Crohn's disease patients [
9]. Most patients with Crohn's disease have obvious severe symptoms when the urgent operation is needed, many of whom were even misdiagnosed or delayed being diagnosed for a long time. The physiological homeostasis environment function in vivo disordered, and the surgical complications such as obstruction, bleeding and fistula further make the body function worsen. In addition, patients with Crohn's disease often suffered immune dysfunction, infection, anemia, malnutrition, and they usually took many immunosuppressants and biological agents. All the complication and therapeutic destroyed the immune function and increased the risk of postoperative complications [
10]
. Therefore, the perioperative optimization strategy to reduce postoperative complications, avoid future recurrence and maintain postoperative remission is particularly important. A logistic regression analysis of one study was revealed that operative age and preoperative EN were independent risk factors for postoperative complications [
10]. A number of studies [
11‐
14] have also confirmed that preoperative parenteral nutrition support can significantly reduce postoperative complications, and the nutritional status and inflammation of patients can be improved. The research results of Grivceva et al. [
15] suggested that the use of TPN had no obvious relationship with postoperative complications, but indicated the positive significance of PN for surgical optimization in different ways. Therefore, prolonging the nutritional time as long as possible is an important treatment strategy in the perioperative period.
Six patients with Crohn's disease were followed up. Five of them were definitely diagnosed with CD several years ago. One of them just diagnosed Crohn's disease with intestinal obstruction after this admission. Three patients with incomplete obstruction had a history of abdominal surgery several years ago, and P3 had multiple operations due to recurrent intestinal obstruction. Five patients took the different immunosuppressive medications to control disease activity. In spite of the usage of strong immunesuppressive drugs, CD patients frequently experience the recurrence and over half will have an intestinal resection within 10 years after diagnosis, one-third undergo a repeat resection within 5 years [
16]. Different from general gastrointestinal diseases, The resection of the intestines of patients with Crohn's disease at the lesion site can not completely cure the disease and will eventually inevitably relapse [
17], while the intestinal fistula and other diseases during abdominal surgery are active factors for incomplete obstruction [
18]. Preoperative treatment measures are to maximize the effect of postoperative resection remission, prolong the recurrence cycle, reduce the recurrence rate and reduce perioperative complications. With the proposal of nutritional immunity and nutritional ecology, nutritional support plays an important role in intentional rehabilitation. These 6 patients were mainly took element diet and normal diet before the onset of intestinal obstruction. The nutritional status of the patients were usually poor after obstruction, and there were weight loss, anemia, albumin, cholinesterase reduction, low iron and calcium. In order to reduce intestinal secretion and protect intestinal mucosa, all the patients fasted, took parenteral nutrition, and were injected somatostatin. After the placement of intestinal obstruction catheter, except for P1, intestinal dilatation of other five patients obviously relived to different extents, which could be seen from X-ray image. Through angiography, P1 was observed multiple segmental stenosis before surgery which possibly resulted into partially-relieved obstruction. Two patients used enteral combined parenteral nutrition to improve nutritional status. Studies have shown that the usage of total enteral nutrition for 3 months before operation can significantly increase the nutritional reserve, reduce adverse reactions and reduce the incidence of postoperative complications in patients of Crohn's with intestinal fistula [
11]. For CD patients presenting with acute small-bowel obstruction without bowel ischaemia or peritonitis, deferred surgery is the preferred option [
3], so all six patients took comparatively long time to improve the nutrition condition before surgery in order to decrease the incidence of adverse surgical outcome. Regarding intestinal stricture treatment, endoscopic balloon dilation(EBD) and surgical treatment can be both considered as one of the options. Studies have shown EBD is more effective and safer for a small number (< 4) or short segment (< 4-5 cm) of strictures in a close proximity, while multiple strictures or long segment strictures(> 5 cm) of bowel may benefit more from surgical resection, anastomosis or stricturoplasty as a result of the involvement of stenotic bowel angulation [
19]. That’s the reason why the six patients underwent surgery to relieve the stenosis.
It is knonwn that malnutrition is an independent dangerous factor for adverse postoperative outcomes of CD. Therefore, oral or enteral nutrition is the priority of nutritional support;[
20]. Compared with 19 patients with nasogastric tube decompression whose nutrition time is about 2 weeks, the nutrition time of the 6 patients with transnasal ileus tube is about 1–2 months which was beneficial to intestinal resection. however, the period of nutrition was still less than 3 months, which may be due to 1.after the insertion, enteral nutrition is usually fed through the intestinal obstruction catheter. The position of enteral nutrition is close to the obstruction site, and there are relatively less enteral tubes that can effectively absorb enteral nutrition. 2. The intestinal obstruction catheter is too thick for some patients to tolerate the long-term compression of the nasal cavity and throat, resulting in a short retention time of the obstruction catheter and affecting the time of enteral nutrition. 3. The site of obstruction is mostly located in the small intestine, and the effective area of enteral nutrition absorption is restricted, which affects enteral nutrition. 4. In addition to obstruction, some patients also have internal fistula. For patient 1 and patient 4 and 5, nutrition infusion to the small intestine may enter into colon or bladder fistula, affecting the absorption of the small intestine, which is not conducive to the healing of fistula and has an adverse impact on the correction of patients' nutritional status. To solve those dilemma, the nasogastric tube or nasointestinal tube may be inserted to nutrition the proximal small intestine in addition to the small intestinal decompression tube. However, if the patient has gastric or duodenal fistula, the nutrition effect is expected not to be satisfied. It is an important method to prolong the period of enteral nutrition as far as possible in the treatment of Crohn's patients with small intestinal obstruction. It is worth mentioning that there is no significant difference in postoperative complications,the results of CRP and ESR between the two groups of patients with different decompression tubes, possibly as a result of the small sample size.
A study [
21] have shown that the way to combine mesalazine with enteral nutrition is effective in the treatment of active Crohn's disease, which can induce remission, improve the nutritional status and improve the surgical tolerance of patients. Five patients had used mesalazine or azathioprine before the onset of this disease, but enteral nutrition was not sustainable. In case of obstruction and internal fistula, patients stopped immunosuppressants, including azathioprine, thalidomide and hormones, corrected the nutritional status as much as possible, and resected the intestinal canal as little as possible during the operation, so as to avoid postoperative complications. The macrosopic and microscopic change of the intestinal resection are consistent with the typical manifestations of Crohn’s disease complicated with intestinal obstruction. The typical manifestations of acute and chronic inflammation, transmural inflammation, pseudopolyps and serous fiber hyperplasia can be seen in patients 1 to 5, and pseudopolyps can be seen in patients 6. Even there was no typical transmural inflammation, the diagnosis of Crohn’s disease still can not be excluded accrouding to the lesion location and clinical symptoms. Four patients were treated with infliximab or vedolizumab. One patient was lost to follow-up after operation, and one was currently observed after operation. Vedolizumab was planned to be given one month after operation. All patients continued EN for now and will gradually adjust to their appropriate diet in the future.
From the comparison of short-tube usage(recommended by all the CD-related guidelines present) group and long-tube application group, we can conclude the patients can still benefit from long-tube insertion even though the patients of short-tube insertion experience the failure of effective treatment of intestinal obstruction. Studies show that long tube decompression have succeeded in more than 70% of the patients with benign adhesive small bowel obstruction [
22,
23]; This procedure has been regarded as a simple, safe and minimally invasive approach. As a result, it is recommended as the initial treatment for benign adhesive bowel obstruction [
24]. However, short tube insertion treatment is not appropriate for complicated intestinal obstruction.
This article described the medical history, diagnosis, perioperative treatment, operation process, postoperative pathology and biological treatment of 6 Crohn’s patients with incomplete obstruction and they were treated with transnasal ileus tube by abstracting their medical record. There were several limitations to this study. Firstly, This was a single-centered, retrospective study. Secondly, the sample size is small. The results need to be confirmed by a larger sample study. In addition, follow-up time was not long enough to observe clinical outcomes. When we confronted with complicated cases of obstruction CD which is still a great challenge for experts of both gastroentergolgy and general surgery department, the treatment strategy may be adopted as followed, first step is rapid decompression, second condition is to prolong the nutrition time as much as possible and improve general condition, and third part is when CDAI scores increased as high as to meet the satisfaction to operation, final method is usage of biological agents and TPN to control the CD activity.
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