About surgical treatment of Crohn's disease
　
Following cases are operation adaptation for Crohn's disease.
A stenosis, ileus, fistulas, an abscess, intractable case. An operation is performed for perforation, massive bleeding, developmental disturbance, intestinal cancer, an anal lesion as these other requirements.
Resections of lesioned parts are rule, but, in a stenosis of the small intestine, stenosis plasty is performed.
The patients who did the remission of an operation take placebo with no medication, and recurrence rate for less than 2 years is 40-63% and a high rate.
For recurrence prevention, you should do ambulatory after having done remission.

1.An operation rate
An operation rate of Crohn's disease is higher than Ulcerative colitis.　This reason is extended to a lesioned part being wide and all intestinal wall layer.
According to the count of an internal medicine 9 institutions of MHLW intractable disease study group, the accumulation operation percentage was 30.3% in appearance of disease 5 years, 70.8% in 10 years.
Classification lesioned part into the type, which small intestine, small intestine large intestine, large intestine reviewed it, and there wasn't the difference of an operation rate by each type.
According to the report of a surgeon and the European and American report, an operation rate becomes higher. It is said to an operation rate of the large intestine type lower than the small intestine type, the small intestine large intestine type.
By a report of Crohn's disease 74 case of 2nd internal medicine Kyushu University Dr.Aoyagi, a lower deserved accumulation operation rate seems to be high. ^*2

2.Operation adaptation　
I show frequency of operation adaptation and disease state of Crohn's disease.
stenosis 48 cases (56%), ileus 10 cases (7%), fistula 23 cases: internal fistula 19 cases (12%), external fistula 4 cases (3%),
abscess 11 cases (7%), perforation 6 cases (4%), being difficult to govern 6 cases (4%), hemorrhage 3 cases (2%),Nutrition disorders 3 cases (2%),
Cancer or doubt 3 cases (2%), 2 cases to discover in an operation (1%)

I think slightly old, but patient who operated on 86 according to the document of 1994 was preoperative IOIBD score an average of 3.1.^*3

1)Stenosis,Ileus
Stenosis, ileus are first many conditions of a patient by operation adaptation to hold in total 63% of the operations. This increased it to the narrow small intestine of the inside diameter and occupied 55% of the small intestine type operation, 35% of the small intestine large intestine type, 12% of the large intestine type.
There is much that abdominal pain develops when the lumen of the small intestine becomes around 5mm (cystography examination). If stenosis becomes intense, digestion absorption disorder is caused.
Even if a symptom reduces fibrosis stenosis in nutritional therapy, I can't expect the improvement of stenosis in itself.　There seem to be many that an intestinal wall thickens in around 1cm.
Stenosis and ileus of the small intestine require a great hardship of patient.
You should operate in ultrasonography and CT at a point confirmed the excessive thickening of bowel.
Stenosis of the large intestine is comparatively asymptomatic, and there is it when improving it by endoscopic balloon dilation instead of much operation adaptation. ^*1.*2.
When a stenosis part is long, I think that there isn't balloon dilation in much effectiveness. However, it is a method to be effective as one preoperative procedure.　You should know that recurrence rate is high as a weak point even if you can dilate stenosis temporarily. 2)fistula, absece
The fistula and abscess occurred in 19% of Crohn's disease, and it was secondly a lot of disease state. There are many internal fistulas when it compares the external fistula with the internal fistula. Internal fistula is the fistula that an interval of bowel is connected with bowel.
An ileal sigmoid colon fistula occurs most a lot, and there is a case to rarely occur between bowel and a bladder and uterus.
A fistula occurs in a center of a comparatively long longitudinal ulcer, and deep cleft and ulcer can break it through.
There is many that the anus side of a fistula includes a stenosis, and mouth side internal pressure of bowel goes up, and I think that a fistula can be easy to. Even if it is assumed that the fistula improved it by nutrition care in being hard to cure, seem to relapse in short term when a patient starts a normal meal. The case that combined a fistula increases with adaptation of an operation so that there are abdominal pain and inflammatory hard spot in anemia, a state of malnutrition. In addition, in external fistula, bowels contents begin to be left out of the abdomen. Peritonitis with much leak is caused, and operate, and be adapted. When a pain of an anal fistula is strong, operate, and be adapted.
Will explain it later.

3)Other operation adaptation
　Bowel perforation is 1-3% of operation adaptation, and about 80% of perforation region are ileum.
Be checked as perforation of acute appendicitis and a peptic ulcer, and there is much what is operated on. Massive bleeding occurs in 1-3%, and there is much ileum, and hemorrhage region is easy to occur in remission, and the thing that there is many is a characteristic to a man. There seem to be much matter cases operated on for being intractable same as Ulcerative colitis. In addition, an anal lesion of intractable is operation adaptation. Developmental disturbance is important operation adaptation in a child. There is a little merger of cancer, but an operation is performed in this.

3.Operative method
　Principle for an operation for Crohn's disease is resection of a lesioned part. Separate about 5cm from an edge of a lesion, and there is much doctor to sew up. When a fistula operates, don't seem to mind by simple close down to the bowels of a partner of a fistula when there is not a lesion. When a range of resection is long, consider short bowel syndrome, and a surgeon has to pay careful attention. Enough drainage is necessary for the space where abscess collects. If there is a lesion of activity in front and back of a stenosis, an operation for small intestine stenosis removes the whole lesion surgically. In addition, site is a limited lesion, but resection seems to be desirable if a patency ulcer is a lesion of activity.

A stenosis plasty technique
　If there are not in fibrosis, scarring and a patency ulcer, a stenosis is good adaptation of stenosis plasty.　

This operation does not need resection of the bowels, and be possible in multiple stenoses. This operative method is a superior operation method that there is not worry there is a little complication, and hospitalization is short and suffer from short bowel syndrome. It looks at postoperative recurrence rate in the long term, and it is assumed that it is equal with the patients who did intestinal resection. There is a report of a group of Oxford which chased the patient group who did stenosis plasty for average 50 months.(for best 182 months) A recurrence reports 3.7% and good results. However, with about 1/3 cases, an extensive stenosis develops in the site that there was not an activity lesion, and this point is the theme that it should solve in future.

 Seton technic
　Most are anal fistulas and becoming chronic changes into it and an anal lesion of Crohn's disease is intractable. Primary exit of an anal fistula occurs from an anal ulcer and an anal fissure, and multiple second exit are noted to perineum skin.　At first confirm a fistula, and stir enough the inside. At first confirm a fistula, and stir enough the inside. Next, insert soft drain in a fistula and anal canal, a fistula and skin. And a loop-shaped, grow, and just leave drain. Fistulas are complicated, and drains are inserted a lot. Do drainage surely, and reduce number of fistulas with follow-up, and expect simplification of fistulas. Pull by one of them, and consider an appearance to simplify it. In several months (a complicated case about 1 year), it can extract drain entirely that it is stable, and it is said that it cures. Meanwhile, it cannot but tolerate discomfort of anal region and unpleasantness for discharge of pus. On that occasion resemble, and be convenient when the patient uses a napkin for rearranging for women.
However, it is not complete cure that say this healing. There seems to be some waste fluid by the conditions that there is not especially a pain and fever to accumulate pus.　I hear that there cannot be complete cure only by Seton technic for the moment. It may be closed when it uses Remicade (an anti-TNF-arufa antibody) together with Seton technic. It is said to Remicade that it is effective in closing the fistula which it had on bowel.

　A habit
According to the report of Cosnes, quantity of tobacco use dependence seems to raise a risk of an operation. Compare it with a man, and the tendency is noted to a woman clearly. An operation rate increased with the case which started smoking in an observation period. On the other hand, be reported that an operation rate fell with the case which they stopped. There are much an aggravation factor of Crohn's disease and reports to do, and tobacco use habit is the point where you should pay attention to in life. On the other hand, for Ulcerative colitis, there is the report that a symptom relaxes by tobacco use. Would like you to be careful with it not to interpret the information in the direction that may be wrong. In addition, birth control pill is estimated with a risk factor of appearance of disease, too.*2

References
*1.Tuneo Fukushima, et al.　Inflammatory Bowel Disease　1. Surgical cure 　Gut and bowel　Vol.32 No.3　389-395 1997 (Japanese)　
*2.Kunio Aoyanagi et al.　Gut and bowel　Vol.32 No.3　421-430 1997 　 (Japanese)　
*3 Tuneo Fukushima, Akira Sugita　Examination of Crohn's disease postoperative recurrence factor MHLW intractable disease Intractable inflammatory bowels disorder investigation study groupA 1994 document report　99-102 1995 (Japanese)　
*4.Stebbing JF,Jewell DP,Kettlewell MG, et al. Longterm results of recurrence and reoperation afte strictureplasty for obstructive Crohn's disease. Br J Surg 82: 1471-1474,1995
*5.Cosnes J. Carbonnel F, Beaugerie L, et al. Effects of cigarette smoking on the long-term couse of Crohn's disease. Gastroenterology 110:423-431,1996
figure "Inflammatory bowel disease Ulcerative colitis and all of Crohn disease" Editing Tetuichiro Muto (Japanese)　
*6Release of a digestive tract stenosis Jyunichi Ishibashi Mebio Vol.15 No.1pp.140-147, (Japanese)　
*7.Acute Corlorectal Obstruction: Stent Placement for Palliative Treatment-Results of a Multicenter Study
*8.Miguel Angel De Gregorio, Antonio Mainar,Eloy Tejero,Ricardo Tobio, etc.Radiology October 1998 pp.117-120
*9.Treatment of Colonic Obstruction with Expandable Metal Stents: Radiologic Feeatures Cheri L.Canon Todd H. Baron AJR:168,January1997 pp199-205
*10.Availability of Metalic Stent detention for Crohn's disease that combined a stenosis Y Ohta、Fukuoka et al Univ. Tsukushi Hospital　The current situation and progress of digestive organ Metallic Stent　第14・15回Japanese Metallic Stent & Graft Study group abstract (Japanese)
*11.Long term results of a tent treatment for intestinal stenosis of Crohn's disease. Nobuyuki Matsuhashi et al.　DDW-Japan 1999 abstract (Japanese)　

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