Reoperative Crohn's surgery: Lessons learned the hard way

Crohn's disease (CD) is a chronic inflammatory disease of the intestinal tract characterized by transmural inflammation, which can progress to intestinal perforation, intra-abdominal abscesses, intestinal strictures, and fistula development. Surgery is frequently required to correct these disease-related complications. Unfortunately, there is no medical or surgical cure for the disease, and the etiology remains undefined. Thus, many patients will undergo multiple operations over their lifetime when the disease process becomes medically refractory and complications ensue. The index operation in CD can be challenging due to the active disease and any associated inflammation in non-diseased bowel. However, reoperative CD surgery even more complex due to the underlying disease process, adhesive disease, altered anatomy from the prior surgery or surgeries and the imperative to preserve small bowel. Several steps can be taken in the preoperative phase to optimize outcomes, and there are many technical aspects should be considered during the reoperation to assist in the performance of a safe operation and attempt to minimize intestinal resection. Herein, we review some of the important principles of operative and reoperative Crohn's surgery that can assist the operating surgeon when approaching this challenging patient population.