Surgical management of Crohn's disease in children.

One of the most common beliefs in the management of Crohn's disease is that surgery should be considered only as a last resort. Surgery is often considered by patients and gastroenterologists to represent a "failure." However, the role of surgery in the care of patients with Crohn's disease has increasingly become a collaborative effort, with surgeons involved in many aspects of the management of these patients. This is particularly true in pediatric patients, as issues of growth and development may involve surgical intervention at earlier stages than might be required in older patients. In fact, surgical interventions may be indicated at any stage of the disease process. For example, early examination under anesthesia with abscess drainage and delineation of fistula tracts has proven very useful in patients with complex perineal disease. Surgery may contribute to the medical management of the disease by way of providing chronic enteral or parenteral access for nutritional interventions such as elemental feedings and total parenteral nutrition. Finally, surgical treatment of intra-abdominal complications including fistulas, phlegmon, and bowel strictures may have a dramatic impact on patient symptoms and side effects. Although bowel resection carries the long-term risk of short bowel syndrome should future resections be required, the improvements in medical therapy continue to reduce the risk of recurrent disease, making surgical resection more palatable. Surgical treatment of complicated disease offers significant potential to limit toxic medical therapy and improve quality of life. In addition, application of minimally invasive techniques can minimize the impact of insults to body image in this vulnerable patient population as well as speed recovery. Future interventions may be facilitated by reducing adhesion formation through the use of minimally invasive techniques. The dynamic nature of growth and development in the pediatric population presents unique complications from medical therapies that are different from those seen in adults. Criteria for surgical intervention must be interpreted in light of the specific challenges facing the pediatric population as frequently pointed out in the oft-quoted maxim, "children are not small adults!"