Surgical management of Crohn's disease involving the duodenum.

The experience with 25 patients who required operation for Crohn's disease involving the duodenum is reviewed. Two distinct patterns of duodenal involvement are apparent. Intrinsic duodenal Crohn's disease has a characteristic clinical presentation that is distinct from the symptoms seen in patients with involvement of other portions of the gastrointestinal tract. Among 70 patients with duodenal Crohn's disease seen over a 30 year period, 22 required surgical intervention at the Lahey Clinic. Although hemorrhage and intractable pain were associated problems in several of these patients, unrelenting duodenal obstruction remained the primary indication for operation. Of patients who underwent operative bypass, 78 percent had a good result with a median follow-up period of 12.3 years. The presence of associated gastric Crohn's disease did not influence long-term results. A third of the patients required reoperation for duodenal disease. Marginal ulceration and recurrent gastroduodenal obstruction have been the primary reasons for reoperation. Although the addition of vagotomy to operative bypass has not helped to protect against subsequent marginal ulceration, the absence of appreciable morbidity associated with vagotomy in our series and the high incidence of marginal ulcers reported with gastroenterostomy in other clinical settings lead us to recommend gastroenterostomy with vagotomy as the procedure of choice for duodenal Crohn's disease. Proceeding with vagotomy in persons who have had previous ileocecal or extensive small bowel resection should not be undertaken without careful consideration. Similar caution should also be used in patients who are already troubled with poorly controlled diarrhea. The duodenum may also be involved by duodenoenteric fistulas which represent a complication of Crohn's disease involving other portions of the gastrointestinal tract. Most frequently this occurs in patients with Crohn's colitis who have no evidence of intrinsic duodenal disease. Management of the internal fistula requires resection of the involved colon and closure of the duodenal defect. Three patients with duodenocolic fistula have been so treated.