Rodeando al enemigo: colectomía derecha laparoscópica por enfermedad de Crohn estenosante y fistulizante

Abstract

1) Introduction.

Crohn's disease has an increasing incidence in recent years in industrialized countries, and ileocecal involvement is the most frequent in this pathology.

Firstly, patients can receive medical treatment, but many of them can present  complications of the disease such as stenosis or fistulas. When these appear, they must be treated surgically, representing a challenge for the surgical team because this are patients in poor general condition and with a large abdominal inflammatory compromise that makes it difficult to correctly identify the anatomical planes.

2) Description.

We present the case of an 84-year-old patient who is admitted to our institution in Emergency Service for presenting a diagnosis of Crohn's disease of 10 years of evolution, poor general condition and severe nutritional deterioration. Physical examination revealed a palpable tumor at the level of the right flank and right iliac fossa.

Entero-MRI: Terminal ileum with fistula towards the right and transverse colon and intermediate cavity with a 3 cm collection.

Laboratory: White blood cells: 12,000x10-9 / L, Albumin: 1.3 gr / dl.

Decission is made to admit the patient, antibiotic treatment, support measures and total parenteral nutrition were instituted.

At 3 weeks, the patient shows improvement in nutritional parameters and general condition, for which surgical treatment of the pathology is scheduled.

An exploratory laparoscopy is performed where a large inflammatory tumor involving the terminal ileum, right and transverse colon is evidenced. Complete mobilization of the aforementioned structures is achieved, which are externalized by a supraumbilical median mini laparotomy, and enbloc resection of the inflammatory tumor is made, performing a terminal ileostomy and leaving the transverse colon in subcutaneous cellular tissue.

Patient presented good postoperative evolution, receiving sanatorial discharge on the seventh postoperative day without complications.

3) Conclusions.

Surgical treatment of Crohn's disease represents a challenge for the surgeon. Performed laparoscopically and after optimizing the patient from a clinical and nutritional point of view, good postoperative results can be obtained.