A 16-year-old patient with a known history of Crohn’s disease presents with an anal fistula. He has had two prior bowel resections.
Crohn’s disease is a chronic inflammation of the gastrointestinal tract with an incidence of 7 in 100,000. The disease can occur anywhere from the mouth to the anus, but it usually involves the ileum and colon. Patients present with abdominal pain, vomiting (which can be constant), diarrhea, and weight loss. Rectal fistulas are common. A combination of antibiotics, immunomodulators, and biologic agents as well as conservative operative procedures are used to treat the fistulas.
The chronic inflammation and hemorrhage may lead to anemia. Albumin loss through diseased mucosa can lead to hypoalbuminemia. Malnutrition can be severe enough to require total parental nutrition. Evaluate the intravascular fluid and electrolyte status, particularly after the patient receives a bowel preparation. Ankylosing spondylitis and Crohn’s disease are both caused by the HLA-B27 genotype, and some patients have both diseases. In patients with ankylosing spondylitis, a direct laryngoscopy can be difficult.
Patients can be very apprehensive about the prospect of multiple bowel resections.
Children on azathioprine or 6-mercaptopurine can have leukopenia and drug-induced hepatitis.
Neuroaxial anesthesia is theoretically a good choice. Most 16-year-old patients prefer to be unconscious during a perianal procedure. The incidence of postdural puncture headache decreases with age, which changes the risk-benefit ratio in young patients with a low risk for cardiac or cerebral complications to favor general anesthesia.
General anesthesia with either total intravenous anesthesia with a nasal canula or laryngeal mask airway may be considered, but positioning of the patient in a lithotomy and steep Trendelenburg position may require endotracheal intubation.
Avoid acetaminophen in patients with concomitant liver disease.
Give a stress dose if the patient is taking steroids or has taken them in the past 6 months.
Patients who take infliximab (a monoclonal antibody used for fistula closure or maintenance therapy) are at risk of an acute coronary syndrome; postoperative muscle weakness has been reported.
Patients with Crohn’s disease usually have chronic abdominal pain, and their postoperative pain may be difficult to control. Consider using a multimodal approach and utilize complementary methods.
DOs and DON’Ts
✓ Do use the patient’s indwelling permanent access, if present.
⊗ Do not give nitrous oxide.
⊗ Do not give paralytics if stimulation of the sphincter muscle is planned.
Surgical site infections in colorectal surgery may be decreased by hyperoxia. Classically, papers quote using a fraction of inspired oxygen of 80%.
Surgical treatment of skin tags in this population, whether conservative or aggressive, is associated with prohibitive morbidity.