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Surgery

IBD_Surgery

Inflammatory Bowel Disease Surgery

It’s possible that you’ll need to face the prospect of surgery at some point during the course of your inflammatory bowel disease (IBD). Approximately 10% of those with ulcerative colitis and 30–50% of people with Crohn’s disease will eventually require surgery.

A recommendation by your clinical team to consider surgery is never made lightly. When treating IBD, the top priority is always to preserve the bowel for as long as possible. Sometimes this just isn’t possible: the disease might be too extensive or severe, and might no longer be responding to medications used to control the inflammation. It is important to understand that surgery for IBD is not simply a last resort that is considered when all else has failed, but a very useful treatment option in some cases. Surgery can offer long-term relief of symptoms and reduce or even eliminate the need for ongoing medication, often vastly improving quality of life.

Occasionally, surgery is required to treat a severe complication such as perforation (rupture) of the bowel or significant rectal bleeding. These are considered to be emergency situations and the decision to have surgery will need to be made quickly with few, if any, other options.

In most cases, however, surgery is pre-planned (elective). This means that you can make an informed decision on whether to proceed with surgery or not, after discussing all possible options with your gastroenterologist and surgeon. You will also be able to consider the reasons why a particular procedure is recommended, and learn what to expect before, during, and after surgery. As surgery in IBD sometimes means either a temporary or permanent colostomy or ileostomy, you will also have the opportunity to meet the stoma nurses before making a decision.

It’s also a good idea to speak to others who’ve already undergone similar procedures so that you can gain a true perspective of life before and after surgery. People naturally have fears about surgery and its consequences but once they’ve had an operation, many wish they hadn’t delayed the procedure, as it would have saved them months or even years of needlessly enduring symptoms.

On this page:

Surgery for Crohn’s disease

Approximately 30–50% of those with Crohn’s disease will need to undergo surgery at some time in their lives. Surgery is not a cure for Crohn’s disease but it can relieve symptoms and greatly improve quality of life.

The most common reasons for surgery in Crohn’s disease are:

  • to manage complications such as stricturing (bowel narrowing), perforation, or abscesses. These can occur suddenly and require an emergency operation
  • to manage disease that does not respond or has stopped responding to medical treatments
  • to eliminate the side effects of certain medications
  • to address delayed growth and pubertal development among children and adolescents.

The location and severity of the disease in the gastrointestinal tract and/or the type of complication that arises will determine the type of surgical procedure that can be performed. Because the inflammation in Crohn’s disease can re-appear in previously healthy parts of the intestine after surgery, surgeons try to conserve as much of the bowel as possible. Their aim is to treat a complication or solve a specific problem while trying to preserve as much of the intestine as possible.

Crohn’s disease surgery can either be performed by laparoscopic (keyhole) or open surgery. Your surgeon might recommend the laparoscopic approach as this reduces post-operative pain, complications, and recovery time. Laparoscopic surgery however is often not suitable for emergency or re-do operations, which are usually best done as open surgery.

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Surgery for abscesses and fistulae

Abscesses and fistulae are complications that can occur when the inflammation of Crohn’s disease penetrates outside the intestinal wall. An abscess is a localised collection of infection (pus). A fistula is an abnormal connection from an area of diseased bowel to another organ. For example, a fistula can connect the small bowel to the skin (entero-cutaneous fistula).

Abscesses develop most frequently in the anus or less commonly in the abdomen or pelvis. Depending on their location, some abscesses can be drained by inserting a needle through the skin directly into the abscess (percutaneous needle drainage), using a CT or ultrasound scan for guidance.

Abscesses adjacent to the anus (perianal abscess) often require a minor surgical procedure to drain the pus. An anal fistula is often associated with the abscess and your surgeon will assess this at the time of your surgery and might insert a drain (seton) through the fistula to prevent further abscess formation.

In some cases, abscesses can burst and drain into the abdominal cavity, causing peritonitis (severe pain), fever, and septicaemia (bacteria in the bloodstream). This is considered to be a surgical emergency and the abdomen must be opened so that it can be washed out, the abscess drained and, if necessary, affected parts of the bowel removed (resected).

Antibiotics are often used in addition to surgery to treat infection associated with abscesses.

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Resection and anastomosis

In Crohn’s disease, the initial treatment is usually medical to try and control the disease and preserve the bowel, but with a severely diseased bowel, surgical removal might be the best option. Surgery might also be required for strictures that are causing bowel obstruction, fistulae, or perforation, or for disease that does not respond to medical treatments.

The surgical procedure involves removing the diseased section of intestine ( bowel resection) and joining together the two ends of healthy intestine (anastomosis). Crohn’s disease bowel resection commonly involves the last part of the small bowel and the first part of the colon (ileo-colic resection), or the just the small bowel or part of the colon.

Sometimes after emergency surgery, often following a perforation with severe infection, the surgeon might conclude that an anastamosis is not healing well. In this case, he or she might opt to form a stoma (colostomy or ileostomy). This is where the bowel is brought to the skin surface and a bag or appliance is worn to collect the bowel motions. Such bags are often temporary and the bowel can be reconnected at a later operation.

Surgeons will form a stoma only if absolutely necessary, and will discuss this with you prior to any surgery.

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Surgery for strictures

A stricture is a narrowing of the bowel which is either caused by inflammation of the bowel or by scarring following this inflammation. Inflammatory strictures can often be treated with medical treatments, but symptomatic strictures caused by scarring usually need treatment by endoscopic dilatation (stretching), surgical resection, or widening.

Stricturoplasty is a procedure used to widen a narrowed area in the intestinal wall that is causing obstruction or blockage, but without removing any part of the intestine. Several stricturoplasties can be done in a single operation if there are several narrow areas, or combined with another procedure, such as a resection.

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Colectomy and proctocolectomy

Although the small bowel is the site most commonly affected by Crohn’s disease, the disease might also be affecting the colon. In this case, if the disease cannot be controlled with medical management, surgical resection of the colon might be necessary.

The operation for Crohn’s disease depends on the extent of the disease and can involve removal of a segment of the bowel (segmental colectomy) if the disease is localised. If the entire colon is affected but the rectum is normal, removal of the entire colon (total colectomy) might be necessary. In this case, an anastamosis between the small bowel and rectum can be formed to avoid a stoma. If the rectum is affected in addition to the colon, it might be necessary to remove both colon and rectum (proctocolectomy), which would involve forming a permanent ileostomy.

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Implications of having an ileostomy

Immediately after surgery, the stoma will be red and swollen but this will subside within a few weeks. You’ll need to use a skin barrier, a doughnut-like wafer designed to fit snugly around the stoma and protect the skin from any irritation caused by drainage of the faeces. It normally takes a few days before any drainage begins to accumulate in the bag. There is an initial learning curve to adjusting to an ostomy; during this time, specialty nurses and/or stomal therapists are available to provide support both in hospital and at home.

No one ever needs to know you have an ostomy unless you tell them. Normal clothing can be worn with only minimal adjustments, and odour isn’t a problem. Changing a bag soon becomes a simple and discreet process.

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Recurrence of disease after surgery

Unfortunately, up to 50% of adult patients with Crohn’s disease will experience a recurrence of active disease within five years of having had a resection. This most commonly occurs at or near the site of the anastomosis. Recent evidence from a clinical trial has shown that a colonoscopy to assess for early recurrence of Crohn’s disease helps plan medical treatment and can reduce the need for further surgery. Unfortunately, recurrent symptoms require surgery in up to 25% of cases.

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Surgery for ulcerative colitis

About 10% of those with ulcerative colitis will eventually require surgery. This usually involves removal of the colon and the rectum.

The most common reasons for surgery in ulcerative colitis are:

  • to manage complications (e.g., acute severe colitis, colon cancer)
  • to manage disease that does not respond or has stopped responding to medical treatments
  • to eliminate the side effects of certain medications
  • to reduce the risk of colorectal cancer among those with pre-cancerous changes in colon tissue.

Because ulcerative colitis only affects the colon, surgical removal of the colon is regarded as a cure. Following the removal of the colon and rectum, the surgeon can form an ileostomy or form a reservoir (pouch) from the small bowel to avoid the need for a permanent stoma.

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Emergency surgery for ulcerative colitis

Sometimes a severe attack of ulcerative colitis will require admission to hospital for medical treatment. Unfortunately, medical treatment does not always control the disease and emergency ulcerative colitis surgery might be necessary. If you are admitted to hospital, your gastroenterologist will ask a surgeon to discuss surgical options with you, if it is required. In uncontrolled acute colitis, the colon can become very thin and distended, which leads to the bowel perforating or bursting. If your clinical team thinks this is a possibility, they will recommend surgery, as perforation leads to peritonitis and severe infection (sepsis). Emergency surgery involves removal of the entire colon with formation of an ileostomy. This is usually done via the open surgical approach.

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Elective surgery for ulcerative colitis

Your gastroenterologist might recommend surgery even if your condition is less severe if it is not adequately controlled by medications, or if there is significant risk of developing colon cancer. The two surgical options both involve removal of the colon and rectum, either with formation of a permanent ileostomy or an ileal pouch.

PROCTOCOLECTOMY AND ILEOSTOMY

The traditional surgical procedure for ulcerative colitis is proctocolectomy (removal of the colon, rectum, and anus) with formation of an ileostomy. This procedure is often done by laparoscopic surgery to improve recovery. Although this operation requires a permanent stoma, it is possible to live a completely normal life afterwards. This also avoids some of the potential problems with a pouch.

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Restorative proctocolectomy or ileoanal pouch

For those who wish to avoid a permanent stoma, the surgeon can form a pouch from the last part of the small bowel ileum. In the two-stage approach, a pouch can be formed during the first operation, or after an emergency colectomy in the three-stage approach.

To form a pouch, the surgeon removes the colon and rectum, but preserves the anus and anal sphincter muscles. The surgeon then uses about 30 to 40 cm of the ileum (the end of the small intestine) to create a J-shaped pouch, which is then brought down and connected directly to the anus. The pouch is a reservoir that stores bowel contents prior to normal defecation.

Since the pouch is formed from the small bowel, the bowel contents are quite liquid, but most patients have full control. And because this operation requires several bowel joins (anastamoses), a temporary ileostomy is formed to rest the pouch and allow bowel healing. This join is subsequently checked with a special x-ray prior to a further operation that will rejoin the bowel and thus allow normal bowel function.

Restorative proctocolectomy is a good option for many people with ulcerative colitis but it doesn’t suit everyone. After surgery, many experience frequent loose bowel movements during the day, plus some during the night. A small amount of leakage can also occur. Over time, however, the number of bowel movements decreases. After about six to 12 months, most people will have an average of about six semi-formed bowel movements during the day and another at night. Although this is the average, there is wide variation in the frequency of bowel motions.

Although many do well after restorative proctocolectomy, there’s a chance that complications will arise:

  • About 5% of those who undergo restorative proctocolectomy develop infection at the site where the ileum is attached to the anus. This can cause abscesses and/or a narrowing (stricture) of the anastamosis.
  • Pouchitis (inflammation of the pouch) is similar to ulcerative colitis in the pouch and occurs in about 30% of patients after surgery. Symptoms include increased frequency of stools with urgency, crampy abdominal pain or bloating and occasionally bleeding. Pouchitis is usually treated with antibiotics and its symptoms can usually be improved.
  • Although less common, bowel obstruction can occur because of adhesions or scar tissue forming after surgery. Symptoms include crampy abdominal pain with nausea and vomiting. In most patients, bowel obstruction can be managed with bowel rest (not eating for a few days) and intravenous fluids. Others might need additional surgery to remove the blockage.
  • An abnormal connection between the pouch and the vagina (pouch-vaginal fistula) occurs in up to 10% of women. This can occur before or after closure of ileostomy. It is a common cause of early pouch failure and might require its removal.
  • Women who have undergone restorative proctocolectomy might experience difficulties in falling pregnant. Most surgeons of pregnant women with ulcerative colitis will recommend a caesarean section for delivery. Women wishing to have children should discuss these issues with their gastroenterologist and fertility specialist before making a decision to undergo surgery.
  • There’s a small chance that men who have had restorative proctocolectomy might have difficulties achieving or sustaining an erection as a direct result of the surgery

In a small proportion of patients undergoing ileoanal pouch surgery, these complications can lead to such poor function that the patient cannot lead a normal life. In such circumstances, the surgeon might need to form a permanent ileostomy with or without removal of the pouch. The rate of pouch failure is approximately 10% at 10 years after surgery.

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Which is the best option for me?

In the event that surgery is required to manage your ulcerative colitis, the decision to have proctocolectomy with ileostomy or restorative proctocolectomy is highly personal and will depend on your age, lifestyle, and general health. For example, some people might have a strong wish to avoid an ileostomy and are prepared to put up with frequent bowel movements and the risks associated with a pouch. On the other hand, some do not wish to have further major surgery with its associated risks and will go for a permanent ileostomy. Your IBD team will discuss all of the options with you and allow plenty of time for decision-making.

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