Surgery for Crohn’s disease
Surgery for Crohn’s disease
Medical therapy is often the first treatment option for Crohn’s disease. Despite the introduction and diffusion of new effective drugs (biologicals), 70% of people with Crohn’s will eventually need surgery during the course of their disease.
Common indications for surgery are:
insufficient/ lack of response to medical treatment
medical complications of Crohn’s disease such as development of intestinal strictures, anal and abdominal abscesses/fistulas, cancer
emergent complications such as intestinal obstruction, perforation (tear in the bowel wall) or toxic megacolon
improvement of quality of life
Anal fistula and anal abscess
An abscess is a collection of pus that usually appears as a palpable and painful swelling in the perianal region. Perianal fistulas are abnormal ducts that connect the lower part of the intestinal tract (the rectum and anus) and the skin around the anus, causing one or more skin openings. The course of perianal fistulas can sometimes be very complicated. The surgical treatment of abscesses consists in the incision and the drainage of all purulent collections. The placement of a seton (a wire or rubber band inserted into the fistula) is the initial treatment of choice for 'fresh' inflamed fistulas. The seton guarantees good drainage and avoids the premature closure of the fistula tract.
Surgical treatment of anal fistulas (aiming at closing the fistula) should only be performed in absence of any signs of local and general inflammation. The surgical treatment of anal fistulas has a dual purpose: the healing of the fistulas and the maximum preservation of the anal sphincters in order to avoid any troubles with the fecal continence. Several techniques can be used to approach anal fistulas depending on patients and fistula characteristics and surgeon’s preference/experience.
Intestinal strictures / fistulas
The development of intestinal complications (strictures, abscesses or fistulas) can lead to severe symptoms with significative impact on patients’ quality of life. These complications do not often respond to medical treatment and therefore need to be approached surgically.
An intestinal resection including the removal of all macroscopic affected bowel is the procedure of choice. This is often followed by the connection (anastomosis) of the two stumps of the remaining bowel using sutures sewn by hand or mechanical staplers. Depending on several patient- and disease-related factors, the anastomosis can be postponed to a second surgical step (few months later) and a temporary stoma can be performed.
When strictures affect a long segment of bowel and resection would result in the loss of a consistent portion of bowel, strictureplasties can be performed. A strictureplasty is a well-established surgical procedure to repair a stricture by widening the narrowed area without removing any portion of the intestine. Several techniques exist and are routinely performed in large referral centers treating Crohn’s patients. Results in terms of safety and efficacy (recurrence after surgery) are similar to those of intestinal resections.
Definitive Surgery for Ulcerative Colitis
Other than for Crohn’s disease, surgery for Ulcerative Colitis can be the definitive treatment in case of poor response to the medical treatment or severe disease’s complications such as acute colitis or toxic megacolon.
The three most frequent options are:
- Resection of the entire colon and rectum including the anal sphincter with creation of a definitive, permanent stoma using the small bowel (terminal ileostomy)
- Resection of the entire colon as well as the rectum, with preservation of the anal sphincter. A new intestinal reservoir is made by folding the last 15-20 cm of small bowel and suturing this to the anus (ileal pouch surgery)
- Resection of the entire colon, preserving the rectum (if not affected by the disease). An ileo-rectal anastomosis (surgical connection between the small bowel and the rectum) is then performed. This procedure is technically less demanding than the previous two. By leaving the rectum in place, patients experience better intestinal function after surgery. However, this procedure has the disadvantage of being not curative. This means that patients receiving an ileo-rectal anastomosis can experience disease recurrence at the level of the rectum. Furthermore, a lifetime annual endoscopic follow-up of the rectum is required in order to detect the possible development of polyps/cancers in the rectum.
The pouch operation
Pouch surgery has been first described in the late 1970s and offers a sphincter-preserving reconstructive procedure in patients with Ulcerative Colitis. The pouch is constructed by attaching two loops of the small intestine together in the shape of a J. Hence the name ileal J-pouch. (Figure1)
Figure 1. Ileo-anal pouch.
Depending on the circumstances, this operation can be performed in several surgical steps (Table 1).
Table 1. Types of different surgical stages in the surgical treatment of Ulcerative Colitis.
Proctocolectomy: surgical resection (removal) of colon and rectum
Subtotal colectomy: surgical resection (removal) of the colon. Rectum is preserved.
Completion Proctectomy: surgical resection (removal) of the rectum
Loop-End Ileostomy: Small bowel stoma in a loop or end configuration
Currently, in reason of the long-time exposure to several drugs (i.e. biologicals, steroids), the majority of patients receive a staged procedure in which the construction of the pouch is postponed to a second time (12-16 weeks after the initial total colectomy with end ileostomy) in order to avoid complications (leakage and abscesses) of the pouch.
After the normal postoperative adaptation phase (6-12 months), pouch function remains good and fairly stable for many years, with few lifestyle barriers in most patients. Eighty percent of patients experience satisfactory pouch function. Patients with a pouch have an increased stool frequency (5-7 during the day, 0-1 during the night). Most patients will have a perfect full daytime continence. Episodes of nocturnal soling (minimal loss of stool) can be present. Normally, no urgency is reported and defecation can be easily postponed.