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IBD and Colorectal Surgery

Steven Wexner, MD and Yair Edden, MD

Introduction

Although surgery is not always the initial treatment for inflammatory bowel disease (IBD), approximately 70%–80% of patients with Crohn's disease (CD) and 30%–40% of patients with ulcerative colitis (UC) will need surgery at some point. While there have been significant advances in the medicine available to treat IBD, surgery continues to be an important part of treatment for many patients. There are many reasons that you might need surgery; we will address a few of the more common ones in this newsletter. We will also provide information about the types of surgery that are usually performed and suggest steps for you to take both before and after surgery to make sure you have the best possible outcome.

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When is Surgery Needed?

If you have CD, surgery cannot cure your disease, but it can help to relieve your symptoms, treat complications, and improve your quality of life. Although such surgery can be quite successful, it's possible that the disease may reoccur in a new area and that additional surgery may be needed. This is most common in patients who have severe disease that extends beyond the large intestine. Other patients may experience remission for as long as 15 years following surgery. If you have UC, surgery can cure your disease by removing your colon.

The following list describes some of the IBD–related complications that may require surgery.

• Strictures

  The inflammation that accompanies CD can result in strictures that cause a narrowing of the intestines. When this problem happens you may have cramping, nausea, and/or vomiting, especially following a meal. Strictures are much less common in UC, occurring only in the colon and never in the small bowel. Because some strictures resolve on their own, the first line of treatment is typically diet and medication. However, you may eventually require surgery.

• Perforations

  A perforation is a hole that develops in the intestine. When a perforation occurs, the contents of the bowel leak into the abdominal cavity. Severe abdominal pain is typically followed by fever, chills, and an elevated white blood cell count, due to inflammation and infection. This situation can be life–threatening and can require emergency surgery. With CD, perforations can be into adjacent structures causing fistulas instead of peritonitis. With UC, perforations can be caused by toxic megacolon.

• Toxic megacolon

  Toxic megacolon is caused by infection and inflammation. It occurs when the muscles in the colon wall become paralyzed, causing bacteria and gases to build up. Toxic megacolon most often begins with severe pain, fever, dehydration, and rapid heartbeat. It is more common in UC than in CD, and typically requires emergency surgery. Toxic megacolon is not the same as other forms of megacolon, such as pseudo–obstruction, acute colonic ileus, or congenital colonic dilation, which occur without infection or inflammation.

• Abscesses and fistulas

  An abscess, which is more common in CD than in UC, is the formation of a pocket where bacteria collect as pus. Abscesses can occur adjacent to the colon or around the rectum or anus and must be drained so that they do not extend to nearby structures or rupture.

  A fistula is a relatively common occurrence in patients with CD. It is an opening from the colon or rectum to other organs or to the skin. If a fistula is small, it can sometimes be treated with antibiotics. Large or multiple fistulas typically require surgery.

• Premalignant or malignant changes in the colon

  Patients with UC, or with CD that affects the colon, are at increased risk of developing colon cancer. (For more information, please see Dr. David Rubin's "IBD and Cancer" newsletter.) Treatment is typically determined based on the extent, or "stage," of the cancer.

In addition to the above complications, surgery may also be necessary if your medication causes serious side effects. Medication–related side effects can be either temporary and generally tolerable or permanent and much more serious. For more information, please see Dr. Gary Lichtenstein's "Treating Inflammatory Bowel Disease: Medication Side Effects" newsletter. Finally, surgery should be considered if your symptoms continue despite optimal medical treatment and/or drug therapy, or when you are unable to maintain remission without the use of corticosteroids.

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Types of Surgery

Different conditions require different surgeries. For example, because surgery doesn't cure CD, surgeons typically take a conservative approach that solves the immediate problem, returns you to the best possible quality of life, and preserves as much bowel as possible. Some types of IBD–related surgery can be done in an outpatient clinic, and other types require a hospital stay. The following list describes some of the most common procedures.

• Strictureplasty

  Strictureplasty involves the widening of a narrowed section of small bowel by opening the affected section of intestine in one direction, pinching it in the opposite direction, and closing it. This results in a slightly shorter, but wider, opening. Numerous strictureplasties can be done during a single operation and can be done in isolation or combined with one or more resections.

• Abscess draining

  If an abscess within the abdomen is contained (i.e., not leaking), drainage can sometimes occur through the skin using a catheter guided by CT or ultrasound. Otherwise, drainage is accomplished through an abdominal incision. An abscess that leaks directly into the abdominal cavity requires immediate surgery to explore the abdomen, drain the abscess, and/or remove the portion of diseased intestine where the abscess is located. An abscess in the anus or rectum can often be opened and drained through the rectum in an outpatient clinic, although deeper anorectal abscesses may require drainage in the operating room.

• Fistula surgery

  Surgical options include a fistulotomy, where an incision is made along the length of the fistula to foster healing of the canal, or a seton procedure, where a length of suture material is looped through the fistula to keep it open and allow pus to drain. After complete resolution of sepsis, procedures may be employed to close the internal opening.

• Balloon dilation

  During balloon dilation, a deflated balloon, which is attached to a long, thin tube, is moved through the intestine. When an obstruction is located, the balloon is inflated to widen narrowed sections. This is a relatively new procedure that includes an increased risk of bowel tearing. There are not much additional data regarding safety or long term success.

• Resection and anastomosis

  Resection is the removal of a diseased section of intestine, and anastomosis is the joining of the remaining healthy sections. Your doctor may refer to this procedure by other names, depending on the part of the intestines that are removed and joined. For example, if part of your ileum and cecum are removed, the surgery is called an ileocecal resection with anastomosis. Typically, a surgeon will try to remove as little intestine as possible to avoid short bowel syndrome, which is associated with chronic diarrhea. Strictureplasty may be performed at the same time as resection.

• Colectomy/proctocolectomy

  Colectomy or proctocolectomy are the two most common procedures for UC. The entire colon is removed because UC is likely to recur if any portion of the colon is left intact. However, if there is no or minimal rectal disease, sometimes the rectum is retained. It is not uncommon for people with UC to tolerate chronic severe symptoms because they fear such surgery, and it isn't until after the surgery that they appreciate how sick they were and how much the surgery has improved their lives.

  There are three major variants of the colectomy/proctocolectomy procedure:

  • Colectomy/proctocolectomy with a permanent ileostomy (Brooke ileostomy)

    For this procedure, the surgeon creates a stoma and attaches the ileum to the opening, allowing the drainage of stool into a stoma bag. The stoma, which is about the size of a quarter, is usually located in the lower right quadrant of the abdomen. When the stoma bag is attached to the stoma, it is inconspicuous under clothing. Colectomy and proctocolectomy have a long history of safety and tend to be the standard against which newer procedures are compared.

  • Colectomy/proctocolectomy with a continent ileostomy (Kock ileostomy)

    This procedure also involves the creations of an external opening in the abdominal wall. But instead of attaching the ileum to the opening, part of the small intestine is used to create an internal pouch that holds waste until a tube is inserted into a valve in the opening to empty it. Risks associated with this procedure include pouchitis and the need for reoperation due to valve malfunction.

  • Colectomy with ileoanal anastomosis

    For this procedure, the anal canal is retained and the surgeon uses the end of the ileum to create an internal pouch that is connected to the interior wall of the anus. The surgery usually involves two or three stages. First the surgeon removes the diseased colon and rectum, creates the pouch, and connects the pouch to the anus. Then, a temporary ileostomy is created to give the new pouch connection a chance to heal. Several months later, the surgeon closes the ileostomy. Following the operation, most people experience both frequent, soft stools and bowel movements at night. Over time, stool frequency typically decreases to about six semiformed bowel movements during the day and one at night.

    This type of surgery is best for individuals with normal anal sphincter muscles. In addition to increased stool frequency, complications can include infection, adhesions, recurrent disease, and pouchitis.

  • Colectomy with ileorectal anastomosis

    Colectomy with ileorectal anastomosis is like colectomy with ileoanal anastomosis, except that the end of the ileum is used to create a pouch which is then attached to the end of the rectum and may result in better sphincter control. Complications are similar to those seen with ileoanal anastomosis.

• Laparoscopy

  Laparoscopy is a surgical technique that involves the use of much smaller incisions than are used for traditional abdominal operations. Typically, a total of three to five such incisions are made. A laparoscope is then inserted through one of the incisions and surgical instruments are inserted through the others. This allows the surgeon to perform minimally invasive surgery using video of the abdominal organs that the laparoscope transmits to a monitor in the operating room.

  For CD, the advantages of using a laparoscopic approach include less pain after the operation, less chance of infection, shorter hospital stay, and improved resection outcome. For UC, although there is little evidence that laparoscopy improves outcomes for proctocolectomy when compared to open resection, it does improve cosmetic results.

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How Can I Prepare for Surgery?

For any surgery, it is best to be well–prepared, both physically and mentally. Reading this newsletter is a great first step. Research your options and choose a surgeon and a hospital with a lot of IBD expertise and experience. For example, you can ask several different surgeons how often they perform the type of surgery you will need and if they can put you in touch with other patients for whom they have performed the same procedure. You can also ask a hospital how often a procedure is done there and how well the patients do. Some state health departments publish outcome study reports about certain procedures at specific hospitals.

If your surgery will or may include an ostomy, you will want to meet with an enterostomal therapist ahead of time. This specialist can talk to you about what to expect and may have free trial samples of some of the materials you'll need. You may want to try wearing a stoma bag filled with some water to get a sense of the best location for your stoma.

When packing for your hospital stay, leave valuables at home, but consider bringing your own toiletries, clothing, and even your own pillow. You may find that surrounding yourself with familiar things brings a measure of comfort in unfamiliar surroundings. If you will have access to a DVD or CD player in your room, bring a few movies or some favorite music. Light reading may also make a nice diversion.

Be sure to arrange for any help you will need at home while you are in the hospital or home recovering. Keep in mind that you may not be able to drive a car for a few weeks or lift anything heavier than five to ten pounds for about six weeks.

Once you have been admitted to the hospital, try to get acclimated by learning how to use the television and phone, figuring out what you can eat and drink, and asking about any tests or other events that may take place before your surgery. Visitors can be great, but you may not always feel in the mood for company, so ask friends and relatives to call before stopping by. Making your stay as predictable as possible can go a long way toward helping you feel more in control of the situation.

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What Can I Expect After Surgery?

When you prepare to leave the hospital, be sure to arrange a ride home, get your discharge instructions in writing, and pay close attention to any activity restrictions. You may want to ask a family member or friend to join this discussion and take notes.

While walking soon after your surgery may help speed your recovery, overdoing it can cause setbacks. Your physician will most likely prescribe pain medication, which can be constipating, so try to wean off of it as quickly as you comfortably can. You may find that a heating pad or a cycle of heat and cold can help with pain. Sleeping with your legs propped up on a few pillows may also ease discomfort. But again, please be sure to follow the specific directions you receive from your health care team.

If your surgery included an ostomy, your stoma will look red and swollen at first, but will get smaller and less red within a few weeks. A wafer–shaped skin barrier that fits tightly around your stoma will protect your skin from irritation. An enterostomal therapist will teach you how to empty and change your bag; however it is normal for a few days to pass before any drainage begins to accumulate. For more information about life after an ostomy, please see the "IBD and Your Lifestyle" newsletter by Dr. Ellen Scherl.

Depending on the type of surgery you have, you may need to make some adjustments to your diet. For example, if a large section of your small intestine is removed, you will be left with less tissue to absorb nutrients and you may need regular B12 injections and other nutritional supplements. You may also need to minimize the amount of fat in your diet. Because small intestine resection increases your risk of developing kidney stones, your doctor may prescribe preventive medication and advise you to drink plenty of water and other fluids and avoid oxalates (e.g., beets, chocolate, colas, cranberry juice, and spinach).

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Conclusion

If you need surgery for IBD, it is not an indication that you have failed to manage your disease. Many people with severe IBD suffer from ongoing pain for years in an attempt to put off surgery as long as possible. Recent research shows that this may not be the best plan. Some doctors now suggest surgery in the earlier stages of IBD instead of using it as a "last resort." Surgery is sometimes the best choice for IBD treatment, even early in the course of disease. It can give you lasting symptom relief and an improved quality of life.

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