Surgery and Crohn s. Crohn s Disease 70 % Why Operate? Complications of Disease. The Gastrointestinal Tract. Surgery for Inflammatory Bowel Disease

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Sophie Martha Ward
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1 The Gastrointestinal Tract Surgery for Inflammatory Bowel Disease Jonathan Chun, MD The regon Clinic Gastrointestinal and Minimally Invasive Surgery Crohn s Disease Can affect anywhere in the GI tract, most commonly small intestine (small bowel) Colon may be involved Medical treatment is mainstay Surgery and Crohn s Approximately 70 % of patients with Crohn s ultimately come to operation Why perate? Surgery not curative Complications of disease Complications of therapy If medications don t work If you can t take medication If you won t take medication Complications of Disease Hole in bowel Perforation Abscess Blockage bstruction Bleeding Fistula Crohn's & Colitis Foundation 1

2 What do surgeons do? When in doubt, Sometimes things don t work cut it out (okay, alter or remove the sites of maximum pathology) Goals for Surgery Remove problem segments of bowel Maximize the amount of useful bowel left behind Avoid surgical complications Goals for Surgeon and Patient Restore quality of life Strictureplasty (pening a blocked portion of intestine) Stricture Strictureplasty Narrowing of a portion of bowel Caused by repeated episodes of inflammation Symptoms may include nausea, vomiting, and pain Surgical technique of opening a portion of bowel Involves making an incision on the diseased segment and sewing it back together in another way Crohn's & Colitis Foundation 2

possible Stool needs an exit from the body stomy (ileostomy or colostomy) The bag Direct

3 Resection (Removal of a portion of intestine) Anastomosis Surgical connection or juncture Putting things back together Sutures (needle and thread) Staples Anastomosis Anastomosis Not always possible Stool needs an exit from the body stomy (ileostomy or colostomy) The bag Direct connection of intestine to outside world Abscess Ileostomy or Stoma (Infection) Crohn's & Colitis Foundation 3

4 Abscess Abscess Infection inside the abdomen Abscess must be drained antibiotics alone are not enough External drain may be image-guided May use operation for drainage The source of an abscess is often diseased segment of bowel nce the abscess is drained, the diseased segment can be removed more safely a Fistula (Abnormal connection) Fistula An abnormal connection between two structures ften between two loops of bowel May connect to bladder, vagina, skin, or other organs Fistula Risks and Complications Treatment may be medical Surgery often required Remove the segment of bowel and the connection Repair the other organ All surgical procedures have risks, but the risk for serious complications depends on your medical condition and age, as well as on your surgeon s and anesthesiologist s experience Crohn's & Colitis Foundation 4

Surgical Complications Bleeding 2-5% Infection 2-10% Breakdown of anastomosis 2-4% Injury to neighboring structures Ulcerative Colitis Ulcerative Colitis Affects large intestine (colon) Inflammation

5 Surgical Complications Bleeding 2-5% Infection 2-10% Breakdown of anastomosis 2-4% Injury to neighboring structures Ulcerative Colitis Ulcerative Colitis Affects large intestine (colon) Inflammation of deep layers of colon wall Multiple medicines available Surgery and UC Approximately 35 % of patients with UC ultimately come to operation Why perate? Complications of disease Complications of therapy If medications don t work If you can t take medication If you won t take medication Complications of Disease Hole in bowel Perforation Toxic megacolon Bleeding Risk of cancer Crohn's & Colitis Foundation 5

6 What do surgeons do? Small bowel pouch Remove the colon Left with small intestine and cuff of rectum Ileostomy (temporary or permanent) Pouch created with small bowel Staged Procedures To minimize complications, sometimes the operations are done in sequence Stage I: Removal of colon and ileostomy Stage II: Reconnection, +/- temporary ileostomy Stage III: Closure of ileostomy Bleeding 2-5% Infection 2-10% Breakdown 2-4% Surgical Complications Surgical Complications Pouchitis Inflammation of pouch Diarrhea and pain Treated with antibiotics Bowel obstruction Infertility Crohn's & Colitis Foundation 6

Minimally Invasive Surgery Minimally Invasive Surgery Also known as Laparoscopic surgery Used in over 20 million Americans MIS proven

may be started with minimally invasive techniques Surgeon can convert to traditional open if deemed safer surgery Long Laparotomy

Experience has shown us that minimally invasive procedures can have an influence over the quality of the patient experience when

7 Minimally Invasive Surgery Minimally Invasive Surgery Also known as Laparoscopic surgery Used in over 20 million Americans MIS proven to be as effective as surgery conventional The Evolution of Incisions Past Present Future Minimally Invasive Surgery Many procedures may be started with minimally invasive techniques Surgeon can convert to traditional open if deemed safer surgery Long Laparotomy Minimally Invasive Surgery Incisionless Surgery Why Bother? Experience has shown us that minimally invasive procedures can have an influence over the quality of the patient experience when compared traditional open surgical options to Patient Benefits of MIS Shorter length of stay in hospital Less recovery time Less pain Less scarring Improved cosmetic outcome Fertility Crohn's & Colitis Foundation 7

MIS verview Involves the use of trocars (thin tubes) placed through three to five small, dime- sized

space between the internal organs and the skin MIS verview Video camera introduced Image on video

placed through the other trocars to perform the operation MIS for IBD Surgery MIS for IBD Surgery

operation Underlying medical conditions Conclusions IBD has surgical options Surgery reserved for

8 MIS verview Involves the use of trocars (thin tubes) placed through three to five small, dime- sized puncture wounds Hand-assisted Carbon dioxide gas used to inflate the abdomen and create a working space between the internal organs and the skin MIS verview Video camera introduced Image on video monitors is magnified, providing better visibility for operating room staff Specialized instruments placed through the other trocars to perform the operation MIS for IBD Surgery MIS for IBD Surgery Not all patients are candidates for MIS Inability to safely visualize organs Problems during the operation Underlying medical conditions Conclusions IBD has surgical options Surgery reserved for complications of disease or therapy Minimally invasive techniques may be applied Crohn's & Colitis Foundation 8

Inflammatory Bowel Disease and Surgery: What You Should Know

Inflammatory Bowel Disease and Surgery: What You Should Know Ask the Experts March 9, 2019 Kristen Blaker, MD Colon and Rectal Surgery MetroHealth Medical Center Disclosures None Outline Who undergoes