Surgery for Inflammatory Bowel Disease Emily Steinhagen, MD Assistant Professor Department of Surgery, Division of Colorectal Surgery University Hospitals Cleveland Medical Center
Common Questions Why would I need surgery? What type of surgery is performed for Crohn s or Ulcerative Colitis? What can I expect after surgery? How will my bowels function? What if I need a stoma?
Emergency Surgery for UC In hospital, sick Reasons: Bleeding Perforation Obstruction (blockage) Sick and not getting better 3
Elective Surgery for UC Not getting better despite medication Complications / side effects of meds Dysplasia & cancer Not growing (children/adolescents)
When to choose surgery? Depends on patient, gastroenterologist, and surgeon Shared decision making is key Realistic goals and expectations for both medicine and surgery Normal to be nervous about idea of surgery Getting information is key! Talk to a surgeon Surgery cures ulcerative colitis Removes urgency, feelings of chronic sickness Dramatically reduces cancer risk 5
What surgery is done for UC? Total proctocolectomy: remove the entire colon and rectum Usually done in stages 1. Remove entire colon + make ileostomy 2. Remove rectum and create j-pouch + leave ileostomy 3. Close ileostomy 6
Why is surgery staged? Goal of staged operation: Reduce infections and complications Between step 1 and 2: Get as healthy as possible Normal nutrition/weight Wean off medications Between step 2 and 3: Let pouch heal Minimize severity problem if there is a leak
Making the pouch 9
Postoperative Expectations Number of BM s: 6-8 per 24 hours 0-1 at night Control: Perfect After pouch: No urgency as with UC Lack of malaise and abdominal pain Minimal cancer risk
Alternatives to J pouch: Total Proctocolectomy with End Ileostomy Was standard of care until J-pouch was popularized in early 80s Some people do not want a pouch: lifestyle, previous problems with sphincters
Alternatives to J Pouch: Continent Ileostomy (Kock pouch) Elaborate building of ileal pouch w/ internal valve prevent & control flow of enteric contents into ostomy bag Up to 95% eventually don t wear appliance
Reasons for Surgery: Crohn s Disease Emergency: No choice Perforation Massive hemorrhage Complete bowel obstruction Cancer/high grade dysplasia Elective: Some choice Not getting better despite medications Partial bowel obstruction Complex fistula/abscess Perianal complication Children or adolescents: not growing
Issues with Surgery Surgery often considered last resort when medication fails Not a cure May be used as means to restore patient with disease to functional health quickly But: Need to be careful not to opt for surgery too soon Decision to stop medication/have surgery should be individualized Shared decision making: patient, gastroenterologist,
Surgical Options for Crohn s Colitis Total proctocolectomy Reconstruction depends on anal canal, perianal disease J-pouch in very selected cases Subtotal colectomy with ileorectal anastomosis Need normal rectum and no perianal disease Segmental colectomy Very selected cases only Localized stricture No dysplasia/cancer 15
Small Bowel/Ileocecal Resection Resection = removal of the affected part of the bowel Ileum = last part of small intestine Cecum = first part of colon Appendix attached and is removed during surgery
Strictureplasty Does not remove intestine but remodels it When? Multiple strictures: would require extensive resection Strictures in patient with extensive previous small bowel resection Fibrotic stricture When not to? Bowel perforation Fistula Multiple strictures close together
Stomas Why divert the stool? Too sick to reconnect Want to protect new connection Ileostomy Temporary ileostomy diverting ileostomy loop ileostomy Permanent ileostomy end ileostomy Colostomy
Living with an Ostomy Meet with enterostomal (ostomy) nurse Before your surgery While you are in the hospital Teach how to empty, change the ostomy After you go home Problems with fit, rashes Ostomy output If too hard or too liquid: Medicines Ostomy support groups On-line or in person LIVE with your ostomy
What s New? Minimally invasive surgery Smaller incisions Less pain Faster return to regular life Enhanced Recovery Protocols Nutrition + surgical/anesthesia techniques + pain control and post-operative care Less time in the hospital Quicker return of bowel function Lower complication rates 21
What is laparoscopic surgery? Uses camera, small incisions and long instruments to do the SAME surgery as open surgery Decreased incision and lung complications Less pain Quicker recovery Less adhesions?
Conclusions Surgery for IBD not a failure Curative for Ulcerative Colitis Treats complications for Crohn s Know your options Individualize decision with your doctors 23
24