Surgical Management Of Inflammatory Bowel Disease (IBD)

Patients with inflammatory bowel disease (IBD) are frequently found in surgical practice.

But the principles applied for ulcerative colitis and crohn’s disease is not the same.

A surgery can cure ulcerative colitis, but crohn’s disease can have remissions even after surgery. 

Therefore surgery for crohn’s disease should be limited to patients with significant surgical problem.

To learn more about inflammatory bowel disease, please visit the link down below as this article contains only about the surgical management of IBD.


Indications For Surgery In IBD

  • In ulcerative colitis
    • Use of maximal therapy / high doses of steroids to control the disease
    • Risk of malignant transformation – Dysplastic transformation of the colonic epithelium
    • Acute severe colitis, not responding to medical therapy 
    • Development of complications
      • Impending perforation / Perforation 
      • Toxic megacolon
  • In crohn’s disease
    • Development of complications 
      • Impending perforation / Perforation
      • Fistula
      • Abscess formation 
      • Strictures
    • Terminal ileal crohn’s that is not responding medication and has developed its’ consequences 


Surgical Management Of Ulcerative Colitis
  • Surgery is often performed in patients with UC
  • Surgical treatment modalities include….
    • Proctocolectomy with ileostomy 
      • Traditional operation 
      • An end ileostomy is required following surgery
    • Sphincter-preserving proctocolectomy with ileal pouch / Ileoanal Pouch 
      • Considered as the best operation for patients with UC
      • Anal canal is preserved along with the sphincter mechanism 
      • Excision of rectum and colon
      • Pouch is constructed using the loops of ileum 
      • Anastamosis of the pouch and anal canal at the level of the dentate line
      • Advantages 
        • Anal sphincters are preserved
        • No need of an ileostomy
      • Disadvantage 
        • Increased frequency of stools (4 – 6 times / day)
        • Complications
          • Anastamosis dehiscence
          • Pouchitis
          • Soiling
    • Subtotal colectomy with mucous fistula
      • Performed in emergency conditions as a damage control procedure
        • Acute severe colitis with poor response to medication
        • Perforation
        • Toxic megacolon 
        • Stricture causing intestinal obstruction
        • Severe haemorrhage
      • Advantages
        • Reduce morbidity 
        • Leaves the rectum and anal canal intact for future reconstruction 
 
 
Surgical Management Of Crohn’s Disease
  • Surgery in crohn’s disease is not done with a curative intent. The aim is to substantiate a symptomatic improvement.
  • Surgeries should be limited to those with specific surgical problems. 
  • Surgery will not cure the disease, rather it will lead to complications like fistulae and perioperative sepsis
  • Crohn’s disease can involve any part from mouth to anus, so even if a surgery is performed, it is very important to preserve as much bowel as possible as these patients might need future surgery.
  • Surgeries are performed to those with complications
    • Fistula
      • Complex perinanal fistulae
        • Best treated with long term draining seton sutures 
        • Closure with advancement flaps has proven to be ineffective 
      • Fistula of bowel
        • Resection of the bowel and fistula
    • Stricture
      • Localized stricturoplasty 
      • Balloon dilatation of the stricture
      • Advantages
        • Both these methods helps to overcome the obstruction while preserving the intestinal length
    • Abscess
      • Incision and drainage of abscess
    • Perforation 
      • Subtotal colectomy with mucous fistula
    • Severe rectal crohn’s not responding to medications
      • Proctectomy
    • Terminal ileal crohn’s not responding to medication 
      • Limited ileocaecal resections with end to end anastamosis 
 
 
Toxic Megacolon
 
It can develop as a complication of acute severe ulcerative colitis.
Toxic megacolon is suggested when the colon diameter is more than 6 cm in a supine X-Ray abdomen.

Management includes….

  • Medical treatment
  • Improvement of nutritional state
  • Correction of fluid and electrolyte imbalance
  • Correction of anaemia
  • Perform investigations
    • Sigmoidoscopy and biopsy 
    • Stool cultures 
    • Supine X-Ray abdomen AP view – Daily
    • Colonoscopy and barium enema are contraindicated
  • Surgery
    • Subtotal colectomy with mucous fistula
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1 year ago

[…] Surgical Management Of Inflammatory Bowel Disease (IBD) […]