Surgery and IBD
by Mr Colin Elton MS FRCS, General and Colorectal Surgeon
Thankfully, with modern medical treatments, significantly more patients with Crohn’s disease and ulcerative colitis avoid surgery compared with patients 15-20 years ago. When surgery is indicated, patients should be referred to a specialist dealing regularly with inflammatory bowel disease (IBD).
Reasons for surgery in Crohn’s disease
Symptoms not controlled with medication
Sometimes, drug treatment is not as effective and a patient’s symptoms can affect their daily life. This may be due to a diseased part of the small bowel, usually the final segment called the terminal ileum, or a diseased colon (large bowel).
Repeated inflammation of the bowel can cause scarring and eventually a stricture which blocks a segment of bowel. Symptoms include abdominal pain, bloating and occasional vomiting. Under these circumstances, surgery may be necessary to dilate the stricture, widen it or remove it. In the latter two cases, this would involve major surgery. However, with recent advances, this could be performed with laparoscopic (keyhole) surgery.
Abscess or Fistula
As Crohn’s disease affects all the layers of the wall of the intestine, an abscess can form (collection of pus). This area may then adhere to another organ such as the bladder, the vagina, another part of the intestine or the skin. When this occurs, a track may form from the original area of Crohn’s disease to the new organ. This is known as a fistula. Symptoms of an abscess could include fever and abdominal pain. When a fistula forms, intestinal contents can pass to the new organ causing infections or a foul discharge. Although medication can be prescribed, generally surgery is required to remove the fistula and the diseased segment of intestine.
Most abscesses and fistulae affect the anus and these are usually treated with a combination of surgery and biological drugs.
Having Crohn’s disease for more than ten years increases the risk of developing bowel cancer. Such patients require a colonoscopy every few years as surveillance. The same is true for patients with ulcerative colitis.
Reasons for surgery in ulcerative colitis
The main reason for undergoing surgery in ulcerative colitis is due to severe symptoms such as diarrhoea, a large amount of blood in the faeces, abdominal pain and weight loss. Although medication controls most symptoms, some patients will benefit from having surgery.
Surgery can involve two or three stage operations. If the patient is under-nourished and has severe symptoms and taking steroids or biological drugs, the first stage surgery involves removing ¾ of the colon and forming an ileostomy (a stoma formed from the end of the small bowel). Although this leaves a small part of the colon as well as the rectum behind, this surgery usually allows the patient ‘to get their life back,’ to return to work and, in most cases, to stop their steroids. This surgery, although major, can be performed using laparoscopic (keyhole) surgery.
The second operation entails removing the remaining colon and the rectum. In young and middle-aged patients, they will be offered “pouch” surgery which means that a new rectum is formed from the small bowel and joined to the remaining anus, thus allowing a patient to avoid a permanent stoma (or bag). Such surgery, however, is protected by a temporary stoma which can then be reversed at a third, smaller operation.
And finally, before undergoing any surgery, your surgeon will want to explain the procedure in great detail, including the benefits and any risks involved to allow you to make an informed decision. Sometimes, this decision could involve more than one or two consultations because it is important to understand fully the reasons for surgery and the impact it can have upon your life.