Surgical procedures

IBD Curriculum Topic 5.1-5.6
IBD Curriculum Topic 7.3-7.4
IBD Curriculum Topic 9.4

80% of patients with Crohn’s disease require abdominal and/or perineal surgery at some stage, with reoperation rates between 30% and 50% after a further 10 years.

  • The decision to proceed to surgery requires liaison between physician, surgeon and patient, and is mainly indicated by predominantly fibro-stenotic (rather than inflammatory) disease.
  • Pre-operative preparation includes smoking cessation; nutritional support if >10% weight loss has occurred in preceding 3 months; and drainage of sepsis. Pre-operative imaging is required if the extent and severity of disease is unknown, using standard diagnostic modalities. Stoma / IBD nurse review is encouraged.
  • The effects of therapy are detailed elsewhere (anti-TNF, thiopurines, methotrexate, corticosteroids), as is post-operative care.

Surgical resection is limited to areas of visible macroscopic disease, to reduce the chance of iatrogenic short bowel syndrome; therefore sometimes Crohn’s disease affected bowel is left in situ.

Jejunal and ileal disease

  • Strictureplasty is a safe alternative to resection for patients with jejunal, or ileal, fibrotic disease. Conventional stricturoplasty is indicated for < 10cm disease.
  • Longer segments of disease can be resected, or treated by non-conventional stricturoplasy to conserve bowel length.

ECCO Statement 7C (CD 2016)

Strictureplasty is a safe alternative to resection in jejuno-ileal Crohn’s disease, including ileocolonic recurrence, with similar short-term and long-term results. Conventional strictureplasty is advised when the length of the stricture is <10 cm. However, in extensive disease with long strictured bowel segments where resection would compromise the effective small bowel length, non-conventional stricturoplasties may be attempted [EL3]

  • Obstructive, non-inflamed or medically refractory localised ileo-caecal disease should be treated by surgery.

ECCO Statement 7A (CD 2016)

Surgery is the preferred option in patients with localised ileocaecal Crohn’s disease with obstructive symptoms, but no significant evidence of active inflammation [EL4]

  • Right hemi-colectomy to resect medically refractory, active Ileo-caecal disease often results in prolonged remission (50% of patients will never require another operation); as such surgery can be considered at an earlier stage in limited ileo-caecal disease.
  • Ileocolonic surgery should be laparoscopic if possible; there is insufficient evidence to guide type of surgery in more complex or recurrent resections.

ECCO Statement 7F (CD 2016)

A laparoscopic approach is to be preferred for ileocolic resections in Crohn’s disease [EL 2] where appropriate expertise is available. In more complex cases or recurrent resection, there is insufficient evidence to recommended laparoscopic surgery as the technique of first choice [EL3]

  • Following resection, a wide lumen, stapled side-to-side (functional end-to-end) anastomosis is the preferred technique, with less complications than an end-to-end anastomosis.

ECCO Statement 7D (CD 2016)

Wide lumen stapled ileocolic side-to-side (functional end-to-end) anastomosis is the preferred technique [EL1]

  • Anastomotic stenosis in those with previous ileo-caecal resection often responds to endoscopic dilation, rather than requiring reoperation.

 

Colonic disease

  • Segmental resection should be performed if <1/3 colon affected, otherwise subtotal colectomy or proctocolectomy is required. Two segmental resections can be performed, depending on disease extent.

ECCO Statement 7G (CD 2016)

If surgery is necessary for localised colonic disease (less than a third of the colon involved) then resection of the affected part only is preferable [EL3]. Two segmental resections can be considered for a patient with an established indication for surgery when macroscopic disease affects two separate segments of the colon [EL3]. Strictureplasty in the colon is not recommended [EL3]

  • A sub-total colectomy is often performed for life-threatening disease (sepsis and/or severe malnutrition is a contra-indication to primary anastomosis).
  • Colonic stricturoplasty and ileopouch-anal anastomosis are not recommended.

ECCO Statement 7H (CD 2016)

Endoscopic dilatation is a preferred technique for the management of symptomatic and short anastomotic strictures It should only be attempted in institutions with surgical back-up [EL3]

Perianal disease

  • Surgery always required for complex fistula, including:
    • Abscess drainage
    • Seton placement
    • Diverting stoma
    • Proctectomy
  • Fistulectomy or fistulotomy is only indicated for simple fistulas

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