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