IBD Academy: Surgery

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When medications fail or their side effects become too risky, many people with inflammatory bowel disease have surgery. According to the Crohn's and Colitis Foundation, approximately 23-45% of UC patients and up to 75% of Crohn's patients eventually need surgery over the course of their disease. Many people with IBD will have more than one. Surgical procedures vary greatly in duration and complexity depending on the location and extent of active disease. In this post, I'll review some surgical terms and anatomy and outline the major surgical options for the treatment of Crohn's disease and ulcerative colitis.

surgery vocab

  • laparoscope: a thin tube with a light and camera on the end that is passed through small incisions (approximately 1/2 inch) in the abdomen to allow the surgeon to see and operate without creating a large incision

  • open procedure: one long incision (approximately 4-8 inches) is made down the center of the abdomen to allow for maximum visualization and room to operate
  • general anesthesia
    • the patient is unconscious, and therefore doesn't feel pain or have memory of the procedure afterwards
    • a flexible tube must be inserted down the windpipe to control breathing
    • medication may be administered via IV and/or inhaled gas 
  • monitored anesthesia care (MAC)
    • sedating drugs (e.g., propofol) are administered via IV for shorter procedures which do not require general anesthesia
    • a local anesthetic injected into the area is also usually required for pain control
  • epidural anesthesia
    • a needle is used to insert a thin catheter between two vertebrae in the lower back 
    • local anesthetics and/or narcotics are injected directly into the spinal canal (in conjunction with general anesthesia for GI surgeries)
    • may also be used for post-operative pain management
  • anastamosis: surgical reconnection of two sections of bowel to restore a continuous GI tract after a piece of bowel is removed
  • ostomy: a surgical opening in the abdominal wall through which stool passes into an external appliance (bag)
    • stoma: small piece of bowel that forms the opening
    • ileostomy: stoma is made from small bowel tissue (specifically, the ileum)
    • colostomy: stoma is made from large bowel tissue (the colon)
  • stricture: a section of bowel that has become narrowed due to scar tissue
  • fistula: an abnormal tunnel formed between two organs
    • women can develop rectovaginal (RV) fistulas as a complication of Crohn's disease
  • abscess: a pocket of pus that develops as the result of an intestinal infection
 The small intestine consists of three sections: the duodenum, which is connected to the stomach, the jejuneum, and the ileum, which connects to the colon. The large intestine consists of the colon (which can be divided into ascending, transverse, descending, and sigmoid portions) and the rectum, which connects to the anus. Crohn's disease most commonly affects the ileum and the colon, although it can be present in any part of the digestive tract from the mouth to the anus. Ulcerative colitis affects only the colon and rectum. Image © 1998-2018 Mayo Foundation for Medical Education and Research (MFMER).

The small intestine consists of three sections: the duodenum, which is connected to the stomach, the jejuneum, and the ileum, which connects to the colon. The large intestine consists of the colon (which can be divided into ascending, transverse, descending, and sigmoid portions) and the rectum, which connects to the anus. Crohn's disease most commonly affects the ileum and the colon, although it can be present in any part of the digestive tract from the mouth to the anus. Ulcerative colitis affects only the colon and rectum. Image © 1998-2018 Mayo Foundation for Medical Education and Research (MFMER).

Bowel Resection

  • a section of intestine is removed and the cut ends are reconnected
  • typically due active Crohn's disease, a bowel obstruction, or a fistula tract
  • small bowel resection: anywhere from a few inches to several feet of the of small bowel is removed (an intact small intestine is 22-23 feet long)
  • large bowel resection (subtotal colectomy): a portion of the colon, not including the rectum, is removed (an intact colon is 5 feet long)

Colectomy

  • removal of the colon with the rectum left intact
  • an option if active disease has spread throughout the colon but the rectum is unaffected
  • ileum is then reconnected to the rectum and stool is passed normally through the anus

Proctocolectomy

  • removal of the entire colon and rectum
  • with end ileostomy: the terminal ileum is used to create a permanent stoma
  • with ileoanal pouch anastamosis (IPAA):
    • almost always in ulcerative colitis patients (and not Crohn's) due to the risk of Crohn's recurring in the pouch in the years following surgery
    • j-pouch, s-pouch, or w-pouch
      • name indicates how many loops of bowel are used to construct the pouch
      • J shape is most common
    • the terminal ileum is folded on itself to form an internal reservoir for stool and the resulting pouch is connected to the anus
      • pouch construction may take place at the same time as the proctocolectomy or may be done in a separate surgery
      • this is largely dependent on the pre-operative health of the patient based on weight, malnutrition, immunosuppression, and steroid dependency
    • a temporary loop ileostomy is placed for 2-3 months to allow the pouch to heal
    • a reconnection surgery is then performed to "reverse" the temporary ostomy and route stool through the pouch
  • with Koch pouch (k- pouch) or Barnett Continent Intestinal Reservoir (BCIR)
    • the terminal ileum is used to construct an internal reservoir that is attached to the abdominal wall
    • pouch is drained several times a day with a small catheter
    • an option for patients with a weak anal sphincter 
 In cases of ulcerative colitis when the entirety of the colon and rectum are affected, a proctocolectomy with the construction of a j-pouch may be performed. The above image shows an intact terminal ileum, colon, and rectum. 

In cases of ulcerative colitis when the entirety of the colon and rectum are affected, a proctocolectomy with the construction of a j-pouch may be performed. The above image shows an intact terminal ileum, colon, and rectum. 

 In the first of a two-step j-pouch procedure, the colon and rectum are removed, the terminal ileum is folded to create a pouch, and a temporary loop ileostomy is placed to divert stool while the newly created pouch heals.

In the first of a two-step j-pouch procedure, the colon and rectum are removed, the terminal ileum is folded to create a pouch, and a temporary loop ileostomy is placed to divert stool while the newly created pouch heals.

 Two to three months later, the temporary ostomy is "reversed" and stool is diverted back down through the intestinal tract and is stored in the pouch before being eliminated via the anus. (image source: American Society of Colon and Rectal Surgeons)

Two to three months later, the temporary ostomy is "reversed" and stool is diverted back down through the intestinal tract and is stored in the pouch before being eliminated via the anus. (image source: American Society of Colon and Rectal Surgeons)

Abdominoperineal Resection (APR)

  • rectum and anus are removed and the entire perineal area is sutured closed
  • may be done in conjunction with a colectomy
  • done in most cases when ostomy reversal is not an option
    • this may be a separate surgery from when the ostomy is first created
  • nicknamed "Barbie butt" surgery

Additional procedures

  • strictureplasty
    • a section of bowel that has narrowed as a result of scar tissue is reopened by folding it on itself and cutting a new, wider passage through the bowel 
  • fistulotomy
    • the fistula tract is opened up to the outside of the body to allow it to heal by itself from the base up
    • alternatively, a rubber band-like tube called a seton may be placed to keep the tract open and allow it to drain and heal
  • abscess incision and drainage: the affected area is opened surgically and drained
    • alternatively, percutaneous abscess drainage can be performed
      • a catheter is placed into the abscess through a tiny incision
      • catheter remains in place for about a week while the contents of the abscess drain

Sources

  1. Crohn's and Colitis Foundation of America: Surgery for Crohn's Disease and Ulcerative Coitis: http://www.crohnscolitisfoundation.org/assets/pdfs/surgery_brochure_final.pdf
  2. Central Vermont Medical Center: Types of Anesthesia: https://www.cvmc.org/our-services/anesthesiology/types-anesthesia
  3. Center for Colorectal Surgery, Department of Surgery, UCSF: https://colorectal.surgery.ucsf.edu/conditions--procedures/crohns-disease.aspx
  4. Lumen: Boundless Anatomy and Physiology: The Small Intestine: https://courses.lumenlearning.com/boundless-ap/chapter/the-small-intestine/
  5. Ileal Pouch Center, Digestive Disease Institute, Cleveland Clinic: https://my.clevelandclinic.org/departments/digestive/depts/ileal-pouch-center
  6. Pouch Procedure & Recovery: Types of Surgeries: https://my.clevelandclinic.org/health/treatments/17379-pouch-procedure--recovery/types-of-surgeries
  7. American Society of Colon and Rectal Surgeons: Ulcerative Colitis: https://www.fascrs.org/patients/disease-condition/ulcerative-colitis
  8. United Ostomy Associations of America: What is an ostomy?: https://www.ostomy.org/what-is-an-ostomy/
  9. The Continent Ostomy Center at Palms of Pasadena Hospital: How is works: https://bcir.com/learn-more/how-it-works.dot
  10. Memorial Sloan Kettering Cancer Center: About Your Abdominal Perineal Resection Surgery: https://www.mskcc.org/cancer-care/patient-education/about-your-abdominal-perineal-resection-surgery

Kristen Weiss Sanders is a proud and third generation girl with guts diagnosed with IBD in 2004. She is passionate about patient education and encourages those with chronic illness to be a knowledgable part of their healthcare team. Kristen credits the constant example and support of the strong women in her family for her determination to thrive with Crohn’s disease and use her IBD journey to empower others.

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