SURGICAL CONSIDERATIONS IN IBD

SURGICAL CONSIDERATIONS IN IBD

• The primary indication for surgical intervention in IBD is the lack of response to medical management.
• In UC, patients are being considered for surgery at an earlier stage of disease, mainly because of restorative procedures that can be offered with successful results.
• In addition, it has been recognized that the complications and side effects of maintaining young patients on high doses of steroids or immunosuppressives, or both, for prolonged periods of time far outweigh the complications of surgical intervention.
• The absolute indications for surgery in UC include
• the development of cancer or severe dysplasia in the colon,
• the presence of growth retardation because of the disease process or its medical treatment,
• and the presence of a stricture or a mass lesion in the colon that precludes complete surveillance or accurate diagnosis.
• In addition, patients who have developed extraintestinal manifestations of the disease may improve when they have undergone surgery.
• This applies to some patients who have developed pyoderma gangrenosum and some patients with musculoskeletal manifestations.
• Some complications, such as sclerosing cholangitis, are unaffected by surgical extirpation of the colon and may continue to be slowly progressive over time.
• The evidence suggests that although medical management is often successful on a temporary basis, it is certainly not curative.
• The majority of patients will require surgery for colon or perianal disease.
• Indications for surgery in Crohn's colitis include failure to respond to medical management or complications of the disease.
• These complications include intestinal obstruction, fistula or abscess formation, and rectal stricture.
• The indications for surgery tend to differ somewhat from those for small bowel disease.
• In a review of patients who underwent surgery at the Cleveland Clinic, bowel obstruction and internal fistula or an abscess tended to be the most common reasons for surgery in patients with small bowel disease.
• The indications for surgery in 127 patients with colonic disease were poor response to medical care (25%), internal fistula and abscess (23%), toxic megacolon (20%), perianal disease (19%), and intestinal obstruction (12%).
• Like all of the operations for CD, recurrence is the major consideration.
• Patients with colon disease alone had a lower recurrence rate than patients with either ileocolonic disease or ileitis.
• The type of operation performed varies depending on the location of the disease.
• Because the rectum and the distal colon are often spared in Crohn's colitis, colectomy with preservation of the rectum is often possible.
• Ileorectal or ileosigmoid anastomosis has the obvious advantage that an ileostomy is not necessary.
• However, to perform an ileorectal anastomosis, the rectum should be spared from disease or be only minimally involved.
• There should be good distensibility of the rectum on air insufflation, sphincter tone should be adequate, there should be no extensive ileal or perianal disease, and patients should not have had a prior significant small bowel resection, because the functional result might be poor.
• None of these criteria are absolute.
• Another option for the patient may be colectomy, ileostomy, and preservation of the rectum in a fashion similar to that described for UC.
• This procedure also allows the option for a future anastomosis if local conditions are favorable.
• During this interval, the patient may be better able to become prepared psychologically for a permanent ileostomy in case removal of the rectum in the future becomes necessary or if reanastomosis appears to be unwise.
• If the rectum is left indefinitely, there is the possibility of the future development of carcinoma.
• Segmental resection for CD is controversial, because disease usually is widespread and occurs both proximally and distally in a patchy distribution.
• Although experience is limited, recurrence after segmental resection appears to be high. Nevertheless, segmental resection may be indicated in patients who have had multiple bowel resections in the past.
• Loop ileostomy may be useful in situations in which the patient may be at some risk with an unprotected anastomosis—for example, after an ileocolic or a sigmoid resection for CD associated with an abscess.
• CD, particularly in the small bowel, may present with obstruction due to stricture formation.
• These strictures are alleviated by a procedure called stricturoplasty.
• To perform a stricturoplasty, the intestine is incised longitudinally and closed horizontally in one layer.
• The results from several institutions, including ours, were reported to be good.
• Stricturoplasty is usually used in CD of the small bowel, and its role in the colon appears to be more limited.
• It has been used in some patients with short colonic strictures and a relatively normal intervening bowel, especially if a significant amount of the intestine has already been removed.
• If a stricture in the colon is present, one must be cautious in offering a stricturoplasty as opposed to a resection because of the risk of carcinoma occurring at the site of the stricturoplasty.

Perianal disease often poses difficult management decisions.

• Treatment will vary in view of the wide spectrum of perianal lesions.
• In making management decisions, one must consider the nutritional status of the patient, the extent and severity of the disease in the remainder of the gastrointestinal tract, and the symptomatology.
• Many patients will have relatively few symptoms from perianal disease, even though it may appear to be quite severe.
• One must understand the limitations of attempting to eradicate the disease, and the aim of treatment, as in other forms of CD, should be to provide symptomatic relief.
• Although treatment may vary according to the specific lesion and the individual patient, certain general measures may be of benefit to most patients, including hospitalization to improve the nutritional status, assessment of the extent and severity of any proximal disease, and treatment of this proximal disease.
• Local skin care includes sitz baths, anesthetic ointments, and frequent dressing changes.
• Skin tags are rarely symptomatic, and their excision should be avoided.
• If they produce symptoms, it is usually because of irritation caused by diarrhea, which results in edema of the tags and generally responds to local care and control of the diarrhea.
• Anal dilatation for anal stenosis is only rarely indicated.
• Dilatation should be performed cautiously and should be limited to one or two fingers only.
• Long strictures, which are also rare occurrences, are a complication of severe rectal disease and, if symptomatic, may require proctectomy.

The typical broad-based fissure seen in CD is often asymptomatic, and no treatment is usually indicated.

• If a fissure is painful, one should suspect associated sepsis, and an examination under anesthesia may be necessary.
• Sphincterotomy should be avoided, because the fissure or ulcer is often a sign of severe rectal or anal involvement.
• Wounds from CD heal poorly, and the disease itself has often damaged the ability of the sphincter to act reliably.
• Treatment with antibiotics, such as metronidazole, or with steroid suppositories may be beneficial in treating the commonly associated rectal disease.

Abscesses and fistulas tend to be the most difficult lesions to treat.

• We do not hesitate to examine the patient under anesthesia to more fully assess the extent and severity of the perianal and rectal disease.
• An abscess should be suspected in patients who complain of severe pain in a previously asymptomatic fissure or fistula.
• Treatment should consist of incision, unroofing, and drainage of the abscess .
• Usually, primary fistulotomy should not be undertaken unless the fistula is of the lowlying variety.
• When cellulitis is associated, broad-spectrum antibiotics such as metronidazole and an aminogly-coside should be prescribed.
• There are several approaches in the treatment of perianal fistulas, depending on various local and general factors.
• low fistula may be managed by fistulotomy with good wound healing.
• For complex fistulas with rectal involvement, treatment should first concentrate on medical management of the rectal disease.
• Antidiarrheal agents may be used judiciously, and nutritional improvement is important.
• Drainage of the abscess with unroofing of the fistula, as well as long-term drains or setons, may be used.
• Metronidazole, azathioprine, 6-mercaptopurine, and cyclosporin have all been used with some success.
• Some patients for whom these treatments fail may require diversion of the intestinal tract as a loop or split ileostomy, and eventually a proctectomy may be necessary.
• After the construction of an ileostomy, initial improvement in the local perianal disease usually occurs; however, it does not usually change the natural history of the disease.
• Relapse is common, and it is not usually possible to restore intestinal continuity.
• Despite these poor long-term results, there may be some merit in the construction of a diverting ileostomy.
• First, the general and nutritional status of the patient often improves, and the perianal sepsis resolves to some extent.
• Therefore, at least theoretically, a subsequent proctectomy or other definitive procedure can be performed with fewer complications.
• Second, some patients may be loath to have definitive surgery in the form of a proctectomy as an initial procedure.
• A loop or split ileostomy allows them to adjust psychologically to a stoma without committing themselves to a permanent ileostomy.

If perianal disease continues and is symptomatic, proctectomy may be necessary, although it is not usually required to treat perianal disease alone.

• Almost always, patients have associated severe rectal or perineal involvement.
• Before a proctectomy is performed, it is important that the patient be in optimal condition, because this operation is associated with relatively high morbidity rates.
• Thus, preoperative measures to decrease local sepsis and improve healing should be undertaken.
• To decrease local sepsis, a staged procedure may be planned.
• As previously discussed, by performing a subtotal colectomy and ileostomy or ileostomy alone, temporary improvement in local perianal sepsis can be expected.
• The general status of the patient is improved, and steroids may be tapered before rectal excision.
• At the time of surgery, measures to decrease the potential for sepsis should be used, including an adequate mechanical bowel preparation and the administration of prophylactic antibiotics.
• An intersphincteric dissection of the anorectum along anatomic planes with meticulous hemostasis is important in preventing the perineal wound problems previously discussed.
• There are some reports that suggest surgical treatment of proximal gastrointestinal disease may result in improvement in the perianal disease.

Laparoscopic Management of Inflammatory Bowel Disease

• The evaluation of the results of these reports reveals that laparoscopy in patients with IBD offers significant advantages compared with laparotomy.
• Reduction in postoperative pain, reduced postoperative ileus, decreased hospitalization time, enhanced cosmesis, less disability, earlier return to work, and a reduction in symptoms attributable to adhesion formation are all advantages of the use of laparoscopy.

Disadvantages of laparoscopic surgery are

• prolonged surgical time,
• difficult instrumentation,
• and demanding expertise.
  

Medical Versus Surgical Approaches in Inflammatory Bowel Disease
Medical as well as surgical efforts in IBD are directed at decreasing and controlling symptoms, thereby improving the patient's quality of life.

• A careful selection of the therapeutic agents is necessary, based on the severity of the disease and of drug side effects.
• Because IBD often is a chronic illness with an unpredictable course and with a significant impact on the patient's quality of life, patient education takes on a very important role in management.
• The medical management of these patients includes systemic, oral, and topical drugs (steroids or 5-ASA derivatives); antibiotics where indicated; immunosuppressives; and the latest cytokines and immunomodulators (see earlier for a detailed discussion).
• Complications, whether chronic or acute, often accompany the course of the disease, necessitating recurrent hospitalizations and surgery when indicated.
• In the United States, the total annual costs (both direct and indirect) incurred by the estimated 380,000 to 480,000 patients affected have been estimated at around $2 billion.
• Drugs were estimated to account for only 10% of total costs, whereas hospitalizations and surgery account for approximately half.
• There are other considerations when weighing medical versus surgical therapy in these patients.
• Side effects of long-term medical treatment (especially steroids and immunosuppressives) and patient compliance are other important concerns with which the physician who treats these patients is faced.
• Although the patient who is compliant, takes his or her medicines regularly, and appears for periodic follow-up on a regular basis can continue on medical treatment, the patient who is noncompliant medically will likely undergo surgery earlier.
• The nature and the extent of the disease are also very important when weighing medical versus surgical treatment.
• An initial medical trial of CD is the usual approach.
• When complications of the disease occur or when patients are noncompliant or do not wish to undergo medical management for fear of the complications involved, then surgery should be undertaken.
• In the case of UC, once operated on, the patient is for all intents and purposes "cured" of the disease, although a different lifestyle is required and follow-up is still necessary.
• Finally, as mentioned, the patient must have an active role in the decisions regarding which kind of therapy should be adopted.
• Patients should be informed about their disease and given all the options of treatment as well as information pertaining to quality of life, and the patient together with the caring physician will then be able to reach the decision of whether to continue the medical therapy or to undergo surgery.
  

QUALITY OF LIFE IN PATIENTS WITH INFLAMMATORY BOWEL DISEASE
There is increasing recognition that quality of life is an important outcome measure in patients with IBD, whether they are treated medically or surgically.

• Quality of life incorporates not only the physical or functional outcome but also the emotional and social well-being of the patients.
• Sometimes somatic sensation (presence or absence of pain) is also included. Calman proposed a definition for quality of life as "the gap between a person's expectation and achievements," which seems appropriate and incorporates the concept that quality of life is personal and may vary among individuals.
• In the area of surgery, particularly surgery for IBD, morbidity and mortality rates have traditionally been used to assess surgical outcome.

Surgery is rarely performed for a life-saving indication; rather, the most common indication for surgery in patients with IBD is failure of medical therapy or, in effect, poor quality of life.

• In view of the high rate of recurrence of CD after surgical resection, surgical therapy is not curative but palliative.
• Operative therapy is reserved for complications of the disease, and bowel resection in patients with uncomplicated disease is justified only in rare circumstances.
• Surgery is also indicated when medical therapy has failed and the patient is chronically debilitated due to the disease.
• Failure of medical management includes intractability, suggesting that the patient's well-being, life-style, and employment are significantly impaired by unrelenting symptoms, and debilitating side effects of medical therapy.
  
• It is difficult to compare the quality of life of patients treated medically with that of those treated surgically.
• For patients who have undergone surgery, their health status is usually much more stable (except for the early convalescent period).
• Thus, quality of life soon after surgery is probably lower than if it is assessed at a later date.
• Another issue that might result in incorrect conclusions is the reporting of stool frequency. Stool frequency is an important indication of disease activity in UC and, by inference, the quality of life in patients under medical treatment.
• On the other hand, stool frequency seems to have less impact on the quality of life of patients after ileal pouch-anal anastomosis.
• These patients have an excellent quality of life, having five or six bowel movements per day, whereas the same number of bowel movements in a patient treated medically may indicate active disease and an impaired quality of life.
• Reasons for this include urgency and bleeding during the active phase of the disease.
  
• Many studies that compared the quality of life in medical versus surgical therapy have shown that patients who undergo surgery seem to have a better outcome (at least in some domains) than those on medical treatment.
  
• In conclusion, quality of life of most patients after surgery for UC is excellent.
• This is true for most patients, unless there is some associated illness or long-term complication related to the procedure.
• Although the ileal pouch-anal anastomosis procedure has become the procedure of choice for most patients, those who undergo conventional ileostomy also seem to have an excellent quality of life.