Chapter 4. Inflammatory Bowel Disease: Surgical Considerations

Ulcerative Colitis

• Surgery is indicated when (1) chronic intractable disease is not controlled with medication, or drug side effects are too severe; (2) patients with severe colitis require an urgent procedure; or (3) dysplasia or cancer is present.
• Most patients needing surgery are candidates for an ileoanal pouch anastomosis (IPAA); the main considerations are age, gender, type of job, and lifestyle.
• In most patients undergoing IPAA, a temporary diverting loop ileostomy is constructed to decrease the likelihood of pelvic sepsis.
• Laparoscopic-assisted and open IPAA give equivalent results.

Crohn Disease

• In general, surgery is indicated for complications (ie, abscess, fistula, perforation, obstruction); considerations include symptom severity, medical treatment failure or side effects, and operative risk.
• Most patients found to have Crohn disease at laparotomy for suspected appendicitis require early ileocolic resection.
• Perianal Crohn disease activity can be assessed using the Perianal Crohn Disease Activity Index.
• Surgical procedures for treatment of fistula-in-ano include fistulotomy, long-term draining setons, and endoanal flap closure, if the rectal mucosa is normal.
• Recent innovative therapy for anal fistula involves adhesive products, fibrin glue, and bioprosthetic plugs of porcine collagen.

The term inflammatory bowel disease (IBD) encompasses a collection of gastrointestinal diseases that medical and surgical specialists treat in a collaborative fashion. Chapter 2 discusses genetic and immunologic factors influencing the development of IBD. Chapter 3 describes medical therapy for IBD. This chapter discusses the indications and types of surgery used for ulcerative colitis and Crohn disease.

In general, these diseases are first treated with medications, and surgery is recommended after medical therapy has been exhausted. However, with certain presentations (eg, anal abscess, toxic colitis), surgery is the first line of therapy, with medication often given after a procedure. Our purpose in this chapter is to survey the surgical procedures used in the treatment of IBD, and to discuss indications and timings relating to their use.

Ulcerative colitis is usually successfully treated medically; however, it is estimated that between 25% and 45% of patients with ulcerative colitis will ultimately require surgery. Surgical therapy is indicated in the following three cases: (1) in patients in whom medication is not controlling the disease, or side effects of the medication are too severe to be endured; (2) in patients with severe acute colitis requiring an urgent procedure; and (3) in patients with either cancer or dysplasia of the colorectal mucosa. Given that ulcerative colitis is a disease limited to the colon and rectum, one needs to remember that it is possible to "cure" this disease with surgical intervention. Further, in most patients, success rates of surgical therapy are high, and sphincter-sparing options exist. Despite the use of new therapies such as infliximab, the incidence of surgery has not ...