Indications for surgery

Indications for surgery

Surgery has a significant role in managing complications of IBD and in improving quality of life for patients with IBD. Current best practice ensures that surgeons and stoma therapists are an integral part of the multidisciplinary team throughout a patient’s journey and that surgery is not presented as a last resort. Patients are then more likely to accept timely surgical intervention when indicated and be better prepared for life with a temporary or permanent stoma. The overall lifetime risk of colectomy for a patient with UC is about 20%. Common indications for surgery in the emergency setting include refractory acute severe colitis or its complications, including perforation, toxic megacolon or, rarely , colonic haemorrhage not controlled by endoscopic or interventional radiological means. The indications for surgery in UC are: /uni25CF severe or fulminating disease failing to respond to medical therapy; /uni25CF chronic disease with anaemia, frequent stools, urgency and tenesmus; maintained without substantial doses of steroids with harmful side e ff ects; /uni25CF intolerance or side e ff ects of medical therapy required to - control the disease, e.g. steroid psychosis, azathioprine - - induced pancreatitis; /uni25CF growth retardation in children or adolescents; /uni25CF neoplastic change: patients who have severe dysplasia or carcinoma; /uni25CF associated sclerosing cholangitis; /uni25CF y be extraintestinal manifestations; /uni25CF escue rarely , severe haemorrhage or stenosis causing obstruction.

(a) Figure 75.6 Subfascial closure of the rectal remnant following subtotal colectomy and end-ileostomy for acute ulcerative colitis remnant can alternatively be brought to the skin as a mucus /f_i stula

Indications for surgery

Population-based studies show that approximately 70% of patients with CD will require a bowel resection in the first decade α after diagnosis, and 40% will require a further resection in the decade after their index resection. Recent population-based - data in the era of monoclonal antibodies suggest that the incidence of surgery may be falling, but surgery nevertheless remains a key component of treatment. Surgical resection will not cure CD. Surgery there - fore focuses on managing the complications of the disease ( Summary box 75.2 ). As many of these indications for surgery may be rela tive, joint management by an aggressive physician and a conservative surgeon is ideal and decisions regarding sur - gical intervention are best made by a multidisciplinary team in consultation with the patient and recognising their preferences. - The fundamental principle is to preserve healthy gut and to - maintain adequate function. Intestinal resection should be kept to the minimum required to treat the local consequences of disease to mitigate against the potential for short bowel syn - drome (see Chapter 91 ). In laparoscopic surgery it may be more di ffi cult to assess the full length of the small intestine, so up-to-date preopera - tive small bowel imaging is important. While surgery carries perioperative risks, it also carries significant benefits, notably in patients with isola ted terminal ileal disease, in whom a pro - longed period of good health may be achieved. T he relative benefits of surgical resection and long-term medical therapy in CD can be very finely balanced and require careful consid - eration and discussion with the pa tient within the setting of a combined gastroenterological and surgical IBD clinic. Summary box 75.2 Principles of management of CD /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF Occasionally unsuspected ileal inflammation is found - during emergency appendicectomy . Determining whether or not to resect the ileum in this situation is a complex clinical decision that should be made by a senior surgeon.

Close liaison between physician and surgeon is crucial Both medical and surgical treatment options should be considered; however, surgery should not be delayed when there is a clear indication Patients must be optimised prior to surgery; this may include radiological drainage of sepsis, antibiotic treatment and nutritional support CD is a chronic relapsing disease with a high likelihood of reoperation; the surgeon must take every reasonable effort to preserve bowel length and sphincter function Shared decision making with patients to accommodate their treatment preferences

ileitis is an expression of CD rather than another aetiology such as Yersinia infection; an assessment of the likelihood of remission with medical therapy rather than surgery; risk of enterocutaneous fistulation from appendiceal base leakage; and an assessment of the rest of the small bowel for the presence of additional sites of inflammation. In the current era of monoclonal therapy , it would be controversial to resect uncomplicated terminal ileitis found during an emergency procedure for suspected appendicitis, as this is likely to respond to medical therapy . If reasonably safe, appendicectomy is now encouraged for histological confirmation in limited previously undiagnosed disease, with appendicectomy carried out using a laparoscopic stapler to reduce the risk of enterocutaneous fistula (see Chapter 76 ). The course of CD after surgery is unpredictable, but recrudescence (a better term than recurrence) is common. Symptomatic recrudescence does not seem to be rela ted to the presence of disease at the resection line. The cumulative prob ability of recrudescence requiring surgery for ileal disease is approximately 20%, 40%, 60% and 80% at 5, 10, 15 and 20 years, respectively , after a previous resection. Surgery for CD is technically demanding as the in volved mesentery is thickened and oedematous and healing may be impaired (see Chapter 65 ). The patient may be malnour ished, on immunosuppr essants or have active infection/sepsis, or potentially all three. Decision making regarding the timing and nature of surgery to be undertaken is key to a satisfac tory outcome of surgical trea tment, and frequently requires experience and multidisciplinary discussion with other health care professionals and, most importantly , the patient. A key decision must be made whether to anastomose the apparently healthy bowel ends after macr oscopically apparent disease has been resected, as anastomotic leaks and fistulation represent a considerable problem after surger y for CD. Intra-abdominal septic complications are more common if one or more of the following risk factors are present: /uni25CF current high-dose steroid therapy (>10 /uni00A0 mg prednisolone for >4 weeks before surgery); /uni25CF current or very recent (<14 days) preoperative monoclonal antibody therapy; /uni25CF preoperative significant weight loss (>10% premorbid weight); /uni25CF coexisting abdominal sepsis (notably an abscess or fistula); /uni25CF low serum albumin <30 /uni00A0 g/L. If any risk factors are present (and particularly if more than one risk factor is present as the risks appear to be addi tive), one should consider exteriorising the bowel to create a stoma, with distal segment closure left close to the ileostomy site , and plan a delayed anastomosis when the risk factors have been corrected. Ileocaecal or colonic resections can be undertaken lapa roscopically , with the potential advantage of smaller incisions and potentially shorter recovery time. Reoperative surgery Walter Hermann von Heineke , 1834–1901, Professor of Surgery , Erlangen, Germany . Jan Mikulicz-Radecki , 1850–1905, surgeon, Kraków and later Königsberg and Wroc ł aw , Poland. John Miller Turpin Finney , 1863–1942, surgeon, Johns Hopkins Medical School, Baltimore, MD, USA. adhesions and fistulae can be di ffi cult to safely dissect lapa - roscopically . Laparotomy should be considered in this setting. Although CD is usually regarded as a contraindication to ileal pouch surgery , the other options (panproctocolectomy or total colectomy with ileorectal anastomosis) are frequently appro - priate and ther e may be considerable rectal sparing in CD, justifying the latter. Where the diagnosis of CD is firmly estab - lished, segmental rather than total colectomy may be appro - priate. The range of operations perfor med for CD depends on the pattern of disease; the most common are outlined below: /uni25CF Ileocaecal resection is the usual procedure for termi - nal ileal disease, with a primary anastomosis between the ileum and the ascending or transverse colon, depending on the extent of the disease. Ileostomy without primary anastomosis is indicated if the patient is unwell, has active infection or is nutritionally depleted. - /uni25CF Segmental resection of short segments of small or large bowel strictures can be performed. /uni25CF Colectomy and ileorectal anastomosis may be undertaken for colonic CD with rectal sparing and a nor - mal anus. /uni25CF Subtotal colectomy and ileostomy for Crohn’s coli - - tis accounts for 8% of such procedures for acute colonic disease. The indications are similar to those for UC. /uni25CF Temporary loop ileostomy . This can be used either - in patients with acute distal CD, allowing remission and later restoration of continuity , or in patients with severe - perianal or rectal disease. /uni25CF Panproctocolectomy . Many patients with severe anal disease failing to respond to medical treatment will even - tually require a permanent colostomy . When this occurs in a setting of severe colonic disease, proctocolectomy and permanent ileostomy may be required. /uni25CF Strictureplasty . Strictured areas of CD ( Figure 75.15a ) can be treated by strictureplasty , a local widening proce - dure, to avoid small bowel resection and is thus an import - ant bowel-sparing technique. Strictureplasty is particularly useful for the treatment of fibrostenotic disease when there is little or no active inflammation in the involved segment. Strictureplasty is contraindicated in the presence of a phlegmon, Cr ohn’s associated cancer or haemorrhage due to mucosal ulceration. If there is any concern about malig - nancy at the site of a stricture, then frozen biopsy carried out intraoperatively may allow a strictureplasty to take place rather than resection, although resection and formal - histological assessment remains the better option if there is any doubt. Multiple strictureplasties can be perf ormed and strictureplasty can be combined with resection. The Heineke–Mikulicz technique of an antimesenteric lon - gitudinal incision that is closed transversely is the most - common technique. A Finney antimesenteric side-to-side anastomosis is used to treat long segments of stenosis when preservation of bowel length is important ( Figure 75.15b ). Recent clinical research has pointed towards the impor tance of the mesentery in disease recurrence following resec tion (see Chapter 65 ). Complete excision of macroscopically diseased mesentery may reduce the incidence of recurrence, as may anastomotic techniques that ensure that an anastomosis is fashioned on the antimesenteric aspect of the bowel (Kono-S pr ocedure). Irrespective of the site of resection or anastomotic tech nique used, it is important to follow patients closely in the postoperative months to ensure that recrudescence of CD is identified at a very early stage and medical treatment reinsti tuted. A strong case can be made for restarting pr ophylactic biological treatment subject to endoscopic review at 6 months following resection.

Figure 75.15 (a) Crohn’s disease affecting the jejunum and ileum (jejunoileitis) with multiple strictures and bowel dilatation between skip lesions. (b) Same patient following multiple strictureplasties: Heineke–Mikulicz (arrows) and Finney (arrowheads).