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Surgery and Inflammatory Bowel Disease Stephen M. Kavic, MD Department of Surgery University of Maryland The Gastrointestinal Tract Inflammatory Bowel Disease Crohn’s Disease Ulcerative Colitis Crohn’s Disease Affects small intestine (small bowel) Colon may be involved

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Surgery and Inflammatory Bowel Disease

Stephen M. Kavic, MD

Department of Surgery

University of Maryland



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Inflammatory Bowel Disease

Crohn’s Disease

Ulcerative Colitis


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Crohn’s Disease

  • Affects small intestine (small bowel)

  • Colon may be involved

  • Medical treatment is mainstay


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Surgery and Crohn’s

Approximately

70 %

of patients with Crohn’s ultimately come to operation


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Why Operate?

  • Complications of disease

  • Complications of therapy

    • If medications don’t work

    • If you can’t take medication

    • If you won’t take medication


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Complications of Disease

  • Hole in bowel

    • Perforation

    • Abscess

  • Blockage

    • Obstruction

  • Bleeding

  • Fistula


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What do surgeons do?

“When in doubt,

cut it out”

(okay, alter or remove the sites of maximum pathology)


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Sometimes things don’t work


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Goals for Surgery

  • Remove problem segments of bowel

  • Maximize the amount of useful bowel left behind

  • Avoid surgical complications


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Goals for Surgeon and Patient

Restore quality of life


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Stricturoplasty(Opening a blocked portion of intestine)


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Stricture

  • Narrowing of a portion of bowel

  • Caused by repeated episodes of inflammation

  • Symptoms may include nausea, vomiting, and pain


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Stricturoplasty

  • Surgical technique of opening a portion of bowel

  • Involves making an incision on the diseased segment and sewing it back together in another way


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Resection(Removal of a portion of intestine)


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“Anastomosis”

  • Surgical connection or juncture

  • Sutures (needle and thread)

  • Staples



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Anastomosis

  • Not always possible

  • Stool needs an exit from the body

  • Ileostomy

    • “The bag”

    • Direct connection of intestine to outside world


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Ileostomy

or

Stoma


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Abscess (Infection)


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Abscess

  • Infection inside the abdomen

  • Abscess must be drained – antibiotics alone are not enough

  • External drain may be image-guided

  • May use operation for drainage


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Abscess

  • The source of an abscess is often a diseased segment of bowel

  • Once the abscess is drained, the diseased segment can be removed more safely


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Fistula(Abnormal connection)


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Fistula

  • An abnormal connection between two structures

  • Often between two loops of bowel

  • May connect to bladder, vagina, skin, or other organs


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Fistula

  • Treatment may be medical

  • Surgery often required

  • Remove the segment of bowel and the connection

  • Repair the other organ


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Risks and Complications

  • All surgical procedures have risks, but the risk for serious complications depends on your medical condition and age, as well as on your surgeon’s and anesthesiologist’s experience


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Surgical Complications

  • Bleeding

    • 2-5%

  • Infection

    • 2-10%

  • Breakdown of anastomosis

    • 2-4%

  • Injury to neighboring structures



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Ulcerative Colitis

  • Affects large intestine (colon)

  • Inflammation of deep layers of colon wall

  • Multiple medicines available


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Surgery and UC

Approximately

35 %

of patients with UC ultimately come to operation


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Why Operate?

  • Complications of disease

  • Complications of therapy

    • If medications don’t work

    • If you can’t take medication

    • If you won’t take medication


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Complications of Disease

  • Hole in bowel

    • Perforation

    • “Toxic megacolon”

  • Bleeding

  • Risk of cancer


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What do surgeons do?

  • Remove the colon

  • Left with small intestine and cuff of rectum

  • Ileostomy (temporary or permanent)

  • Pouch created with small bowel



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Staged Procedures

  • To minimize complications, sometimes the operations are done in sequence

  • Stage I: Removal of colon and ileostomy

  • Stage II: Reconnection


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Surgical Complications

  • Bleeding

    • 2-5%

  • Infection

    • 2-10%

  • Breakdown

    • 2-4%


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Surgical Complications

  • “Pouchitis”

    • Inflammation of pouch

    • Diarrhea and pain

    • Treated with antibiotics

  • Bowel obstruction

  • Infertility



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Minimally Invasive Surgery

  • Also known as “Laparoscopic” surgery

  • Used in over 20 million Americans

  • MIS proven to be as effective as conventional surgery


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O

O

O

O

O

The Evolution of Incisions

Past Present Future

Long Laparotomy Minimally Invasive SurgeryIncisionless Surgery


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Minimally Invasive Surgery

  • Many procedures may be started with minimally invasive techniques

  • Surgeon can convert to traditional open surgery if deemed safer


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Why Bother?

Experience has shown us that minimally invasive procedures can have an influence over the quality of the patient experience when compared to traditional open surgical options


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Patient Benefits of MIS

  • Shorter length of stay in hospital

  • Less recovery time

  • Less pain

  • Less scarring

  • Improved cosmetic outcome


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MIS Overview

  • Involves the use of trocars (thin tubes) placed through three to five small, dime- sized puncture wounds

  • Carbon dioxide gas used to inflate the abdomen and create a working space between the internal organs and the skin


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MIS Overview

  • Video camera introduced

  • Image on video monitors is magnified, providing better visibility for operating room staff

  • Specialized instruments placed through the other trocars to perform the operation




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Not all patients are candidates for MIS

  • Inability to safely visualize organs

  • Problems during the operation

  • Underlying medical conditions


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Conclusions

  • IBD has surgical options

  • Surgery reserved for complications of disease or therapy

  • Minimally invasive techniques may be applied


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