Surgery and Inflammatory Bowel Disease

1. Surgery and Inflammatory Bowel Disease Stephen M. Kavic, MD Department of Surgery University of Maryland

2. The Gastrointestinal Tract

3. Inflammatory Bowel Disease Crohn’s Disease Ulcerative Colitis

4. Crohn’s Disease • Affects small intestine (small bowel) • Colon may be involved • Medical treatment is mainstay

5. Surgery and Crohn’s Approximately 70 % of patients with Crohn’s ultimately come to operation

6. 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

7. Complications of Disease • Hole in bowel • Perforation • Abscess • Blockage • Obstruction • Bleeding • Fistula

8. What do surgeons do? “When in doubt, cut it out” (okay, alter or remove the sites of maximum pathology)

9. Sometimes things don’t work

10. Goals for Surgery • Remove problem segments of bowel • Maximize the amount of useful bowel left behind • Avoid surgical complications

11. Goals for Surgeon and Patient Restore quality of life

12. Stricturoplasty(Opening a blocked portion of intestine)

13. Stricture • Narrowing of a portion of bowel • Caused by repeated episodes of inflammation • Symptoms may include nausea, vomiting, and pain

14. 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

15. Resection(Removal of a portion of intestine)

16. “Anastomosis” • Surgical connection or juncture • Sutures (needle and thread) • Staples

17. Anastomosis

18. Anastomosis • Not always possible • Stool needs an exit from the body • Ileostomy • “The bag” • Direct connection of intestine to outside world

19. Ileostomy or Stoma

20. Abscess (Infection)

21. 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

22. 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

23. Fistula(Abnormal connection)

24. Fistula • An abnormal connection between two structures • Often between two loops of bowel • May connect to bladder, vagina, skin, or other organs

25. Fistula • Treatment may be medical • Surgery often required • Remove the segment of bowel and the connection • Repair the other organ

26. 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

27. Surgical Complications • Bleeding • 2-5% • Infection • 2-10% • Breakdown of anastomosis • 2-4% • Injury to neighboring structures

28. Ulcerative Colitis

29. Ulcerative Colitis • Affects large intestine (colon) • Inflammation of deep layers of colon wall • Multiple medicines available

30. Surgery and UC Approximately 35 % of patients with UC ultimately come to operation

31. 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

32. Complications of Disease • Hole in bowel • Perforation • “Toxic megacolon” • Bleeding • Risk of cancer

33. What do surgeons do? • Remove the colon • Left with small intestine and cuff of rectum • Ileostomy (temporary or permanent) • Pouch created with small bowel

34. Small bowel pouch

36. Staged Procedures • To minimize complications, sometimes the operations are done in sequence • Stage I: Removal of colon and ileostomy • Stage II: Reconnection

37. Surgical Complications • Bleeding • 2-5% • Infection • 2-10% • Breakdown • 2-4%

38. Surgical Complications • “Pouchitis” • Inflammation of pouch • Diarrhea and pain • Treated with antibiotics • Bowel obstruction • Infertility

39. Minimally Invasive Surgery

40. Minimally Invasive Surgery • Also known as “Laparoscopic” surgery • Used in over 20 million Americans • MIS proven to be as effective as conventional surgery

41. O O O O O The Evolution of Incisions Past Present Future Long Laparotomy Minimally Invasive SurgeryIncisionless Surgery

42. Minimally Invasive Surgery • Many procedures may be started with minimally invasive techniques • Surgeon can convert to traditional open surgery if deemed safer

43. 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

44. Patient Benefits of MIS • Shorter length of stay in hospital • Less recovery time • Less pain • Less scarring • Improved cosmetic outcome

45. 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

46. 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

47. MIS for IBD Surgery

48. MIS for IBD Surgery

49. Not all patients are candidates for MIS • Inability to safely visualize organs • Problems during the operation • Underlying medical conditions

50. Conclusions • IBD has surgical options • Surgery reserved for complications of disease or therapy • Minimally invasive techniques may be applied