11.14: Inflammatory Bowel Disease V: Surgical Management

Surgical interventions for inflammatory bowel disease (IBD), which includes ulcerative colitis and Crohn's disease, are essential in managing symptoms and addressing complications. The selection of surgical procedures is contingent upon the specific conditions and complications that stem from these illnesses.

Here are some common surgical interventions for IBD:

1. Strictureplasty
2. Proctocolectomy or total colectomy with ileostomy
3. Restorative proctocolectomy with Ileal pouch-anal anastomosis
4. Continent ileostomy

Strictureplasty is a technique primarily used to treat strictures in the small bowel that often occur in Crohn's disease. This minimally invasive surgical procedure uses a laparoscope to widen obstructed or narrowed sections of the intestines. If the stricture is too severe or cannot be treated with strictureplasty, a small bowel resection may be performed to remove the affected segments of the intestine.

Proctocolectomy or Total Colectomy with Ileostomy:

1. Proctocolectomy involves the surgical removal of both the colon and rectum and is commonly recommended for patients with ulcerative colitis when inflammation extends continuously from the rectum throughout the colon. Following this procedure, the surgeon must create an alternate pathway for waste elimination, such as an ileostomy or an ileoanal pouch.
2. Total Colectomy involves the removal of the entire colon while preserving the rectum. In this procedure, the end of the small intestine (the ileum) is attached to the rectum, enabling waste elimination through the anus. This approach is typically used for ulcerative colitis when inflammation is confined to the colon, and the rectum remains healthy and functional.

Following either surgery, an Ileostomy is performed, creating a stoma in the ileum for the drainage of bowel contents.

Restorative Proctocolectomy with Ileal Pouch-Anal Anastomosis: The procedure is particularly beneficial for ulcerative colitis and familial adenomatous polyposis (FAP). It is less commonly performed for Crohn's disease due to the risk of disease recurrence in the pouch. It involves removing the diseased colon and rectum while preserving the anal sphincter to maintain voluntary defecation and anal continence. A key aspect of this procedure is the creation of an ileal pouch, or J pouch, from the small intestine to serve as a reservoir for intestinal contents, mimicking the function of the removed rectum. The ileal pouch is surgically connected to the anus to restore gastrointestinal continuity.

Continent Ileostomy (Kock Pouch) involves the construction of a J- or S-shaped continent ileal reservoir using 30 to 45 cm of the terminal ileum after a proctocolectomy. The design of the Kock pouch includes a nipple valve created by pulling a portion of the terminal ileal loop back into the ileum, functioning as a controlled outlet. It allows for the accumulation of gastrointestinal effluent in the pouch, which can be emptied through a catheter, offering a degree of continence and control over bowel movements without needing an external fecal collection bag. However, the Kock pouch is less commonly performed today due to advancements in other surgical techniques like the ileal pouch-anal anastomosis.

Surgical management in IBD aims to alleviate symptoms, address complications, and improve quality of life by balancing disease control with the preservation of normal bowel function. These surgeries are considered when medical treatments prove insufficient.

Surgical interventions for IBD include the following:

Strictureplasty treats small bowel strictures by widening narrowed sections while preserving intestinal integrity. If specific sections are severely affected, a small bowel resection may be performed, removing diseased parts and reconnecting the healthy bowel segment.

For severe ulcerative colitis, a proctocolectomy or total colectomy with ileostomy is often required.

A proctocolectomy removes the colon and rectum, while a total colectomy removes only the colon. An ileostomy is then performed, creating a stoma in the ileum to drain bowel contents outside the body.

Furthermore, in restorative proctocolectomy with ileal pouch-anal anastomosis, the colon and rectum are removed, but the anal sphincter is preserved. An internal pouch is then created from the small intestine to restore gastrointestinal continuity.

Lastly, continent ileostomy, another option, involves proctocolectomy. It utilizes 30 to 45 cm of the terminal ileum to create a Kock pouch, diverting a portion of the distal ileum to the abdominal wall and creating a stoma.