Inflammatory Bowel Disease V: Surgical Management

Strictureplasty is a minimally invasive surgical procedure that widens narrowed or obstructed sections of the small bowel while preserving intestinal integrity. It is primarily used to treat strictures in Crohn's disease. If the stricture is too severe for this approach, a small bowel resection may be performed to remove the affected segments instead.

Proctocolectomy removes both the colon and rectum, typically recommended when inflammation extends continuously throughout the colon. Total colectomy removes only the colon while preserving the rectum, used when inflammation is confined to the colon and the rectum remains healthy. Both procedures require creating an alternate pathway for waste elimination, such as an ileostomy.

An ileostomy is a surgically created opening, or stoma, in the ileum that allows bowel contents to drain outside the body into an external collection bag. It is performed following proctocolectomy or total colectomy to provide an alternate pathway for waste elimination when the colon and rectum are removed or no longer functional.

This procedure removes the diseased colon and rectum while preserving the anal sphincter and maintaining voluntary defecation. An ileal pouch, or J pouch, is created from the small intestine to serve as a reservoir, mimicking the removed rectum's function. The pouch is surgically connected to the anus to restore gastrointestinal continuity and continence.

A continent ileostomy, or Kock pouch, uses 30 to 45 centimeters of the terminal ileum to create a J- or S-shaped reservoir after proctocolectomy. A nipple valve is constructed to function as a controlled outlet, allowing gastrointestinal effluent to accumulate in the pouch and be emptied through a catheter, providing continence without an external fecal collection bag.

Surgical interventions for inflammatory bowel disease are considered when medical treatments prove insufficient to manage symptoms and complications. The selection of specific procedures depends on the type of IBD, severity of inflammation, location of disease, and complications present. Surgery aims to alleviate symptoms, address complications, and improve quality of life while balancing disease control with preservation of normal bowel function.

Restorative proctocolectomy with ileal pouch-anal anastomosis is less commonly performed for Crohn's disease due to the significant risk of disease recurrence in the newly created pouch. While this procedure is particularly beneficial for ulcerative colitis and familial adenomatous polyposis, the chronic inflammatory nature of Crohn's disease makes the pouch vulnerable to further disease involvement.