Surgery for IBD

Question 1

What ‘planned emergency’ IBD surgeries can be carried out ?

Answer 1

-Sub total colectomy for UC
-Resection of Crohn’s disease
-Perforation in Crohn’s

etc

Question 2

What is a stricturoplasty ?

Answer 2

Widening a narrowed lumen ratrher than cutting that segment out
-E.g. Crohn’s

Question 3

What surgical approaches can be taken in treating Crohn’s

Answer 3

Resection
-Take out as little small intestine as possible, need about a metre of it for normal life

Stricturolplasty
Operations on fistulas

Question 4

What are the two main surgeries for UC ?

Answer 4

Proctocolectomy with end ileostomy
-Removal of the colon and rectum with the end of the ileum brought out as a permanent stoma.

Proctocolectomy with ileorectal anastomosis
-Removal of the colon while preserving the rectum, with the ileum joined directly to the rectum to maintain defecation via the anus.

Proctocolectomy = rectum and colon coming out

Question 5

What does an anastomosis refer to here ?

Answer 5

Join in two ends of bowel

Question 6

What the two main types of ileostomy ?

Answer 6

Loop and ends
-Ileostomy stomas usually right sided
-Leak small bowel contents

Question 7

What is a loop ileostomy ?

Answer 7

Temporary stoma where a loop of ileum is brought to the surface, primarily to divert intestinal contents away from a distal anastomosis.
-Commonly after low rectal surgery (e.g. for cancer) where the join is low in pelvis and high leak risk
-Diversion prevents faeces and bile acids from passing over the join, reducing the severity of complications if a leak occurs.
-Protective
-Usually reversed after a few months once healing is confirmed, by closing the stoma and restoring bowel continuity.
-Afferent (inflow) and efferent (outflow) limb

Question 8

What is an end ileostomy ?

Answer 8

End ileostomy involves bringing out the end of the ileum as a permanent stoma, typically after removal of the colon and rectum.
-Stoma stands up from skin as small bowel contents is irritating; stump keeps off skin

Question 9

What are colostomy stomas like ?

Answer 9

Usually on left and leak stool

Question 10

What are indications for elective surgery in UC ?

Answer 10

-Medically unresponsive disease
-Intolerability; can develop allergies to drugs
-Choice; may not want to be on drugs/immunosuppresants
-Dysplasia/malignancy
-Growth retardation in children; sub-total colectomy
-Attempted resolution of extra-intestinal disease e.g. primary sclerosinign colongitis or skin lesions from UC

Question 11

How is dysplasia treated in UC ?

Answer 11

Normal dysplasia exciced endoscopically

Low-grade = recommend colectomy

High-grade = colectomy

Question 12

What planned operation is used for UC ?

Answer 12

Elective Proctocolectomy; planned removal of rectum and colon (and wee bit of ileum)
-Ileum and anal canal left in body

Solution:
-With end ileostomy?
-With a pouch?
-Ileorectal anastomosis? - leave rectum behind ?? and survey

Elective = planned

Question 13

Why is the rectum so goated ?

Answer 13

Provides a lot of information about texture and state of contents

Can accomodate a lot of content for ages

Removing rectum does not mean life as normal

Not ideal to have no rectum

Question 14

What are pouches ?

Answer 14

Solution to proctocolectomy; folds over small intestine to make resiour/fake rectum joined to anal-rectal cuff
-W, J, S pouches - J safest
-Every staple line is a leak, bleed and stenosis risk
-Popular in younger/stoma adverse people; relationship viability
-Not perfect; small intestine is slim, small bowel contents coming out - watery and burney, litre made about a day, toilet frequency increased, may need drugs to thicken output, may need to wear pads almost definetly at night due to seepage

No stoma, but other problems

Question 15

What are potential complications of proctocolectomy ?

Answer 15

eneterotomy is accidental hole in intestine

pouchitis = inflammed pouch, cant do anything, inevitable to get at some point

Procto = anus/rectum

Question 16

When are pouches almost never made ?

Answer 16

Those who haven’t had children
-Advise to freeze sperm/eggs
-Nerves which supply sexual functional lie around rectum and are often damaged during pouch creation
-Massive pelvic sugery like this, male may have problems with erection or damage to seminal vesicles, may be properly infetile, simialr difficulties in women who can fail to achieve orgasm - big bummer if youre like 25

Question 17

What defines a UC emergency and how are they treated?

Answer 17

Severe UC attacks which are treatment resisent
-Colon needs to come out; treated with subtotal colectomy

Question 18

How is the severity of a UC emergency assessed ?

Answer 18

Truelove and Witt Criteria
Assessment of severity
-ESR (CRP used now)
-Haemoglobin
-Number of bloody Stools
-Temperature
-Heart rate

Easy to use and practically relevant

ESR = erythro sed rate

Question 19

What are values of the Truelove and Witt Criteria ?

Answer 19

CRP now instead of ESR

-Also very imporant is bowel movement at night; not normal and pathological usually

Question 20

What is a subtotal colectomy ?

Answer 20

Used to treat emergency UC; colon cut out and rectum left behind
-Rectum left behind as is no inflamed as would damage nerves by removing; urinary incontenence, impotent etc
-If rectum looks cooked, can bring it out as mucous fistula; unproductive stoma which leaks mucous on left with ileostomy from subtotal colectomy on right; tube in anus would come out here

Once rectum defunctioned should settle down, if not can use topical/enma

Question 21

Why are mucous fistulae made after subtotal colectomy ?

Answer 21

Stapled proximal end of rectum risks leak from pressure from dying and manky rectum inside into abdomen;
-Fistula drains all this stuff

Ts is manky tho and not good to have two stoma (other ileostomy from subtotal colectomy) so rectal catheter can be used to drain via anus for first few days when risk leak highest

Question 22

How is the rectum approached in UC subtotal colectomy ?

Answer 22

Nerves around rectum are problematic; Nervi erigenti

In acute flare up stay out of the rectum, can proceed when quiscent

Removal of colon tends to settle rectal disease

No immediate rush to deal with rectum after subtotal colectomy
-Rectum left in-situ with blood supply, stappled at top
-End ilesostomy are stable
-Rectum checked for dysplasia every now and again

Manage with meds (predfoam enemas etc)

Question 23

Outline cancer risk in IBD

Answer 23

Clear relationship in UC

Less clear in Crohn’s

Colonoscopy at 10 years post diagnosis in both

Stats from pre-biologic era, inflamation drives cancer but biologic turn off inflammation basically - cancer risk could go back to normal

Question 24

What is toxic megacolon ?

Answer 24

Life-threatening medical emergency characterized by extreme dilation of large intestine with systemic toxicity
-Not really a thing anymore due to biologics
-Sepsis, distension, pain
-Requires decompression and colectomy as may perforate

Can be caused by C. diff, used to be caused by UC

Question 25

What is Rigler's sign ?

Answer 25

Toxic megacolon perforation -Can see inside and outside of colon on AXR due to air in peritoneal cavity

Question 26

How good is surgery for UC

Answer 26

Patient is “cured” -Many people live with a stoma no problem -Pouches have good QoL -Many pouches get turned into end ileostomy eventually, when in stable relationships and dont want pouch downsides anymorexfd | 50% of colostomy will get a parostomal hernia, only fix if problematic

Question 27

How is surgery in Crohn's approached

Answer 27

Can't cut a bit out and say they're cured forver (unlike removing colon in UC), may need multiple surgeries 1) Conservatisim without procrastination -Operate when needed, minimal removals 2) Recrudescence rather than recurrence -In Crohn's we use 'recrudescence' when it comes back

Question 28

What needs to be stopped in Crohn's ?

Answer 28

Smoking -People can significantly refeverse severity by stopping smoking

Question 29

What are indications for surgery in Crohn's ?

Answer 29

-Preference -Stenosis causing lumen constriction and obstruction -Enterocutaneous fistulas; small bowel fistulate to skin -Intra-abdominal fistulas; small bowel fistulate to vagina, bladder etc -Abscesses -Bleeding (acute or chronic) - uncommon -Free perforation; uncommon, emergency -Remove TI disease (LIRIC) | Entero-entero fistula usually not noticable, lots of small b in pelvs

Question 30

What is gastroduodenal disease ?

Answer 30

Rare manifestation of Crohn's -Difficult to treat and important structures nearby e.g. bile ducts, head of pancreas -Gastrojejunostomy for duodenal or pyloric stenosis

Question 31

How is duodenal or pyloric stenosis treated ? (gastroduodenal disease)

Answer 31

Gastrojejunostomy

Question 32

What is ileocolic disease ?

Answer 32

Manifestation of Crohn's -Up to 80% of CD patients need an operation for ileocolic disease -Although disease comes back, surgery is very good at achieving relief of symptoms; will need reoperation

Question 33

What is multisite Crohn's disease and how is it treated ?

Answer 33

Multisite disease = multiple strictures occur at different bowel locations poses extensive resection risks significant bowel loss Strictureplasty used -Widens narrowed segments without removing them -Preserves bowel length Balloon dilatation, alternatively -Endoscopic for select strictures to non-surgically relieve obstruction. -Also minimises loss of bowel function. | Small bowel leak rare, stitches heal well due to good blood supply

Question 34

Give examples of different types of fistulae

Answer 34

Enterocutaneous fistulae -Communiaction and leakage from small bowel out to skin -Burns and damagesn skin, infection, pain Intra-abdominal -Small bowel to small bowel; occult -Small bowel into bladder or vagina; definetly not occult -Any organ can be affected | All can be caused by Crohn's

Question 35

What must be done in treating a fistula ?

Answer 35

"SNAP” treat Sepsis Nutrition - no food, nothing in gi tract, TPN; Anatomy Plan….. (or prolonged hospital stay) also shoukd encourage mobility | Patients get pissed off cause hospital and no food for like 3 months ## Footnote patients go up and down during treatment cause will get sick with other things

Question 36

What is TPN ?

Answer 36

Total Parenteral Nutrition (TPN) -IV scran and ginger

Question 37

What are postoperative fistulae ?

Answer 37

Accidental fistulae made during surgery -Usually close with conservative measures (unlike active disease causing spontaneous fistulae like Crohn's) -Vacuum assisted drains may help

Question 38

How are intra-abdominal fistulae treated ?

Answer 38

Resect en-bloc primary defect and close secondary organ -aka, Take out the diseased bowel segment causing the fistula as one piece, and separately close the hole in the other involved organ. ## Footnote Can chop quite a bit of bladder out without problems, same with vagina because its stretchy and forgiving

Question 39

Someone has emergency colitis, unsure if it is UC or Crohn's, what surgery is done ?

Answer 39

Emergency sub-total colectomy -Colon gone but rectum and anus left -Total colectomy less common in emegency

Question 40

When are you definetly not doing a pouch ?

Answer 40

Crohn's colitis -If you take the whole colon and rectum out and then get crohn's in fake rectum, less small bowel and material to work with

Question 41

Give examples of perianal diseases

Answer 41

Primary lesions (fissure, ulcer) Secondary lesions (abscess, tags, fistula) Incidental lesions (piles, Hidradenitits)

Question 42

How can perianal Crohn's appear

Answer 42

Crohn's perineum often looks like watering can head -Absesses due to underlying fistulas -Multiple chronic holes, all pouring pus

Question 43

What can perianal Crohn's lead to in someone who is immunosuppressed ?

Answer 43

Big SSCs -Fistulas overtime turn to cancer

Question 44

How are fistulas treated ?

Answer 44

Aim to control rather than cure Seton is a good option Surgery Lay open Stomas for severe disease

Question 45

How is UC treated with surgery ?

Answer 45

Cured with surgery -All bad bits go in bin

Question 46

How good are pouches ?

Answer 46

Good but not as good as rectum -Not returned to pre diseased state but no stoma

Question 47

What can be done to help bad perianal disease ?

Answer 47

Temporary stoma for like 6 months to a year -Diverts faeces until it can heal