Crohn's Disease: Inflammatory Bowel Disease

Description

Alternative Names

Surgery

Between two third to three quarters of Crohns patients eventually need surgery when symptoms cannot be controlled by medication. Among children with Crohn's, half require surgery within five years of diagnosis.

In general, surgery is used to remove damaged areas of the colon:

• The entire colon (proctocolectomy) or a section of it (subtotal colectomy) may need to be removed in cases of extensive disease in the large intestine.
• Resection or strictureplasty, which remove limited sections of the colon and may be appropriate for many patients.

Surgery is useful only for reducing symptoms. Crohn's disease cannot be cured with surgery because new disease can appear in other areas of the intestine. Surgery may be helpful for relieving symptoms and to correct blockage, perforation, fistulas, or bleeding.

Surgery has reportedly improved the quality of life in most patients, except for those who continued to have active disease. Many children with Crohn's who have suffered growth problems catch up to near-normal growth levels after surgery. Some experts are urging, in fact, that many patients should consider surgery in the early stages of the disease.

Strictureplasty

Some patients may be candidates for a procedure called strictureplasty, which involves cutting and stitching only the areas obstructing the intestine, so that it widens the intestine without removing sections of it. It involves the following:

• A balloon attached to a catheter (a thin tube) is passed along the intestine.
• If it becomes blocked, then a stricture (an obstruction) is indicated.
• The surgeon widens the intestine at the point, but does not remove sections of it.
• The procedure is by no means foolproof. Nearly half of patients require re-operation, but strictureplasty in the jejunum and ileum of the small intestine is safe and generally effective over the long term. It may not be useful for Crohn's disease in duodenum (the first section of the small intestine).

Procedures Used to Remove Damaged Portions of the Colon

The invasiveness of the surgical procedure to remove damaged portions of the colon depends on the severity of the disease:

Resection of the Colon. In most cases of Crohn's disease, only a part of the colon needs to be removed, a procedure called resection.

Click the icon to see an illustrated series depicting large bowel resection surgery.

Subtotal Colectomy. Subtotal colectomy is more extensive than resection and removes more of the colon. Disease in the upper parts of the small intestine tends to require more extensive surgery than in the lower small intestine.

In general, either procedure requires a general anesthetic and involves the following:

• An incision is made in the abdomen.
• The diseased portion of the colon is identified and removed. (Strictureplasty is sometimes used alone with resection.)
• Once a diseased segment of the colon is removed, the two ends are reconnected, and this connection is called an anastomosis.

Open Surgery or Laparoscopy. Resection or subtotal colectomy may be performed using one of two surgical approaches:

• Open surgery, which requires a wide abdominal incision.
• Laparoscopy, which uses a few small incisions through which a tube is inserted containing a tiny camera for viewing the area. To date, however, this procedure is best suited for patients with short-segment disease in the ileum who also have no other complications, such as fistulas and abscesses.

Click the icon to see an image of a laparoscopy procedure.

Complications After Resection or Subtotal Colectomy

• Short-bowel syndrome. If large segments of the small intestine are removed, the patient is at higher risk for short-bowel syndrome, a complication in which there is a problem absorbing nutrients. The risk is far lower with strictureplasty. The condition used to be fatal, but patients now can live normal and productive lives using total parenteral nutrition (the intravenous administration of nutrients), which can now be self-administered at home in many cases.
• Leakage or obstruction in the areas where the colon has been reconnected (the anastomosis).
• Infections. In a 2003 study, the use of agents that modify the immune system (azathioprine, 6-MP, methotrexate, and infliximab) was effective in reducing the risk for serious infection in the abdomen.

Proctocolectomy and Ileostomy

Proctocolectomy with ileostomy is removal of the entire colon and creation of an ileostomy. It involves the following:

• To perform proctocolectomy, the surgeon removes the entire colon, including the lower part of the rectum and the sphincter muscles that control bowel movements.
• To perform ileostomy, the surgeon makes a small opening in the lower right corner of the abdomen called a stoma. The surgeon then connects cut ends of the small intestine to this opening. A bag is placed over the opening and accumulates waste matter. It requires emptying several times a day.

Disease Recurrence After Surgery

Recurrence of Crohn's disease is very common after any procedure. One expert described the risk as being between 7% and 25% for each year after resection, with an average risk of 50% at five years after resection. (Even if the entire colon is removed there is still a high chance of recurrence in the rectum and a somewhat lower risk for recurrence in the small intestine.)

Patients at highest risk for recurrence are the following:

• Smokers.
• Those whose disease occurred in the ileum (the lowest part of the small intestine) and colon. (One expert reported an 86% chance of recurrence.)
• Those with abscesses or fistulas.
• Those have had previous surgeries.

Various agents have been used to prevent recurrence. They include the antibiotic metronidazole (Flagyl), mesalamine, infliximab, and mercaptopurine. These agents can have severe side effects. And it is not clear if these or any other agents are effective in preventing recurrence. Even if medications can help prevent recurrence in some patients, it is not yet known who these individuals might be. (In any case, steroids do not appear to help prevent recurrence.)

Emergency Surgeries

In some cases, surgery is needed for emergency conditions that can occur with Crohn's disease. The conditions most likely to require such surgery in Crohn's disease include the following:

• Stopping severe intestinal bleeding.
• Clearance of small bowel obstruction.
• Surgery to drain and heal abscesses or fistulas.
• Surgery to repair perforation.

Small Intestine Transplantation

Procedures for transplanting the small intestine in patients with intestinal failure are under investigation. These are still experimental and are being tested in patients who have lost so much of their small intestine that they must rely on total parenteral nutrition (intravenous administration of nutrition). Medicare does not cover it. Small-bowel transplantation is a more difficult procedure than some other transplants, because of the high rate of potential complications, including infection and organ rejection. Patients who have transplants must be on immunosuppressant agents for the rest of their lives. Furthermore, there is some evidence that Crohn's disease recurs in the transplanted bowel.