Surgery and Surgery and Inflammatory Bowel Inflammatory Bowel

DiseaseDiseaseStephen M. Kavic, MD

Department of Surgery University of Maryland

The Gastrointestinal Tract

Inflammatory Bowel Disease

Crohn’s Disease

Ulcerative Colitis

Crohn’s DiseaseAffects small intestine

(small bowel)

Colon may be involved

Medical treatment is mainstay

Surgery and Crohn’sApproximately

70 %

of patients with Crohn’s ultimately come to

operation

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

Complications of Disease Hole in bowel

– Perforation– Abscess

Blockage– Obstruction

Bleeding Fistula

What do surgeons do?

“When in doubt,

cut it out”

(okay, alter or remove the sites of maximum pathology)

Sometimes things don’t work

Goals for Surgery Remove problem segments of

bowel Maximize the amount of useful

bowel left behind Avoid surgical complications

Goals for Surgeon and Patient

Restore quality of life

Stricturoplasty

(Opening a blocked portion of intestine)

Stricture Narrowing of a portion of bowel Caused by repeated episodes of

inflammation Symptoms may include nausea,

vomiting, and pain

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

Resection

(Removal of a portion of intestine)

“Anastomosis”Surgical connection or juncture

Sutures (needle and thread)Staples

Anastomosis

Anastomosis Not always possible Stool needs an exit from the body Ileostomy

– “The bag”– Direct connection of intestine to

outside world

Ileostomy orStoma

Abscess

(Infection)

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

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

Fistula

(Abnormal connection)

Fistula An abnormal connection between

two structures Often between two loops of bowel May connect to bladder, vagina,

skin, or other organs

Fistula Treatment may be medical Surgery often required Remove the segment of bowel and

the connection Repair the other organ

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

Surgical Complications Bleeding

– 2-5% Infection

– 2-10% Breakdown of anastomosis

– 2-4% Injury to neighboring structures

Ulcerative Colitis

Ulcerative ColitisAffects large intestine (colon)

Inflammation of deep layers of colon wall

Multiple medicines available

Surgery and UCApproximately

35 %

of patients with UC ultimately come to

operation

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

Complications of Disease Hole in bowel

– Perforation– “Toxic megacolon”

Bleeding Risk of cancer

What do surgeons do? Remove the colon Left with small intestine and cuff of

rectum Ileostomy (temporary or permanent) Pouch created with small bowel

Small bowel pouch

Staged Procedures To minimize complications,

sometimes the operations are done in sequence

Stage I: Removal of colon and ileostomy

Stage II: Reconnection

Surgical Complications Bleeding

– 2-5% Infection

– 2-10% Breakdown

– 2-4%

Surgical Complications “Pouchitis”

– Inflammation of pouch– Diarrhea and pain– Treated with antibiotics

Bowel obstruction Infertility

Minimally Invasive Surgery

Minimally Invasive Surgery

Also known as “Laparoscopic” surgery

Used in over 20 million Americans

MIS proven to be as effective as conventional surgery

The Evolution of Incisions Past Present Future

Long Laparotomy Minimally Invasive Surgery Incisionless Surgery

O

O

O

O

O

Minimally Invasive Surgery

Many procedures may be started with minimally invasive techniques

Surgeon can convert to traditional open surgery if deemed safer

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

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

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

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

MIS for IBD Surgery

MIS for IBD Surgery

Not all patients are candidates for MIS

Inability to safely visualize organs

Problems during the operation

Underlying medical conditions

Conclusions IBD has surgical options Surgery reserved for

complications of disease or therapy

Minimally invasive techniques may be applied