IBD SURGERY
| OPTIMAL MANAGEMENT OF ANORECTAL CROHN’S DISEASE—Ann Lowry, MD, Adjunct Professor of
Surgery, University of Minnesota School of Medicine, Minneapolis
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| Points to remember: symptoms may not always match appearance of anus; anorectal disease can predate proximal
bowel disease and intestinal symptoms; anorectal Crohn’s disease may mimic more common problems, eg, anorectal
fissure
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| Diagnostic hints: multiple lesions; fissures in atypical locations; fissures or hemorrhoids associated with stricture
in patient with no history of surgery; nonhealing ulcers; bluish tinge to perianal skin; large edematous skin tags;
discrepancy between symptoms and appearance
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| Fissures: in one series, 20% located laterally (60% posterior); one-third of patients had multiple fissures; often deep,
with undermined edges; often painless, despite appearance; if asymptomatic, treatment not necessary; in some series,
80% heal spontaneously; if painful, suspect associated perianal sepsis; treatment—includes controlling bowel
habits and use of topical agents, including metronidazole; anecdotal evidence supports use of oral antibiotics; if
symptoms persist without sepsis, consider lateral internal sphincterotomy (associated with high risk for incontinence;
use with caution)
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| Hemorrhoids: rare in individuals with Crohn’s disease; often confused with skin tags or edema; avoid hemorrhoidectomy,
due to high morbidity (poor wound healing, stenosis, increased risk for proctectomy); try symptomatic
treatment first, including control of diarrhea or constipation, sitz baths, and topical therapy; exception—persistent
internal prolapsing hemorrhoids that do not respond to control of bowel movements; rubber band ligation recommended
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| Fistulae: American Gastroenterological Association recommends empiric classification distinguishing simple and
complex fistulae
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 | Simple: low, with single external opening, and no sign of concomitant problem; treatment recommendations—
include fistulotomy; healing rates good, but associated with high risk for incontinence, proctectomy, and long-
term diversion
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| Complex: high, with multiple external openings; may have had associated separation, rectovaginal fistula, anorectal
stricture, or active Crohn’s disease in rectum; more common than simple fistulae; treatment
recommendations—include placement of noncutting seton, with long-term drainage (however, many patients
need second seton or proctectomy); other suggested treatments include antibiotics (eg, metronidazole, ciprofloxacin),
azathioprine, or 6-mercaptopurine; tumor necrosis factor (TNF)-α monoclonal antibodies (infliximab)
now being studied (Crohn’s disease associated with elevations in TNF-α activity); in recent study of patients receiving
infliximab in dose of 5 mg/kg, 68% experienced >50% reduction in draining fistulae (55% with complete
closure), but median closure duration only 3 mo after stopping infliximab; 11% of patients developed perianal
abscesses, likely due to persistence of subcutaneous tracts; later study suggested that induction plus maintenance
therapy superior to induction alone; cyclosporine and tacrolimus also studied
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| Procedure at University of Minnesota: drain sepsis, insert noncutting seton, and start antibiotics; when local sepsis
controlled, trial of infliximab, with seton removed after second infusion if patient responds; continuing use of antibiotics
and infliximab questionable; if patient does not respond to infliximab, leave seton and consider other biologic
agents; consider surgery for patients who do not improve and do not have proctitis; with proctitis, leave
seton, continue medical management, and consider proctectomy if symptoms warrant
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| Management principles: maintain high index of suspicion; diagnose with care; tailor therapy to specific symptoms;
symptom relief main goal
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| CURRENT SURGICAL MANAGEMENT OF CROHN’S DISEASE—Victor W. Fazio, MD, Professor of Surgery,
Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, and Rupert Turnbull Chair, Department
of Colorectal Surgery, Cleveland Clinic, Cleveland, OH
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| Indications for surgery: failure of medical therapy; obstruction; fistula abscess; hemorrhage
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| Most common disease patterns: disease of small bowel, small and large bowel, and large bowel alone account
for 95% of indications; rare exceptions include oral, esophageal, or ectopic Crohn’s disease
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| Failure of medical therapy: rarely primary indication; usually associated with colon disease; advent of anti-TNF-
α agents has expanded pool of patients eligible for reconstructive surgery
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| Preparation for surgery: use imaging methods to develop “road map”; for small bowel, computed tomographic
(CT) enterography current state-of-art (usually performed when extraintestinal problems suspected); most patients
with complicated disease (includes risk for sepsis) benefit from stoma site marker before surgery, when optimal
site can be chosen; stoma possibility for any patient with inflammatory bowel disease (IBD); consider withdrawing
immunosuppressive agents before surgery (immunocompromise may impair healing); if not possible, consider covering
stoma in cases involving corrective surgery with anastomosis; evidence accumulating that mechanical bowel
preparation does not reduce rates of sepsis and anastomotic leaks; speaker suggests taking patient off solid food for
2 to 3 days before surgery, then dealing with residual obstructions on operating table; during surgery, administer
intravenous (IV) antibiotics and stress-dose steroids; nasogastric tubes no longer used during elective surgery, but
Foley catheters “de rigueur;” consider ureteric stents for reoperative abdominal surgery; most ureteric complications
result from failure to identify injury during surgery; prophylaxis for deep venous thrombosis
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| Proportion of patients with small-bowel Crohn’s disease who undergo surgery: 50% at 5 yr; 70% at 10 yr; results
similar for colitis; with iliac colitis, 75% at 5 yr and 90% at 10 yr
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| Planning for surgery: Crohn’s disease recurrent and in-curable; strategic approach required over patient’s lifetime;
within 20 yr, 50% to 60% of patients have surgery (some patients have 3-4 resections by 15-20 yr); sometimes,
recurrence downstream of original anastomosis; implication—1 in 6 patients with small-bowel disease
eventually needs ostomy; anticipate eventual need for stoma (use midline rather than paramedian incisions)
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| Bowel and colon economy: colon economy reduces risk for postoperative dehydration; address stricture formation
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| Indications for colon surgery: failure to thrive; perianal disease; toxic megacolon; toxic colitis
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| Margins for small-bowel surgery: establish at macroscopic margin of clearance (requires palpation of mesenteric
margin; shift from thick to thin margin demarcates presence and absence of disease); avoid leaving strictures or
seriously ulcerated bowel; no advantage to taking >2 to 3 cm; also no advantage to frozen sections
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| Complications: bowel obstruction—nearly all cases resolve with conservative therapy (IV fluids, steroids); can then
assess need for further treatment; chronic colon obstruction—treatments include resection, bypass, and stricturoplasty;
resection usually preferred; conditions simulating Crohn’s disease include tuberculosis, lymphoma, and adenocarcinoma;
intra-abdominal abscesses—major types interloop, mesenteric, pelvic, and extraperitoneal
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| Mesenteric abscess: hardest to treat; results from mesenteric bowel margin perforating into leaves of small-bowel
mesentery; pus collects, vessels fragment, and hematoma can spread to duodenum; treat by draining and excluding
mesentery
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| Other types of fistulae: organs of origin include small bowel, colon, and rectum; may ulcerate and penetrate into target
organs, including vagina, bladder, and sigmoid colon; management—excise diseased segment; repair target organ;
omental interposition recommended to prevent recurrence; for psoas abscess, CT enterography especially helpful in
developing road map; drain active sepsis ahead of time; control active disease; perform surgery few weeks after
drainage; consider temporary stoma if warranted; occult psoas abscess—may be identified on CT, but undetectable
at surgery; explore psoas sheath with large-bore aspirating needle; colonic disease—pancolectomy and end-
ileostomy treatment of choice; major perineal sepsis, malnutrition, and toxic states indicate subtotal colectomy;
30% to 50% of patients develop unhealed perineal wound requiring more surgery; however, stapling anorectal
stump interferes with later biopsy collection (4%- 5% of patients develop cancer); also, abscess may develop at staple
line
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| Laparoscopic surgery: sometimes used for pancolectomy and ileostomy; contraindications include toxic states
due to fragility of colon
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| Management of rectosigmoid stump: staple; exteriorize; create mucus fistula
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| Ileorectal anastomosis: disease often spares rectum; even if rectum involved, surgery feasible if adjuvant therapies
available (provided rectum distensible, with no evidence of other disease); other contraindications include active
perianal sepsis and significant small-bowel disease (markers for early recurrence)
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| Megacolon and toxic colitis: consider fulminant if >2 indicators present (tachycardia, fever, elevated white
blood cell count, albumin <3 g%); in these cases, do not wait for sigmoid stump to mature; with subtotal colectomy,
part of sigmoid colon left behind, so it can be exteriorized, wrapped in gauze, and amputated after 5 to 7
days; mature it as mucus fistula
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| INFLIXIMAB, CYCLOSPORINE, STEROIDS: WHEN ENOUGH IS ENOUGH IN ULCERATIVE COLITIS—
John H. Pemberton, MD, Professor of Surgery, Mayo College of Medicine, the Mayo Clinic, Rochester, MN
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| Problem: patient with active disease and management failing
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| Adequate management: outpatient—standard treatment includes aspirin, oral or topical steroids, and azathioprine;
infliximab (some evidence of symptom control); end point clear (“if you can’t steroid-spare, then enough
is enough”); inpatient—IV high-dose prednisone; possibly cyclosporine; infliximab; distinguish between fulminant
and acute disease
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| Fulminant disease (inpatients): high stool frequency (>10/day); continuous bleeding; fever; tachycardia; patient unstable,
requires transfusion; colon at least slightly dilated, with tenderness and possibly early peritoneal signs;
treatment—establish diagnosis; colectomy indicated for unstable patients; treat stable patients with high-dose
steroids; if patient responds within 2 to 3 days, progress to cyclosporine; if not, go to surgery
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| Acute disease (inpatients): administer high-dose steroids for 5 days; if no response, go to surgery, or try cyclosporine
or infliximab; surgery indicated if patient does not respond to infliximab and steroid-sparing impossible
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| Problems associated with hospitalization for severe ulcerative colitis: malnutrition; debilitation; timing; adverse effects
of medication; longstanding anticolectomy bias among gastroenterologists
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| Ileal-pouch anal anastomosis (IPAA): performed in >80% of cases; now accomplished through minimally invasive
techniques; associated with better quality of life (QOL) scores, compared to patients with chronic ulcerative colitis;
reasons—removes disease; avoids stoma; function predictably good over 22 to 24 yr; virtually eliminates
risk for malignancy associated with chronic ulcerative colitis
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| Experience with IPAA at Mayo Clinic: nearly 3000 patients (2400 for ulcerative colitis); median follow-up time 11
yr (maximum 24 yr); 92% chance that pouch will be in place and functioning at 21 yr; in cohort of 409 patients
followed over 20 yr, QOL did not change “as they aged along with their pouch”; conclusion—IPAA viable operation
associated with good QOL and predictable stable outcome over time; continually evolving (now performed
laparoscopically, either completely or hand-assisted)
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| Dysplasia: still poorly understood; often not recognized or appreciated by gastroenterologists; data complicated by
high dropout rate among patients in surveillance studies; random colon biopsies unreliable; “holding on” to patient
with even low-grade dysplasia may be dangerous
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| Deciding when enough is enough: outpatients—in conjunction with gastroenterologists, determine when delaying
surgery no longer tenable; inpatients—after short course of aggressive treatment (IV steroids, infliximab), use
presence of bleeding and multiple daily stools as evidence of fulminant disease and indication for surgery; deteriorating
patients—surgeon and gastroenterologist determine together when surgery warranted; high-grade
dysplasia—indication for surgery by itself; “maybe even low-grade as well”
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Suggested Reading
Cendan JC, Behrns KE: Associated neoplastic disease in inflammatory bowel disease. Surg Clin North Am
87:659, 2007; Cima RR, Pemberton JH: Medical and surgical management of chronic ulcerative colitis. Arch
Surg 140:300, 2005; Colombel JF et al: Early postoperative complications are not increased in patients with
Crohn’s disease treated perioperatively with infliximab or immunosuppressive therapy. Am J Gastroenterol 99:878,
2004; Colombel JF et al: Management of Crohn’s disease of the ileoanal pouch with infliximab. Am J Gastroenterol
98:2239, 2003; Hahnloser D et al: Results at up to 20 years after ileal pouch-anal anastomosis for chronic ulcerative
colitis. Br J Surg 94:333, 2007; Larson DW, Pemberton JH: Current concepts and controversies in
surgery for IBD. Gastroenterology 126:1611, 2004; Penninckx F et al: Success and failure after repair of rectovaginal
fistula in Crohn’s disease: analysis of prognostic factors. Colorectal Dis 3:406, 2001;Reese GE et al: The
effect of Crohn’s disease on outcomes after restorative proctocolectomy. Dis Colon Rectum 50:239, 2007; Sachar
DB: Indications for surgery in Crohn’s disease. Am J Gastroenterol 102 Suppl 1:S76, 2007; Sandborn WJ et al:
AGA technical review on perianal Crohn’s disease. Gastroenterology 125:1508, 2003; Scarpa M et al: Systematic
review of dysplasia after restorative proctocolecomy for ulcerative colitis. Br J Surg 94:534, 2007; Schaus BJ et al:
Clinical features of ileal pouch polyps in patients with underlying ulcerative colitis. Dis Colon Rectum 50:832, 2007;
Strong SA, Fazio VW: Surgical treatment of inflammatory bowel disease. Curr Opin Gastroenterol 15:326, 1999;
Topstad DR et al: Combined seton placement, infliximab infusion, and maintenance immunosuppressives improve
healing rate in fistulizing anorectal Crohn’s disease: a single center experience. Dis Colon Rectum 46:577,
2003; Vader JP et al: Appropriate treatment for Crohn’s disease: methodology and summary results of a multidisciplinary
international expert panel approach—EPACT. Digestion 73:237, 2006.
Educational Objectives
| The goal of this program is to improve medical and surgical management of inflammatory bowel disease. After hearing
and assimilating this program, the listener will be able to:
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| Recognize and treat fissures, hemorrhoids, and fistulae in patients with anorectal Crohn’s disease.
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| Develop principles for the surgical management of anorectal Crohn’s disease.
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| Identify indications for surgery in patients with Crohn’s disease.
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| Maintain surveillance for and manage the most likely complications of Crohn’s disease surgery.
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| Determine when a patient with ulcerative colitis should undergo colectomy.
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Faculty Disclosure
In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty members to disclose
relevant financial relationships within the past 12 months that might create any personal conflicts of interest. Any
identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary
business or commercial interest. For this program, the following has been disclosed: Dr. Fazio has received
grant funding from Genzyme.
Acknowledgements
Drs. Lowry and Pemberton spoke at Colon and Rectal Surgery, held September 7-9, 2006, in Minneapolis, MN, and
sponsored by the University of Minnesota Medical School, Colon and Rectal Surgery Associates, Ltd, and the Minnesota
Colon and Rectal Foundation. Dr. Fazio was recorded at the Phoenix Surgical Symposium, held February 14-
17, 2007, in Phoeniz, AZ, and sponsored by Banner Health and the Phoenix Surgical Society. The Audio-Digest
Foundation thanks the speakers and the sponsors for their cooperation in the production of this program.
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