Inflammatory Bowel Disease from the perspective of a colorectal surgeon

What is inflammatory bowel disease?

There are two inflammatory bowel diseases: ulcerative colitis and Crohn’s disease. These diseases both involve an autoimmune attack on the gastro-intestinal tract. The inflammation of the small and large bowel causes many different symptoms including abdominal pain, diarrhoea, weight loss, fever and rectal bleeding. Some patients may complain of wounds and discharges from around the anus and pelvic floor.

What are the medical treatments for inflammatory bowel disease?

Medical treatments for inflammatory bowel disease are supervised by specialist gastroenterologists who prescribe oral medications and infusions such that the disordered attack on self is reduced and the inflammation brought under control.

Unfortunately, some patients continue to suffer from inflammation and their disease progresses despite the medical attempts to suppress the inflammation. These patients with ongoing inflammation sometimes develop narrow segments of bowel called strictures or segments of bowel with severe inflammation and heavy bleeding or thinned walls.

What is the role of surgery in the treatment of ulcerative colitis?

There are two common operations designed for ulcerative colitis patients, these include a subtotal colectomy, and formation of temporary end ileostomy and proctectomy and formation of ileal pouch.

The surgeon will assess which procedure is best suited based on the patient’s condition. A subtotal colectomy involves partial removal of the colon up the lower part of the descending colon. Subsequently, an ‘anastomosis’ procedure is performed whereby the small bowel is joined to the healthy portion of the remaining colon.  For other patients, an ileal pouch is required and surgery is performed in two stages. Stage one involves total removal of the colon and rectum while constructing a J shaped or S shaped internal pouch from the end of the small intestine (ileum) and attaching to the anus. Parts of the small intestine are temporarily diverted to the abdomen wall in a temporary ileostomy through an ostomy bag to allow for the J or S shaped pouch to heal. Healing time takes up to 12 weeks. Stage two involves reversing the ileostomy and creating the ileal reservoir where the patient can remove waste from their anus as normal.

What is the role of surgery in the treatment for Crohn’s disease?

For Crohn’s patients segments of bowel which remain inflamed despite medication are resected or dilated with surgical techniques.

Before any surgery, complex patients are discussed at multidisciplinary meetings to ensure that every medical and surgical option is considered, evaluated and a consensus decision reached.

Surgery for Crohn’s patients is associated with a greater risk of complications. The inflammatory disease itself can lead to a higher risk of anastomotic leak and the medications given to reduce inflammation can also potentially increase trouble from surgery and the creation of new joins.

Are there any new surgical techniques?

One technique to reduce the risk of anastomotic leak and post resection recurrence is to perform the Kono-S technique. This surgical technique which originated in Japan very deliberately assesses the extent of the Crohn’s disease. The blood vessels to the affected segment of bowel are ligated very close to the bowel itself using a sealing power source device. This maintains good nerve and blood supply to the segments of bowel which will be re-joined. The bowel ends are stapled off and these ends are joined to create supportive pillars to the new anastomosis. Then, incisions are made into the bowel to create a new end to end widened join. The join is completed with hand sewn sutures.

This technique can reduce anastomotic leak and anastomotic recurrence. Furthermore, robotic technology can be used to generate this join. The stable robotic vision and instrumentation can enhance the accuracy of the tissue apposition and reduce the size of the wound needed to complete the surgery.

Authored by Dr Rohan Gett, Colorectal Surgeon at St Vincent’s Clinic.

St Vincent’s Clinic offers three complementary specialties in Gastroenterology, Colorectal Surgery and Diagnostic Endoscopy for treatments of inflammatory bowel disease.