Surgery in IBD: when it is necessary, preparation and possible complications.

Inflammatory Bowel Disease (IBD), whether Crohn’s disease or ulcerative colitis, can have a significant impact on the quality of life of those who suffer it. Thankfully, a broad arsenal of drugs and other therapies are now available to manage the disease prior to surgery.

In those cases where the disease progresses or is not under control with any of the medications currently available, surgical treatment is another alternative.

According to GETECCU (Spanish Crohn’s Disease and Ulcerative Colitis Group) approximately 15-20% of patients with UC and 60-70% of patients with CD will require surgical treatment during the course of their disease.

When is surgery considered in Inflammatory Bowel Disease?

• When there is no response to treatment because the symptoms of the disease are not controlled.
• In case the side effects of medical treatments are intolerable for the patient.
• In case of severe complications such as intestinal obstructions, perforations, abscesses or fistulas that do not respond adequately to other forms of treatment.
• When IBD significantly impacts the patient’s quality of life, interfering with daily activities and compromising general health.

Common types of surgery in IBD:

When facing surgery in IBD, the most common strategies in surgical treatment are:

• total proctocolectomy with ileostomy or with ileoanal reservoir,
• total colectomy with ileorectal anastomosis,
• subtotal colectomy with ileostomy and
• rectosigmoid mucosal fistula.

When a total proctocolectomy is performed, the entire rectum and colon are removed. If a total proctocolectomy with ileostomy is decided, an opening or orifice is made to connect the ileum with the exterior (ileostomy) to eliminate the intestinal waste in a bag (ostomy*). In the event that the medical professionals choose to perform a restorative proctocolectomy or ileoanal reservoir, a reservoir or internal pouch is created with part of the small intestine (ileum) that will be attached to the anus and function as a new rectum.

The technique known as total colectomy with ileorectal anastomosis consists of resecting the entire colon and joining (anastomosis) the ileum to the rectum.

On the other hand, in a subtotal colectomy with ileostomy and rectosigmoid mucosal fistula, only the affected areas of the colon are removed and an ileostomy is performed. If the sigma (final part of the colon) is not affected, it is left intact and communicates with the exterior through the anus or through a mucosal fistula made in the abdominal wall to drain secretions.

Possible complications in IBD surgery:

Although surgery can be transformative for many patients, it is not without risks and complications.

Some of the possible complications include:

• Infections: postoperative infections related to the surgery itself.
• Anesthesia: there are risks associated with anesthesia, such as allergic reactions or breathing problems.
• Fistulas: leaks may develop in the intestinal connections or new fistulas may form.
• Obstructions: although surgery may resolve an obstruction, the patient is not exempt from developing a new obstruction after surgery. It is recommended to follow closely the indications of the health professional to prevent it.
• Ostomy*: in case of having an ostomy, it is necessary to adapt to the new situation with the help of health professionals as this is an important change for the patient.

Thus, although surgery is reserved as a necessary measure when other options have proven to be insufficient, it is considered a treatment of choice and highly effective for the treatment of IBD.

Proper care in preparation for surgery and a correct postoperative period will be essential to minimize risks and maximize benefits.

*An ostomy consists in the externalization of the small intestine (ileostomy) or the large intestine (colostomy) through the abdominal wall, suturing it to the skin; in order to create an artificial exit for the fecal contents (stoma). The intestinal contents exiting through the stoma will be collected in a bag attached to the surrounding wall.