IBD Medical and Surgical Management
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This document discusses the medical and surgical management of inflammatory bowel disease. It outlines the main drug therapies used for ulcerative colitis and provides indications for when surgery is necessary, such as treatment failure or complications like obstruction or hemorrhage. It also describes how patients should be prepared for surgery, including correcting medical issues and withdrawing immunosuppressants. The key types of operations for Crohn's disease of the small bowel are resections and strictureplasty, with the latter aimed at avoiding short bowel syndrome. Complications of strictureplasty can include hemorrhage, restricture, or fistula/abscess/leak.
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IBD Medical and Surgical Management
- 1. General Principles of Medical and Surgical Management of Inflammatory Bowel Disease Joseph A. Di Como MD
- 2. Medical Therapy of Ulcerative Colitis • 5-Aminosalicyclic acid agents • Corticosteroids • Cyclosporine • 6-Mercaptopurine • Azathioprine
- 3. 5-Aminosalicylic Acid Agents • Sulfasalazine - 5-ASA linked to sulfapyridine by an azo bond - poorly absorbed in upper GI tract - principle use to maintain remission
- 4. Operative Indications • Failure of medical therapy • Obstruction • Fistula or abscess • Hemorrhage • Growth retardation (in pediatric population) • Perforation of carcinoma • Extraintestinal manifestations
- 5. Preparation of the Patient • Endoscopic and Radiologic studies • Correction of dehydration, electrolyte deficiencies, coagulation deficits, and anemia • Optimization of comorbid conditions • Nutritional optimization • Pre-op marking for stoma (if needed) • Bowel prep
- 6. Preparation of patient • Withdrawal of immunosuppressives • Perioperative antibiotics • Stress dose steroids • DVT prophylaxis
- 7. Strategic Planning for Surgery • Midline incision to preserve potential stoma sites • Preservation of small bowel • Resection margins—extended resection margins are unnecessary • Use of temporary stoma
- 8. Management of Small Bowel Crohn’s Diesease • Chronic obstruction (35%) • Internal fistulas (30%) • Intractability (22%) • Abscess formation (11%)
- 9. Types of Operations • Small bowel resection • Multiple small bowel resections (with enteroenterorostomy, diversion, or both) • Bypass • Strictureplasty • Balloon dilatation
- 10. Resection • Most common surgical procedure • Wide resection unnecessary • Division of inflamed mesentery
- 12. Indications for Strictureplasty • Diffuse involvement of small bowel with multiple strictures • Strictures in a pt who has undergone prev major resection of small bowel • Rapid recurrence of disease manifested as obstruction • Stricture in pt with short bowel syndrome • Nonphlegmonous fibrotic stricture
- 13. Relative Contraindications for Stictureplasty • Free or contained perforation of the small bowel • Phlegmonous inflammation, internal fistula, or external fistula involving the affected site • Multiple strictures within a short segment • Stricture in close proximity to a site chosen for resection • Colonic strictures • Hypoalbuminemia
- 19. Complications • Hemorrhage form suture line • Restricture at strictureplasty site • Fistula/Abscess/Leak • Small bowel adenocarcinoma
- 20. Take Home Points • Conservative Management • Preservation of small bowel
Editor's Notes
- The drug consists of 5-aminosalicylic acid (5-ASA) linked to sulfapyridine by an azo bond, which is poorly absorbed in the upper gastrointestinal tract. Once sulfasalazine reaches the colon after oral ingestion, bacterial azoreductases split the azo bond to release the two components. For active disease, sulfasalazine is less effective than glucocorticoids; its principal use is to maintain remission once active inflammation has subsided. The suppressive effect of sulfasalazine on the disease is maintained over many years. When given by mouth, 5-ASA is absorbed rapidly from the jejunum and does not reach the colon. Therefore, two types of delivery systems have been used to obtain high concentrations of drug in the colonic lumen. The first is to coat 5-ASA with a resin or a semipermeable membrane that is pH sensitive. The second is to link 5-ASA with another molecule by an azo bond. Table 104–6 lists the 5-ASA drugs that have been developed. The generic name for enteric-coated or delayed-release preparations is mesalamine (mesalazine in Europe). Asacol is coated with Eudragit S, which dissolves at pH 7.0 or above, whereas Salofalk and Claversal are coated with Eudragit L and release the active ingredient at pH 6.0 and above. Pentasa is mesalamine within a semipermeable membrane that releases the drug at luminal pH values greater than 6.0 in a timed-release manner. The two prodrugs are olsalazine (two molecules of 5-ASA linked by an azo bond) and balsalazide (5-ASA linked to a peptide). The pharmacodynamics of these two prodrugs is similar to that of sulfasalazine. Many clinical trials have shown that these newer salicylate drugs are as effective as sulfasalazine, both for treating active ulcerative colitis and for maintaining remission. [96] [100] Adverse effects have been minimal and occur in less than 5% of patients. Furthermore, the majority of patients who are intolerant to sulfasalazine are able to tolerate these newer preparations. Increasing the dose of these drugs increases their therapeutic efficacy without causing adverse effects. Which of these new compounds should be given? There is no clear answer to this question at the present time. One trial has shown that the relapse rate with olsalazine is lower than that with mesalamine, but this study was small and not totally blind.[101] Loose stools and occasionally frank diarrhea occur with all the 5-ASA drugs but especially with olsalazine. However, diarrhea is rarely a problem if the dose is built up gradually and the drug is taken with food. There is concern that 5-ASA may affect renal function adversely. Because the resin-coated mesalamine drugs may be released rapidly in the small intestine, blood concentrations of 5-ASA tend to be higher than those associated with olsalazine. It is therefore wise to check renal function at occasional intervals in patients receiving the mesalamine preparations. Topical treatment with sulfasalazine or mesalamine (as an enema, foam, or suppository) also can be used and is effective both for active disease and for maintenance therapy.[102] [103] It has been shown that topical mesalamine is at least as effective as, and possibly better than, topical glucocorticoids for treating active distal disease.[104] The combination of a topical glucocorticoid and mesalamine appears to be better than either alone. [105]
- Most pts with Crohn’s require at least one operation for Crohn’s in their lifetime. Need for surgery is related to the length of time the pts have had disease: &%% of pt req Sx by 20 yrs from the onset of symptoms and 90% by 30 yrs.
- Bypass—BAD. Once recommended as the procedure of choice. It was argued that this operation could be performed with few complications and might preserve intestine for later use. Later found that the bypass is associated with overgrowth of intestinal bacteria in the bypassed segment. They also have a persistent inflammatory process in the bypassed segment with the potential for abscess, bleeding or perforation. Also cancers may develop in the bypassed segment.
- Small bowel resection is the most common surgical procedure utilized to treat small bowel Crohn's disease. For many years, the optimal extent of resection necessary to provide the lowest risk for recurrence has been a subject of controversy. It was once thought that wide resection with generous margins of normal bowel combined with radical mesenteric excision would result in lower recurrence rates. The accumulated clinical data, however, do not support the need for wide or radical resection for Crohn's disease. Resection should be wide enough to encompass the limits of gross disease; wider resections offer no benefit in terms of lessening the risk for recurrence, even when the mucosal margins of the resected portion are positive for microscopic features of Crohn's disease (36). The extent of mesenteric resection does not affect the rate of disease recurrence. Division of the small bowel mesentery that has been affected by Crohn's disease is often challenging. The mesentery in Crohn's disease is typically massively thickened, with indurated fat, hypertrophied lymphatics, and engorged blood vessels. Standard techniques of simple clamping of mesenteric vessels and ligation are inadequate to handle the thickened mesentery because it is often impossible to fashion vascular pedicles for simple ligation. Inadequate control of mesenteric vessels may result in the development of large mesenteric hematomas, which further complicate the ability to gain vascular control and may even result in a compromise of mesenteric perfusion and resultant bowel ischemia.
- The preferred technique for dividing the thickened mesentery without losing vascular control is to apply overlapping clamps on either side of the intended line of transection. The mesentery is incised and the tissue within the clamps is suture-ligated
- Intestinal strictureplasty is a surgical technique that relieves intestinal obstruction while preserving the length of the small bowel. Although strictureplasty is not appropriate for all surgical cases of Crohn's disease, strictureplasty techniques are being utilized with increasing frequency
- The Heineke-Mikulicz strictureplasty technique is appropriate for strictures less than 7 cm long (37). With this technique, a longitudinal incision is made along the antimesenteric border of the stricture. The longitudinal enterotomy is then closed in a transverse fashion to increase the width of the bowel at the point of the stricture
- The <Finney> strictureplasty can be utilized for longer strictures, up to 15 cm in length (38). With this technique, the affected bowel is folded onto itself in a U shape and the two limbs are sutured together (Fig. 27.10). A longitudinal enterotomy is then made halfway between the mesenteric and antimesenteric borders, following the course of the U. Again, the mucosal surface is examined and samples are taken as necessary. Sutures are then placed on the posterior wall of the enteroenterostomy, beginning at the apex of the strictureplasty. This suture line is continued anteriorly and is reinforced with an outer layer of interrupted nonabsorbable sutures. For long strictures, the <Finney> strictureplasty may result in a functional intestinal bypass, with a sizable lateral diverticulum at risk for bacterial overgrowth. For this reason, <Finney> strictureplasties are utilized far less frequently than Heineke-Mikulicz strictureplasties.
- Patients with multiple strictures in close proximity to one another are better treated with a “side-to-side isoperistaltic strictureplasty” (39). With this technique, the loop of diseased bowel is divided at its midpoint between bowel clamps, and the mesentery is incised (Fig. 27.11). The proximal intestinal loop is moved over the distal loop in a side-to-side fashion. With the stenotic areas of one loop placed adjacent to dilated areas of the other loop, the two limbs are approximated by a layer of seromuscular interrupted, nonabsorbable sutures. A longitudinal enterostomy is performed on both loops, and the intestinal ends are tapered to avoid blind stumps. Suspected areas of disease are sampled for frozen section to exclude the presence of occult malignancy. The outer suture line is reinforced with an internal row of running, full-thickness absorbable sutures, continued anteriorly. This layer is reinforced by an outer layer of seromuscular interrupted, nonabsorbable sutures. The side-to-side isoperistaltic strictureplasty is a very recent advance in the surgical management of difficult cases of extensive Crohn's disease, and initial experience with the technique indicates that it is a safe and effective procedure in appropriately selected patients
- In a stapled stricturoplasty, the mid point of the stricture becomes the apex. The bowel is held in position by a suture or a Babcock clamp. Two small enterotomies are created and the two limbs of the stapler are inserted and fired.
- Then the linear stapler is fired. Residual tissue can be trimmed and sent as a biopsy specimen
- In resections, diseased tissue is removed and anastomotic sutures are placed in healthy intestine, whereas in strictureplasties, diseased segments are retained and suture lines are placed in diseased tissue. Perioperative morbidity after strictureplasty is similar to that after resection. The most common postoperative complication directly related to strictureplasty is hemorrhage from the suture line. Hemorrhage occurs in up to 9% of the cases. Hemorrhage following strictureplasty is typically minor and can usually be managed conservatively with blood transfusions alone. Occasionally, arteriography with selected infusion of vasopressin into the branches of the superior mesenteric artery is required to control bleeding. Only in rare instances is reoperation required to control hemorrhage following strictureplasty. Septic complications such as dehiscence, intraabdominal abscess, and fistula formation occur in only 2% to 3% of strictureplasty cases (37, 43). Although no randomized, controlled studies have directly compared recurrence rates after resection versus those after strictureplasty, the observed recurrence rates after strictureplasty in several reports compare well with published recurrence rates after resection, and rapid recurrence of symptoms following strictureplasty has not proved to be a problem (43, 44, 45). There is an increased risk for small bowel adenocarcinoma in patients with Crohn's disease. Persistently diseased intestine and continued long-term inflammation at the strictureplasty site may increase the risk for adenocarcinoma. Although isolated cases of adenocarcinoma developing close to or at the site of strictureplasty have been reported, the precise risk for neoplastic degeneration is not currently known.
- Joseph Dicomo