Surgical Interventions in Inflammatory Bowel Disease

Abstract

Inflamatuar bowel disease represent a disease spectrum with protean manifestation and complications. Although as many as half of the patients with inflammatory bowel disease require at least one surgical procedure during their lifetime, the decision to operate is rarely an easy one. Such a decision should be the result of collaboration between the gastroenterologist and the surgeon, assisted by the radiologist and the pathologist. The age and general conditions of the patient, the extent of disease, the duration of disease and prior treatment, as well as any specific complication must be considered in making the decision. Surgical interventions in Crohn’s disease are usually performed in patients who develop complications or have symptoms that are resistant to drug therapy. Surgical treatment is not curative, it is aimed at minimizing the disease. Ulcerative colitis surgery, on the other hand, is examined as an emergency and elective. Once the need for surgical intervention has been established, other factors, specific to the individual, must be considered to choose the most appropriate surgical procedure.

1. Introduction

Inflammatory bowel diseases (IBD) represent a complex disease spectrum, showcasing a multitude of clinical manifestations and potential complications. Deciding to proceed with surgical intervention in IBD cases is a nuanced process, demanding a collaborative effort involving gastroenterologists, surgeons, radiologists, and pathologists. Several critical factors, such as the patient’s age, overall health, extent and duration of the disease, prior treatment history, and the presence of specific complications, must be meticulously considered in the decision-making process. Upon confirming the necessity for surgical intervention, it becomes imperative to customize the surgical procedure based on the individual patient’s unique characteristics and needs.

2. Crohn’s disease

Crohn’s disease is a chronic, diffuse condition that has the potential to affect all segments of the gastrointestinal system, characterized by recurrent flare-ups and for which surgical cure is not attainable. Surgical intervention becomes imperative when conservative medical therapy proves ineffective or when patients develop complications such as spontaneous bowel perforation, intestinal obstruction, profuse hemorrhage, and severe inflammatory responses, such as acute fulminant colitis, necessitating immediate surgical management [1]. Additionally, patients with Crohn’s disease may encounter chronic complications like recurrent bowel obstructions and neoplastic growths, both of which can serve as indications for surgical intervention (Table 1). Nevertheless, it is worth noting that the determination of appropriate surgical indications and the optimal timing for surgical intervention remain subjects of ongoing debate.

Fistula

Abscesses

Obstruction

Hemorrhage

Cancer

Failure of medical therapy

Perforation

Toxic colitis

Table 1.

Indications for surgery in Crohn’s disease.

2.1 Fistula

The association between fistulas and Crohn’s disease is unsurprising, given the transmural inflammatory nature of the condition. Fistulas can manifest either in the early postoperative phase, within weeks following surgery, or at a later stage. Fistulas can present as either internal or external, with internal fistulas potentially arising as enteroenteric connections or extending from the bowel to various adjacent structures or organs, including but not limited to the bladder, vagina, or retroperitoneum. Enterocutaneous fistulas are categorized as external fistulas. Frequently, a stenotic region in the bowel wall is found distal to the point of fistula origin, leading to an elevation in intraluminal pressure. This particular scenario increases the predisposition to the development of such fistulas [2]. Low-output fistulas, especially in patients at high surgical risk, should be approached with non-surgical methods. If surgery is deemed necessary, resection should involve the portion of the diseased or obstructed segment proximal to the fistula. Performing wedge resection or strictureplasty within the fistula-containing segment is not recommended, as it may lead to postoperative leakage and fistula recurrence [3]. In cases of complicated fistula in a patient with widespread enterolysis, multiple anastomoses, closure of enterotomies, and procedures such as strictureplasty, the creation of a diverting ileostomy from a proximal location is warranted. Enteroenteric fistulas represent the prevailing form of abdominal fistulas encountered in Crohn’s disease, with the majority originating from the terminal ileum. These fistulas initiate within the affected segment of the bowel; nevertheless, they possess the capacity to penetrate into adjacent normal tissue. Ileosigmoid fistula is the most prevalent among this category of fistulas. Standard treatment approaches for these cases involve the removal of the diseased bowel, excision or division of the fistula tract, and the repair of the non-inflamed bowel wall. Additionally, some patients may manifest with a psoas abscess, resulting from a blind-ending fistula originating from the ileum and extending into the retroperitoneum. The management of such cases necessitates the excision of the inflamed bowel to address the condition and forestall its recurrence [4]. Enteroenteric fistulas represent the prevailing type of abdominal fistula observed in the context of Crohn’s disease, predominantly originating from the terminal ileum. These fistulas have their onset within the affected bowel segment; however, they possess the capacity to breach the boundaries into adjacent normal tissue. The standard approach for managing these cases typically involves the resection of the diseased bowel, excision or separation of the fistula tract, and restoration of the non-inflamed bowel wall. Additionally, some patients may present with a psoas abscess, which results from a blind-ending fistula extending from the ileum into the retroperitoneal space. In such instances, the resolution and prevention of recurrence necessitate the excision of the inflamed bowel [5]. Enterocutaneous fistulas can manifest either spontaneously or as a consequence of prior surgical procedures. These fistulas can significantly impact patients by causing dehydration, metabolic disturbances, skin damage, and disruptions in daily life due to uncontrolled discharge. The etiology of these fistulas plays a critical role in determining the most appropriate treatment and the likelihood of success. Approximately 75–85 percent of enterocutaneous fistulas occur in the postoperative period and are often linked to anastomotic leaks or inadvertent bowel injuries. Given the healthy nature of the affected bowel in these cases, conservative measures are more likely to lead to fistula closure. On the other hand, 15–25 percent of enterocutaneous fistulas are spontaneous and typically arise from diseased bowels affected by conditions like Crohn’s disease, radiation damage, or cancer. Surgical intervention is usually necessary for the closure of such fistulas [6, 7]. In fistula surgery, following the resection of the diseased segment and subsequent anastomosis, the primary repair of the fistula opening in adjacent organs (e.g., stomach, duodenum, bladder, vagina, and sigmoid colon) is recommended. Resection of the adjacent organ related to the fistula is only warranted if that organ is affected by Crohn’s disease. Bridging should be avoided, as it can perpetuate the disease in the bridged area, leading to potential complications such as abscess formation, bleeding, perforation, and bacterial contamination [8].

2.2 Abscesses

The formation of an abscess arises due to a microperforation stemming from the transmural inflammation of the affected bowel. The predominant anatomical site within the abdominal cavity where these abscesses tend to develop is the ileocecal region [5]. Psoas abscess emerges due to retroperitoneal perforation in the ileocecal region. Clinical presentations range from mild sepsis to pronounced psoas spasm, characterized by hip pain, thigh flexion, and external thigh rotation, often accompanied by the presence of an abdominal mass. Typically, relief is achieved through the resection of the inflammatory mass and drainage of the abscess. When practicable, it is advisable to handle these patients through a regimen involving image-guided drainage and antibiotics, reserving elective resection for a subsequent juncture. This strategy proves viable for approximately half of the patient population [9]. Technical success is achieved in more than 90% of percutaneous drainage procedures, and in the short term, over 50% of patients can circumvent the necessity for surgery [10]. In cases involving multiple abscesses, the likelihood of necessitating surgical intervention is higher. Surgical intervention becomes imperative if the patient either does not respond to drainage or fails to show improvement. In cases where the extent of the inflammatory response is extensive and encompasses multiple adjacent bowel loops, the approach should be primarily focused on abscess drainage and the establishment of a proximal diverting stoma. The primary objective of the procedure should be the drainage of the abscess, resolution of sepsis, and resection of the affected intestinal segment. Subsequently, if the patient’s hemodynamic and nutritional status permit and the final suture line can be placed at a distance from the abscess cavity, a primary anastomosis can be constructed. It is also prudent to apply an omental flap onto the remaining wall of the abscess cavity to isolate any lingering infection from the abdominal cavity and the anastomosis. If a primary anastomosis is not deemed advisable, the creation of a temporary end ileostomy becomes necessary. Subsequently, after the acute inflammatory reaction has largely subsided, a selective resection of the affected bowel can be undertaken, thus preserving a substantial portion of the bowel that might otherwise have been resected during the initial exploration. Abdominal wall abscesses, including iliopsoas and rectus sheath abscesses, are relatively less common, with an estimated prevalence falling within the range of 0.4–4%. Nevertheless, it is noteworthy that they present a more formidable challenge in terms of control when compared to intra-abdominal abscesses [9].

2.3 Obstruction

Around 20–25% of Crohn’s disease surgeries are necessitated by obstruction-related issues [11]. Patients often present with episodic crampy abdominal pain and abdominal distention. Subsequent recurrent acute episodes can exacerbate the scarring process, resulting in the formation of a fibrotic stricture and a potential escalation in symptom severity. Additional causes of obstruction in Crohn’s disease patients encompass anastomotic strictures and cancers. Chronic small bowel obstructions can arise from either singular or multiple strictures, which may be either short or long in length. Patients afflicted by this condition typically exhibit symptoms such as postprandial abdominal pain, nausea, and vomiting, which can gradually escalate into a high-grade obstruction. In cases where multiple constrictive strictures exist, the small bowel undergoes a transformation, assuming the form of a series of dilated saccular segments interspersed by constrictive, ring-like strictures. The expanded segments, characterized by the presence of partially digested food particles, create a conducive environment for bacterial overgrowth. Due to this bacterial overgrowth and the resultant stasis, patients frequently report symptoms such as intermittent diarrhea, malabsorption issues. If there are multiple strictures in the intestine, they can only be resolved through resection [12]. In selected cases, balloon dilation and stricturoplasty are preferred methods for managing intestinal strictures. The choice of strictureplasty techniques is determined by several factors, including the quantity of strictures, the length of each stricture, the extent of inflammation in the affected bowel segments, and the interplay between the bowel strictures. Indications for strictureplasty in surgery encompass multiple small bowel strictures, a history of substantial bowel resection exceeding 100 cm, patients suffering from short bowel syndrome, strictures without concurrent inflammatory lesions but accompanied by fistula formation or phlegmon, strictures occurring at previous anastomotic sites, as well as instances involving growth retardation [13, 14]. It is well-established that strictureplasty is contraindicated in patients with sepsis associated with abscess or phlegmon, as well as in cases characterized by severe inflammation leading to diffuse peritonitis. Other contraindications include suspicion of carcinoma, hypoalbuminemia (<2 g/dl), and tension during strictureplasty closure [15]. The Heineke-Mikulicz (HM) strictureplasty represents a traditional approach primarily utilized for addressing short-segment strictures measuring less than 10 cm. Conversely, the Finney strictureplasty is designed for intermediate strictures spanning from 10 to 25 cm in length, employing a side-to-side technique. This procedure involves the creation of a “U”-shaped enterotomy and anastomosis, forming a blind pouch to alleviate the stricture. The Jaboulay strictureplasty, similar to the Finney method, is intended for intermediate bowel strictures. Notably, it differs in terms of the anastomotic site, which involves relatively healthy bowel sections excluding the stricture site. Following the exposure of the antimesenteric border of the bowel, encompassing the stricture site, an enterotomy is performed via a longitudinal incision in a separate healthy bowel segment. The Judd strictureplasty is a valuable technique designed for short-segment strictures accompanied by a fistulous opening. In contrast, the Moskel-Walske-Neumayer strictureplasty is employed to align the constricted distal bowel lumen with the dilated proximal lumen, utilizing a “Y”-shaped enterotomy. The side-to-side isoperistaltic strictureplasty is a procedure intended for lengthy strictures spanning more than 20–25 cm (Table 2) [16, 17].

Segment length	Strictureplasty technique
<10 cm	Heineke-Mikulicz strictureplasty
	Judd strictureplasty
	Moskel-Walske-Neumayer strictureplasty
10–25 cm	Finney strictureplasty
	Jaboulay strictureplasty
>25 cm	Side-to-side isoperistaltic strictureplasty
	Michelassi’s strictureplasty
	Sasaki strictureplasty

Table 2.

Strictureplasty procedures based on the length of strictures.

In the past, bypass or exclusion surgery was a common approach for ileocecal Crohn’s disease. However, in the current medical landscape, bypass surgery is no longer recommended due to the increased occurrence of septic complications post-surgery and the elevated risk of malignant transformation in the bypassed segment [18].

Endoscopic balloon dilation may be regarded as a viable component within the therapeutic repertoire for addressing obstructive complications of Crohn’s disease resulting from strictures. However, it is crucial to exercise caution, as the risk of perforation not only raises morbidity but also elevates the potential for mortality.

2.4 Hemorrhage

Massive intestinal hemorrhage is an uncommon complication associated with terminal ileitis in Crohn’s disease. Since the bleeding stems from active disease, individuals with Crohn’s disease may experience recurrent episodes, often necessitating surgical intervention. The assessment and management of this complication closely align with approaches used for other causes of gastrointestinal bleeding [19]. In cases where the disease’s extent is restricted, as assessed through contrast radiography, deliberation should lean towards elective resection. However, in the presence of persistent and uncontrollable hemorrhaging, it is prudent to pursue an angiogram (typically after a preceding bleeding scan) to precisely identify the bleeding source, especially when multiple disease sites are involved [20].

2.5 Cancer

Individuals afflicted with Crohn’s disease face an elevated lifetime risk of developing cancer. The majority of cancers that arise in individuals with Crohn’s disease are adenocarcinomas. However, in comparison to de novo cancers, these cancers tend to manifest at a younger age, exhibit a higher prevalence in the distal small bowel, and can often present as multifocal malignancies [21]. The occurrence of cancer is intricately associated with the presence of chronic perineal fistulae and segments of the small bowel that have been excluded from the normal digestive process. Surgeons have traditionally refrained from performing intestinal bypass procedures or leaving excluded intestinal segments in situ for prolonged periods due to the increased susceptibility to cancer development within these bypassed loops, coupled with the inherent difficulties in imaging such segments. Surgical management of small bowel carcinomas in individuals with Crohn’s disease primarily involves segmental radical resection, whenever possible. Unfortunately, the prognosis for such cases tends to be grim [22].

2.6 Failure of medical therapy

Approximately one-third of patients undergo surgery for Crohn’s disease after failure of medical treatment [4]. In the end, surgical intervention becomes a consideration when all medical avenues have been explored exhaustively. The criteria for medical therapy failure go beyond mere symptom control; it also encompasses cases where patients, even with symptom management, experience intolerable side effects or adverse reactions stemming from their prescribed medications. The timing of intervention plays a pivotal role in averting the worsening of health status, the onset of malnutrition or weight loss, or the requirement for escalating steroid doses, all of which could have substantial adverse effects on surgical results.

2.7 Perforation

Perforation is an exceedingly uncommon event in Crohn’s disease. When sepsis, abdominal pain, and diffuse peritonitis are present, emergency surgical intervention is required to manage sepsis effectively. This condition is typically associated with complete obstruction or toxic colitis. Diagnostic laparotomy frequently entails the need for stoma creation following resection. The decision for intestinal resection should be based on surgical findings and the patient’s condition [9]. When the perforation is a result of complete obstruction caused by a small bowel stricture, it frequently appears just proximal to the stricture site. In such instances, the optimal therapeutic approach entails resection with primary anastomosis, with potential consideration of a proximal diversion. On the other hand, in cases where the perforation is associated with toxic colitis, it tends to occur at the necrotic segment of the bowel wall. In these scenarios, the advised course of action is total abdominal colectomy with the establishment of an end ileostomy.

2.8 Toxic colitis

Toxic colitis represents a grave and potentially life-threatening condition if not managed appropriately and promptly. Patients with severe colitis typically exhibit signs of systemic toxicity. These individuals present with persistent and frequently bloody diarrhea, as well as abdominal pain that remains unresponsive to medical intervention [23]. With the progression of the condition, toxic colitis can ensue. While this complication is more commonly associated with ulcerative colitis, it’s crucial to bear in mind that it can also manifest in individuals with Crohn’s disease. Age, gender, and colon perforation are among the factors that affect mortality. In the absence of perforation, the treatment regimen often includes high-dose steroids, bowel rest, and antibiotics. If no improvement is observed, emergency surgery should be promptly carried out. Patients require immediate surgical intervention within a 24–72 hour window. Delaying surgery can have severe repercussions and result in heightened postoperative complications [24]. The preferred surgical procedure for these patients involves performing a total abdominal colectomy with the creation of an end ileostomy.

3. Ulcerative colitis

Ulcerative colitis primarily affects the colon and rectum. While surgical intervention in Crohn’s disease is typically palliative, in the case of ulcerative colitis, the complete removal of the colon and rectum offers a curative resolution for the disease. Roughly 25–30% of individuals afflicted with ulcerative colitis (UC) will necessitate surgical intervention during their lifetime [25]. Surgical strategies for UC can be categorized into two main groups: emergency and elective procedures (Table 3) [26].

Elective	Emergency
Colorectal cancer/dysplasia	Toxic megacolon
Extraintestinal manifestations	Perforation
Intractability to medical treatment	Fulminant colitis
Treatment-related complications	Uncontrolled hemorrhage

Table 3.

Indications for surgery in ulcerative colitis.

3.1 Toxic megacolon

Toxic megacolon is an infrequent yet potentially fatal condition. The primary contributor to mortality among individuals with ulcerative colitis is toxic megacolon. While toxic megacolon typically arises as a consequence of disease relapse in most patients, it can also manifest as an initial presentation of the condition in some cases. Due to impaired colon motility stemming from the nerve plexus involvement within the muscularis propria layer, colon dilation and subsequent ischemia ensue, leading to the onset of toxic megacolon. It’s important to note that colon dilation in isolation does not warrant immediate surgical intervention [26, 27]. “Jalen” criteria in the clinical diagnosis of toxic megacolon is the most widely used measure. The presence of at least two of these criteria, which include fever >38°C, a heart rate exceeding 120 beats per minute, leukocytosis >10,500/μL, and anemia, in conjunction with at least one of the following: dehydration, electrolyte disturbances, alterations in consciousness, or hypotension, is required. The colon diameter is usually wider than 6 cm. Initially, a regimen of bowel rest, intravenous fluids, broad-spectrum antibiotics, and intravenous steroids should be considered [28]. In the absence of clinical deterioration or significant clinical conditions, the recommended duration for medical treatment is 4–7 days, during which it has been demonstrated that the need for emergency surgery dissipates in 50% of patients [29]. The goal is to eliminate the need for emergency surgery and transition the patient to an elective status. In emergent situations, the primary surgical intervention typically involves a total abdominal colectomy with the creation of an end ileostomy (with or without a mucus fistula). This resection effectively eliminates the majority of the diseased colon [27].

3.2 Perforation

Although the risk of perforation is low in the absence of toxic megacolon, the risk of perforation is high in the first attack. Although rare, its mortality rate is high. The risk of perforation is associated with the severity of the acute attack and the extent of inflammatory conditions within the colon. A direct radiograph usually allows for a diagnosis of free perforation, but in cases of closed perforation, computerized tomography is helpful. Surgical method total colectomy and terminal ileostomy should be preferred [30].

3.3 Fulminant colitis

Fulminant colitis is a condition defined by extensive transmural inflammation of the serosa and systemic manifestations of toxicity. Acute fulminant colitis occurs in approximately 10% of patients with ulcerative colitis [29]. The severity of UC can be classified into categories of mild, moderate, severe, or fulminant, depending on factors such as daily bowel movements, systemic symptoms, and inflammatory markers. It is imperative to routinely evaluate these patients objectively by monitoring parameters like hemoglobin levels, C-reactive protein (CRP) levels, stool frequency, and abdominal imaging. Surgery is typically recommended in cases of clinical deterioration or if significant clinical improvement is not observed within a 7-day timeframe [31]. When a diagnosis of fulminant colitis is established, treatment should be initiated promptly, and if possible, the patient should be monitored under intensive care conditions. In cases of unresponsiveness to medical treatment, emergency colectomy should be performed for the patient [29].

3.4 Uncontrolled hemorrhage

Massive hemorrhage represents another indication for emergency surgery. The bleeding arises from extensive mucosal ulcerations, necessitating abdominal colectomy. For patients who do not respond to resuscitation, the preferred surgical approach is total colectomy, the creation of an end ileostomy, and closure of the rectal stump. Keeping the rectal stump in place preserves the possibility of a future restorative procedure. Nevertheless, it is important to note that bleeding may persist in certain cases where proctectomy was not performed. In such instances, it typically responds to higher doses of systemic steroids, topical steroid administration, or intrarectal tamponade using gauzes soaked in a diluted adrenaline solution. In cases of persistent bleeding, proctectomy should be considered as the recommended course of action [32].

3.5 Colorectal cancer/dysplasia

A diagnosis of dysplasia, dysplasia-associated lesions or invasive carcinoma in a patient with UC is an unequivocal indication for surgery. Patients with ulcerative colitis are recognized to be at a heightened risk of developing colorectal cancer [33]. The likelihood of malignancy rises with extensive colonic involvement and the duration of symptoms, with an estimated risk of approximately 2% at the end of 10 years, 8% at the end of 20 years, and 18% at the end of 30 years [34]. Therefore, the preferred course of action for UC patients presenting with colorectal cancer or high-grade dysplasia is proctocolectomy, either with an end ileostomy or through ileal pouch anal anastomosis. The necessity and timing of surgery in patients with low-grade dysplasia continue to be subjects of intense debate. While low-grade dysplasia has long been considered to carry minimal risk, up to 20% of patients with low-grade dysplasia may have invasive cancer present. Furthermore, patients can advance from low-grade dysplasia to colorectal cancer without any intermediate signs of high-grade dysplasia. It should be noted that when dysplasia of any degree is discovered at colonoscopy, the likelihood of a concomitant carcinoma is high [35]. Nonetheless, it is worth mentioning that a variety of small observational studies have not demonstrated a definitive pattern of dysplasia progression. Consequently, some proponents argue for close endoscopic surveillance as a management strategy for low-grade dysplasia, with surgical intervention reserved for those patients who subsequently develop high-grade dysplasi or colorectal cancer [36, 37]. When low-grade dysplasia is localized to a single lesion, annual colonoscopy suffices. In instances of multifocal occurrence, monitoring every 6 months is recommended, with the patient being educated about the possibility of prophylactic proctocolectomy [34, 38, 39]. In ulcerative colitis, there are two widely accepted elective surgical options: total proctocolectomy with an end ileostomy or restorative proctocolectomy with ileal pouch anal(J,S,W) anastomosis. Various risk factors have been proposed during the postoperative period. In ulcerative colitis, pouch-related septic complications, especially in immunosuppressed patients. Closure of a diverting loop ileostomy is typically carried out 6–8 weeks following confirmation of the intact ileal J-pouch-anal anastomosis. Assessment of the ileal J-pouch is conducted through either a colonoscopy.

3.6 Extraintestinal manifestations

Surgical treatment is seldom required for the extraintestinal symptoms of ulcerative colitis. Among the extraintestinal manifestations that show improvement after colectomy are peripheral arthritis, erythema nodosum, pyoderma gangrenosum, thromboembolic complications, and ocular symptoms like uveitis, iritis, and episcleritis [40].

3.7 Intractability to medical treatment/treatment-related complications

It is the most frequent surgical indication in ulcerative colitis. Prolonging the course of medical treatment in the event of therapeutic failure also diminishes the likelihood of a favorable response to surgical intervention. Patients with chronic, active disease and a short tubular colon due to chronic mucosal inflammation and scarring on radiological assessment should be considered for surgical evaluation and treatment. Patients with ongoing active disease despite a 3-month course of medical treatment or those requiring steroid therapy for more than 12 months should undergo assessment for surgical intervention.

Patients who develop severe side effects or complications during medical treatment are also candidates for surgical intervention. Surgery should be considered for reasons such as bone pathologies, ocular issues, psychiatric problems, and growth retardation that arise due to immunosuppressive therapy [41, 42].

4. Indeterminate colitis

In approximately 5% of cases of inflammatory bowel diseases, a definitive diagnosis of either ulcerative colitis or Crohn’s disease cannot be established [43]. The most significant reasons for this are inadequate clinical, radiological, endoscopic, and pathological information or the presence of features showing both ulcerative colitis and Crohn’s disease in the patient [44]. In such cases, it is termed indeterminate colitis, which is not a specific disease. Indications for surgery for indeterminate colitis are consistent with ulcerative colitis; It includes incurability, complications from medical treatment, and risk or onset of malignancy. If the diagnosis strongly suggests ulcerative colitis, ileal pouch-anal anastomosis can be performed. In cases where the diagnosis remains unclear, the most logical surgical option is to proceed with completion proctectomy and create an end ileostomy (as in Crohn’s colitis) [45].