IBD is a group of chronic, progressive inflammatory bowel diseases, including Crohn’s disease and ulcerative colitis, that are prolonged and often require surgical intervention due to complications or failure of medical therapy. In a recent multicenter study, the cumulative surgical rates were 16.3%, 33.3%, and 46.6% 1, 5, and 10 years after the diagnosis of Crohn’s disease, respectively, and 4.9%, 11.6%, and 15.6% 1, 5, and 10 years after the diagnosis of ulcerative colitis, respectively.
With increasing understanding of IBD and advances in drug development, such as the availability of anti-TNF-α monoclonal antibodies, the overall surgical rate for this disease has declined over the years. Even so, surgical treatment remains an indispensable option for some patients. Although surgical treatment allows patients with IBD to achieve longer remission, the difficulty and complication rate of reoperation is much higher than that of the first surgery, and multiple surgeries can lead to malnutrition and short bowel syndrome, so surgical treatment needs to be chosen carefully.
1 Current status of IBD surgical treatment
There is a consensus that intestinal complications of IBD, including intestinal obstruction, intestinal fistula, abdominal abscess, toxic colitis, and gastrointestinal bleeding, often require emergency surgical management.
In a cohort study conducted by Danish scientists, of 2,889 patients with IBD treated surgically, half had emergency surgery and half had elective surgery, with a 30-d postoperative mortality rate of 5.2% in patients with ulcerative colitis and 8.1% in patients with Crohn’s disease who had emergency surgery, compared with 0.9% in patients with ulcerative colitis and 1.5% in patients with Crohn’s disease who had elective surgery. Therefore, the choice of the appropriate timing of surgery to avoid emergency surgery is a decisive point in the overall treatment strategy of IBD.
The timing of surgery cannot be standardized due to the individual patient’s condition, and surgical treatment is often the last but not the best option for IBD patients. The majority of IBD patients are admitted to gastroenterology, and internists often choose surgical consultation only when drug therapy has failed or serious complications have developed, which leads to a loss of optimal timing for surgery.
At this time, patients have already developed acute abdomen, malnutrition, water-electrolyte disorders and even unstable vital signs, and the condition is complicated.
Based on the modern medical concept, some large medical centers in China have built a multidisciplinary treatment model for IBD, which consists of medical teams of specialists in internal medicine, surgery, imaging, ultrasound, pathology, etc. to develop an overall treatment strategy for IBD and help patients choose the right time for surgical treatment. The promotion of this model is expected to reduce the emergence of awkward treatment situations.
2 Surgical treatment strategies and techniques for Crohn’s disease
2.1 Crohn’s disease combined with intestinal obstruction
IBD with intestinal obstruction is most commonly seen in Crohn’s disease, and Aarnio et al. found that about one-third of patients with early Crohn’s disease required surgical treatment, with most of them having intestinal obstruction as an indication for surgery. Most of the intestinal obstruction associated with Crohn’s disease is due to intestinal inflammatory activity, tissue edema, or inflammatory fibrosis. Early intestinal obstruction may be due to tissue edema only and can be restored by fasting, indwelling gastric tube and treatment with anti-inflammatory drugs such as glucocorticoids or biologics.
Once fibrosis has formed in the intestinal wall, conservative medical treatment is often difficult to relieve the obstruction, and surgery becomes a better option.
CT or MR imaging of the intestine can make a preliminary determination of fibrosis-like changes in the intestine, but most patients need to rely on the clinical course for identification. In addition, post-IBD anastomotic stricture is a common cause of intestinal obstruction in Crohn’s disease.
Endoscopic stenosis dilatation is a safer way to treat primary and secondary intestinal strictures in Crohn’s disease, but this procedure is currently limited to the treatment of colonic-type strictures. Follow-up of endoscopic treatment of intestinal strictures in Crohn’s disease showed that 1 in 3 patients with Crohn’s disease treated endoscopically still required surgery; however, endoscopic treatment extended the time to surgery for patients by an average of 33 months.
In terms of disease progression and treatment options, surgical management is the ultimate choice for patients with Crohn’s disease combined with intestinal obstruction, especially in those who have developed intestinal fibrosis. The choice of segmental resection or stenoplasty for the management of intestinal strictures is controversial, but both procedures are safe and feasible.
2.2 Crohn’s disease combined with abdominal abscess
Crohn’s disease is prone to perforation due to transmural inflammation of the intestine, and although free perforation rarely occurs, spontaneous abdominal abscesses are likely to develop. The treatment of Crohn’s disease combined with abdominal abscesses is still a great challenge for clinicians. In the past, it was often treated surgically, with the main modality being abscess incision and drainage, combined with or without resection of the diseased bowel segment. This has the advantage of removing a large amount of necrotic tissue in a single, more complete procedure, especially in the case of isolated abscesses, multiple abscesses or giant abscesses.
However, abscess incision and drainage is highly invasive and has a high incidence of postoperative complications. Percutaneous drainage was commonly used in the past with outdated medical equipment to treat abscesses that were superficial or could not tolerate surgery. Nowadays, the rapid development of imaging and radiological interventional techniques not only allows a more accurate diagnosis of Crohn’s disease, but also percutaneous percutaneous drainage under CT or ultrasound guidance makes abscess drainage simple and feasible, even for complex abscesses, with the advantages of less trauma and lower incidence of extraintestinal fistulae.
Gervais et al. reported that the short-term effectiveness of percutaneous drainage in the treatment of Crohn’s disease combined with abdominal abscesses (i.e., no need for surgical treatment within 60 d after drainage) reached 50%, and further studies found that 50% of patients with short-term effectiveness still did not require surgical treatment at long-term follow-up, suggesting that percutaneous drainage can lead to clinical cure of abdominal abscesses.
However, Gutierrez et al. showed that about 1/3 of patients with simple drainage still required surgical treatment within 1 year; failure of puncture drainage required surgical intervention or even emergency surgery, which is extremely risky. Therefore, it is recommended that patients with Crohn’s disease combined with abdominal abscesses should first be treated with antibiotics and percutaneous drainage to control the infection, followed by a limited period of surgical treatment. This will not only correct the patient’s electrolyte disturbance and improve his nutritional status in the short term and avoid emergency surgery, but also reduce the incidence of postoperative complications.
Abdominal abscesses due to anastomotic leakage occurring after surgery, diffuse peritonitis and limited peritonitis due to abscesses should be treated differently. Patients with diffuse peritonitis or severe intra-abdominal contamination require, in most cases, dissection to cleanse the abdominal cavity and perform an enterostomy. Since the anastomosis has been completely destroyed and the stump is not suitable for reanastomosis, a proximal enterostomy with ten distal closures is required. Therefore, in the author’s opinion: anastomotic leak with restrictive peritonitis needs to be diagnosed as soon as possible to understand the severity of the anastomotic leak.
Early surgical management can reduce the morbidity and mortality rate of this complication. However, the preoperative diagnosis of patients with combined restrictive peritonitis is often unclear and requires the vigilance of the clinician. Once an abscess is evident, puncture drainage can be performed by ultrasound or radiologic guidance. If open drainage of the intra-abdominal abscess is required, a simultaneous proximal enterostomy is recommended. For patients who develop an extra-intestinal fistula within a short period of time after surgery, Iesalnieks et al. suggest an early resection of the anastomosis and a proximal ileostomy.
2.3 Techniques for reconstruction of the GI tract after bowel resection for Crohn’s disease
The success of GI reconstruction after Crohn’s disease bowel resection is not only to reduce the occurrence of recent anastomosis-related complications, but also, and more importantly, to prevent the recurrence of postoperative anastomotic inflammation. Due to the special condition of the intestinal tract in IBD, the “mass-like” adhesions, edema of the intestinal wall, and the broken intestinal wall make the anastomosis more difficult, therefore, the quality of the anastomosis should be emphasized in the reconstruction of the GI tract. A good blood supply to the anastomosis after Crohn’s disease resection, a tension-free anastomosis, and maximum drainage (both intra- and extra-intestinal) are the skills and basic requirements for GI anastomosis.
The choice of anastomosis has always been an important part of the surgical management of Crohn’s disease. The mode of anastomosis after intestinal resection for Crohn’s disease is still controversial. It has been shown that if a larger anatomical channel can be formed in the intestine after anastomosis, obstruction, stool retention and bacterial overgrowth at the anastomosis site can be reduced, thus reducing the recurrence of anastomotic inflammation. Local alteration of the bacterial flora at the anastomosis is one of the important factors contributing to anastomotic leakage.
Simillis et al. reported a Meta-analysis of surgical anastomotic approaches in Crohn’s disease. The study summarized the clinical data of 712 patients with Crohn’s disease, and their findings showed that the incidence of postoperative complications, especially anastomotic leakage, was high in patients with Crohn’s disease who underwent enteroenteric end-to-end anastomosis after bowel resection, and the average length of hospital stay was longer, while the rate of inflammatory recurrence was comparable to that of lateral enteroenteric anastomosis. However, if the anastomosis is not handled properly or skillfully, it will lead to anastomosis-related complications.
The results of a previous study by the author’s team found that the former has the advantages of fewer overall postoperative complications, lower inflammatory recurrence rate, and lower reoperation rate when compared with manual end-to-end anastomosis after ileocolic resection in patients with Crohn’s disease.
In intestinal reconstruction, fecal diversion is an important tool in the surgical management of IBD. Temporary fecal diversion can often stabilize complex, acute IBD patients to allow for better management of other clinical management at a later stage. Surgeons’ concerns about fecal diversion are mainly related to restoring the original bowel continuity, especially in patients with Crohn’s disease.
A German study analyzing the indications for temporary stoma in patients with IBD showed that approximately 70% of patients requiring a temporary stoma to prevent anastomotic leakage or complications were able to undergo stoma retraction, but only 40% of patients with perianal Crohn’s disease, urogenital fistula, inflammation or stricture of the rectum were able to close the temporary stoma.
The temporary stoma can be closed. Although failure of stoma retraction is not due to the choice of stoma per se, but rather to disease progression in Crohn’s disease itself, it is desirable to aim for a longer stoma-free time in Crohn’s disease patients. Therefore, the choice of temporary fecal diversion in Crohn’s disease surgery needs to be made with caution.
3 Surgical treatment strategies and techniques for ulcerative colitis
3.1 Surgical treatment strategies for ulcerative colitis
The main reason for patients with ulcerative colitis to undergo emergency surgery is acute severe ulcerative colitis. According to Truelove&Witts criteria, patients with ulcerative colitis are diagnosed with severe ulcerative colitis if they have blood in their stools ≥6 times/d, tachycardia (heart rate >90 beats/mm), with or without fever (temperature >37.8°C) and anemia (Hb<105>30 mm/h).
Patients with acute severe ulcerative colitis often have a history of treatment with glucocorticoids or even high doses of glucocorticoids, or have undergone “remedial therapy”, and surgical treatment should be chosen as soon as possible if these treatments fail. In addition, ulcerative colitis with toxic megacolon and gastrointestinal hemorrhage are also indications for emergency surgery for ulcerative colitis.
Cancer of the intestinal tract is a serious complication in the progressive stage of ulcerative colitis, as reported by Eaden et al. In China, only 4 out of 242 patients with ulcerative colitis reported to have cancer in 2008 in Shanghai Ruijin Hospital, which is not common in clinical practice. It is important to monitor the disease progression of these patients and to take early surgical interventions for those who are prone to cancer or show signs of cancer.
3.2 Surgical treatment techniques for ulcerative colitis
Total colorectal resection ileal pouch anastomosis is the mainstay of surgical treatment of ulcerative colitis. For ulcerative colitis that is refractory or ineffective to drug therapy, there is not much controversy about the elective choice of ileal pouch anastomosis. Although it has been suggested that ileal pouch anastomosis should be performed in a single visit even in emergency surgery, it is sometimes difficult to perform ileal pouch anastomosis in an emergency setting, especially for less experienced surgeons.
If the surgeon is not sure of the first ileal pouch anastomosis, it is recommended to complete it in steps, i.e., subtotal colectomy first, and the level of rectal dissection is chosen to be the level of sacral capsule, which can reduce the difficulty of operation and the risk of pelvic nerve injury when performing rectal resection later.
There are many ways to deal with the rectal stump, including simple closure of the rectal stump and fixation to the anterior abdominal wall, subcutaneous closure through the abdominal fascia, or creation of a mucus fistula. Because the dissected rectum may also be inflamed, fluid secretion for a short period of time can cause the rectal stump to fracture, and it is wise to choose to leave the anal canal in place for decompression therapy.
The production of ileal storage bag is an important step in ileal storage bag anastomosis, and the good blood supply and tension-free anastomosis of ileal storage bag is the key to the success of ileal storage bag anastomosis. Before making the pouch, the small bowel mesentery is dragged along the mesenteric vascular axis as far as possible to the pubic symphysis, and then the pouch-anal anastomosis is performed directly, and the anastomosis is tension-free; if there is mesenteric shortening, the mesentery needs to be free to the ascending duodenum, and sometimes it is necessary to open the
Kocher incision.
There are two forms of anastomosis between the ileal pouch and the anal canal: anastomosis without stripping the rectal mucosa, leaving 1-2 cm of migrating epithelium and rectal mucosa; and manual anastomosis with stripping of the rectal mucosa followed by manual suturing. However, there is no accepted standard method of anastomosis between the ileal pouch and the anal canal, and ClevelandClinic in the United States prefers to use anastomosis without conventional rectal mucosal debridement, while Mayo Clinic
Mayo Clinic believes that atypical hyperplasia can still occur in the migratory area of the anal canal and the pouch, therefore, they advocate that ulcerative colitis with atypical hyperplasia is an indication for manual anastomosis after mucosal debridement.
There are no studies to confirm whether atypical hyperplasia occurs in the residual rectal mucosa after rectal resection for ulcerative colitis. Therefore, the Cleveland Clinic experience in the treatment of ulcerative colitis has been used by the author’s team to facilitate the use of the anastomosis during surgery, and the patient has better postoperative anal function and better postoperative quality of life than with mucosal debridement.
4 Preoperative medication use
The use of perioperative medications is important in the choice of surgical timing and sometimes influences the decision of the medical surgeon. Most patients with IBD requiring surgical treatment have undergone long-term drug therapy, including glucocorticoids, immunosuppressive agents, or biologics.
4.1 Glucocorticoids
It is now clear that preoperative glucocorticoid use is a high risk factor for postoperative complications in both patients with ulcerative colitis and Crohn’s disease, especially at high doses (prednisolone >20 mg/d or equivalent). The results of one study showed that the incidence of complications after total colectomy in patients with acute severe ulcerative colitis with preoperative glucocorticoid use >8 d was about 60%.
Continued use of glucocorticoids in cases of ineffective glucocorticoid therapy, hormone resistance or dependence will greatly increase the risk of surgery, and emergency surgery at this time will significantly increase the risk of surgical complications.
According to the Consensus Opinion on Diagnosis and Treatment of Inflammatory Bowel Disease (2012) developed by the Inflammatory Bowel Disease Group of the Chinese Society of Gastroenterology, once a patient with inflammatory bowel disease has been treated with sufficient glucocorticoids for 5 d but with poor results, the treatment should be changed immediately and remedial therapy or surgery should be chosen. The most commonly used drugs for remedial therapy are cyclosporine A and infliximab.
Remedial therapy may allow some patients with acute toxic ulcerative colitis to avoid total colectomy; some patients who do not respond to remedial therapy will require reoperation, but the risk of reoperation will be further increased; and even if remedial therapy is successful, some patients will eventually need to undergo surgery. Therefore, the author believes that the possibility of success should be considered during the remedial treatment of patients with inflammatory bowel disease, and once the chance of success is considered slim, remedial treatment should be stopped and surgery should be performed immediately.
4.2 Biological agents
There is considerable debate as to whether the use of biologic agents increases postoperative complications in IBD. The effect of preoperative anti-TNF-α monoclonal antibodies on IBD
The effect of preoperative anti-TNF-α monotherapy on complications after abdominal surgery is clearly controversial, even if Crohn’s disease and ulcerative colitis are analyzed in subgroups. The results of two Meta-analyses of the study conducted by Fan Deming’s team in China on the effect of infliximab on the complications of abdominal surgery in ulcerative colitis reflect a shift from the previously accepted view that infliximab increases the incidence of early postoperative complications in patients with IBD to one in which it does not increase the incidence of early postoperative complications.
The impact of infliximab on postoperative complications in Crohn’s disease is even more hotly debated. Most scholars believe that infliximab increases the incidence of postoperative complications, especially infectious complications, in patients with Crohn’s disease. However, the safe duration of preoperative discontinuation of infliximab in Crohn’s disease patients is unclear and still needs to be verified by further studies.
4.3 Nutritional agents
Most patients with IBD have malnutrition, which is one of the high-risk factors for postoperative complications in patients with IBD. Malnutrition is not only associated with slow wound healing, but also with more severe incisional dehiscence, incisional hernia and anastomotic leakage.
Therefore, it is very important to improve the nutritional status of patients with appropriate preoperative medications. The results showed that the incidence of postoperative complications was higher in malnourished patients, but the difference between the cumulative endoscopic recurrence rate and clinical recurrence rate in malnourished and normal patients was not statistically significant, indicating that the perioperative nutritional status affects the short-term postoperative outcome of Crohn’s disease patients.
For patients with malnourished IBD, adequate perioperative nutritional support, active use of nutritional support to improve their nutritional status, and correction of malnutrition before surgery can reduce the incidence of postoperative complications in patients with Crohn’s disease from 30.0% to 9.3%. In recent years, my medical center has adopted enteral nutrition combined with parenteral nutrition as the main means to improve the nutritional status of patients with IBD before surgery, and the improvement of enteral nutrients has enabled most patients, including some with abdominal infection, to tolerate enteral nutrition for a period of time, creating a better opportunity for surgery.
5 Conclusion
In most cases, IBD is a medical disease. When medical treatment is unable to maintain the patient in remission or irreversible complications have occurred, the patient needs to be rapidly transferred to preoperative preparations including adjustment of medications and improvement of nutritional status to obtain the best physiological functional reserve for surgical treatment of IBD patients. The choice of surgical treatment and timing is determined by the type of disease, its progression, and the individual patient’s condition. The development of an overall treatment strategy for IBD through a multidisciplinary approach will be the trend in the treatment of prolonged IBD.