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Surgical therapy for inflammatory bowel disease

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VOL: 97, ISSUE: 10, PAGE NO: 34

Judy Sercombe, RN, is inflammatory bowel disease specialist nurse, centre of gastroenterology, Royal Free Hospital, London

Crohn's disease and ulcerative colitis are chronic, relapsing inflammatory bowel disorders that affect the gastrointestinal tract. Their symptoms are similar and may include the passing of uncontrollable bloody diarrhoea, abdominal pain, fever, anaemia, and loss of appetite and weight.

Crohn's disease and ulcerative colitis are chronic, relapsing inflammatory bowel disorders that affect the gastrointestinal tract. Their symptoms are similar and may include the passing of uncontrollable bloody diarrhoea, abdominal pain, fever, anaemia, and loss of appetite and weight.

Long-term medical treatments are necessary to control these symptoms and prevent complications. But if the disease cannot be controlled with medication, surgery will be required. Although the medical management of both diseases is similar, the surgical interventions available and the outcomes of surgical therapy are different.

The indications for surgery in inflammatory bowel disease vary (Table 1) and several factors have to be considered before surgical interventions are carried out (Table 2).

Most operations are performed as elective procedures, which allows the gastroenterologist and surgeon to decide on the most appropriate operation and gives patients time to consider their options. But in some cases emergency surgery is essential and is performed as a life-saving measure.

Crohn's disease
Crohn's disease can occur in any part of the gastrointestinal tract but the most common sites include the terminal ileum, colon and perianal area. It is associated with patchy transmural inflammation, with giant cells and granulomas (Finlay, 1999). Inflammatory changes can spread through the entire depth of the bowel wall, causing fistulae to develop in adjacent loops of the intestine or other structures, such as the vagina, bladder or skin. Luminal narrowing and strictures of the bowel wall can occur, resulting in the symptoms of intestinal obstruction or perforation.

Crohn's disease remains incurable by either surgical or medical treatments, so the aims of surgical treatment are:

- To control the symptoms while maintaining continuity of the gastrointestinal tract (Strong, 1997);

- To restore health by eliminating or alleviating complications, such as strictures, fistulas or abscesses (Rowlinson, 1999).

Intestinal resection

This is the most common operation performed on the small bowel for intestinal obstruction. It involves resection of the terminal ileum and caecum with ileocolic anastomosis (Fig 1). In most cases intestinal continuity is maintained, but if the diseased bowel is dilated or toxic, a stoma may be required.

Because of the risk of further flare-ups and the possibility of more operations, most surgeons resect only severely diseased bowel, preserving as much of the intestine that appears normal as possible.

Resections for Crohn's disease in the small bowel may result in diarrhoea because of the excision of the ileocaecal valve or the amount of small bowel removed. As a consequence of surgery there may also be a decrease in the absorption of nutrients, fats and vitamin B12 by the small intestine.

Stricturoplasty

In the past, patients requiring multiple resections for intestinal obstruction and narrowed segments of bowel were sometimes left with an insufficient length of functioning small intestine. A life-threatening complication of this is short bowel syndrome.

Stricturoplasty was developed to prevent these patients from becoming nutritionally compromised. The aim is to conserve small bowel while safely eliminating symptomatic strictures (Strong, 1997). The technique is accomplished by excising the stricture longitudinally and closing the incision transversely (Fig 2). This means the narrowed area is made wider without the loss of any intestine. Most patients are able to eat well and therefore regain weight soon after this procedure.

Surgical intervention colon and rectum

In colonic Crohn's disease, patients are likely to present with life-threatening complications, such as perforating disease, haemorrhage or toxic megacolon. The most common emergency procedure is subtotal colectomy with ileostomy and oversewing of the rectum. This allows for ileorectal anastomosis to be considered at a later stage (Becker, 1999).

The need for elective surgery in colonic Crohn's disease evolves over a period of time, usually after acute flare-ups (Rolandelli, 1994). Several types of surgical intervention can be considered, ranging from temporary defunctioning ileostomy to removal of the entire colon and rectum (Becker, 1999).

Segmental resection of colonic Crohn's disease remains controversial as it is associated with a high incidence of disease recurrence (Becker, 1993). However, it does prevent the need for a permanent stoma.

Subtotal colectomy with ileostomy and oversewing of the rectum followed by an ileorectal anastomosis at a later stage may be considered in some patients with rectal sparing or limited rectal disease.

The most radical approach to Crohn's proctocolitis is total colectomy and Brooke ileostomy. Although this procedure is associated with the lowest rate of recurrence, patients may develop complications. These could include chronic perianal wounds; ileostomy complications, especially with fluid and electrolyte problems; and vitamin B12 deficiency (Becker, 1999).

Ulcerative colitis
Ulcerative colitis affects only the large bowel, usually beginning in the rectum and extending continuously throughout the colon to a varying extent. The mucosa and submucosa become inflamed, resulting in superficial ulceration and sloughing of the mucosal layer. In severe cases the muscularis is eroded and perforation of the bowel may occur (Finlay, 1999).

As well as being curative for ulcerative colitis, surgical removal of the large bowel and rectum can reduce the risk of colonic cancer in patients with total colitis who have had the disease for longer than 10 years. Although it is generally accepted that duration of disease is a risk factor for the development of colorectal cancer in those with ulcerative colitis, the magnitude of this risk in total colitis is still being considered (Lewis et al, 1999). Surgery can also relieve some of the symptoms of the extraintestinal manifestations of the disease, such as skin lesions and arthritis (Becker, 1999).

With the development of operative procedures, gastroenterologists and patients are considering surgery much earlier in the disease process because many patients are able to lead healthy, active lives afterwards (Jacobs and Becker, 1994).

About 20-45% of patients with ulcerative colitis will require surgery, with almost half having it within 10 years of diagnosis (Heppell et al, 1997).

The aims of surgical treatment in ulcerative colitis are:

- To alleviate symptoms and prevent complications;

- To restore health while improving the patient's quality of life.

Proctocolectomy with pelvic ileal reservoir

Proctocolectomy with pelvic ileal reservoir, also known as ileo-anal pouch surgery, is an established operation for patients with ulcerative colitis. The indications for surgery in ulcerative colitis are shown in Table 1. This operation removes the diseased colon and rectum but excludes the need for a permanent stoma.

The ileo-anal pouch procedure can involve one, two or three operations. The number of stages will depends on the severity of the disease, presence of other health problems, operative risks, technical demands of the surgery and expertise of the surgeon (Eckles and Norton, 1997).

In patients with severe colitis who are taking high doses of steroids and are nutritionally compromised, a three-stage procedure is most likely to be considered. The colon is usually removed as an urgent or semi-urgent operation, the rectal stump is left in place and an ileostomy is formed.

The rectal stump is either sutured to the undersurface of the distal aspects of the midline wound (Fig 3a) or brought out at the synthesis pubis as a mucus fistula (Fig 3b). After several months, when the patient is well, proctectomy and the creation of the ileo-anal reservoir with a loop ileostomy is undertaken (Fig 4). The ileal pouch is constructed from the terminal ileum and anastomosed to the anal canal. About six to eight weeks later the loop ileostomy is closed (Fig 5).

If the patient is systemically well, the procedure may be completed in one or two stages after discussion between the patient, surgeon and gastroenterologist.

There are a number of ways in which a pouch can be constructed and each has advantages and disadvantages. The three most popular designs are the S-pouch, W-pouch and J-pouch. The J-pouch is the most widely used as it is a simple design and is the easiest to construct (Sagar and Pemberton, 1995). Postoperatively, patients with J-pouches tend to be satisfied with the functional outcome and their quality of life (Fazio, 1994). The J-pouch will accommodate almost 400ml of content, preserve the rectal angle, generate low but coordinated propulsive contractions and empty spontaneously (Heppell et al, 1997).

Complications of an ileo-anal reservoir

Since the first ileo-anal reservoir operation was performed more than 20 years ago, a growing body of evidence suggests that three important long-term complications are associated with this procedure. They include surgical failure, an increased incidence of pouchitis and dysplasia in the ileo-anal pouch (Sandborn, 1997).

Further studies need to be carried out in these areas to assess these findings. Unless this work is undertaken and evaluated we may never understand the true risks and benefits of this procedure.

Panproctocolectomy with Brooke ileostomy

Total proctocolectomy with a Brooke ileostomy was once the mainstay of treatment for patients with ulcerative colitis. It remains an option for patients who do not want ileo-anal restorative surgery or have been identified as unsuitable for this procedure.

The surgery involves the removal of the diseased colon and rectum and the creation of a permanent ileostomy in one operation.

Having to live with a permanent ileostomy can sometimes detract from the benefits of no longer having a chronic disease (Kelly and Henry, 1992).

The nurse's role
Many patients are anxious and frightened. Body image is a serious issue after the formation of a stoma, representing the worst-case scenario for many patients (Finlay, 1999). Nurses need to help patients develop effective coping skills so they are able to manage their changing condition and come to terms with a changing lifestyle. The nursing considerations for patients undergoing surgical therapy are highlighted in Table 3.

Future considerations
Laparoscopic surgery

The development of laparoscopic surgery is being considered for patients with Crohn's disease (Skaife and Hershman, 2000). The benefits would include a shorter recovery period, a reduction in operative blood loss, a lower rate of infection and the earlier recovery of gut function, permitting earlier oral consumption.

In the longer term, laparoscopic surgery is more aesthetically pleasing and can have advantages for patients whose body image may be distorted by corticosteroids, weight loss and abdominal wounds. Although the potential value of laparoscopic surgery in Crohn's disease has been recognised, the guidelines for its application are not yet clear.

Small bowel transplant

Although still experimental, 180 small bowel transplants have been performed in 170 patients, about 150 of them in the USA. Some transplants have been performed for inflammatory bowel disease (Herbage Busch, 1999).

Although patient survival rates are improving, further research is needed to make this option safer and more reliable.

Conclusion
There are several different surgical options to consider in the management of inflammatory bowel disease. It is important that patients have a clear understanding of these interventions so that they are able to make informed treatment choices. Nurses caring for these patients also need to have a clear understanding of the differences between surgery for Crohn's disease and ulcerative colitis so that they can provide patients with appropriate information, education and support.

- Further information is available on the internet at: http://www.GastroHep.com

The first article in this series, which was published in NT last week, focused on the medical and nursing management of inflammatory bowel disease. The subject of next week's article is colorectal cancer.

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