August 3, 2020

When surgery is an option for inflammatory bowel disease

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If you have ulcerative colitis or Crohn’s disease, colorectal surgery may be the answer to improving long-term symptoms of inflammatory bowel disease.

The symptoms of inflammatory bowel disease can greatly impact your life. Surgery is an option for patients experiencing complications with Crohn’s not otherwise medically controlled. And if you’re frustrated with managing ulcerative colitis, surgery even presents a cure.

We interviewed Timothy Geiger, M.D., a colon and rectal surgery specialist at Vanderbilt University Medical Center, to provide details on the various surgeries available and the potential outcomes.

Although they are both conditions of IBD, Crohn’s disease and ulcerative colitis impact the body differently. “Crohn’s can affect anywhere from the mouth to the anal canal, whereas ulcerative colitis is only in the colon and rectum,” Geiger explained. “Because of that, they’re treated differently from a surgical standpoint, but surgery may be a good option to give you back your quality of life.”

When is surgery a consideration for inflammatory bowel disease?

Inflammatory bowel disease brings up considerations for different surgery methods. For Crohn’s disease, surgery is necessary when a patient becomes toxic or septic as a result of the condition or when medications aren’t providing adequate symptom control. Issues may include a fistula, abscess, bowel obstruction or bleeding. An operation may warrant itself when inflammation causes complications with eating or eliminating waste.

“Surgery doesn’t cure Crohn’s disease,” Geiger said. “Surgery can only get rid of the symptoms due to a problem.”

Ulcerative colitis only affects the colon and rectum, however. “Surgery for ulcerative colitis can be curative. Once we remove the colon and rectum, patients will be symptom-free and typically not need further medical treatment,” he explained. For that reason, surgery is an option for patients with ulcerative colitis who no longer want to be on medications.

In either condition, if a patient has pre-cancerous legions or has developed colorectal cancer, an operation will be necessary. The risk of developing colorectal cancer increases with disease duration.

“Starting at 10 years,” Geiger explained, “it is a cumulative 1 percent risk per year. So if you’ve had ulcerative colitis for 30 years, then you have a 20 percent risk of getting colon and rectal cancer.”

What types of surgeries are available?

A procedure for Crohn’s disease will depend on symptoms and the anatomy involved. “The most common operations that we do are for the small bowel, the colon and the rectum,” Geiger said. “It is less common to do an operation for the stomach or the esophagus.”

Patients with ulcerative colitis can choose to have a proctocolectomy, the removal of the rectum and the colon. But there are two options for this. The first involves the creation of an ileoanal anastomosis, also called a J-pouch, made out of the small bowel. This allows for the storage and passage of waste. The second option is a proctocolectomy with an ileostomy. This procedure also removes the large intestine. The small intestine then connects to an opening in the lower abdomen called a stoma, where an attached ostomy bag collects waste.

Between these two procedures, there’s no difference in the quality of life or the ability to do activities, Geiger said. But each surgery has several considerations. Creating a J-pouch usually involves two procedures, for example, whereas creating the ileostomy involves just one. With the ileostomy, body image comes into play for some patients, he added, because it is a part of the bowel that comes outside of the body, and it involves caring for it to avoid infection. With the J-pouch, however, patients will experience up to six bowel movements a day.

Geiger said he spends a lot of time with patients just talking through these considerations. The goal is to figure out: “What is the most positive outcome and how do we balance that against everything else that you’re dealing with?” he explained.

Make sure your surgeon often performs the operation you want, Geiger advised. If you’re considering a proctocolectomy with ileostomy, make sure the surgeon has stomal therapists on staff to measure you for the correct positioning of your stoma and to teach you how to care for the stoma after surgery. “Those things are outside the surgery itself, but they are important to returning a patient back to a normal life with no limitations,” he added.

The Inflammatory Bowel Disease Clinic at Vanderbilt University Medical Center provides comprehensive care and management for IBD. Our specialists work together to offer long-term relief for symptoms, to minimize flare-ups and to help patients achieve longer periods of remission.

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Timothy Geiger, M.D.

Timothy Geiger, M.D., M.M.H.C., is associate professor of surgery, executive medical director of the Surgery Patient Care Center, chief of the Division of General Surgery, and director of the Colon and Rectal Surgery Program at Vanderbilt University Medical Center.