The most common forms of inflammatory bowel disease are Crohn’s disease and ulcerative colitis.
Together these affect around a quarter of a million people in the UK. Crohn’s disease can affect any part of the gastrointestinal tract from the mouth to the anus, while ulcerative colitis exclusively targets the large intestine.
Coping with inflammatory bowel disease
Inflammatory bowel disease typically causes diarrhoea, rectal bleeding and abdominal pain, which can be mild or severe.
A range of medical treatments is now available for inflammatory bowel disease. This ranges from steroids to more contemporary biological therapy with TNF-alpha inhibitors (e.g. infliximab).
It is possible to combine such treatments with careful lifestyle choices and minimise the impact of inflammatory bowel disease on your daily life.
Hopefully, the initial presenting symptoms of inflammatory bowel disease can be controlled with modern medications. Patients can experience severe flares in their disease that may require colorectal surgery.
Surgery is avoided wherever possible
“Surgery is not usually the first line of treatment for inflammatory bowel disease. The objective is to control the inflammation in the digestive system in the first instance with drugs.
If that fails, the surgical options for patients with ulcerative colitis are very different from those for patients with Crohn’s disease, so establishing an accurate diagnosis is essential.”
Mr Jonathan Wilson is a colorectal surgeon with many years of experience operating on patients with inflammatory bowel disease. He uses the latest techniques in laparoscopic colorectal surgery to enable patients to benefit from a faster recovery and less post-operative pain.
Role of the colorectal surgeon
Surgeons may become involved in the initial diagnosis of inflammatory bowel disease in patients with new symptoms. In other cases, a gastroenterologist will ask the opinion of a colorectal surgeon for a patient when medical management has failed, or complications have arisen.
Why is laparoscopic colorectal surgery necessary?
Unfortunately, some people experience flare-ups during treatment.
A drug works for a while and then no longer produces any benefit. Or their symptoms deteriorate rapidly resulting in a life-threatening scenario requiring urgent surgery to remove the affected segment of bowel.
The operations for ulcerative colitis and Crohn’s disease are very different, so establishing the correct diagnosis at the beginning is crucial.
Surgery options for ulcerative colitis
Ulcerative colitis is a more limited disease than Crohn’s disease as it only affects the large bowel (colon). Crohn’s disease can cause inflammation in other parts of the digestive tract.
Around three in ten people have severe ulcerative colitis and eventually need colorectal surgery. Repeated inflammation over many years can cause changes to the cells that line the colon. This represents significant steps towards colon cancer. To prevent this, surgery may be required to remove the entire colon.
As the colon is the only part of the digestive system affected in ulcerative colitis, this surgery, although seemingly drastic, can actually be curative as it removes symptoms in the long term.
Surgery may also be required urgently in patients whose symptoms deteriorate rapidly and are unresponsive to medical therapies.
Types of laparoscopic colorectal surgery available
Two main forms of surgery are possible, and both can now be done laparoscopically. Although this is still major surgery, using a minimally invasive surgical technique helps speed recovery, particularly when combined with an enhanced recovery programme.
- Removal of the colon and rectum with a permanent ileostomy: here, the end of the small intestine (ileum) is brought out through a small hole in the abdominal wall on to the skin. The faeces drops into a small bag attached with adhesive to the skin. The bag can be emptied into the toilet when necessary.
- Removal of the colon and rectum with an internal ileal pouch: to avoid the permanent ileostomy described above. A new rectum can be fashioned from the small intestine (ileal pouch), which is then joined on to the anus. This allows the patient to go to the toilet in the usual way, without the prospect of a long-term stoma. It is not essential to have pouch surgery, and many people lead full and normal lives with stomas, as it is a lifestyle operation that many younger patients prefer. Pouch surgery is usually undertaken in two or three separate operations.
Colorectal surgery options and Crohn’s disease
Laparoscopic colorectal surgery in Crohn’s disease
The majority of patients with Crohn’s disease will ultimately have more than one operation in their lifetime. Therefore the aim is to preserve as much intestine as possible in each operation.
Surgery cannot cure Crohn’s disease but it does become necessary in three-quarters of patients because of worsening symptoms unresponsive to drugs. Also, severe complications such as bowel perforation, obstruction and bleeding, or the concern of malignancy. The extent of surgery depends on how much of the bowel has become severely damaged.
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