surgery and inflammatory bowel disease
TRANSCRIPT
Surgery and Surgery and Inflammatory Bowel Inflammatory Bowel
DiseaseDiseaseStephen M. Kavic, MD
Department of Surgery University of Maryland
The Gastrointestinal Tract
Inflammatory Bowel Disease
Crohn’s Disease
Ulcerative Colitis
Crohn’s DiseaseAffects small intestine
(small bowel)
Colon may be involved
Medical treatment is mainstay
Surgery and Crohn’sApproximately
70 %
of patients with Crohn’s ultimately come to
operation
Why Operate?Complications of disease
Complications of therapy–If medications don’t work–If you can’t take medication–If you won’t take medication
Complications of Disease Hole in bowel
– Perforation– Abscess
Blockage– Obstruction
Bleeding Fistula
What do surgeons do?
“When in doubt,
cut it out”
(okay, alter or remove the sites of maximum pathology)
Sometimes things don’t work
Goals for Surgery Remove problem segments of
bowel Maximize the amount of useful
bowel left behind Avoid surgical complications
Goals for Surgeon and Patient
Restore quality of life
Stricturoplasty
(Opening a blocked portion of intestine)
Stricture Narrowing of a portion of bowel Caused by repeated episodes of
inflammation Symptoms may include nausea,
vomiting, and pain
Stricturoplasty Surgical technique of opening a
portion of bowel Involves making an incision on the
diseased segment and sewing it back together in another way
Resection
(Removal of a portion of intestine)
“Anastomosis”Surgical connection or juncture
Sutures (needle and thread)Staples
Anastomosis
Anastomosis Not always possible Stool needs an exit from the body Ileostomy
– “The bag”– Direct connection of intestine to
outside world
Ileostomy orStoma
Abscess
(Infection)
Abscess Infection inside the abdomen Abscess must be drained –
antibiotics alone are not enough External drain may be
image-guided May use operation for drainage
Abscess The source of an abscess is often
a diseased segment of bowel
Once the abscess is drained, the diseased segment can be removed more safely
Fistula
(Abnormal connection)
Fistula An abnormal connection between
two structures Often between two loops of bowel May connect to bladder, vagina,
skin, or other organs
Fistula Treatment may be medical Surgery often required Remove the segment of bowel and
the connection Repair the other organ
Risks and Complications
All surgical procedures have risks, but the risk for serious complications
depends on your medical condition and age, as well as on your surgeon’s and anesthesiologist’s experience
Surgical Complications Bleeding
– 2-5% Infection
– 2-10% Breakdown of anastomosis
– 2-4% Injury to neighboring structures
Ulcerative Colitis
Ulcerative ColitisAffects large intestine (colon)
Inflammation of deep layers of colon wall
Multiple medicines available
Surgery and UCApproximately
35 %
of patients with UC ultimately come to
operation
Why Operate?Complications of disease
Complications of therapy–If medications don’t work–If you can’t take medication–If you won’t take medication
Complications of Disease Hole in bowel
– Perforation– “Toxic megacolon”
Bleeding Risk of cancer
What do surgeons do? Remove the colon Left with small intestine and cuff of
rectum Ileostomy (temporary or permanent) Pouch created with small bowel
Small bowel pouch
Staged Procedures To minimize complications,
sometimes the operations are done in sequence
Stage I: Removal of colon and ileostomy
Stage II: Reconnection
Surgical Complications Bleeding
– 2-5% Infection
– 2-10% Breakdown
– 2-4%
Surgical Complications “Pouchitis”
– Inflammation of pouch– Diarrhea and pain– Treated with antibiotics
Bowel obstruction Infertility
Minimally Invasive Surgery
Minimally Invasive Surgery
Also known as “Laparoscopic” surgery
Used in over 20 million Americans
MIS proven to be as effective as conventional surgery
The Evolution of Incisions Past Present Future
Long Laparotomy Minimally Invasive Surgery Incisionless Surgery
O
O
O
O
O
Minimally Invasive Surgery
Many procedures may be started with minimally invasive techniques
Surgeon can convert to traditional open surgery if deemed safer
Why Bother?Experience has shown us that minimally
invasive procedures can have an influence over the quality of the
patient experience when compared to traditional open surgical options
Patient Benefits of MIS Shorter length of stay in hospital Less recovery time Less pain Less scarring Improved cosmetic outcome
MIS Overview Involves the use of trocars (thin tubes)
placed through three to five small, dime-sized puncture wounds
Carbon dioxide gas used to inflate the abdomen and create a working space between the internal organs and the skin
MIS Overview Video camera introduced
Image on video monitors is magnified, providing better visibility for operating room staff
Specialized instruments placed through the other trocars to perform the operation
MIS for IBD Surgery
MIS for IBD Surgery
Not all patients are candidates for MIS
Inability to safely visualize organs
Problems during the operation
Underlying medical conditions
Conclusions IBD has surgical options Surgery reserved for
complications of disease or therapy
Minimally invasive techniques may be applied