Surgery for Crohn’s Disease
What Is Crohn’s Disease?
Crohn’s disease involves chronic inflammation of all or part of your digestive tract. The inflammation can occur anywhere in the entire digestive tract, which includes the esophagus, stomach, large intestine and the small intestine. It can be painful, and in more severe cases, result in life-threatening complications.
Surgery for Crohn’s Disease in General
In the early stages of Crohn’s disease, medication may be recommended to manage symptoms. But if medication is not sufficient or complications arise from the progression of the disease, surgery may become necessary. Though surgery is a last alternative, it should be considered an important part of the overall treatment of Crohn’s disease, when needed.
Surgery is most commonly recommended when Crohn’s disease has resulted in an infection, an abscess, when there is a bowel obstruction, when abnormal connections to other organs (fistulae) develop or when the patient is experiencing malnutrition from an inability to properly absorb nutrients. Having Crohn’s disease increases your risk of cancer, which may also require surgery.
There are times when emergency surgery is needed as a life-saving procedure. These situations include a perforated bowel, the presence of a severe infection (sepsis) or a hemorrhage.
Surgical procedures for Crohn’s disease are more common than you might think. Approximately three out of four people with Crohn’s disease will have at least one surgical procedure during their lifetime. Many people find that their quality of life improves significantly following surgery.
Surgery for Crohn’s Disease (Abdominal/Intestinal)
Surgery for abdominal/intestinal Crohn’s disease is most commonly recommended when there is significant bleeding, bowel blockages (obstructions), a perforation or hole in your bowel, or cancer. Surgery may involve removing a portion of the intestine that is inflamed or in some cases involves removing an entire organ such as the colon (large intestine) or rectum. The main goal of surgery for Crohn’s is to remove the diseased portion while saving as much of the bowel as possible.
Types of Surgery for Crohn’s Disease
There are four types of surgical procedures used to treat the symptoms of Crohn’s disease. The type used will depend on the specific complication, the location in the gastrointestinal tract and the severity of the symptoms. These surgical approaches include:
This surgical procedure removes a part of the intestine and is the most commonly performed procedure. After one or more select sections of the intestine are removed, which are usually identified through pre-operative investigations, the remaining healthy sections are put back together. Once the diseased portion(s) are removed it may provide many years of relief from the common symptoms associated with Crohn’s disease. If symptoms do recur, it typically appears at the point where the sections of intestine were joined.
If Crohn’s disease affects a significant portion of the colon (large intestine) a colectomy, a partial or complete removal of the colon, may be necessary. After a segmental or partial resectioning of the colon, the colon can often be put back together . If the colon is totally removed, the end of the small intestine can be attached to the rectum.
If both the colon and rectum are diseased, it may be necessary to remove both in a procedure called a proctocolectomy. This may be done in one operation, or in stages. The surgery can involve bringing the ends of the small intestine through an incision in the lower abdomen (called a stoma) so that waste can empty from the body into an external bag (pouch).
In situations where multiple segments of intestine are inflamed or damaged by Crohn’s disease, a special procedure called a strictureplasty can be performed to widen portions of the intestine that have narrowed (or become constricted) due to the buildup of scar tissue over time. This accumulated damage occurs from the repeated process of inflammation and healing. The surgery involves making a cut lengthwise along one side of the intestine where narrowing has occurred and suturing the ends widthwise. This shortens and widens the bowel and eliminates the stricture. Because inflammation from Crohn’s can occur at various places in the bowel, strictureplasty can be performed at multiple places during the same surgery without the need for removing (resectioning) portions of the bowel. This procedure is reserved for patients who may be at risk of having too little bowel, called “short gut,” if a significant portion of affected bowel is removed.
Many of the surgical procedures used to treat Crohn’s disease can be performed using laparoscopic surgery, which means less pain, less risk of infection and a shorter hospital stay. But not all Crohn’s disease patients are candidates for a laparoscopic procedure and a person’s suitability for this minimally invasive option is determined by your doctor on a case-by-case basis.
Surgery for Anal Fistulas
One of the complications that can occur with Crohn’s is the development of sores or ulcers that tunnel through the intestine and into the surrounding tissue. These tunnels are called fistulas and often appear around the anus and rectum. Approximately half of all adults with Crohn’s disease will develop a fistula during their lifetime with many of these appearing in the anal area.
How Anal Fistulas Begin
Anal fistulas usually begin in the anal glands, which drain into the anal canal. The anal canal is located at the end of the large intestine between the rectum and anus. If drainage from the anal canal becomes blocked an infection can occur between the inside of the anus and the skin surrounding the anus. This area of skin is sometimes referred to as the perineum. As pus collects (called an abscess) the abscess increases in size and tends to work its way to the surface. The tunnel or track that develops from this process is called a fistula. This tunnel can pass pus, bacteria and fluids to surrounding organs, such as the bladder, vagina or skin.
Initial treatment of anal fistula usually involves draining the blocked glands. Some patients may need repeated draining procedures to keep the infection under control. This may involve the placement of small plastic drains in the fistula, called a “seton”. Setons can be helpful toward maintaining an infection-free fistula, and can help with definitive repair. Because it is an infection, antibiotics may also be used but often prove to be inadequate. Biologic mediations, such as Remicade and Humira, have shown to be very helpful in gaining control of the infection and healing the fistulae, if treated in the early stages. If symptoms do not respond to medication, surgery may be needed to prevent spread of the infection to the rest of the body.
Surgery for Anal Fistulas
Surgery for anal fistulas is not a cure but an intervention to control infection. The most common surgical procedure is called a fistulotomy, which opens the fistula tract. The goal is to repair the anal fistula while avoiding damage to the nearby sphincter muscles, which are necessary for control of the bowel. Damage to the sphincter muscles can result in fecal incontinence.
Specific treatment of anal fistula depends on the location and the complexity of the fistula. In a typical fistulotomy, the surgeon cuts the fistula tract, and scrapes out the infected tissue. If the fistula is more complex there is a higher risk of damage to the sphincter muscles. Advanced approaches of fistula repair, such as flaps may be required to cover the fistula opening with healthy tissue. The post-surgical recurrence rate for anal fistulas in Crohn’s disease is high and attempts at definitive surgery may cause problems with incontinence. Any approach at definitive repair requires a careful discussion with your surgeon and your gastroenterologist.
Considerations Before Surgery
Because every patient’s disease pattern is unique, you must form a plan that is designed to meet your individual needs. Before making a final decision, it’s helpful to understand why you may need surgery, to educate yourself about the different surgical options, and to ask questions of your doctor and surgeon. You also may want to speak with patients who have undergone the procedure you are considering.
Surgery for Crohn’s disease is never a decision that is taken lightly. All surgery carries some risks. Some risks are common to all surgeries and some are specific to the individual procedures. Ask your surgeon to explain all of the relevant risks associated with the procedure as they pertain to you and your individual condition.
Outside of emergency procedures, a decision to perform surgery should be made in collaboration with your doctor and surgeon. It’s important to seek out a surgeon who has significant experience working with Crohn’s disease. And don’t forget to think of yourself as part of your healthcare team. In fact, you are the most important member of your healthcare team and your voice counts as much as anyone’s.