Adhesions

1
Surgery and Inflammatory Bowel Disease
Stephen M. Kavic, MD Department of Surgery
University of Maryland
2
The Gastrointestinal Tract
3
Inflammatory Bowel Disease
Crohns Disease Ulcerative Colitis
4
Crohns Disease

• Affects small intestine (small bowel)
• Colon may be involved
• Medical treatment is mainstay

5
Surgery and Crohns
Approximately 70 of patients with Crohns
ultimately come to operation
6
Why Operate?

• Complications of disease
• Complications of therapy
• If medications dont work
• If you cant take medication
• If you wont take medication

7
Complications of Disease

• Hole in bowel
• Perforation
• Abscess
• Blockage
• Obstruction
• Bleeding
• Fistula

8
What do surgeons do?
When in doubt, cut it out
(okay, alter or remove the sites of maximum
pathology)
9
Sometimes things dont work
10
Goals for Surgery

• Remove problem segments of bowel
• Maximize the amount of useful bowel left behind
• Avoid surgical complications

11
Goals for Surgeon and Patient

• Restore quality of life

12
Stricturoplasty(Opening a blocked portion of
intestine)
13
Stricture

• Narrowing of a portion of bowel
• Caused by repeated episodes of inflammation
• Symptoms may include nausea, vomiting, and pain

14
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

15
Resection(Removal of a portion of intestine)
16
Anastomosis

• Surgical connection or juncture
• Sutures (needle and thread)
• Staples

17
Anastomosis
18
Anastomosis

• Not always possible
• Stool needs an exit from the body
• Ileostomy
• The bag
• Direct connection of intestine to outside world

19
Ileostomy or Stoma
20
Abscess (Infection)
21
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

22
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

23
Fistula(Abnormal connection)
24
Fistula

• An abnormal connection between two structures
• Often between two loops of bowel
• May connect to bladder, vagina, skin, or other
  organs

25
Fistula

• Treatment may be medical
• Surgery often required
• Remove the segment of bowel and the connection
• Repair the other organ

26
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
  surgeons and anesthesiologists experience

27
Surgical Complications

• Bleeding
• 2-5
• Infection
• 2-10
• Breakdown of anastomosis
• 2-4
• Injury to neighboring structures

28
Ulcerative Colitis
29
Ulcerative Colitis

• Affects large intestine (colon)
• Inflammation of deep layers of colon wall
• Multiple medicines available

30
Surgery and UC
Approximately 35 of patients with UC
ultimately come to operation
31
Why Operate?

• Complications of disease
• Complications of therapy
• If medications dont work
• If you cant take medication
• If you wont take medication

32
Complications of Disease

• Hole in bowel
• Perforation
• Toxic megacolon
• Bleeding
• Risk of cancer

33
What do surgeons do?

• Remove the colon
• Left with small intestine and cuff of rectum
• Ileostomy (temporary or permanent)
• Pouch created with small bowel

34
Small bowel pouch
35
(No Transcript)
36
Staged Procedures

• To minimize complications, sometimes the
  operations are done in sequence
• Stage I Removal of colon and ileostomy
• Stage II Reconnection

37
Surgical Complications

• Bleeding
• 2-5
• Infection
• 2-10
• Breakdown
• 2-4

38
Surgical Complications

• Pouchitis
• Inflammation of pouch
• Diarrhea and pain
• Treated with antibiotics
• Bowel obstruction
• Infertility

39
Minimally Invasive Surgery
40
Minimally Invasive Surgery

• Also known as Laparoscopic surgery
• Used in over 20 million Americans
• MIS proven to be as effective as conventional
  surgery

41
The Evolution of Incisions
Past Present
Future
Long Laparotomy Minimally Invasive Surgery
Incisionless Surgery
42
Minimally Invasive Surgery

• Many procedures may be started with minimally
  invasive techniques
• Surgeon can convert to traditional open surgery
  if deemed safer

43
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

44
Patient Benefits of MIS

• Shorter length of stay in hospital
• Less recovery time
• Less pain
• Less scarring
• Improved cosmetic outcome

45
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

46
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

47
MIS for IBD Surgery
48
MIS for IBD Surgery
49
Not all patients are candidates for MIS

• Inability to safely visualize organs
• Problems during the operation
• Underlying medical conditions

50
Conclusions

• IBD has surgical options
• Surgery reserved for complications of disease or
  therapy
• Minimally invasive techniques may be applied

51
(No Transcript)