**Abstract**

The incidence of inflammatory bowel disease (IBD) is increasing world-wide and most patient will require some surgical treatment once in life. IBD surgical patients are a challenge to surgeons. Main goals of surgical treatment are (1) to preserve the small bowel integrity because many resections may lead the patient to a small bowel short syndrome and (2) restore normal function as they have absorption disturbances. IBD patients may present mal-nutrition status and/or immunosuppression at the time of surgery. Types of surgery range from a simple plasty in Crohn disease to a total proctocolectomy in Ulcerative Colitis. For Crohn disease most procedures avoid resection and use diseased segments to prevent disabsorption. Herein we describe the most currently used techniques to treat IBD patients, when to indicate surgery and how to prepare them to less outcomes. Patients with Crohn disease with high risk for short bowel syndrome and intestinal failure should be submitted to Strictureplasty otherwise, Bowel Resection is the favored surgical technique for the management of fibrostenotic. Bowel Resection is associated with lower recurrence rate and longer recurrence-free survival.

**Keywords:** inflammatory bowel disease, strictureplasty, bowel resection, Crohn's disease, ulcerative colitis, surgical outcomes

## **1. Introduction**

#### **1.1 Epidemiology**

Many epidemiologic studies report an increase in incidence and prevalence of Crohn's disease [CD] and Ulcerative Colitis (UC) in a global proportion. It is more evident in countries that going through an industrialization process, e.g., Asia, South America and Middle East [1–3]. The incidence follows the country industrialization and people living in urban areas has a greater incidence of IBD [4, 5]. The global prevalence of IBD has increased from 79.5 to 84.3 per 100,000 persons in recent years. IBD has been considered a disease of high-income regions. The USA had the highest age-standardized prevalence rate globally; approximately a quarter of total global patients with IBD living there in 2017. The UK had the highest age-standardized prevalence in Europe. The prevalence of IBD range from 252 to 439 cases per 100 000 population in the USA and 373 per 100 000 population in UK [6].

#### **1.2 Pathogenesis**

The complete mechanism of pathogenesis of IBD still unclear. IBD has a complex immune-mediated inflammatory disease that affects primarily the digestive tube. Those individuals with a genetic predisposition when exposed to different environmental factors may initiate an inflammatory response that is influenced by gut microbiome (**Figure 1**) [7]. The process is characterized by chronic relapsing and remitting inflammation for life.

Many diet components were reported to be protective factors to IBD as fiber, short-chain fatty acids, wheat, gluten, zinc, vitamin D. On the other hand some kind of food may worsen the disease: FODMAPs, red meat, emulsifiers and sugar [8].

The interaction of diet components with the microbiome is not so simple: more fiber, less flares. Some patients complain worsening of symptoms with fibers consumption. One hypothesis is that altered microbiome may produce incomplete fermentation and then, originating pro-inflammatory byproducts as succinate [9].

The microbiome is the group of all organisms found in the whole gut and includes bacteria, fungi, viruses and protozoa. Most of them are found in the colon. Many studies showed that IBD patients have altered microbiome and pro-inflammatory bacteria. When you treat a patient with Crohn disease and make an ostomy avoid intestinal transit in affected bowel segment it result in decreased inflammation [10–13].

Another evidence of environmental factor is the impairment in Peroxisome proliferator-activated receptors-γ (PPARγ) activity. Environmental pollutants can block the PPARy signaling pathway while mesalazine enhances its expression [14].

The Hippo pathway is an evolutionarily conserved pathway that controls organ size and homoeostasis through modulating cell proliferation, survival, apoptosis, and stemness. Hippo pathway is involved in the IBD pathogenesis, including intestinal cell regeneration, gut microbiota, and angio- genesis of the intestines [15, 16].

Crohn disease (CD) and Ulcerative Colitis (UC) are grouped as inflammatory bowel diseases but each one has distinct clinical characteristics (**Table 1**). These differences have to be in mind when a bowel resection and anastomosis is done in a patient with Crohn disease.

Clinically CD may be classified into three phenotypes: inflammatory, penetrating (fistulizing) and stricturing [17]. During the diagnosis evaluation 10% may be

**Figure 1.** *Pathogenesis of IBD.*

#### *Current Elective Surgical Treatment of Inflammatory Bowel Disease DOI: http://dx.doi.org/10.5772/intechopen.100112*

in the stricturing group and one decade later up to one third of patients may present stricturing **Figure 2** [18, 19].

The treatment of strictures may be done by endoscopy (endoscopic balloon dilatation, strictureplasty or surgical resection of bowel segment.

According to Cosnes et al. [18] the site of lesions is the most important factor to determine the disease behavior and progression to complication:


In general, 75% of patients with strictures may require surgery once during lifetime but it may range from 70–90%. Right timing in indication of surgery for CD


#### **Table 1.**

*Characteristics of n disease (CD) and Ulcerative Colites (UC).*

#### **Figure 2.**

*Natural progression of Crohn disease. (From Jacques Cosnes et al. [18].)*


**Table 2.** *Indications for surgery in CD.*

#### *Current Topics in Colorectal Surgery*

may reduce complication rates, diminish operative technical difficulties and stoma indication, less emergency surgeries and also better mortality rates [18, 20, 21].

As CD does not have cure, surgery has a well-defined hole in therapeutic armamentarium. The aim of surgery is to treat complications, control symptoms, to try to preserve bowel length and keep to bowel function (**Table 2**).
