**An Update to Surgical Management of Inflammatory Bowel Diseases**

V. Surlin, C. Copaescu and A. Saftoiu

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/53057

## **1. Introduction**

[12] Masselli G, Gualdi G. MR Imaging of the Small Bowel. Radiology 2012; 264(2):

[13] Sinha R, Murphy P, Hawker P, et al. Role of MRI in Crohn's disease. Clinical Radiol‐

[14] Darge K, Anupindi S, Keener H, Rompel O. Ultrasound of the bowel in children:

[15] Migaleddu V, Quaia E, Scano D, Virgilio G. Inflammatory activity in Crohn disease:

[16] Gotthardt M, Bleeker-Rovers CP, Boerman OC, Oyen WJG. Imaging of inflammation by PET, conventional scintigraphy, and other imaging techniques. Journal of nuclear medicine : official publication, Society of Nuclear Medicine 2010; 51(12): 1937-1949.

[17] McBride HJ. Nuclear imaging of autoimmunity: focus on IBD and RA. Autoimmuni‐

[18] Pearce MS, Salotti JA, Little MP, et al. Radiation exposure from CT scans in child‐ hood and subsequent risk of leukaemia and brain tumours: a retrospective cohort

[19] Peloquin JM, Pardi DS, Sandborn WJ, et al. Diagnostic ionizing radiation exposure in a population-based cohort of patients with inflammatory bowel disease. The Ameri‐

[20] Desmond AN, O'Regan K, Curran C, et al. Crohn's disease: factors associated with exposure to high levels of diagnostic radiation. Gut 2008; 57(11): 1524-1529.

[21] Gee MS, Nimkin K, Hsu M, et al. Prospective evaluation of MR enterography as the primary imaging modality for pediatric Crohn disease assessment. AJR Am J Roent‐

how we do it. Pediatric radiology 2010; 40(4): 528-536.

ultrasound findings. Abdominal imaging 2008; 33(5): 589-597.

333-348.

196 Inflammatory Bowel Disease

ogy 2009; 64(4): 341-352.

ty 2010; 43(7): 539-549.

genol; 197(1): 224-231.

study. Lancet 2012; 380(9840): 499-505.

can Journal of Gastroenterology 2008; 103(8): 2015-2022.

Surgery still has its place in the treatment of inflammatory bowel diseases (IBD) but it is re‐ served generally to cases in which medical treatment is unsuccessful in relieving symptoms, preventing disease progression and complications. As the medical treatment has added new drugs (especially newly targeted therapy) and surgical advance in technology has gain in more complex procedures with less morbidity and mortality and minimal invasivity there is a need for periodic update.

## **2. Perioperative care of patients with IBD**

Good perioperative care always ensures better surgical results. Patients undergoing surgery for IBD must be prepared psychologically and medically.

Psychological preparation should start by explaining the patient the need for surgery. In this approach the surgeon must be aided by the gastroenterologist that has managed the patient for a long time in most of the cases. After acceptance of surgery, the patient must be ex‐ plained the objectives, the advantages and disadvantages of each surgical intervention and the decision must be taken in common. People that will be submitted to stomas should also get a consultation from stomatherapist.

Medical preparation of the patients includes correction of hemoglobin, volemia, electrolytes and acid-base levels, coagulopathy, liver function. Total parenteral nutrition may be neces‐ sary in patients with nutritional deficits. Coexisting diseases should also be addressed. Any corticosteroid and immunosuppressive therapy should be discontinued before surgery, but corticosteroids need to be tapered immediately after surgery.

© 2012 Surlin et al.; licensee InTech. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2012 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

## **2.1. Prevention of infection**

Adequate antibiotic prophylaxis or antibiotic therapy should be given, especially in cases with prolonged corticosteroid or infliximab therapy. Anyway, antibiotic prophylaxis pre and intraoperative is mandatory in colon surgery, but we think that may be continued sev‐ eral days after surgery especially in patient treated by corticosteroids and immunosupres‐ sive and immunomodulator therapy because of higher risk of infection on a reduced immune host defense.

**3.1. Elective procedures**

unsuccessful or undesirable.

**3.3. Intractable chronic disease**

**3.2. Refractory colitis**

**3.5. Emergency surgery**

The development of restorative procedures such as the ileal pouch anal-canal anastomosis has made surgery a more attractive option in patients in whom medical therapy has been

An Update to Surgical Management of Inflammatory Bowel Diseases

http://dx.doi.org/10.5772/53057

199

The treatment of choice for acute severe steroid refractory ulcerative colitis is controversial [4]. Gastroenterologists sustain infliximab [5], while surgeons plead for colectomy [6].

The most common indication for elective surgery is disease activity that has been intractable to medical therapy. However, "intractable" is kind of blurry. Some authors have suggested that disease should be considered intractable when it or its treatment is associated with se‐ vere and persistent impairment in the quality of life [7]. However, these parameters are dif‐

Refractory acute severe ulcerative colitis (RASUC), is defined by greater than six bloody stools per day and one of the following: heart rate more that 90 beat/min, erythrocyte sedi‐ mentation rate more than 30mm/h, temperature more than 37.8°C, and hemoglobin less than 10.5 g/dl. The appropriate time to initiate surgical intervention during the treatment of RA‐ SUC has been a topic of investigation, because patients are usually severely malnourished, immunocompromised, and weakened by side-effects of immunomodulating drugs. [8].

Advances in medical therapy (including use of infliximab) have reduced the need for emer‐ gency surgery due to catastrophic complications such as massive hemorrhage, perforation,

A longer duration of in-hospital ineffective medical therapy (8 versus 5 days) that delays surgical therapy in patients with acute severe ulcerative colitis is associated with an in‐

Biologic agents were introduced with the intent to help avoid operative intervention in pa‐ tients with moderately to severely active IBD who have demonstrated an inadequate re‐ sponse to conventional therapies. Ananthakrishnan et al. analyzing a large number of cases hospitalized for IBD found that the use of biologic agents decreases the incidence of emer‐

For Ousslan et al, failure to respond to infliximab determined the decision for colectomy in 19% of the patients. Predicting factors for colectomy were C-reactive protein > 10mg/l before treatment with infliximab, hemoglobin less than 9.4 g/dl, episodic use of infliximab, and pre‐

gency surgery in patients with mild disease, but not in those with severe forms. [11]

ficult to measure and are variable among individual patients.

**3.4. Refractory Acute Severe Ulcerative Colitis (RASUC)**

fulminant colitis, and acute colonic obstruction [9].

creased risk of postoperative complications [10].

vious treatment with cyclosporin. [12]

The mechanical bowel preparation in elective cases is no longer mandatory in colon surgery and is contraindicated in patients with an acute abdomen or obstruction [1]

## **2.2. Prophylaxis for venous thrombosis**

Patients with IBD are at increased risk for thromboembolic venous and arterial complica‐ tions [2, 3]. Thus, intermittent pneumatic compression and/or low dose heparin should be used prophylactically.

## **3. Indications for surgery in ulceative colitis (UC)**

Approximately 30–40% of patients with ulcerative colitis will require surgical treatment.

Indications for surgery are:


## **3.1. Elective procedures**

**2.1. Prevention of infection**

198 Inflammatory Bowel Disease

immune host defense.

used prophylactically.

Indications for surgery are:

fects,

**•** colonic strictures,

steroids, cyclosporine, or infliximab,

**•** extracolonic manifestations.

**•** intractable chronic disease,

**2.2. Prophylaxis for venous thrombosis**

Adequate antibiotic prophylaxis or antibiotic therapy should be given, especially in cases with prolonged corticosteroid or infliximab therapy. Anyway, antibiotic prophylaxis pre and intraoperative is mandatory in colon surgery, but we think that may be continued sev‐ eral days after surgery especially in patient treated by corticosteroids and immunosupres‐ sive and immunomodulator therapy because of higher risk of infection on a reduced

The mechanical bowel preparation in elective cases is no longer mandatory in colon surgery

Patients with IBD are at increased risk for thromboembolic venous and arterial complica‐ tions [2, 3]. Thus, intermittent pneumatic compression and/or low dose heparin should be

Approximately 30–40% of patients with ulcerative colitis will require surgical treatment.

**•** significant treatment-related complications such as severe steroid or infliximab side ef‐

**•** dysplasia or cancer in patients with long-standing colitis during endoscopic surveillance,

**•** acute exacerbation of the disease not responsive to rescue therapy such as intravenous

**•** acute complications: hemorrhage, toxic megacolon, perforation, fulminant colitis,

and is contraindicated in patients with an acute abdomen or obstruction [1]

**3. Indications for surgery in ulceative colitis (UC)**

**•** lack of response to high-dose corticosteroid therapy

**•** disease progression under maximal medical therapy,

**•** recurrence of symptoms upon stop of corticosteroid therapy,

The development of restorative procedures such as the ileal pouch anal-canal anastomosis has made surgery a more attractive option in patients in whom medical therapy has been unsuccessful or undesirable.

## **3.2. Refractory colitis**

The treatment of choice for acute severe steroid refractory ulcerative colitis is controversial [4]. Gastroenterologists sustain infliximab [5], while surgeons plead for colectomy [6].

## **3.3. Intractable chronic disease**

The most common indication for elective surgery is disease activity that has been intractable to medical therapy. However, "intractable" is kind of blurry. Some authors have suggested that disease should be considered intractable when it or its treatment is associated with se‐ vere and persistent impairment in the quality of life [7]. However, these parameters are dif‐ ficult to measure and are variable among individual patients.

## **3.4. Refractory Acute Severe Ulcerative Colitis (RASUC)**

Refractory acute severe ulcerative colitis (RASUC), is defined by greater than six bloody stools per day and one of the following: heart rate more that 90 beat/min, erythrocyte sedi‐ mentation rate more than 30mm/h, temperature more than 37.8°C, and hemoglobin less than 10.5 g/dl. The appropriate time to initiate surgical intervention during the treatment of RA‐ SUC has been a topic of investigation, because patients are usually severely malnourished, immunocompromised, and weakened by side-effects of immunomodulating drugs. [8].

#### **3.5. Emergency surgery**

Advances in medical therapy (including use of infliximab) have reduced the need for emer‐ gency surgery due to catastrophic complications such as massive hemorrhage, perforation, fulminant colitis, and acute colonic obstruction [9].

A longer duration of in-hospital ineffective medical therapy (8 versus 5 days) that delays surgical therapy in patients with acute severe ulcerative colitis is associated with an in‐ creased risk of postoperative complications [10].

Biologic agents were introduced with the intent to help avoid operative intervention in pa‐ tients with moderately to severely active IBD who have demonstrated an inadequate re‐ sponse to conventional therapies. Ananthakrishnan et al. analyzing a large number of cases hospitalized for IBD found that the use of biologic agents decreases the incidence of emer‐ gency surgery in patients with mild disease, but not in those with severe forms. [11]

For Ousslan et al, failure to respond to infliximab determined the decision for colectomy in 19% of the patients. Predicting factors for colectomy were C-reactive protein > 10mg/l before treatment with infliximab, hemoglobin less than 9.4 g/dl, episodic use of infliximab, and pre‐ vious treatment with cyclosporin. [12]

In the study of Gustavsson et al, with 3-year follow-up, infliximab significantly reduced the need for surgery at 3 month compared to placebo (29% vs 67%), for patients with corticoste‐ roid refractory UC. At 3 years, 50% of patients in the infliximab group and 76% of patients in placebo group needed colectomy. [13]

**•** Avoiding of ileostomy - IPAA. Patients under infliximab - three stages IPAA

lies in its limited use of bowel, reliable emptying, and ease of construction. [8]

consequences [16,17].

complications.

**3.9. In emergency situations**

ileorectal anastomosis (IRA)

**•** Refusal of ileostomy

Functional results after IRA

or ascites),

**•** Patients not suitable for IPAA

Indications

leaving a small stump of distal rectum.

**3.10. Other options for restorative proctocolectomy**

**•** Women of childbearing age because of the risk of infertility,

**•** Patients with colitis complicated by advanced colonic malignancy,

**•** Patients in whom Crohn's disease cannot be excluded,

In the elective surgical population, the standard operation performed is a total proctocolec‐ tomy with ileal pouch anal anastomosis. Described by Parks and Nichols in 1978, the proce‐ dure involves excision of the abdominal colon, pelvic dissection to remove the rectum, creation of an ileal reservoir, and anastomosis of the pouch to the anus. A variety of pouch designs can be used. The most commonlyof thrm is the J-pouch. Preference for the J-pouch

An Update to Surgical Management of Inflammatory Bowel Diseases

http://dx.doi.org/10.5772/53057

201

Mortality is low - 0.2–0.4%; however, the risk of pelvic sepsis can be as high as 23% from leaks from the ileoanal anastomosis. To prevent this complication, the operation could be performed in multiple stage (two or three), to allow anastomoses to heal without important

Toxic megacolon – the procedure of choice is open colectomy with ileostomy and closure of the rectum or distal colostomy. The rectum may be resected afterwards with ileal pouchanal anastomosis. IPAA from the beginning should not be performed because of risk of

Hemmorhage – Proctocolectomy, suture of a bleeding ulcer or Hartmann-type colectomy

Ileal pouch distal rectum anastomosis (IPDRA) – anastomosis between ileal pouch and dis‐ tal rectum – easier to perform, better anal sensation and continence especially at night.

Main disadvantage – leaving rectal mucosa behind, that should be avoided in patients with cancer or severe dysplasia in colorectal mucosa, severe extraintestinal manifestations.

Advantage – older patients, lack of adequate mobilisation for tension-free anastomosis –

**•** Medical conditions in which a stoma is relatively contraindicated (eg, portal hypertension

In a spanish multicenter experience, patients in whom corticosteroids and ciclosporin failed to control the disease, were submitted to infliximab. A 40 years patient, operated because of infliximab failure died after surgery from nosocomial pneumonia. Authors stated that sal‐ vage therapy with infliximab after failed corticosteroids and ciclosporin may be associated with risk for morbidity and mortality and therefore should be used in selected patients. [14]

Adalimumab emerged as an indication in the cases in which there is partial or no response to infliximab. In a study from Taxonera et al at 48 weeks of follow-up only 20% of the pa‐ tients needed surgery. Therefore, application of this new therapy may diminish the indica‐ tions for surgery in the group of patient non-responders to infliximab therapy.

## **3.6. Suspicion of cancer**

The risk of malignancy is directly proportional to the duration of disease. The risk during the first decade of disease is low, but increases substantially after that. After 30 years of dis‐ ease the risk is about 50 %. [8] Patients with more than 10 years of disease should undergo a colonoscopy each year. Most of the gastroenterologists consider discovery of moderate to se‐ vere dysplasia an indication for surgery.

## **3.7. Extraintestinal manifestations**

Surgical indication is seldom for extracolonic manifestations of IBD. Benefits from surgery will be in the rare cases of massive hemolytic anemia unresponsive to treatment. In those cases splenectomy should be associated to colectomy [7]. Another extracolonic indication for colectomy is thromboembolic complications. Erythema nodosum and arthralgia of the small and large joints appear to benefit the most from proctocolectomy [15]. In cases of pyoderma gangrenosum, ankylosing spondylitis and arthritis, sclerosing cholangitis surgery may not be so profitable.

Surgical options for ulcerative colitis are:


#### **3.8. Elective procedures**

**•** Curative procedure - Proctocolectomy with permanent ileostomy.

**•** Avoiding of ileostomy - IPAA. Patients under infliximab - three stages IPAA

In the elective surgical population, the standard operation performed is a total proctocolec‐ tomy with ileal pouch anal anastomosis. Described by Parks and Nichols in 1978, the proce‐ dure involves excision of the abdominal colon, pelvic dissection to remove the rectum, creation of an ileal reservoir, and anastomosis of the pouch to the anus. A variety of pouch designs can be used. The most commonlyof thrm is the J-pouch. Preference for the J-pouch lies in its limited use of bowel, reliable emptying, and ease of construction. [8]

Mortality is low - 0.2–0.4%; however, the risk of pelvic sepsis can be as high as 23% from leaks from the ileoanal anastomosis. To prevent this complication, the operation could be performed in multiple stage (two or three), to allow anastomoses to heal without important consequences [16,17].

## **3.9. In emergency situations**

In the study of Gustavsson et al, with 3-year follow-up, infliximab significantly reduced the need for surgery at 3 month compared to placebo (29% vs 67%), for patients with corticoste‐ roid refractory UC. At 3 years, 50% of patients in the infliximab group and 76% of patients

In a spanish multicenter experience, patients in whom corticosteroids and ciclosporin failed to control the disease, were submitted to infliximab. A 40 years patient, operated because of infliximab failure died after surgery from nosocomial pneumonia. Authors stated that sal‐ vage therapy with infliximab after failed corticosteroids and ciclosporin may be associated with risk for morbidity and mortality and therefore should be used in selected patients. [14] Adalimumab emerged as an indication in the cases in which there is partial or no response to infliximab. In a study from Taxonera et al at 48 weeks of follow-up only 20% of the pa‐ tients needed surgery. Therefore, application of this new therapy may diminish the indica‐

The risk of malignancy is directly proportional to the duration of disease. The risk during the first decade of disease is low, but increases substantially after that. After 30 years of dis‐ ease the risk is about 50 %. [8] Patients with more than 10 years of disease should undergo a colonoscopy each year. Most of the gastroenterologists consider discovery of moderate to se‐

Surgical indication is seldom for extracolonic manifestations of IBD. Benefits from surgery will be in the rare cases of massive hemolytic anemia unresponsive to treatment. In those cases splenectomy should be associated to colectomy [7]. Another extracolonic indication for colectomy is thromboembolic complications. Erythema nodosum and arthralgia of the small and large joints appear to benefit the most from proctocolectomy [15]. In cases of pyoderma gangrenosum, ankylosing spondylitis and arthritis, sclerosing cholangitis surgery may not

tions for surgery in the group of patient non-responders to infliximab therapy.

in placebo group needed colectomy. [13]

vere dysplasia an indication for surgery.

Surgical options for ulcerative colitis are:

**•** Proctocolectomy with permanent ileostomy (Brooke ileostomy)

**•** Colectomy and stapled ileal pouch distal rectal anastomosis (IPDRA)

**•** Curative procedure - Proctocolectomy with permanent ileostomy.

**•** Colectomy, mucosal proctectomy, and ileal pouch-anal canal anastomosis (IPAA)

**•** Proctocolectomy with continent ileostomy (Kock pouch)

**•** Abdominal colectomy with ileorectal anastomosis

**3.7. Extraintestinal manifestations**

**3.6. Suspicion of cancer**

200 Inflammatory Bowel Disease

be so profitable.

**3.8. Elective procedures**

Toxic megacolon – the procedure of choice is open colectomy with ileostomy and closure of the rectum or distal colostomy. The rectum may be resected afterwards with ileal pouchanal anastomosis. IPAA from the beginning should not be performed because of risk of complications.

Hemmorhage – Proctocolectomy, suture of a bleeding ulcer or Hartmann-type colectomy leaving a small stump of distal rectum.

#### **3.10. Other options for restorative proctocolectomy**

Ileal pouch distal rectum anastomosis (IPDRA) – anastomosis between ileal pouch and dis‐ tal rectum – easier to perform, better anal sensation and continence especially at night.

Main disadvantage – leaving rectal mucosa behind, that should be avoided in patients with cancer or severe dysplasia in colorectal mucosa, severe extraintestinal manifestations.

Advantage – older patients, lack of adequate mobilisation for tension-free anastomosis – ileorectal anastomosis (IRA)

Indications


Functional results after IRA

A retrospective analysis of the functional results after IRA for ulcerative colitis or indetermi‐ nant colitis in 86 patients found that the rectum was eventually resected in 17% of cases, rec‐ tal dysplasia occurred in 17%, rectal cancer 8% and refractory proctitis 28%. The cumulative probability of developing rectal dysplasia at 5, 10, 15, and 20 years was 7, 9, 20, and 25 per‐ cent, respectively. The cumulative probability of developing rectal cancer at 5, 10, 15, and 20 years was 0, 2, 5, and 14 percent, respectively. The cumulative probability of having a func‐ tioning IRA at 10 and 20 years was 74 and 46 percent, respectively. [18]

Ileocolic resections should be followed by a side-to-side anastomosis. A meta-analysis of eight comparative studies found that a side-to-side anastomosis was associated with fewer anastomotic leaks and postoperative complications, a shorter hospital stay and a lower peri‐ anastomotic recurrence rates compared to end-to-end anastomosis [22]. However, the au‐ thors suggested that further randomized controlled trials are needed to confirm these

An Update to Surgical Management of Inflammatory Bowel Diseases

http://dx.doi.org/10.5772/53057

203

Duodenal Crohn's disease very rarely requires surgery. The major indications for surgery are obstruction and less often perforation or fistula formation. Gastrojejunostomy rather than resection is typically performed. Strictureplasty, duodenojejunostomy, and endoscopic

**•** Intraperitoneal abscesses were classically drain by open surgery and were followed by

**•** Progress of interventional radiology, new biologic agents and progress of laparoscopy

**•** Percutaneous drainage guided by CT or abdominal ultrasound has a low rate of compli‐ cations and a high rate of success - approximately 70% of attempted cases. Complete drainage of the abscess may necessitate repeated punctures. This attitude allows the pa‐ tient to be prepared for an elective resection of the bowel after the sepsis resides, after im‐ proving nutritional status and decreasing corticosteroids. Controversy exists regarding the need for subsequent operation after adequate abscess drainage as intractable disease

**•** If percutaneous drainage is unsuccessful, surgical drainage should be performed. The timing of surgery following percutaneous abscess drainage, when clinically indicated, oc‐

**•** Peritonitis is rare in Crohn's disease. Exploratory laparotomy with peritoneal lavage, with construction of a stoma is most commonly required. The decision whether to resect or not

**•** Abdominal wall abscesses (psoas and rectus sheath) are less common and more difficult to control locally than intra-abdominal abscesses. In a retrospective review of 13 patients with an abdominal wall abscess treated by percutaneous and/or open operative drainage, all 13 required resection of the diseased segment even after successful drainage of the abscess [25].

Fistulas to adjacent organs (stomach, duodenum, bladder, vagina, and sigmoid colon) are treated by resection and anastomosis of the diseased segment of the bowel and closure of

the bowel depends upon the operative findings and the patient's condition [26].

or recurrent abscess occurs in at least 30% of these patients within a year.

associations.

**4.1. Duodenal disease**

balloon dilation have also been described [23].

surgical resection of the diseased segment of the bowel.

**4.2. Intra-abdominal abscess, peritonitis**

changed this classic approach [24,25].

curs after clinical resolution of sepsis.

**4.3. Fistulas**

Satisfactory rectal function varies greatly depending upon the selections of patients and length of follow-up. The risk of cancer in the residual rectum has been reported to be 6 % at 20 years and 15 % at 30 years. The risk is significant considering that most patients are young and have many years to live.

Farouk et al noted that in 1386 patients with restorative proctocolectomy and over 8-year follow-up, 80% reported complete diurnal continence, with 50% requiring medications to slow intestinal transit. [19]

## **4. Surgical options for Crohn's disease**

Crohn's disease is not curable by surgery. Therefore, this is actualy reserved for complica‐ tions or to symptoms refractory to medical therapy [20].

Surgical decision making in Crohn's disease is driven by anatomic distribution and inflam‐ matory subtype of disease. Forty percent of patients have ileal disease with segments of co‐ lonic involvement, with 20–25% of patients exhibiting isolated colonic disease and 5–10% with isolated anorectal disease [21]. Surgical intervention is primarily performed for the complications of Crohn's disease: stricture and obstruction, fistula, or medically refractory disease. Approximately 70% of Crohn's disease patients ultimately require surgery, often multiple, making minimally invasive options appealing

Indications for surgery are:


Surgery should to adress only to segments causing obstruction, bleeding, or perforation. Re‐ section is performed when there is an abscess or fistula to an adjacent organ. The diseasefree margins are established by gross inspection, microscopic disease at the margins will not be associated with recurrence. Therefore we should avoid large margins, in the idea of pre‐ serving as much as possible of small bowel capital because the patients may need another resection in the future and thus preventing the short bowel syndrome.

Ileocolic resections should be followed by a side-to-side anastomosis. A meta-analysis of eight comparative studies found that a side-to-side anastomosis was associated with fewer anastomotic leaks and postoperative complications, a shorter hospital stay and a lower peri‐ anastomotic recurrence rates compared to end-to-end anastomosis [22]. However, the au‐ thors suggested that further randomized controlled trials are needed to confirm these associations.

## **4.1. Duodenal disease**

A retrospective analysis of the functional results after IRA for ulcerative colitis or indetermi‐ nant colitis in 86 patients found that the rectum was eventually resected in 17% of cases, rec‐ tal dysplasia occurred in 17%, rectal cancer 8% and refractory proctitis 28%. The cumulative probability of developing rectal dysplasia at 5, 10, 15, and 20 years was 7, 9, 20, and 25 per‐ cent, respectively. The cumulative probability of developing rectal cancer at 5, 10, 15, and 20 years was 0, 2, 5, and 14 percent, respectively. The cumulative probability of having a func‐

Satisfactory rectal function varies greatly depending upon the selections of patients and length of follow-up. The risk of cancer in the residual rectum has been reported to be 6 % at 20 years and 15 % at 30 years. The risk is significant considering that most patients are

Farouk et al noted that in 1386 patients with restorative proctocolectomy and over 8-year follow-up, 80% reported complete diurnal continence, with 50% requiring medications to

Crohn's disease is not curable by surgery. Therefore, this is actualy reserved for complica‐

Surgical decision making in Crohn's disease is driven by anatomic distribution and inflam‐ matory subtype of disease. Forty percent of patients have ileal disease with segments of co‐ lonic involvement, with 20–25% of patients exhibiting isolated colonic disease and 5–10% with isolated anorectal disease [21]. Surgical intervention is primarily performed for the complications of Crohn's disease: stricture and obstruction, fistula, or medically refractory disease. Approximately 70% of Crohn's disease patients ultimately require surgery, often

Surgery should to adress only to segments causing obstruction, bleeding, or perforation. Re‐ section is performed when there is an abscess or fistula to an adjacent organ. The diseasefree margins are established by gross inspection, microscopic disease at the margins will not be associated with recurrence. Therefore we should avoid large margins, in the idea of pre‐ serving as much as possible of small bowel capital because the patients may need another

tioning IRA at 10 and 20 years was 74 and 46 percent, respectively. [18]

young and have many years to live.

**4. Surgical options for Crohn's disease**

tions or to symptoms refractory to medical therapy [20].

multiple, making minimally invasive options appealing

**•** failure to respond to medical therapy in patients with colonic involvement,

resection in the future and thus preventing the short bowel syndrome.

**•** perforation in small intestinal Crohn's disease,

slow intestinal transit. [19]

202 Inflammatory Bowel Disease

Indications for surgery are:

**•** obstruction,

**•** strictures,

**•** fistula

Duodenal Crohn's disease very rarely requires surgery. The major indications for surgery are obstruction and less often perforation or fistula formation. Gastrojejunostomy rather than resection is typically performed. Strictureplasty, duodenojejunostomy, and endoscopic balloon dilation have also been described [23].

## **4.2. Intra-abdominal abscess, peritonitis**


#### **4.3. Fistulas**

Fistulas to adjacent organs (stomach, duodenum, bladder, vagina, and sigmoid colon) are treated by resection and anastomosis of the diseased segment of the bowel and closure of the fistula. Resection of the adjacent segment is necessary only when it is primarily involved with Crohn's disease. Bypasses should be avoided because persistent disease in the by‐ passed segment can lead to abscess formation, bleeding, perforation, bacterial overgrowth, and malignancy.

*4.4.2. Balloon dilation*

same [40]

*4.4.3. Stenting*

Crohn's colitis

**4.5. Colorectal disease**

volved colonic segments.

type of concomitant medical therapy [37].

up to 11 months for 62% of patients. [38]

Another method to dilate intestinal strictures is with a hydrostatic balloon Experience is rel‐ atively limited compared with strictureplasty or resection, and the long-term efficacy and safety is therefore less well-established. A meta-analysis of 13 studies (with a total of 347 pa‐ tients) reported overall technical success in 86 % of cases and long-term efficacy in 58 per‐ cent, with up to 33 months of follow-up [36]. On multivariate analysis, a stricture length of ≤4 cm was associated with better surgery-free outcomes. The outcome of balloon dilatation to relieve obstruction from intestinal strictures in Crohn's disease is not influenced by the

An Update to Surgical Management of Inflammatory Bowel Diseases

http://dx.doi.org/10.5772/53057

205

Couckuyte et al performed 78 dilatation procedures for 59 ileocolonic strictures in 55 pa‐ tients, all procedures were carried out endoscopically under general anesthesia. Succes was registered in 90% with 11% perforations from which 30% needed surgery and 60% were solved only with medical treatment. Mean period of time to recurrence of obstruction was

In pediatric patients injections of corticosteroids into strictures after balloon dilatations were followed by fewer redilatations than in placebo group. [39]. For adults it didn't work the

Placement of an expandable metal stent within colonic strictures has been described, but ex‐

Options for surgery range from temporary diverting ileostomy to resection of segments of diseased colon or even the entire colon and rectum. Same conservative principles applied to disease involving the small intestine should also be applied to the surgical management of

The optimal procedure depends in part upon the extent of the disease and the clinical setting: **•** Segmental colectomy may be adequate for isolated areas of colonic involvement. An Ileor‐ ectal anastomosis can be carried out if the rectum is spared. A proctectomy will be re‐ quired in half of the patients [42]. While no prospective randomized study has been undertaken to compare segmental colectomy and total colectomy with ileorectal anasto‐ mosis, both procedures appear to be equally effective as treatment options for colonic Crohn's disease. However, patients undergoing segmental resection may have earlier re‐ currence [43]. The choice of operation depends upon the extent of colonic disease; there may be better outcomes with ileorectal anastomosis in those who have two or more in‐

**•** Total proctocolectomy is indicated for patients with extensive, diffuse colorectal disease.

**•** Subtotal colectomy with ileostomy is usually performed in emergency situations.

perience is limited, and the safety of this approach is uncertain [41].

#### **4.4. Strictures**

Intestinal strictures can be relieved by resection; synchronous small bowel resection in pa‐ tients with multiple strictures is common [27]. Strictureplasty or balloon dilation may be a suitable alternative for selected patients.

## *4.4.1. Strictureplasty*

Strictureplasty is performed by longitudinal incision across the stricture and a transversal closure that enlarges the lumen. Indication is represented by the patients that have isolated areas of short stricture and are at risk for short bowel syndrome due to previous surgery or extension of enterectomy. Strictureplasty can relieve obstruction, and is often performed in association with a small bowel resection [27, 28]. It can also be performed without excision of bowel [29, 30]. It should not be performed in acutely inflamed bowel.

To avoid large enterectomy for extensive and/or multiple strictures occurring over long in‐ testinal segments, a side-to-side isoperistaltic or other type of nonconventional strictureplas‐ ty is safe and effective [31, 32].

Strictureplasty has been associated with excellent results, including relief of obstruction, the ability to withdraw steroids, and improvement in symptoms [31, 33] the risk of fistula or re‐ current stricture formation is low and comparable to resection. Whether preservation of dis‐ eased bowel increases the long-term risk of malignancy is unknown, although case reports have documented adenocarcinoma arising from sites of previous strictureplasty [34].

The following examples illustrate the range of findings in two of the largest series

In a series of 1124 procedures of strictureplasty on 314 patients there was a synchronous bowel resection in 66% of cases, overall morbidity was 18%, septic complications in 5%, morbidity was higher in patients with preoperative weight loss and older age, recurrence af‐ ter surgery was met in 34% during a median follow-up of 7.5 years, recurrence was higher in younger patients [30]:

Another study included 479 procedures of strictureplasty performed in 100 patients with a follow-up of 7 years in average [35]. Overall morbidity was 22% and included sepsis – 11%, obstruction 4%, hemorrhage - 4% percent, and mortality – 3%. After a first strictureplasty the reoperation rate were 52% at 40 months, 56% at 26 months after a second, 86% at 27 months after a third, 63% at 26 months after a fourth. The major risk factor for reoperation was young age. The early relaparotomy rate was 8 percent. One patient developed cancer after many years of disease. The authors biopsied suspicious lesions, rather than going for routine biopsy of all lesions.

## *4.4.2. Balloon dilation*

the fistula. Resection of the adjacent segment is necessary only when it is primarily involved with Crohn's disease. Bypasses should be avoided because persistent disease in the by‐ passed segment can lead to abscess formation, bleeding, perforation, bacterial overgrowth,

Intestinal strictures can be relieved by resection; synchronous small bowel resection in pa‐ tients with multiple strictures is common [27]. Strictureplasty or balloon dilation may be a

Strictureplasty is performed by longitudinal incision across the stricture and a transversal closure that enlarges the lumen. Indication is represented by the patients that have isolated areas of short stricture and are at risk for short bowel syndrome due to previous surgery or extension of enterectomy. Strictureplasty can relieve obstruction, and is often performed in association with a small bowel resection [27, 28]. It can also be performed without excision

To avoid large enterectomy for extensive and/or multiple strictures occurring over long in‐ testinal segments, a side-to-side isoperistaltic or other type of nonconventional strictureplas‐

Strictureplasty has been associated with excellent results, including relief of obstruction, the ability to withdraw steroids, and improvement in symptoms [31, 33] the risk of fistula or re‐ current stricture formation is low and comparable to resection. Whether preservation of dis‐ eased bowel increases the long-term risk of malignancy is unknown, although case reports

In a series of 1124 procedures of strictureplasty on 314 patients there was a synchronous bowel resection in 66% of cases, overall morbidity was 18%, septic complications in 5%, morbidity was higher in patients with preoperative weight loss and older age, recurrence af‐ ter surgery was met in 34% during a median follow-up of 7.5 years, recurrence was higher

Another study included 479 procedures of strictureplasty performed in 100 patients with a follow-up of 7 years in average [35]. Overall morbidity was 22% and included sepsis – 11%, obstruction 4%, hemorrhage - 4% percent, and mortality – 3%. After a first strictureplasty the reoperation rate were 52% at 40 months, 56% at 26 months after a second, 86% at 27 months after a third, 63% at 26 months after a fourth. The major risk factor for reoperation was young age. The early relaparotomy rate was 8 percent. One patient developed cancer after many years of disease. The authors biopsied suspicious lesions, rather than going for

have documented adenocarcinoma arising from sites of previous strictureplasty [34].

The following examples illustrate the range of findings in two of the largest series

of bowel [29, 30]. It should not be performed in acutely inflamed bowel.

and malignancy.

204 Inflammatory Bowel Disease

*4.4.1. Strictureplasty*

ty is safe and effective [31, 32].

in younger patients [30]:

routine biopsy of all lesions.

suitable alternative for selected patients.

**4.4. Strictures**

Another method to dilate intestinal strictures is with a hydrostatic balloon Experience is rel‐ atively limited compared with strictureplasty or resection, and the long-term efficacy and safety is therefore less well-established. A meta-analysis of 13 studies (with a total of 347 pa‐ tients) reported overall technical success in 86 % of cases and long-term efficacy in 58 per‐ cent, with up to 33 months of follow-up [36]. On multivariate analysis, a stricture length of ≤4 cm was associated with better surgery-free outcomes. The outcome of balloon dilatation to relieve obstruction from intestinal strictures in Crohn's disease is not influenced by the type of concomitant medical therapy [37].

Couckuyte et al performed 78 dilatation procedures for 59 ileocolonic strictures in 55 pa‐ tients, all procedures were carried out endoscopically under general anesthesia. Succes was registered in 90% with 11% perforations from which 30% needed surgery and 60% were solved only with medical treatment. Mean period of time to recurrence of obstruction was up to 11 months for 62% of patients. [38]

In pediatric patients injections of corticosteroids into strictures after balloon dilatations were followed by fewer redilatations than in placebo group. [39]. For adults it didn't work the same [40]

#### *4.4.3. Stenting*

Placement of an expandable metal stent within colonic strictures has been described, but ex‐ perience is limited, and the safety of this approach is uncertain [41].

#### **4.5. Colorectal disease**

Options for surgery range from temporary diverting ileostomy to resection of segments of diseased colon or even the entire colon and rectum. Same conservative principles applied to disease involving the small intestine should also be applied to the surgical management of Crohn's colitis

The optimal procedure depends in part upon the extent of the disease and the clinical setting:


**•** An abdominoperineal resection with a permanent end-colostomy is indicated in patients with severe Crohn's disease limited to the anorectum. An intersphincteric proctectomy will minimize the risk of a nonhealing wound and sexual or urinary dysfunction, by avoiding dissection near the hipogastric plexuses. In the presence of anorectal disease and sepsis a Hartmann procedure can be carried out in the first place leaving a small stump of distal rectum, followed by a perineal proctectomy. [44].

to the anal sphincters. Some of the newest approaches use fibrin glue and collagen plugs to

An Update to Surgical Management of Inflammatory Bowel Diseases

http://dx.doi.org/10.5772/53057

207

A study from Chung et al comparing collagen fistula plug to fibrin glue, rectal advancement flap, and seton placement for treatment of 51 patients with complex perianal fistulas showed a 75% resolution rate with use of the plug compared with less than 30% for each of the other

The systematic review by Soltani and Kaiserof evaluating the efficacy of endorectal flap ad‐

The review by Lewis and Maron on anorectal Crohn's disease provides an algorithm for management of complex perianal fistulas, stressing that surgical therapy in excess of seton

Postoperative medical treatment for prevention of Crohn's disease recurrence is controver‐ sial in light of data supporting increased incidence of complications with preoperative im‐ munosuppressive therapy. However, a randomized, placebo-controlled clinical trial showed no difference in incidence of adverse events (anastomotic leak, wound complications, infec‐ tion, obstruction, bleeding, death) between postoperative patients treated with infliximab

Bordeianou et al studied the effect of immediate vs. tailored medical prophylaxis on endo‐ scopic and/or symptomatic recurrence in 199 patients who underwent ileocecectomy for Crohn's disease. The group found that there was no difference in recurrence rates between patients treated with medication immediately after surgery and those treated based on en‐ doscopic finding, adding to the debate on whether perioperative and postoperative medical

A way to use laparoscopy is only for the mobilization of the colon (cecum, ascendent, de‐ scendent, sigmoid) and to perform the rest of the operation in open but with a smaller inci‐

Laparoscopic subtotal colectomy performed in emergency conditions was followed by ac‐ ceptable outcomes and shorter hospital stay, although in such cases is not usually recom‐

Another possibility is to perform colon and rectal mobilisation, section of the mesocolon and even the rectum with liniar ENDO-GIA. Some authors do that by hand assisted technique.

**5. Minimally invasive surgery for inflammatory bowel disease**

The laparoscopic approach was already proven feasible both for UC and CD.

**5.1. Minimally invasive surgery for chronic ulcerative colitis**

placement should not be attempted during active proctitis due to inflammation [50].

vancement for complex perianal Crohn's disease found a 46% resolution [49].

occlude fistulous tracts without requiring incision.

within 4 weeks of surgery and those untreated. [51]

suppression is advantageous. [52]

sion [53]

mended [54].

modalities. [48]

#### **4.6. Anorectal disease**

The management of anorectal disease, present in 14–38% of patients, remains difficult de‐ spite advances in medical therapy. Perianal fistula or abscess is the initial presentation of Crohn's disease in approximately 30% of cases and has been associated with increased extra‐ intestinal symptoms and steroid resistance, resulting in significant disability [8].

The number of Crohn's patients who require surgery has, however, decreased with the ad‐ vances in medical management.

Most of the abscesses are small, difficult to drain and can disappear with antibiotics alone. The antibiotic therapy should associate ciprofloxacin to metronidazole. Greater abscesses can be drained by placement of a seton or by ultrasound or CT guided large bore needle as‐ piration or drain placement.

Treatment of the perianal fistula depends on the type of fistula (simple vs. complex) and un‐ derlying rectal inflammation.

Simple fistulas are intersphincteric or transsphincteric below the dentate line in origin with a single opening and no associated stricture or abscess. Such fistulas have an excellent response to antibiotic and surgical therapy and heal 80–100% of the time with simple fistulotomy [8]

Complex fistulas on the contrary, involve the superficial, transsphincteric, or intersphincter‐ ic region below the dentate line, have multiple openings, and can be associated with rectal stricture or rectovaginal fistula.

Pelvic MRI provides the most accurate information (90% accuracy) about fistulous burden and underlying rectal inflammation and is instrumental in surgical planning and monitor‐ ing response to therapy. Accuracy approaches 100% when MRI is combined with examina‐ tion under anesthesia. [45, 46]

Complex fistulas represent a challenge and require aggressive immunomodulating therapy in combination with surgical therapy. Many patients feel improvement in symptoms with antibiotic therapy (ciprofloxacin and metronidazole); however, symptom relief is transient with recurrence on withdrawal of antibiotics. Infliximab has proven to be the immunosup‐ pressive drug of choice in treatment of complex perianal fistulas with two randomized trials showing decreased number of fistulas, increased disease-free period, and fewer required hospitalizations and surgeries.[47]

Surgical therapy has evolved for complex fistulas as well with the development of less inva‐ sive techniques for closure of high fistulas to prevent incontinence associated with damage to the anal sphincters. Some of the newest approaches use fibrin glue and collagen plugs to occlude fistulous tracts without requiring incision.

**•** An abdominoperineal resection with a permanent end-colostomy is indicated in patients with severe Crohn's disease limited to the anorectum. An intersphincteric proctectomy will minimize the risk of a nonhealing wound and sexual or urinary dysfunction, by avoiding dissection near the hipogastric plexuses. In the presence of anorectal disease and sepsis a Hartmann procedure can be carried out in the first place leaving a small stump of

The management of anorectal disease, present in 14–38% of patients, remains difficult de‐ spite advances in medical therapy. Perianal fistula or abscess is the initial presentation of Crohn's disease in approximately 30% of cases and has been associated with increased extra‐

The number of Crohn's patients who require surgery has, however, decreased with the ad‐

Most of the abscesses are small, difficult to drain and can disappear with antibiotics alone. The antibiotic therapy should associate ciprofloxacin to metronidazole. Greater abscesses can be drained by placement of a seton or by ultrasound or CT guided large bore needle as‐

Treatment of the perianal fistula depends on the type of fistula (simple vs. complex) and un‐

Simple fistulas are intersphincteric or transsphincteric below the dentate line in origin with a single opening and no associated stricture or abscess. Such fistulas have an excellent response to antibiotic and surgical therapy and heal 80–100% of the time with simple fistulotomy [8]

Complex fistulas on the contrary, involve the superficial, transsphincteric, or intersphincter‐ ic region below the dentate line, have multiple openings, and can be associated with rectal

Pelvic MRI provides the most accurate information (90% accuracy) about fistulous burden and underlying rectal inflammation and is instrumental in surgical planning and monitor‐ ing response to therapy. Accuracy approaches 100% when MRI is combined with examina‐

Complex fistulas represent a challenge and require aggressive immunomodulating therapy in combination with surgical therapy. Many patients feel improvement in symptoms with antibiotic therapy (ciprofloxacin and metronidazole); however, symptom relief is transient with recurrence on withdrawal of antibiotics. Infliximab has proven to be the immunosup‐ pressive drug of choice in treatment of complex perianal fistulas with two randomized trials showing decreased number of fistulas, increased disease-free period, and fewer required

Surgical therapy has evolved for complex fistulas as well with the development of less inva‐ sive techniques for closure of high fistulas to prevent incontinence associated with damage

intestinal symptoms and steroid resistance, resulting in significant disability [8].

distal rectum, followed by a perineal proctectomy. [44].

**4.6. Anorectal disease**

206 Inflammatory Bowel Disease

vances in medical management.

piration or drain placement.

derlying rectal inflammation.

stricture or rectovaginal fistula.

tion under anesthesia. [45, 46]

hospitalizations and surgeries.[47]

A study from Chung et al comparing collagen fistula plug to fibrin glue, rectal advancement flap, and seton placement for treatment of 51 patients with complex perianal fistulas showed a 75% resolution rate with use of the plug compared with less than 30% for each of the other modalities. [48]

The systematic review by Soltani and Kaiserof evaluating the efficacy of endorectal flap ad‐ vancement for complex perianal Crohn's disease found a 46% resolution [49].

The review by Lewis and Maron on anorectal Crohn's disease provides an algorithm for management of complex perianal fistulas, stressing that surgical therapy in excess of seton placement should not be attempted during active proctitis due to inflammation [50].

Postoperative medical treatment for prevention of Crohn's disease recurrence is controver‐ sial in light of data supporting increased incidence of complications with preoperative im‐ munosuppressive therapy. However, a randomized, placebo-controlled clinical trial showed no difference in incidence of adverse events (anastomotic leak, wound complications, infec‐ tion, obstruction, bleeding, death) between postoperative patients treated with infliximab within 4 weeks of surgery and those untreated. [51]

Bordeianou et al studied the effect of immediate vs. tailored medical prophylaxis on endo‐ scopic and/or symptomatic recurrence in 199 patients who underwent ileocecectomy for Crohn's disease. The group found that there was no difference in recurrence rates between patients treated with medication immediately after surgery and those treated based on en‐ doscopic finding, adding to the debate on whether perioperative and postoperative medical suppression is advantageous. [52]

## **5. Minimally invasive surgery for inflammatory bowel disease**

The laparoscopic approach was already proven feasible both for UC and CD.

## **5.1. Minimally invasive surgery for chronic ulcerative colitis**

A way to use laparoscopy is only for the mobilization of the colon (cecum, ascendent, de‐ scendent, sigmoid) and to perform the rest of the operation in open but with a smaller inci‐ sion [53]

Laparoscopic subtotal colectomy performed in emergency conditions was followed by ac‐ ceptable outcomes and shorter hospital stay, although in such cases is not usually recom‐ mended [54].

Another possibility is to perform colon and rectal mobilisation, section of the mesocolon and even the rectum with liniar ENDO-GIA. Some authors do that by hand assisted technique.

## *5.1.1. To divert or not after laparoscopic surgery*

This is a question still under debate. Ky et al had a series of 32 laparoscopic IPAA (29 for UC) in which they didn't divert and had a morbidity of 34% and 3% leak rate [55]. Hasega‐ wa et al performed 18 cases all with diversions and had 33% morbidity and 0% leak rate [56]. Others like Marcello et al from 20 cases (13 for UC) divert only in 60% of cases and had 5% leak rate.[57]

creased early complications such as wound infections and bleeding with laparoscopic sur‐

An Update to Surgical Management of Inflammatory Bowel Diseases

http://dx.doi.org/10.5772/53057

209

Two large studies on laparoscopic surgery for isolated colonic disease found similarly good outcomes with fewer complications. Holubar et al reported their outcomes for 92 patients who underwent laparoscopic colectomy, showing a total complication rate of 34%, reinter‐ vention rate of 7.6%, and anastomotic leak rate of 3.8%, all consistent with reported out‐ comes for open colectomy. Fifteen percent of laparoscopic cases were converted to open and presence of small bowel disease was the only predictive factor identified, independent of

Umanskiy et al compared outcomes of 125 patients who underwent laparoscopic vs. open co‐ lectomy and/or proctectomy for Crohn's disease. The most common procedure in both groups was total proctocolectomy with end ileostomy and the only statistically significant difference in procedures performed applied to completion proctectomies, which were more likely to be open. Patients in the laparoscopic group had earlier return of bowel function, reduced length of hospital stay, and decreased intraoperative blood loss. Interestingly, the reduced blood loss

There was also no clinical recurrence at 20 months [60]. In a study by Tabet et al with 39

Watanabe et al and Bemelman et al performed laparoscopic-assisted resection for Crohn's disease, including patients with enteric fistulas. Postoperative outcome was better in laparo‐ scopic group [68, 69]. Same results were noted by Duepree et al., Tabet et al, and Young Fa‐ dok et al. (all comparative studies) who found short term outcome benefits associated with

For Duepree et al costs per case were higher for laparoscopic group.[70]. Young-Fadok et al reported an overall cost for laparoscopic cases significantly less than for the open ones [60]. There is a broad range of conversion rates (1.4-24 %), morbidity (10-29 %), length of stay (3.3-8.8 days), and leak rates (0-5%). Most of the series involve relatively small numbers of

Laparoscopic surgery is considered to generate less postoperative adhesions and less inci‐

Bergamaschi et al reported the results of a comparative study with long term follow up be‐ tween laparoscopic and open ileocecal resections. At 5 years, they found a rate of 11.1 % small bowel obstructions for laparoscopic group and 35.4 percent for the open group, and

did not result in fewer transfusions, which were similar in both groups [66].

months follow up, there were similar rates of recurrence 48% vs 45%. [67]

presence of phlegmonous or fistulous disease. [65]

*5.2.1. Recurrence after laparoscopic surgery*

the minimally invasive approach [60, 67, 70].

*5.2.3. Long term benefits of laparoscopic approach*

the result was statistically significant.[59]

gery. [20]

*5.2.2. Costs*

patients. [59, 69, 70]

sional hernias.

Is laparoscopy superior to open approach? In short term yes – as already proven by compar‐ ison between them, with faster recovery (including faster ambulation, less postoperative pain, faster return of bowel movement and time to first passage of flatus and feces).

Brown et al compared laparoscopic-assisted restorative proctocolectomy to open approach and found shorter operative time in open group, and similar functional outcome and recov‐ ery, only better cosmesis by shorter abdominal scar. The hand-assisted method seems to re‐ duce the operative time with more than 30 minutes [58].

Postoperative morbidity is still relatively high duet o extensive procedure (25-34%) [55, 56, 57]

## **5.2. Minimally invasive surgery for Crohn's disease**

Laparoscopic approach have the potential of decreasing morbidity, speeding recovery, and reducing costs, while decreasing the incidence of small bowel obstruction and ventral (ab‐ dominal wall) hernias [59,60].

A randomized comparative trial between open and laparoscopic ileo-colic resection found a conversion rate of 6% and no significant difference in immediate postoperative recovery (passage of flatus and length of hospital stay). The only benefice was a faster recovery of forced expiratory volume and forced expiratory vital capacity. [61]

Maartense et al performed a comparative randomized controlled trial between laparoscopicassisted ileocolonic resection performed by experienced surgeons in laparoscopy with open resections in Crohn's disease [62]. Morbidity, hospital stay, and costs were lower in the lapa‐ roscopic group, although there were no significant differences in quality-of-life at three months follow-up.

Alves et al found that the need for conversion to an open procedure was predicted by the severity of disease; independent predictors of conversion including a history of recurrent medical episodes of Crohn's disease and the presence of intra-abdominal abscess or fistula at the time of laparoscopy [63].

Recurrences after laparoscopic surgery were similar after conventional surgery. Laparoscop‐ ic colectomy was found to be safe and effective in the hands of experienced surgeons for se‐ lected patients with Crohn's colitis [64].

In the review by Fichera et al on Crohn's disease, the author highlights three meta-analyses that compared laparoscopic with open ileocolic surgery that demonstrated earlier return of bowel function leading to shorter hospital stay, fewer late small bowel obstructions, and de‐ creased early complications such as wound infections and bleeding with laparoscopic sur‐ gery. [20]

Two large studies on laparoscopic surgery for isolated colonic disease found similarly good outcomes with fewer complications. Holubar et al reported their outcomes for 92 patients who underwent laparoscopic colectomy, showing a total complication rate of 34%, reinter‐ vention rate of 7.6%, and anastomotic leak rate of 3.8%, all consistent with reported out‐ comes for open colectomy. Fifteen percent of laparoscopic cases were converted to open and presence of small bowel disease was the only predictive factor identified, independent of presence of phlegmonous or fistulous disease. [65]

Umanskiy et al compared outcomes of 125 patients who underwent laparoscopic vs. open co‐ lectomy and/or proctectomy for Crohn's disease. The most common procedure in both groups was total proctocolectomy with end ileostomy and the only statistically significant difference in procedures performed applied to completion proctectomies, which were more likely to be open. Patients in the laparoscopic group had earlier return of bowel function, reduced length of hospital stay, and decreased intraoperative blood loss. Interestingly, the reduced blood loss did not result in fewer transfusions, which were similar in both groups [66].

## *5.2.1. Recurrence after laparoscopic surgery*

There was also no clinical recurrence at 20 months [60]. In a study by Tabet et al with 39 months follow up, there were similar rates of recurrence 48% vs 45%. [67]

Watanabe et al and Bemelman et al performed laparoscopic-assisted resection for Crohn's disease, including patients with enteric fistulas. Postoperative outcome was better in laparo‐ scopic group [68, 69]. Same results were noted by Duepree et al., Tabet et al, and Young Fa‐ dok et al. (all comparative studies) who found short term outcome benefits associated with the minimally invasive approach [60, 67, 70].

## *5.2.2. Costs*

*5.1.1. To divert or not after laparoscopic surgery*

duce the operative time with more than 30 minutes [58].

**5.2. Minimally invasive surgery for Crohn's disease**

forced expiratory volume and forced expiratory vital capacity. [61]

dominal wall) hernias [59,60].

months follow-up.

the time of laparoscopy [63].

lected patients with Crohn's colitis [64].

5% leak rate.[57]

208 Inflammatory Bowel Disease

This is a question still under debate. Ky et al had a series of 32 laparoscopic IPAA (29 for UC) in which they didn't divert and had a morbidity of 34% and 3% leak rate [55]. Hasega‐ wa et al performed 18 cases all with diversions and had 33% morbidity and 0% leak rate [56]. Others like Marcello et al from 20 cases (13 for UC) divert only in 60% of cases and had

Is laparoscopy superior to open approach? In short term yes – as already proven by compar‐ ison between them, with faster recovery (including faster ambulation, less postoperative

Brown et al compared laparoscopic-assisted restorative proctocolectomy to open approach and found shorter operative time in open group, and similar functional outcome and recov‐ ery, only better cosmesis by shorter abdominal scar. The hand-assisted method seems to re‐

Postoperative morbidity is still relatively high duet o extensive procedure (25-34%) [55, 56, 57]

Laparoscopic approach have the potential of decreasing morbidity, speeding recovery, and reducing costs, while decreasing the incidence of small bowel obstruction and ventral (ab‐

A randomized comparative trial between open and laparoscopic ileo-colic resection found a conversion rate of 6% and no significant difference in immediate postoperative recovery (passage of flatus and length of hospital stay). The only benefice was a faster recovery of

Maartense et al performed a comparative randomized controlled trial between laparoscopicassisted ileocolonic resection performed by experienced surgeons in laparoscopy with open resections in Crohn's disease [62]. Morbidity, hospital stay, and costs were lower in the lapa‐ roscopic group, although there were no significant differences in quality-of-life at three

Alves et al found that the need for conversion to an open procedure was predicted by the severity of disease; independent predictors of conversion including a history of recurrent medical episodes of Crohn's disease and the presence of intra-abdominal abscess or fistula at

Recurrences after laparoscopic surgery were similar after conventional surgery. Laparoscop‐ ic colectomy was found to be safe and effective in the hands of experienced surgeons for se‐

In the review by Fichera et al on Crohn's disease, the author highlights three meta-analyses that compared laparoscopic with open ileocolic surgery that demonstrated earlier return of bowel function leading to shorter hospital stay, fewer late small bowel obstructions, and de‐

pain, faster return of bowel movement and time to first passage of flatus and feces).

For Duepree et al costs per case were higher for laparoscopic group.[70]. Young-Fadok et al reported an overall cost for laparoscopic cases significantly less than for the open ones [60].

There is a broad range of conversion rates (1.4-24 %), morbidity (10-29 %), length of stay (3.3-8.8 days), and leak rates (0-5%). Most of the series involve relatively small numbers of patients. [59, 69, 70]

## *5.2.3. Long term benefits of laparoscopic approach*

Laparoscopic surgery is considered to generate less postoperative adhesions and less inci‐ sional hernias.

Bergamaschi et al reported the results of a comparative study with long term follow up be‐ tween laparoscopic and open ileocecal resections. At 5 years, they found a rate of 11.1 % small bowel obstructions for laparoscopic group and 35.4 percent for the open group, and the result was statistically significant.[59]

Generally, laparoscopic colectomy is followed by lower incidence of incisional hernia and small bowel obstruction, with significant differences, as reported by Duepree et al [70].

mary IPAA, high patient satisfaction and quality of life can be achieved [80]. Furthermore, excision of the pouch is associated with a high risk of complications, especially delayed peri‐

An Update to Surgical Management of Inflammatory Bowel Diseases

http://dx.doi.org/10.5772/53057

211

The long-term success of surgery depends upon the type of operation, the clinical setting, and surgical expertise. Several studies have suggested that functional results are poor dur‐ ing the long-term follow-up in patients who had adverse personality factors before surgery (such as problems with sexual satisfaction, difficulty expressing emotions, perfectionist body ideals, and poor frustration tolerance) [79]. The following results were described in

One series included 1885 patients who underwent an ileal pouch-anal anastomosis for ulcer‐ ative colitis and were followed for an average of 11 years. The mean number of stools was 5.7 per day at one year and 6.4 at 20 years, and also increased at night from 1.5 to 2.0. The incidence of frequent fecal incontinence increased from 5 to 11 percent during the day and from 12 to 21 percent at night. The overall rate of pouch success at 5, 10, 15, and 20 years was 96, 93, 92, and 92 percent, respectively. Quality of life remained unchanged and 92 per‐

In another report that included 486 patients who had undergone proctocolectomy and ileoa‐ nal anastomosis for ulcerative colitis or familial adenomatous polyposis, the cumulative probabilities of pouch failure were 1, 5, and 7 percent at 1, 5, and 10 years, respectively [87]

Tulchinsky et al reported 634 patients who underwent restorative proctocolectomy for IBD. Patients were followed for a mean of 85 months. Failure (defined as removal of the pouch or the need for an ileostomy) was divided into early (occurring within one-year) or late (occur‐ ring more than one-year postoperatively). Three patients died postoperatively while an ad‐ ditional 23 died (of a variety of causes) during follow-up. Of the remaining patients, there

A number of unusual late complications have been described including [83, 84, 85]:

neal wound healing [81, 82].

**•** Traumatic ileal ulcer perforation

**6.3. Long-term results of surgery**

some of the largest series.

cent remained in the same employment. [86]

The most common cause of pouch failure was fistula formation.

**•** Superior mesenteric artery syndrome

**•** Mucosal prolapse with outlet obstruction

**•** Solitary ileal ulcer

**•** Sacral osteomyelitis **•** Puborectal spasm

**•** Fibroid polyps **•** Pharmacobezoar

**•** Volvulus

Functional outcome [71], quality of life [71] are similar but cosmetic results [71] especially for women [72] are higher after laparoscopy.

## **6. Complications**

## **6.1. Early complications**

Are usual after restorative proctocolectomy.

The most frequent are bowel obstruction, pouch bleeding, pelvic and wound sepsis, transi‐ ent urinary dysfunction, and dehydration from temporary loop ileostomy with high output. Surgery is not mandatory in many of those cases. Incidence of pelvic abscess after IPAA is estimated to 5% [73]. Pelvic abscesses lead to transabdominal or local surgery in most of the cases, failure of pouch in quarter of cases, incontinence, need for constipating or bulking medications was in the patients in whom the reservoir was preserved. There was also a de‐ crease in the quality of life of those patients.

Portal vein thrombosis can occur after IPAA. Clinical manifestations may include pain, fe‐ ver, vomiting, leukocytosis, and unexplained postoperative ileus. Diagnose is made with CT-scanner. Treatment with anticoagulation will lead to full resolution.

## **6.2. Late complications**


Majority of the pouch related complication can be solved by medical treatment consisting main‐ ly in local measures, surgery being required in a minority. In one series of almost 1000 patients who had undergone IPAA, reoperation for complications was necessary in only 12 % [77].

As an example, ileal pouch fistulas and strictures refractory to dilatation are difficult to treat and may require revision of the pouch if Crohn's disease can be excluded. A transvaginal repair is favored for a pouch-vaginal fistula [78]. A combined abdominal perineal repair may offer better results compared with a local procedure [79]. A controlled septic condition does not preclude salvage surgery. Although pouch failure occurs more often than with pri‐ mary IPAA, high patient satisfaction and quality of life can be achieved [80]. Furthermore, excision of the pouch is associated with a high risk of complications, especially delayed peri‐ neal wound healing [81, 82].

A number of unusual late complications have been described including [83, 84, 85]:


Generally, laparoscopic colectomy is followed by lower incidence of incisional hernia and small bowel obstruction, with significant differences, as reported by Duepree et al [70].

Functional outcome [71], quality of life [71] are similar but cosmetic results [71] especially

The most frequent are bowel obstruction, pouch bleeding, pelvic and wound sepsis, transi‐ ent urinary dysfunction, and dehydration from temporary loop ileostomy with high output. Surgery is not mandatory in many of those cases. Incidence of pelvic abscess after IPAA is estimated to 5% [73]. Pelvic abscesses lead to transabdominal or local surgery in most of the cases, failure of pouch in quarter of cases, incontinence, need for constipating or bulking medications was in the patients in whom the reservoir was preserved. There was also a de‐

Portal vein thrombosis can occur after IPAA. Clinical manifestations may include pain, fe‐ ver, vomiting, leukocytosis, and unexplained postoperative ileus. Diagnose is made with

**•** pouchitis - this is the most frequent. In one series, the cumulative probability of suffering at least one episode of clinical pouchitis was 18 and 48 % at 1 and 10 years, respectively [75],

Majority of the pouch related complication can be solved by medical treatment consisting main‐ ly in local measures, surgery being required in a minority. In one series of almost 1000 patients who had undergone IPAA, reoperation for complications was necessary in only 12 % [77].

As an example, ileal pouch fistulas and strictures refractory to dilatation are difficult to treat and may require revision of the pouch if Crohn's disease can be excluded. A transvaginal repair is favored for a pouch-vaginal fistula [78]. A combined abdominal perineal repair may offer better results compared with a local procedure [79]. A controlled septic condition does not preclude salvage surgery. Although pouch failure occurs more often than with pri‐

CT-scanner. Treatment with anticoagulation will lead to full resolution.

**•** irritable pouch syndrome and anismus (anorectal dysfunction)[76].

for women [72] are higher after laparoscopy.

Are usual after restorative proctocolectomy.

crease in the quality of life of those patients.

**6. Complications**

210 Inflammatory Bowel Disease

**6.1. Early complications**

**6.2. Late complications**

**•** stricture of the anastomosis,

**•** anal fistula and abscess,

**•** reduced fertility [74],

**•** poor postoperative anorectal function,


#### **6.3. Long-term results of surgery**

The long-term success of surgery depends upon the type of operation, the clinical setting, and surgical expertise. Several studies have suggested that functional results are poor dur‐ ing the long-term follow-up in patients who had adverse personality factors before surgery (such as problems with sexual satisfaction, difficulty expressing emotions, perfectionist body ideals, and poor frustration tolerance) [79]. The following results were described in some of the largest series.

One series included 1885 patients who underwent an ileal pouch-anal anastomosis for ulcer‐ ative colitis and were followed for an average of 11 years. The mean number of stools was 5.7 per day at one year and 6.4 at 20 years, and also increased at night from 1.5 to 2.0. The incidence of frequent fecal incontinence increased from 5 to 11 percent during the day and from 12 to 21 percent at night. The overall rate of pouch success at 5, 10, 15, and 20 years was 96, 93, 92, and 92 percent, respectively. Quality of life remained unchanged and 92 per‐ cent remained in the same employment. [86]

In another report that included 486 patients who had undergone proctocolectomy and ileoa‐ nal anastomosis for ulcerative colitis or familial adenomatous polyposis, the cumulative probabilities of pouch failure were 1, 5, and 7 percent at 1, 5, and 10 years, respectively [87] The most common cause of pouch failure was fistula formation.

Tulchinsky et al reported 634 patients who underwent restorative proctocolectomy for IBD. Patients were followed for a mean of 85 months. Failure (defined as removal of the pouch or the need for an ileostomy) was divided into early (occurring within one-year) or late (occur‐ ring more than one-year postoperatively). Three patients died postoperatively while an ad‐ ditional 23 died (of a variety of causes) during follow-up. Of the remaining patients, there were a total of 61 failures (10 %) of which 24.6% were early and 75.4% late. Failures were due to pelvic sepsis (52 %), poor function (30 %), pouchitis (11 %), and miscellaneous causes (four patients, all early failures). Predictors of failure included a final diagnosis of Crohn's disease, a type J or S reservoir, female gender, postoperative pelvic sepsis, and a one-stage procedure. Failure rates increased with time from 9% at five years to 13% at 10 years. [88]

**6.4. Morbidity of operation due to use of biologic agents**

elective operations for their IBD.

appears to refute that notion. [99]

area there is need for more controlled trials.

tion therapy.[83]

[105]

**6.5. Pouchitis**

*Preoperative use of infliximab*. The efficacy of the biologic agents must be balanced against the morbidity associated with their usage, and surgeons have been worried about the safety as‐ sociated with the preoperative use of these medications in patients requiring elective or non‐

An Update to Surgical Management of Inflammatory Bowel Diseases

http://dx.doi.org/10.5772/53057

213

Beddy et al believed the evidence showed that recent biologic agent administration in a pa‐ tient with Crohn's disease should not cause the surgeon to delay surgery or employ fecal di‐ version proximal to an anastomosis. However, they felt that patients with ulcerative colitis preoperatively managed with infliximab and immunosuppressant medications should un‐ dergo a three-stage rather than two-stage restorative proctocolectomy and ileal pouch-anal anastomosis (IPAA); the first operation would be a total or subtotal colectomy and creation of ileostomy that allows patients to be withdrawn from medications prior to performing the IPAA procedure. They proposed this approach in hopes of improving long-term ileal pouch function by decreasing the risk of short-term infectious complications attributed to combina‐

Gainsbury et al, remarked that there is an increased risk of septic complications associated with preoperative infliximab and elective surgery for ulcerative colitis, growing evidence

Whether immunosuppressive therapy increases the risk of postoperative complications is still controversy. For some authors [98, 99, 100, 101] it may not be responsible but for others [102, 103, 104] it is, increasing risk for sepsis, intraabdominal abscesses [102,104], and espe‐ cially when associated with other immunomodulators (ciclosporin) [103]. In this conceptual

Ellis et al found that unlike surgical mortality for most disorders, the operative mortality as‐ sociated with colectomy for ulcerative colitis has increased in recent years despite centraliza‐ tion of care. This finding raises considerable concern that patients potentially are not receiving prompt or appropriate surgical care because of alterations in medical therapy.

Outside of the perioperative period, the most common late complication of ileal pouch anal anastomosis is pouchitis, occurring in up to 60% of patients.[106] Pouchitis is thought to be the result of immunologic reaction to altered bowel flora. Symptoms range from mild diar‐ rhea to severe abdominal pain and fistulization with neighboring organs. In a recent review from the Cleveland Clinic, multivariate analysis identified pulmonary co-morbidities, Spouch reconstruction, disease proximal to the splenic flexure, and extraintestinal disease are the factors predictive of subsequent pouchitis. Patients who developed pouchitis had higher incidence of obstruction, fistula, and stricture and reported lower quality of life than con‐ trols [94]. Once identified, the treatment of pouchitis is primarily medical, with most pa‐ tients showing excellent response to antibiotics and/or probiotics and immunomodulators. A Cochrane database review of trials through 2010 found that ciprofloxacin was more effec‐

Another series showed that results in older patients (>65) are not as good; however, appro‐ priate case selection was followed by acceptable function and quality of life to patients of all ages [89].

Anal canal strictures were described in up to 11 percent of 213 patients [82]. Strictures that were not fibrotic responded well after anal dilation while fibrotic strictures were more com‐ monly associated with intra- or postoperative complications and frequently required surgi‐ cal therapy.

A systematic review of 43 observational studies (with a total of 9317 patients) found a pouch failure rate of 6.8%, increasing to 8.5% in those with more than five-year follow-up [90]. Pel‐ vic sepsis occurred in 9.5%. Severe, mild, and urge fecal incontinence was reported in 3.7, 17, and 7.3 percent, respectively. These results suggest that current techniques are associated with non-negligible complication rates and leave room for improvement and continued de‐ velopment of alternative procedures.

IPAA may have long-term effects:


Satisfactory long-term functional outcome and excellent quality of life have also been descri‐ bed after stapled restorative proctocolectomy. In a series of 977 patients, quality of life in‐ creased for two years after surgery, with no deterioration thereafter [95]. The prevalence of perfect continence increased from 76 percent before surgery to 82 percent after surgery and, although continence deteriorated somewhat more than two years after surgery, it was no worse than preoperative values. Ninety-eight percent of patients would have recommended the surgery to others. In another prospective, observational study, patients who had a sta‐ pled anastomosis had higher rates of daytime, nighttime, and complete continence com‐ pared with patients who underwent a hand-sewn anastomosis [32].

## **6.4. Morbidity of operation due to use of biologic agents**

*Preoperative use of infliximab*. The efficacy of the biologic agents must be balanced against the morbidity associated with their usage, and surgeons have been worried about the safety as‐ sociated with the preoperative use of these medications in patients requiring elective or non‐ elective operations for their IBD.

Beddy et al believed the evidence showed that recent biologic agent administration in a pa‐ tient with Crohn's disease should not cause the surgeon to delay surgery or employ fecal di‐ version proximal to an anastomosis. However, they felt that patients with ulcerative colitis preoperatively managed with infliximab and immunosuppressant medications should un‐ dergo a three-stage rather than two-stage restorative proctocolectomy and ileal pouch-anal anastomosis (IPAA); the first operation would be a total or subtotal colectomy and creation of ileostomy that allows patients to be withdrawn from medications prior to performing the IPAA procedure. They proposed this approach in hopes of improving long-term ileal pouch function by decreasing the risk of short-term infectious complications attributed to combina‐ tion therapy.[83]

Gainsbury et al, remarked that there is an increased risk of septic complications associated with preoperative infliximab and elective surgery for ulcerative colitis, growing evidence appears to refute that notion. [99]

Whether immunosuppressive therapy increases the risk of postoperative complications is still controversy. For some authors [98, 99, 100, 101] it may not be responsible but for others [102, 103, 104] it is, increasing risk for sepsis, intraabdominal abscesses [102,104], and espe‐ cially when associated with other immunomodulators (ciclosporin) [103]. In this conceptual area there is need for more controlled trials.

Ellis et al found that unlike surgical mortality for most disorders, the operative mortality as‐ sociated with colectomy for ulcerative colitis has increased in recent years despite centraliza‐ tion of care. This finding raises considerable concern that patients potentially are not receiving prompt or appropriate surgical care because of alterations in medical therapy. [105]

#### **6.5. Pouchitis**

were a total of 61 failures (10 %) of which 24.6% were early and 75.4% late. Failures were due to pelvic sepsis (52 %), poor function (30 %), pouchitis (11 %), and miscellaneous causes (four patients, all early failures). Predictors of failure included a final diagnosis of Crohn's disease, a type J or S reservoir, female gender, postoperative pelvic sepsis, and a one-stage procedure. Failure rates increased with time from 9% at five years to 13% at 10 years. [88]

Another series showed that results in older patients (>65) are not as good; however, appro‐ priate case selection was followed by acceptable function and quality of life to patients of all

Anal canal strictures were described in up to 11 percent of 213 patients [82]. Strictures that were not fibrotic responded well after anal dilation while fibrotic strictures were more com‐ monly associated with intra- or postoperative complications and frequently required surgi‐

A systematic review of 43 observational studies (with a total of 9317 patients) found a pouch failure rate of 6.8%, increasing to 8.5% in those with more than five-year follow-up [90]. Pel‐ vic sepsis occurred in 9.5%. Severe, mild, and urge fecal incontinence was reported in 3.7, 17, and 7.3 percent, respectively. These results suggest that current techniques are associated with non-negligible complication rates and leave room for improvement and continued de‐

**•** some women experience increased dyspareunia [92], although the ability to experience

**•** female fertility is significantly decreased [93], possibly due to pelvic adhesions, although successful pregnancies occur regularly [94], patients may experience a transient increase in stool frequency (including incontinence) during pregnancy, which resolves after deliv‐ ery, pregnancy and delivery are safe in patients with IPAA. Patients should not be dis‐ couraged from childbearing because of the pouch. Whether vaginal or cesarean delivery

Satisfactory long-term functional outcome and excellent quality of life have also been descri‐ bed after stapled restorative proctocolectomy. In a series of 977 patients, quality of life in‐ creased for two years after surgery, with no deterioration thereafter [95]. The prevalence of perfect continence increased from 76 percent before surgery to 82 percent after surgery and, although continence deteriorated somewhat more than two years after surgery, it was no worse than preoperative values. Ninety-eight percent of patients would have recommended the surgery to others. In another prospective, observational study, patients who had a sta‐ pled anastomosis had higher rates of daytime, nighttime, and complete continence com‐

ages [89].

212 Inflammatory Bowel Disease

cal therapy.

velopment of alternative procedures.

**•** on female reproductive health [91],

orgasm and coital frequency remain unchanged,

is better for women with a pelvic pouch remains controversial.

pared with patients who underwent a hand-sewn anastomosis [32].

IPAA may have long-term effects:

Outside of the perioperative period, the most common late complication of ileal pouch anal anastomosis is pouchitis, occurring in up to 60% of patients.[106] Pouchitis is thought to be the result of immunologic reaction to altered bowel flora. Symptoms range from mild diar‐ rhea to severe abdominal pain and fistulization with neighboring organs. In a recent review from the Cleveland Clinic, multivariate analysis identified pulmonary co-morbidities, Spouch reconstruction, disease proximal to the splenic flexure, and extraintestinal disease are the factors predictive of subsequent pouchitis. Patients who developed pouchitis had higher incidence of obstruction, fistula, and stricture and reported lower quality of life than con‐ trols [94]. Once identified, the treatment of pouchitis is primarily medical, with most pa‐ tients showing excellent response to antibiotics and/or probiotics and immunomodulators. A Cochrane database review of trials through 2010 found that ciprofloxacin was more effec‐ tive than metronidazole and budesonide enemas were equally effective to metronidazole in the treatment of acute pouchitis. The probiotic VSL#3 was more effective than placebo for prevention and treatment of chronic pouchitis[108]. Haveranet al reported complete resolu‐ tion of symptoms in stricturing and antibiotic resistant pouchitis with azathioprine and 6 mercaptorpurine. However, fistulizing disease required the addition of infliximab, with 46% of such patients ultimately requiring diverting ileostomy for relief. Alternatives to ileostomy for pouch failure include pouch salvage techniques such as transanal mobilization or ab‐ dominoperineal revision of the pouch, with success rates ranging from 48 to 93%.[18] A small percentage of patients will ultimately be identified as having Crohn's disease as the cause of their fistulae and pouch complications.[109]

lymphoma in the pouch, three developed squamous cell carcinoma at the anal transitional zone, and 23 developed pouch dysplasia. The prognosis of pouch adenocarcinoma appeared

An Update to Surgical Management of Inflammatory Bowel Diseases

http://dx.doi.org/10.5772/53057

215

If the rectal cuff becomes symptomatic or develops dysplasia, the retained rectal mucosa from the restorative proctocolectomy can be removed by a transanal completion mucosecto‐ my and reconstructing the ileal pouch-anal anastomosis as an alternative to a complete anal rectal resection and permanent ileostomy. The mucosectomy removes all rectal mucosa, con‐ fers a highest likelihood of a surgical cure, and reduces the risk of future dysplasia. Short term results in a series of 27 patients included reduced pouchitis symptoms and 90 % of pa‐ tients were moderately to very satisfy with the procedure. Incontinence was reduced by 70

The optimal frequency of pouch endoscopy and biopsy is not well established. It is recom‐ mended to perform an initial screening five years after creation of an ileal pouch in children

In patients that had severe villous atrophy or dysplasia in the resected colon or rectum the aforementioned interval may be reduced. In patients with pouch or anal high-grade dyspla‐ sia detected during surveillance, resection of the ileal pouch and anal canal should be con‐

In a retrospective review of 222 patients who required operative intervention for Crohn's colitis, there were 2.3% dysplasia and 2.7% adenocarcinoma. In this small cohort, the risk factors for the development of dysplasia or adenocarcinoma included longer disease dura‐ tion (over 17 years), extensive disease, and older age at diagnosis (38 years of age or older). These findings support colonoscopic screening and surveillance of patients with Crohn's

The postoperative recurrence rate for patients undergoing a resection and anastomosis is high in Crohn's disease. In most series up to 20 percent of patients will not have a clinical recurrence even at 15 years after surgery Those with severe endoscopic or radiologic find‐ ings are at increased risk to have or develop symptoms (72 versus 42%). An increased risk

A laparoscopic approach does not appear to decrease the risk of recurrence. A retrospective review of 89 patients undergoing laparoscopically resected primary ileocolonic Crohn's coli‐ tis found recurrent disease in 61 percent [118]. The median time to recurrence was 13 months (range 1.3 months to 8.7 years). Only the presence of granulomas in the resected specimen was identified as a risk factor for time to recurrence, and these patients were al‐

The recurrence rate is lower in patients with Crohn's colitis who undergo a total colectomy and ileostomy compared to those with disease involving other segments of the digestive tract. We already know, from a study in 1985 by Goligher et al Such patients have only a 10

for reoperation has been associated with perforating disease and smoking [117].

most three times more likely to develop a recurrence.

to be poor [100].

sidered.

colitis. [116]

**7.2. Recurrence**

percent at 12 months of observation [101].

or when the total disease duration exceeds seven years [102].

In a review of almost 1800 IPAA attempts from the Mayo Clinic, abandonment was required in 4.1 % [97].

## **7. Postoperative monitoring**

Risk of dysplasia and cancer

All patients who undergo surgical procedures for ulcerative colitis should be monitored reg‐ ularly for the development of long-term complications.

In addition to functional problems, complications can occur at any stage, including the de‐ velopment of dysplasia and possibly cancer.

However, in a study of potentially high-risk patients (eg, Kock pouch for ≥14 years, a pelvic pouch for ≥12 years, a history of dysplasia or cancer in the proctocolectomy specimen or troublesome pouchitis), the development of dysplasia was rare [98].

## **7.1. Dysplasia**

The presence of inflammatory changes in a retained rectal stump, anal transitional zone, and ileal reservoir after stapled pouch-anal anastomosis is a cause of concern because of the long-term risk of dysplasia.

A systematic review of 23 observational and case control studies estimated that the preva‐ lence of confirmed dysplasia in the pouch, anal transitional zone, or rectal cuff was 1.13 % (0-19%) The prevalence of high-grade, low-grade, or indefinite dysplasia was 0.15, 0.98, and 1.23 %, respectively. Dysplasia was equally frequent in the pouch and rectal cuff or anal transitional zone [112].

If dysplasia and cancer are identified before or at operation the risk for postoperative dys‐ plasia is higher. The risk of neoplasia is not completely eliminated by colectomy and muco‐ sectomy. A retrospective review of 3203 patients with a preoperative diagnosis of IBD who underwent restorative proctocolectomy found that the cumulative incidence for pouch neo‐ plasia at 5, 10, 15, 20 and 25 years were 0.9, 1.3, 1.9, 4.2, and 5.1 %, respectively 11 patients developed adenocarcinoma of the pouch or at the anal transitional zone, one developed lymphoma in the pouch, three developed squamous cell carcinoma at the anal transitional zone, and 23 developed pouch dysplasia. The prognosis of pouch adenocarcinoma appeared to be poor [100].

If the rectal cuff becomes symptomatic or develops dysplasia, the retained rectal mucosa from the restorative proctocolectomy can be removed by a transanal completion mucosecto‐ my and reconstructing the ileal pouch-anal anastomosis as an alternative to a complete anal rectal resection and permanent ileostomy. The mucosectomy removes all rectal mucosa, con‐ fers a highest likelihood of a surgical cure, and reduces the risk of future dysplasia. Short term results in a series of 27 patients included reduced pouchitis symptoms and 90 % of pa‐ tients were moderately to very satisfy with the procedure. Incontinence was reduced by 70 percent at 12 months of observation [101].

The optimal frequency of pouch endoscopy and biopsy is not well established. It is recom‐ mended to perform an initial screening five years after creation of an ileal pouch in children or when the total disease duration exceeds seven years [102].

In patients that had severe villous atrophy or dysplasia in the resected colon or rectum the aforementioned interval may be reduced. In patients with pouch or anal high-grade dyspla‐ sia detected during surveillance, resection of the ileal pouch and anal canal should be con‐ sidered.

In a retrospective review of 222 patients who required operative intervention for Crohn's colitis, there were 2.3% dysplasia and 2.7% adenocarcinoma. In this small cohort, the risk factors for the development of dysplasia or adenocarcinoma included longer disease dura‐ tion (over 17 years), extensive disease, and older age at diagnosis (38 years of age or older). These findings support colonoscopic screening and surveillance of patients with Crohn's colitis. [116]

## **7.2. Recurrence**

tive than metronidazole and budesonide enemas were equally effective to metronidazole in the treatment of acute pouchitis. The probiotic VSL#3 was more effective than placebo for prevention and treatment of chronic pouchitis[108]. Haveranet al reported complete resolu‐ tion of symptoms in stricturing and antibiotic resistant pouchitis with azathioprine and 6 mercaptorpurine. However, fistulizing disease required the addition of infliximab, with 46% of such patients ultimately requiring diverting ileostomy for relief. Alternatives to ileostomy for pouch failure include pouch salvage techniques such as transanal mobilization or ab‐ dominoperineal revision of the pouch, with success rates ranging from 48 to 93%.[18] A small percentage of patients will ultimately be identified as having Crohn's disease as the

In a review of almost 1800 IPAA attempts from the Mayo Clinic, abandonment was required

All patients who undergo surgical procedures for ulcerative colitis should be monitored reg‐

In addition to functional problems, complications can occur at any stage, including the de‐

However, in a study of potentially high-risk patients (eg, Kock pouch for ≥14 years, a pelvic pouch for ≥12 years, a history of dysplasia or cancer in the proctocolectomy specimen or

The presence of inflammatory changes in a retained rectal stump, anal transitional zone, and ileal reservoir after stapled pouch-anal anastomosis is a cause of concern because of the

A systematic review of 23 observational and case control studies estimated that the preva‐ lence of confirmed dysplasia in the pouch, anal transitional zone, or rectal cuff was 1.13 % (0-19%) The prevalence of high-grade, low-grade, or indefinite dysplasia was 0.15, 0.98, and 1.23 %, respectively. Dysplasia was equally frequent in the pouch and rectal cuff or anal

If dysplasia and cancer are identified before or at operation the risk for postoperative dys‐ plasia is higher. The risk of neoplasia is not completely eliminated by colectomy and muco‐ sectomy. A retrospective review of 3203 patients with a preoperative diagnosis of IBD who underwent restorative proctocolectomy found that the cumulative incidence for pouch neo‐ plasia at 5, 10, 15, 20 and 25 years were 0.9, 1.3, 1.9, 4.2, and 5.1 %, respectively 11 patients developed adenocarcinoma of the pouch or at the anal transitional zone, one developed

cause of their fistulae and pouch complications.[109]

ularly for the development of long-term complications.

troublesome pouchitis), the development of dysplasia was rare [98].

velopment of dysplasia and possibly cancer.

**7. Postoperative monitoring**

Risk of dysplasia and cancer

in 4.1 % [97].

214 Inflammatory Bowel Disease

**7.1. Dysplasia**

long-term risk of dysplasia.

transitional zone [112].

The postoperative recurrence rate for patients undergoing a resection and anastomosis is high in Crohn's disease. In most series up to 20 percent of patients will not have a clinical recurrence even at 15 years after surgery Those with severe endoscopic or radiologic find‐ ings are at increased risk to have or develop symptoms (72 versus 42%). An increased risk for reoperation has been associated with perforating disease and smoking [117].

A laparoscopic approach does not appear to decrease the risk of recurrence. A retrospective review of 89 patients undergoing laparoscopically resected primary ileocolonic Crohn's coli‐ tis found recurrent disease in 61 percent [118]. The median time to recurrence was 13 months (range 1.3 months to 8.7 years). Only the presence of granulomas in the resected specimen was identified as a risk factor for time to recurrence, and these patients were al‐ most three times more likely to develop a recurrence.

The recurrence rate is lower in patients with Crohn's colitis who undergo a total colectomy and ileostomy compared to those with disease involving other segments of the digestive tract. We already know, from a study in 1985 by Goligher et al Such patients have only a 10 percent recurrence rate in the small intestine at 10 years [106]. A number of medical options are available that may reduce the risk of recurrence. A relatively aggressive approach should be considered in patients with diffuse and distal Crohn's colitis. Total proctocolecto‐ my in properly selected patients is associated with low morbidity, a decreased risk of recur‐ rence, and a longer time to recurrence [20]

[8] Nandivada P, Poylin V, Nagle D, Advances in the Surgical Management of Inflam‐

An Update to Surgical Management of Inflammatory Bowel Diseases

http://dx.doi.org/10.5772/53057

217

[9] Goudet P, Dozois RR, Kelly KA, et al. Changing referral patterns for surgical treat‐

[10] Michelassi, F. Indications for surgical treatment in ulcerative colitis and Crohn's dis‐ ease. In: Operative Strategies in Inflammatory Bowel Disease, Michelassi, F, Milson,

[11] Ananthakrishnan AN, McGinley EL, Binion DG, Saeian K. A nationwide analysis of changes in severity and outcomes of inflammatory bowel disease hospitalizations. J

[12] Oussalah A, Evesque L, Laharie D, et al. A multicenter experience with infliximab for ulcerative colitis: outcomes and predictors of response, optimization, colectomy, and

[13] Gustavsson A, Järnerot G, Hertervig E, et al. Clinical trial: colectomy after rescue therapy in ulcerative colitis - 3-year follow-up of the Swedish-Danish controlled in‐ fliximab study. Aliment Pharmacol Ther 2010; 32:984–989.Chaparro M, Burgueño P, Iglesias E, et al. Infliximab salvage therapy after failure of ciclosporin in corticoste‐ roid-refractory ulcerative colitis: a multicentre study. Aliment Pharmacol Ther 2012; 35:275–283.Goudet P, Dozois RR, Kelly KA, et al. Characteristics and evolution of ex‐ traintestinal manifestations associated with ulcerative colitis after proctocolectomy.

[14] Cima R, Pemberton JH. Medical and surgical management of chronic ulcerative coli‐

[15] Heuschen UA, Hinz U, Allemeyer EH, et al. Risk factors for ileoanal J pouchrelated septic complications in ulcerative colitis and familial adenomatous polyposis. Ann

[16] da Luz Moreira A, Kiran RP, Lavery I. Clinical outcomes of ileorectal anastomosis for

[17] Farouk R, Pemberton JH,WolffBG, et al. Functional outcomes after ileal pouchanal

[18] Fichera A, Michelassi F. Surgical treatment of Crohn's disease. J Gastrointest Surg

[19] Grucela A, Steinhagen RM. Current surgical management of ulcerative colitis. Mt Si‐

[20] Simillis C, Purkayastha S, Yamamoto T, et al. A meta-analysis comparing conven‐ tional end-to-end anastomosis vs. other anastomotic configurations after resection in

matory Bowel Disease, Curr Opin Gastroenterol. 2012;28(1):47-51.

ment of ulcerative colitis. Mayo Clin Proc 1996; 71:743.

hospitalization. Am J Gastroenterol 2010; 105:2617–2625.

JW (Eds), Springer, 1997. p.151.

Gastrointest Surg 2011; 15:267–276.

Dig Surg 2001; 18:51.

Surg 2002; 235:207–216.

nai J Med 2009; 76:606–612.

2007; 11:791.

tis. Arch Surg 2005; 140:300–310.

ulcerative colitis. Br J Surg 2010; 97:65.

anastomosis for chronic ulcerative colitis. Ann Surg 2000;

Crohn's disease. Dis Colon Rectum 2007; 50:1674.

## **Author details**

V. Surlin1 , C. Copaescu2 and A. Saftoiu1

1 Department of Surgery, University of Medicine and Pharmacy of Craiova, and Attending Surgeon in the 1st Clinic of Surgery, Clinical County Emergency Hospital of Craiova, Roma‐ nia

2 University Of Medicine Carol Davila, Head General Surgery Department, Delta Hospital Bucharest, Romania

Department of Gastroenterology and Hepatology, University of Medicine and Pharmacy of Craiova and Attending Physician in Gastroenterology Clinic of Clinical County Emergency Hospital of Craiova, Romania

## **References**


[8] Nandivada P, Poylin V, Nagle D, Advances in the Surgical Management of Inflam‐ matory Bowel Disease, Curr Opin Gastroenterol. 2012;28(1):47-51.

percent recurrence rate in the small intestine at 10 years [106]. A number of medical options are available that may reduce the risk of recurrence. A relatively aggressive approach should be considered in patients with diffuse and distal Crohn's colitis. Total proctocolecto‐ my in properly selected patients is associated with low morbidity, a decreased risk of recur‐

1 Department of Surgery, University of Medicine and Pharmacy of Craiova, and Attending Surgeon in the 1st Clinic of Surgery, Clinical County Emergency Hospital of Craiova, Roma‐

2 University Of Medicine Carol Davila, Head General Surgery Department, Delta Hospital

Department of Gastroenterology and Hepatology, University of Medicine and Pharmacy of Craiova and Attending Physician in Gastroenterology Clinic of Clinical County Emergency

[1] Zmora O., Mahajna A., Bar-ZakaiI B., Hershko D., Shabtai M., Krausz M., Ayalon A. – Is mechanical bowel preparation mandatory for left-sided colonic anastomosis? Re‐ sults of a prospective randomised trial. Tech coloproctol, 01 july 2006; 10(2): 131-5

[2] Schapira M, Henrion J, Ravoet C, et al. Thromboembolism in inflammatory bowel

[3] Irving PM, Pasi KJ, Rampton DS. Thrombosis and inflammatory bowel disease. Clin

[4] Cohen RD. How should we treat severe acute steroid-refractory ulcerative colitis? In‐

[5] Becker JM, Stucchi AF. Treatment of choice for acute severe steroid-refractory ulcera‐

[6] Randall J, Singh B, Warren BF, et al. Delayed surgery for acute severe colitis is associ‐ ated with increased risk of postoperative complications. Br J Surg 2010; 97:404.

[7] Heyries L, Bernard JP, Perrier H, et al. [Hemorrhagic rectocolitis and autoimmune

rence, and a longer time to recurrence [20]

and A. Saftoiu1

disease. Acta Gastroenterol Belg 1999; 62:182.

tive colitis is colectomy. Inflamm Bowel Dis 2009; 15:146.

hemolytic anemia]. Gastroenterol Clin Biol 1998; 22:741.

Gastroenterol Hepatol 2005; 3:617.

flamm Bowel Dis 2009; 15:150.

, C. Copaescu2

**Author details**

216 Inflammatory Bowel Disease

Bucharest, Romania

**References**

Hospital of Craiova, Romania

V. Surlin1

nia


[21] Worsey MJ, Hull T, Ryland L, Fazio V. Strictureplasty is an effective option in the op‐ erative management of duodenal Crohn's disease. Dis Colon Rectum 1999; 42:596.

[37] Di Nardo G, Oliva S, Passariello M, et al. Intralesional steroid injection after endo‐ scopic balloon dilation in pediatric Crohn's disease with stricture: a prospective,

An Update to Surgical Management of Inflammatory Bowel Diseases

http://dx.doi.org/10.5772/53057

219

[38] East JE, Brooker JC, Rutter MD, Saunders BP. A pilot study of intrastricture steroid versus placebo injection after balloon dilatation of Crohn's strictures. Clin Gastroen‐

[39] Matsuhashi N, Nakajima A, Suzuki A, et al. Long-term outcome of non-surgical stric‐ tureplasty using metallic stents for intestinal strictures in Crohn's disease. Gastroint‐

[40] Horgan, AF, Dozois, RR. Management of colonic Crohn's disease. Problems in Gener‐

[41] Tekkis PP, Purkayastha S, Lanitis S, et al. A comparison of segmental vs subtotal/ total colectomy for colonic Crohn's disease: a meta-analysis. Colorectal Dis 2006; 8:82.

[42] Sher ME, Bauer JJ, Gorphine S, Gelernt I. Low Hartmann's procedure for severe ano‐

[43] Buchanan GN, Halligan S, Bartram CI, et al. Clinical examination, endosonography, and MR imaging in preoperative assessment of fistula in ano: comparison with out‐

[44] Schwartz DA, Wiersema MJ, Dudiak KM, et al. A comparison of endoscopic ultra‐ sound, magnetic resonance imaging, and exam under anesthesia for evaluation of

[45] Present DH, Rutgeerts P, Targan S, et al. Infliximab for the treatment of fistulas in

[46] Chung W, Ko D, Sun C, et al. Outcomes of anal fistula surgery in patients with in‐

[47] Soltani A, Kaiser AM. Endorectal advancement flap for cryptoglandular or Crohn's

[49] Regueiro M, El-Hachem S, Kip KE, et al. Postoperative infliximab is not associated with an increase in adverse events in Crohn's disease. Dig Dis Sci 2011; 56:3610–3615.

[50] Bordeianou L, Stein SL, Ho VP, et al. Immediate vs tailored prophylaxis to prevent symptomatic recurrences after surgery for ileocecal Crohn's disease. Surgery 2011;

[51] Kienle P, Weitz J, Benner A, et al. Laparoscopically assisted colectomy and ileoanal‐ pouch procedure with and without protective ileostomy. Surg Endosc. 2003May;

[48] Lewis RT, Maron DJ. Anorectal Crohn's disease. Surg Clin N Am 2010; 90:83–97.

rectal Crohn's disease. Dis Colon Rectum 1992; 35:975.

come-based reference standard. Radiology 2004; 233:674–681.

Crohn's perianal fistulas. Gastroenterology 2001; 121:1064– 1072.

patients with Crohn's disease. N Engl J Med 1999; 340:1398–1405.

flammatory bowel disease. Am J Surg 2010; 199:609–613.

fistula-in-ano. Dis Colon Rectum 2010; 53:486–495.

randomized, double-blind, controlled trial. Gastrointest Endosc 2010; 72:1201.

terol Hepatol 2007; 5:1065.

est Endosc 2000; 51:343.

al Surgery 1999; 16:68.

149:72–78.

17(5):716-20.


[37] Di Nardo G, Oliva S, Passariello M, et al. Intralesional steroid injection after endo‐ scopic balloon dilation in pediatric Crohn's disease with stricture: a prospective, randomized, double-blind, controlled trial. Gastrointest Endosc 2010; 72:1201.

[21] Worsey MJ, Hull T, Ryland L, Fazio V. Strictureplasty is an effective option in the op‐ erative management of duodenal Crohn's disease. Dis Colon Rectum 1999; 42:596. [22] Cellini C, Safar B, Fleshman J. Surgical management of pyogenic complications of

[23] Neufeld D, Keidar A, Gutman M, Zissin R. Abdominal wall abscesses in patients

[24] Fleshman JW. Pyogenic complications of Crohn's disease, evaluation, and manage‐

[25] Spencer MP, Nelson H, Wolff BG, Dozois RR. Strictureplasty for obstructive Crohn's

[26] Tjandra JJ, Fazio VW, Lavery IC. Results of multiple strictureplasties in diffuse

[27] Yamamoto T, Keighley MR. Long-term results of strictureplasty without synchro‐ nous resection for jejunoileal Crohn's disease. Scand J Gastroenterol 1999; 34:180. [28] Dietz DW, Fazio VW, Laureti S, et al. Strictureplasty in diffuse Crohn's jejunoileitis:

[29] Tonelli F, Fedi M, Paroli GM, Fazi M. Indications and results of side-to-side isoperis‐

[30] Michelassi, F. Indications for surgical treatment in ulcerative colitis and Crohn's dis‐ ease. In: Operative Strategies in Inflammatory Bowel Disease, Michelassi, F, Milson,

[31] Michelassi F, Taschieri A, Tonelli F, et al. An international, multicenter, prospective, observational study of the side-to-side isoperistaltic strictureplasty in Crohn's dis‐

[32] Menon AM, Mirza AH, Moolla S, Morton DG. Adenocarcinoma of the small bowel arising from a previous strictureplasty for Crohn's disease: report of a case. Dis Co‐

[33] Fearnhead NS, Chowdhury R, Box B, et al. Long-term follow-up of strictureplasty for

[34] Hassan C, Zullo A, De Francesco V, et al. Systematic review: Endoscopic dilatation in

[35] Thienpont C, D'Hoore A, Vermeire S, et al. Long-term outcome of endoscopic dilata‐ tion in patients with Crohn's disease is not affected by disease activity or medical

[36] Couckuyt H, Gevers AM, Coremans G, et al. Efficacy and safety of hydrostatic bal‐ loon dilatation of ileocolonic Crohn's strictures: a prospective longterm analysis. Gut

taltic strictureplasty in Crohn's disease. Dis Colon Rectum 2004; 47:494.

with Crohn's disease: clinical outcome. J Gastrointest Surg 2006; 10:445.

Crohn's disease. Inflamm Bowel Dis 2010; 16:512.

disease: the Mayo experience. Mayo Clin Proc 1994; 69:33.

safe and durable. Dis Colon Rectum 2002; 45:764.

JW (Eds), Springer, 1997. p.151.

lon Rectum 2007; 50:257.

therapy. Gut 2010; 59:320.

1995; 36:577.

ease. Dis Colon Rectum 2007; 50:277.

Crohn's disease. Br J Surg 2006; 93:475.

Crohn's disease. Aliment Pharmacol Ther 2007; 26:1457.

Crohn's disease of the small bowel. Aust N Z J Surg 1993; 63:95.

ment. J Gastrointest Surg 2008; 12:2160.

218 Inflammatory Bowel Disease


[52] Fowkes L, Krishna K, Menon A, et al. Laparoscopic emergency and elective surgery for ulcerative colitis. Colorectal Dis 2008; 10:373–378.-

[66] Watanabe M, Hasegawa H, Yamamoto S, et al. Successful application of laparoscopic surgery to the treatment of Crohn's disease with fistulas. Dis Colon Rectum. 2002

An Update to Surgical Management of Inflammatory Bowel Diseases

http://dx.doi.org/10.5772/53057

221

[67] Bemelman WA, Slors JF, Dunker MS et al. Laparoscopic-assisted vs. open ileocolic re‐ section for Crohn's disease. A comparative study. Surg Endosc. 2000 ug;14(8):721-5.

[68] Duepree HJ, Senagore AJ, Delaney CP, et al. Advantages of laparoscopic resectionfor

[69] Dunker MS, Bemelman WA, Slors JFM, et al. Functional outcome, quality of life, body image, and cosmesis in patients after laparoscopic-assisted and conventional restorative proctocolectomy: a comparative study. Dis Colon Rectum 2001; 44:1800–

[70] Polle SW, Dunker MS, Slors JF, et al. Body image, cosmesis, quality of life, and func‐ tional outcome of hand-assisted laparoscopic versus open restorative proctocolecto‐

[71] Farouk R, Pemberton JH,WolffBG, et al. Functional outcomes after ileal pouchanal

[72] Olsen KO, Joelsson M, Laurberg S, Oresland T. Fertility after ileal pouch-anal anasto‐

[73] Hahnloser D, Pemberton JH, Wolff BG, et al. Pregnancy and delivery before and after ileal pouch-anal anastomosis for inflammatory bowel disease: immediate and long-

[74] Shen B, Remzi FH, Lavery IC, et al. A proposed classification of ileal pouch disorders and associated complications after restorative proctocolectomy. Clin Gastroenterol

[75] Galandiuk S, Scott NA, Dozois RR, et al. Ileal pouch-anal anastomosis. Reoperation

[76] Burke D, van Laarhoven CJ, Herbst F, Nicholls RJ. Transvaginal repair of pouch-vag‐

[77] Johnson P, Richard C, Ravid A, et al. Female infertility after ileal pouch-anal anasto‐

[78] Baixauli J, Delaney CP, Wu JS, et al. Functional outcome and quality of life after re‐ peat ileal pouch-anal anastomosis for complications of ileoanal surgery. Dis Colon

[79] Karoui M, Cohen R, Nicholls J. Results of surgical removal of the pouch after failed

[80] Prudhomme M, Dozois RR, Godlewski G, et al. Anal canal strictures after ileal

my: long-term results of a randomized trial. Surg Endosc 2007; 21:1301.

anastomosis for chronic ulcerative colitis. Ann Surg 2000;

for pouch-related complications. Ann Surg 1990; 212:446.

mosis for ulcerative colitis. Dis Colon Rectum 2004; 47:1119.

restorative proctocolectomy. Dis Colon Rectum 2004; 47:869.

pouch-anal anastomosis. Dis Colon Rectum 2003; 46:20.

mosis in women with ulcerative colitis. Br J Surg 1999; 86:493.

term consequences and outcomes. Dis Colon Rectum 2004; 47:1127.

ileocecal Crohn's disease. Dis Colon Rectum. 2002 May;45(5):605-10.

Aug;45(8):1057-61.

Hepatol 2008; 6:145.

Rectum 2004; 47:2.

inal fistula. Br J Surg 2001; 88:241.

1807.


[66] Watanabe M, Hasegawa H, Yamamoto S, et al. Successful application of laparoscopic surgery to the treatment of Crohn's disease with fistulas. Dis Colon Rectum. 2002 Aug;45(8):1057-61.

[52] Fowkes L, Krishna K, Menon A, et al. Laparoscopic emergency and elective surgery

[53] Ky AJ, Sonoda T, Milsom JW. One-stage laparoscopic restorative proctocolectomy:an alternative to the conventional approach? Dis Colon Rectum. 2002 Feb;45(2):

[54] Hasegawa H, Watanabe M, Baba H, Nishibori H, Kitajima M.Laparoscopic restora‐ tive proctocolectomy for patients with ulcerative colitis. J Laparoendosc Adv Surg

[55] Marcello PW, Milsom JW, Wong SK, et al. Laparoscopic restorative proctocolecto‐ my:case-matched comparative study with open restorative proctocolectomy. Dis Co‐

[56] Brown SR, Eu KW, Seow-Choen F. Consecutive series of laparoscopic-assisted vs.minilaparotomy restorative proctocolectomies. Dis Colon Rectum. 2001 Mar;44(3):

[57] Bergamaschi R, Pessaux P, Arnaud JP. Comparison of conventional and laparoscopi‐ cileocolic resection for Crohn's disease. Dis Colon Rectum. 2003 Aug;46(8):1129-33.

[58] Young-Fadok TM, Hall Long K, McConnell EJ et al. Advantages of laparoscopicre‐ section for ileocolic Crohn's disease. Improved outcomes and reduced costs. SurgEn‐

[59] Milsom JW, Hammerhofer KA, Bohm B, et al. Prospective, randomized trialcompar‐ ing laparoscopic vs. conventional surgery for refractory ileocolic Crohn'sdisease.Dis

[60] Maartense S, Dunker MS, Slors JF, et al. Laparoscopic-assisted versus open ileocolic resection for Crohn's disease: a randomized trial. Ann Surg 2006; 243:143.

[61] Alves A, Panis Y, Bouhnik Y, et al. Factors that predict conversion in 69 consecutive patients undergoing laparoscopic ileocecal resection for Crohn's disease: a prospec‐

[62] Lowney JK, Dietz DW, Birnbaum EH, et al. Is there any difference in recurrence rates in laparoscopic ileocolic resection for Crohn's disease compared with conventional

[63] Holubar SD, Dozois EJ, Privitera A, et al. Minimally invasive colectomy for Crohn's colitis: a single institution experience. Inflamm Bowel Dis 2010; 16:1940–1946.

[64] Umanskiy K, Malhotra G, Chase A, et al. Laparoscopic colectomy for Crohn's colitis. A large prospective comparative study. J Gastrointest Surg 2010; 14:658–663.

[65] Tabet J, Hong D, Kim CW et al. Laparoscopic versus open bowel resection forCrohn's

surgery? A long-term, follow-up study. Dis Colon Rectum 2006; 49:58.

for ulcerative colitis. Colorectal Dis 2008; 10:373–378.-

207-10;discussion 210-1.

397-400.

220 Inflammatory Bowel Disease

Tech A. 2002 Dec;12(6):403-6.

dosc. 2001 May;15(5):450-4.

Colon Rectum. 2001 Jan;44(1):1-8.

tive study. Dis Colon Rectum 2005; 48:2302.

disease. Can J Gastroenterol. 2001 Apr;15(4):237-42.

lon Rectum. 2000 May;43(5):604-8.


[81] Taylor WE, Wolff BG, Pemberton JH, Yaszemski MJ. Sacral osteomyelitis after ileal pouch-anal anastomosis: report of four cases. Dis Colon Rectum 2006; 49:913.

[95] Colombel JF, Loftus EV Jr, Tremaine WJ, et al. Early postoperative complications are not increased in patients with Crohn's disease treated perioperatively with infliximab

An Update to Surgical Management of Inflammatory Bowel Diseases

http://dx.doi.org/10.5772/53057

223

[96] Marchal L, D'Haens G, Van Assche G, et al. The risk of post-operative complications associated with infliximab therapy for Crohn's disease: a controlled cohort study.

[97] Gaertner WB, Decanini A, Mellgren A, et al. Does infliximab infusion impact results of operative treatment for Crohn's perianal fistulas? Dis Colon Rectum 2007; 50:1754.

[98] Appau KA, Fazio VW, Shen B, et al. Use of infliximab within 3 months of ileocolonic resection is associated with adverse postoperative outcomes in Crohn's patients. J

[99] Schluender SJ, Ippoliti A, Dubinsky M, et al. Does infliximab influence surgical mor‐ bidity of ileal pouch-anal anastomosis in patients with ulcerative colitis? Dis Colon

[100] Selvasekar CR, Cima RR, Larson DW, et al. Effect of infliximab on short-term compli‐ cations in patients undergoing operation for chronic ulcerative colitis. J Am Coll Surg

[101] Ellis MC, Diggs BS, Vetto JT, Herzig DO. Trends in the surgical treatment of ulcera‐ tive colitis over time: increased mortality and centralization of care. World J Surg

[102] Lipman JM, Kiran RP, Shen B, et al. Perioperative factors during ileal pouchanal

[103] Holubar SD, Cima RR, Sandborn WJ, Pardi DS. Treatment and prevention of pouchi‐ tis after ileal pouch anal anastomosis for chronic ulcerative colitis. Cochrane Data‐ base Syst Rev 2010:CD001176. doi: 10.1002/14651858. CD001176.pub2.Simchuk EJ, Thirlby RC. Risk factors and true incidence of pouchitis in patients after ileal pouch-

[104] Haveran LA, Sehgal R, Poritz LS, et al. Infliximab and/or azathioprine in the treat‐ ment of Crohn's disease-like complications after IPAA. Dis Colon Rectum 2011; 54:15–20.Browning SM, Nivatvongs S. Intraoperative abandonment of ileal pouch to

anal anastomosis--the Mayo Clinic experience. J Am Coll Surg 1998; 186:441.

[105] Thompson-Fawcett MW, Marcus V, Redston M, et al. Risk of dysplasia in long-term ileal pouches and pouches with chronic pouchitis. Gastroenterology 2001; 121:275.

[106] Scarpa M, van Koperen PJ, Ubbink DT, et al. Systematic review of dysplasia after re‐

[107] Kariv R, Remzi FH, Lian L, et al. Preoperative colorectal neoplasia increases risk for pouch neoplasia in patients with restorative proctocolectomy. Gastroenterology 2010;

storative proctocolectomy for ulcerative colitis. Br J Surg 2007; 94:534.

anastomosis predict pouchitis. Dis Colon Rectum 2011; 54:311–317.

anal anastomoses. World J Surg 2000; 24:851–856.

or immunosuppressive therapy. Am J Gastroenterol 2004; 99:878.

Aliment Pharmacol Ther 2004; 19:749.

Gastrointest Surg 2008; 12:1738.

Rectum 2007; 50:1747.

2007; 204:956.

2011; 35:671–676.

139:806.


[95] Colombel JF, Loftus EV Jr, Tremaine WJ, et al. Early postoperative complications are not increased in patients with Crohn's disease treated perioperatively with infliximab or immunosuppressive therapy. Am J Gastroenterol 2004; 99:878.

[81] Taylor WE, Wolff BG, Pemberton JH, Yaszemski MJ. Sacral osteomyelitis after ileal pouch-anal anastomosis: report of four cases. Dis Colon Rectum 2006; 49:913. [82] Jain A, Abbas MA, Sekhon HK, Rayhanabad JA. Volvulus of an ileal J-pouch. In‐

[83] Mmeje C, Bouchard A, Heppell J. Image of the month. Pharmacobezoar: a rare com‐ plication after ileal pouch-anal anastomosis for ulcerative colitis. Clin Gastroenterol

[84] Hahnloser D, Pemberton JH, Wolff BG, et al. Results at up to 20 years after ileal pouch-anal anastomosis for chronic ulcerative colitis. Br J Surg 2007; 94:333.

[85] Lepistö A, Luukkonen P, Järvinen HJ. Cumulative failure rate of ileal pouch-anal anastomosis and quality of life after failure. Dis Colon Rectum 2002; 45:1289. - [86] Tulchinsky H, Hawley PR, Nicholls J. Long-term failure after restorative proctocolec‐

[87] Delaney CP, Fazio VW, Remzi FH, et al. Prospective, age-related analysis of surgical results, functional outcome, and quality of life after ileal pouch-anal anastomosis.

[88] Hueting WE, Buskens E, van der Tweel I, et al. Results and complications after ileal pouch anal anastomosis: a meta-analysis of 43 observational studies comprising 9,317

[89] Wax JR, Pinette MG, Cartin A, Blackstone J. Female reproductive health after ileal pouch anal anastomosis for ulcerative colitis. Obstet Gynecol Surv 2003; 58:270. [90] Cornish JA, Tan E, Teare J, et al. The effect of restorative proctocolectomy on sexual function, urinary function, fertility, pregnancy and delivery: a systematic review. Dis

[91] Johnson P, Richard C, Ravid A, et al. Female infertility after ileal pouch-anal anasto‐ mosis for ulcerative colitis. Dis Colon Rectum 2004; 47:1119.Hahnloser D, Pemberton JH, Wolff BG, et al. Pregnancy and delivery before and after ileal pouch-anal anasto‐ mosis for inflammatory bowel disease: immediate and long-term consequences and

[92] Beddy D, Dozois EJ, Pemberton JH. Perioperative complications in inflammatory

[93] Gainsbury ML, Chu DI, Howard LA, et al. Preoperative infliximab is not associated with an increased risk of short-term postoperative complications after restorative proctocolectomy and ileal pouch-anal anastomosis. J Gastrointest Surg 2011; 15:397–

[94] Subramanian V, Pollok RC, Kang JY, Kumar D. Systematic review of postoperative complications in patients with inflammatory bowel disease treated with immunomo‐

tomy for ulcerative colitis. Ann Surg 2003; 238:229.

outcomes. Dis Colon Rectum 2004; 47:1127.FAZIO

bowel disease. Inflamm Bowel Dis 2011; 17:1610–1619.

flamm Bowel Dis 2010; 16:3.

Hepatol 2010; 8:A28.

222 Inflammatory Bowel Disease

Ann Surg 2003; 238:221.

patients. Dig Surg 2005; 22:69.

Colon Rectum 2007; 50:1128.

dulators. Br J Surg 2006; 93:793.

403.


[108] Sarigol S, Wyllie R, Gramlich T, et al. Incidence of dysplasia in pelvic pouches in pe‐ diatric patients after ileal pouch-anal anastomosis for ulcerative colitis. J Pediatr Gas‐ troenterol Nutr 1999; 28:429.

**Section 3**

**Future Therapeutic Directions in IDB**


**Future Therapeutic Directions in IDB**

[108] Sarigol S, Wyllie R, Gramlich T, et al. Incidence of dysplasia in pelvic pouches in pe‐ diatric patients after ileal pouch-anal anastomosis for ulcerative colitis. J Pediatr Gas‐

[109] Maykel JA, Hagerman G, Mellgren AF, et al. Crohn's colitis: the incidence of dyspla‐ sia and adenocarcinoma in surgical patients. Dis Colon Rectum 2006; 49:950.

[110] Avidan B, Sakhnini E, Lahat A, et al. Risk factors regarding the need for a second op‐

[111] Malireddy K, Larson DW, Sandborn WJ, et al. Recurrence and impact of postopera‐ tive prophylaxis in laparoscopically treated primary ileocolic Crohn disease. Arch

[112] Goligher JC. The long-term results of excisional surgery for primary and recurrent

[113] Litzendorf ME, Stucchi AF, Wishnia S, et al. Completion mucosectomy for retained rectal mucosa following restorative proctocolectomy with double-stapled ileal

eration in patients with Crohn's disease. Digestion 2005; 72:248.

Crohn's disease of the large intestine. Dis Colon Rectum 1985; 28:51.

pouch-anal anastomosis. J Gastrointest Surg 2010; 14:562.

troenterol Nutr 1999; 28:429.

224 Inflammatory Bowel Disease

Surg 2010; 145:42.

**Chapter 7**

**Targeting Colon Drug Delivery by Natural Products**

Inflammatory Bowel Disease (IBD) classified with Ulcerative Colitis (UC) and Crohn Dis‐ ease (CD) is an idiopathic, life-long, destructive chronic inflammatory disease in gastrointes‐ tinal tract [1] and probably multi-factorial disease caused by interplay of the external and internal environment. Little is known about the mechanism of pathogenesis of the disease but it has been reported that immunological mechanisms are involved in etiology. Under normal situations, the intestinal mucosa is in a state of controlled inflammation regulated by a delicate balance of pro-inflammatory (tumor necrosis factor [TNF]-alpha, interferon [IFN] gamma, interleukin [IL]-1, IL-6, IL-12 and anti-inflammatory cytokines (IL-4, IL-10, IL-11),

where particularly, IL-6 stimulates T-cell and B-cell proliferation and differentiation.

injury, with cytokines playing a central role in modulating inflammation [2,3].

Therefore, the mucosal immune system is the central effect or of intestinal inflammation and

During last a couple of decade, the therapeutic agents for IBD have been changed rapidly and anti-inflammatory agents such as corticosteroid and salicylates or its metabolite were used but recently biological agents are introduced. Emerging changes in IBD medications or their use for an instance, balsalazid, budesonide, 5-aminosalicylate (5-ASA) and purine ana‐ logues such as azathioprine are improvements in conventional application, additionally, mycophenolate mofetil (MMF), thalidomide and heparin are newly introduced into IBDther‐

On the contrary, advances in molecular technology have enabled the development of novel and potentially effective targeted therapies with anti-TNF particularly infliximab, interfer‐ on-gamma and interleukin [7, 8]. Nevertheless, biologically active agents have some prob‐ lems in terms of long termstorage conditions and immune-toxicity, additionally biocompatibility against major histological complex (MHC) of immunoglobulin G, which may cause in inconvenience of patient compliance and more expenditure. Thus, the great in‐

> © 2012 Kim; licensee InTech. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use,

© 2012 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution,

distribution, and reproduction in any medium, provided the original work is properly cited.

and reproduction in any medium, provided the original work is properly cited.

Additional information is available at the end of the chapter

Hyunjo Kim

**1. Introduction**

apy [4-6].

http://dx.doi.org/10.5772/52346
