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Inflammatory Bowel Disease: Update Course 2015
Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
For Crohn's disease with terminal ileum stricture and phlegmonous changes encasing the ureter, laparoscopic ileocystectomy with a lighted ureteral stent for ureter identification is the appropriate surgical approach.
If the patient is stable, giving a couple weeks of antibiotics to cool down inflammation before surgery is advisable in Crohn's disease.
There is no data to support the exact timing of preoperative antibiotics in Crohn's disease.
Based on small literature, surgery should be delayed 2-4 weeks from the last TNF inhibitor infusion preoperatively if possible.
Postoperatively, TNF inhibitor can be restarted after about 2 weeks if active disease is seen in other parts of the bowel, or after 4 weeks if disease is less aggressive.
The literature on anastomotic complications with TNF inhibitors is mixed; wound complications are the biggest concern in the literature.
The decision to perform single-stage versus diverted J-pouch reconstruction depends on intraoperative findings including ease of pouch creation, tissue health, and presence of tension.
Patients on steroids and infliximab have risk factors for anastomotic complications.
Surgery for ulcerative colitis may be indicated when complications of medical therapy (long-term side effects of anti-TNF drugs, steroids, growth failure) become intolerable, even if the disease is controlled.
Only about 20% of patients with ulcerative colitis develop colon cancer by 20 years from the time of original diagnosis.
Patients with ulcerative colitis can live their entire life with their colons if they undergo yearly surveillance colonoscopy; there is no reason to have a colectomy without other indications beyond cancer risk alone.
For indeterminate colitis with patchy disease throughout the colon, the conservative approach is to divert with ileostomy and observe what happens to the colon.
For indeterminate colitis with extensively diseased colon, one would consider subtotal colectomy with ileostomy to obtain a large specimen for pathologic determination of disease type.
There is literature on doing total proctocolectomy and J-pouch for indeterminate colitis, but it carries more risk.
Performing a J-pouch in a patient who turns out to have Crohn's disease creates significant challenges.
Thin asthenic females with indeterminate colitis do not do well with J-pouch.
A stepwise approach to J-pouch in indeterminate colitis allows time to obtain more diagnostic information between stages.
J-pouch is a procedure with a definite learning curve in terms of technical aspects.
In pediatric patients, the rectum can be divided laparoscopically, everted or stapled across at the columns, then the J-pouch created externally with anvil placement for EEA anastomosis, as an alternative to the adult technique.
J-pouch provides the best operation for control of bowel issues in ulcerative colitis patients, and patients can still carry pregnancies even if natural conception is impaired.
In Sweden, 50% of facilities are doing ileorectal anastomosis instead of ileal pouch-anal anastomosis due to concerns about infertility in females.
Infertility rates after J-pouch are as high as 60% in some series.
The infertility rate in the United States general population is around 10-11%.
Infertility rate after laparoscopic J-pouch procedures is about 20-30%, compared to 50-60% with open procedures.
Fecundity rate (ability to carry a pregnancy) is the same after J-pouch; patients may need assistance with conception but can carry pregnancies.
In some European practices, performing a pull-through operation on a patient before the end of their childbearing years is considered unacceptable.
It is no longer necessarily true that the colon must be removed in all ulcerative colitis patients; surveillance colonoscopy is an acceptable alternative.
Some surgeons perform total proctocolectomy with J-pouch reconstruction in selected Crohn's patients with good results, as presented in adult literature.