Surgery for Crohn’s
In approximately one in four people with Crohn’s disease, the disease affects the anus. This is called ‘perianal disease’ and includes abscesses and fistulas (abnormal openings and weeping tracts leading to the skin). Perianal disease does not occur in ulcerative colitis (although ulcerative colitis patients may develop significant irritation of the anal area as a result of frequent diarrhea).
Abscesses and fistulas in Crohn’s disease develop when there is a microscopic break in the intestinal lining which allows bacteria to spread beyond the bowel. An anal abscess may begin as a pimple-like boil that may enlarge and become quite painful. Surgery for an abscess involves an “incision” or surgical cut into the abscess which allows the pus inside to drain away.
A fistula is an abnormal opening, or tract, that directly connects the rectum to the skin (an external fistula), or connects the rectum to an organ, such as the bladder or the vagina (an internal fistula). Fistulas are the result of abscesses that track from one area to another and leave a passageway behind. If fistulas occur in the abdomen in patients with Crohn’s disease, surgery is usually warranted. If they develop in the anal area however, they should rarely be managed with surgery since surgery can sometimes make matters much worse. More often, medical treatment using Flagyl is more appropriate.
Surgery for small-bowel obstruction
The most common abdominal surgical procedure for Crohn’s disease involves removing a blockage or obstruction in the small bowel. Obstructions happen because, as the disease progresses, inflammation causes the wall of the small bowel to thicken so that the passageway within the bowel (the lumen) narrows. Eventually, the bowel becomes so narrow that foodstuffs can no longer pass through it. This leads to cramps and sometimes complete obstruction of the intestine.
An area of narrowed bowel is called a “stricture”. Strictures can be temporary (swelling that will resolve with anti-inflammatory medications and time) or permanent (due to scaring). Strictures that cause significant symptoms and that do not respond to medications will require surgical treatment.
At operation, a stricture may be corrected by either making it wider (“strictureplasty”) or by removing the segment of bowel containing the stricture (“resection”). When strictureplasty can be done, it is generally favored because it doesn’t involve removing part of the small bowel. However, if the stricture is more than two to three inches in length, strictureplasty may not be possible. In a resection, the diseased area is removed and the remaining ends of bowel are joined.
The farther down the small bowel, the more important the intestine is for absorbing nutrients and fluid, so that removing sections of the upper small bowel (jejunum) may not be as significant as removing portions of the lower small bowel (ileum).
If too much small bowel is removed, the patient can develop what is known as “short bowel syndrome” in which a number of symptoms occur as a result of malabsorption of nutrients. Surgeons try everything they can to prevent their patients from developing short bowel syndrome and when the strictureplasty operation was first described at the Radcliffe Infirmary in Oxford, England in the 1970’s it spread rapidly amongst intestinal surgeons throughout the world. The bowel is opened along its length right through the narrowed area and is then sewn closed in the opposite direction. This results in a wider segment of bowel.
Strictureplasty now appears to be an effective option and the results seem long-lasting. If further strictures develop, they are generally new ones or ones that were not treated by strictureplasty. In some case however, the development of short bowel syndrome is often unavoidable since some individuals will continue to develop strictures over the years, necessitating repeated operations and inevitable resections. Even experienced, conservative intestinal surgeons will have a few short bowel patients in their practice. Symptoms of short bowel syndrome include chronic diarrhea and difficulty maintaining appropriate fluid and nutritional balance within the body.
Surgery for Crohn’s disease of the colon
A short portion of the first part of the colon (the cecum) is often involved with Crohn’s disease of the end of the small bowel (terminal ileitis). In such cases, the small bowel segment and a small portion of the first part of the colon may be removed in one piece and the ends rejoined. This is called a limited right hemicolectomy.
In general, however, when the colon is involved with Crohn’s disease it is usually fairly extensive. Strictureplasties are not done in the colon and multiple small resections of pieces of colon are also not usually performed. Rather, surgeons will generally remove a third, or half or all of the colon. Names of these types of operations are right hemicolectomy if the right side of the colon is removed, left hemicolectomy if the left side is removed, transverse colectomy if the middle third is removed and total colectomy if the entire colon is removed but the rectum is not.
The most troubling consideration is what to do when the rectum (the last 12 inches of bowel above the anus) is involved. The rectum is the most difficult part of the intestine to remove and, if it is removed, the patient will need a new means of expelling stool, usually through an opening on the abdominal wall called a stoma (meaning ‘mouth’). If all of the colon has been removed in addition to the rectum, the operation is called a proctocolectomy (‘procto’ means rectum). After a proctocolectomy, the stoma will consist of the end of the small bowel and will be called an ileostomy since the end of the small bowel is called the ileum.
Proctocolectomy and ileostomy is the standard procedure for extensive and debilitating Crohn’s disease of the colon and rectum. The results are generally very good. The small intestine adjusts over time to take over most of the functions of the large intestine. An ileostomy is created to permit the elimination of waste through the abdominal wall. An appliance (plastic device) is fitted over the opening to collect waste material. The patient with an ileostomy can’t control the passing of stool, however, he or she can empty the collection bag when convenient – usually three or four times a day. There are some fancier alternatives to the conventional ileostomy called internal ileostomies and pelvic pouches, but these are rarely successful in patients who have Crohn’s disease.
If the rectum is still reasonable healthy, a total proctocolectomy may not be necessary. The alternative is the colectomy with ileorectal anastomosis, in which only the diseased colon (but not the rectum or anus) is removed, and the ileum is joined directly to the rectum. Waste can be eliminated through the anus. About five per cent of cases are eligible for this procedure. There is a chance that the disease will flare-up in the rectum. If the rectum becomes badly diseased later, it may have to be removed and a conventional ileostomy will then be needed. It is difficult to predict how the patient will do after a colectomy and ileorectal anastomosis. It depends very much on the status of the remainder of the bowel. If the rectum is reasonably healthy and most of the small bowel remains, it is worth a try since it preserves the normal route of stool elimination and the operation is much less surgery if the rectum can be left alone. If there is significant perianal disease with abscesses or fistulas, however, a colectomy and ileorectal anastomosis is not a good choice since the anal problems will often get worse following the operation.
More Information to Follow – modified – Aug 2003
Now for all those important questions we all want to know , how long will i be off work? will I be in pain? etc etc
right info on ops, your first Q is usually, how long you’ll be off work, right? After a straighforward resection with no complications, the average time is about 8wks
As for the op, they usually want you in the day before, when you’ll be checked over by the junior doc, see the anaethetist, possibly physio- who’ll come round to visit you for the first few days, they’ll want to make sure you have no problems coughing, to reduce risk of chest infections & of course your surgeon. You won’t remember much of your op day, some anaethetists like to give a pre-op med so do ask, usually a sleeping tab or valium, which is great & stops the anxiety Another good idea is to ask for a sleeping tablet the night before.
After your op they take you to a recovery area till you come round then you’ll get wheeled back to the ward. Your usually on morphine, either by PCA, see below, or epidural. But, only for the first day or two. You’ll be on NIL ORALLY until your bowel starts functioning again, your docs will know this by listening for bowel sounds Once this happens roundabout 2-3rd post-op day. They’ll then start you on 30mls/oz of water every hour whoopie 
it tastes like the best wine, if you cope ok with this it’s upped slowly till your on full fluids, often this includes a clear soup & even jelly maybe, then your iv infusion will come down. From then on you go onto real food I was back eating 3 course meals before I left, which was on my 5th or 6th post op day. Then comes the hard bit, healing, you’ll be sore & your wound area will feel numb for a while, this is normal. Do make sure you get enough exercise, it’s important for recovery & it starts on the day after your op. You’ll probably have a catheter into your bladder but they’ll do this when your under so you won’t feel it, makes it easier for the 1st day or two but the sooner it’s out the better, less risk of urine infections. As I said walking is encouraged after surgery but don’t push yourself to do too much too soon. Gradually build up both the length of time and the distance that you walk. So, on your 1st post-op day the nurses will help give you a blanket wash, change your nightie etc, don’t worry you’ll be able to shower as soon as your up & about. They’ll want you to sit out of bed for a while at least, this is to reduce the likelihood of a DVT, oh you’ll get a pr of those glamerous white stockings for the same reason. Although it’ll hurt do try & keep exercising, by this i mean walking round the ward NOT lifting weights lol it helps you recover quickeR. Do take care bout lifting tho, you should not lift anything heavier than a carton of milk for the first 6 wks or so & avoid things which will cause you to stress or strain against your incision for a period of at least six weeks following your operation.
You also need to eat well, to aid the healing process, vit C & zinc are supposed to help too
Driving may be resumed two weeks following discharge from the hospital providing you are no longer taking prescription pain medication.
Sex may be resumed three weeks following surgery.
As for your wound, you’ll have either metal staples or stitches, which are usually removed about the 10th post-op day, unless, if your lucky, your surgeon closed your wound with subcuticular suturing using absorbable sutures, all this means is the sutures are under the skin which makes for a less visible scar,
absorbable sutures are associated with less pain and less risk of suture sinus
SO usually by the time you go home your wound will be clean & dry with no dressing required.
What is Patient Controlled Analgesia?
This allows your child to have control over their pain. The system works by allowing your child to give him/herself extra medicine when it hurts. A special machine containing a syringe of medicine (usually morphine) is attached to a cannula, or ‘drip’, which is a small plastic tube into a vein. A handset is attached to the machine which is programmed to deliver a safe dose of morphine (a bolus) when the button on the handset is pressed. There is sometimes a small amount of morphine going in continuously. If your child is sore, he/she can press the button without having to ask the nurse. It takes about five to ten minutes to work, and if your child is still sore after this time he/she can press it again. If your child is about to move or have any procedure done, it is a good idea for them to press the button about five minutes beforehand to make it less painful. It is important that only your child presses the button. This is a safety mechanism so that if they become sleepy from pressing the button a lot, they will stop using it.
Added 26/8/05 by Em