Surgery for Crohn’s Disease

Treatment with medication is the first therapeutic option for people with Crohn’s disease. However, about two-thirds to three-quarters of people with Crohn’s will eventually undergo surgery as part of the therapeutic management of their illness. Surgery may be needed for serious complications; for disease that doesn’t respond to medication; or as a last resort to relieve symptoms that cannot be brought under control.

The primary goals of surgery are to alleviate complications, achieve the best possible quality of life, and conserve as much bowel as possible. It can often make the difference between severe pain/steroid-dependence and the possibility of living a healthy and productive life.

Complications of Crohn’s disease that may require surgery include:

• Intestinal obstruction or blockage
• Excessive bleeding in the intestine
• Perforation of the bowel
• Formation of a fistula or abscess
• Toxic megacolon (dilation and loss of muscle tone in the colon)

Several different types of surgical procedures may be performed, depending on the type of complication, the severity of the illness, or the location of the disease in the intestines. Crohn’s disease can affect the colon, small intestine, or stomach. Unlike ulcerative colitis, Crohn’s cannot be cured with surgery. Even if the diseased portion of the intestine is removed, the inflammation can reappear in a previously unaffected portion of the intestine.

Strictureplasty

When Crohn’s disease affects the small intestine, areas of diseased bowel may alternate with areas of normal bowel. The areas of active disease may narrow, forming strictures, which can block the passage of digested food. The sections of normal bowel compensate by pushing against this strictured area, causing severe crampy pain.

When this occurs, a procedure called strictureplasty may be performed. This procedure widens the strictured area without removing any portion of the small intestine. The surgeon makes a lengthwise incision along the narrowed area and then sews it up crosswise.

Removal of Portions of the Intestines (Resection)

If a stricture is long, or there are multiple strictures close to one another, it may be necessary to remove the affected section of the intestine. This is called a resection. The two ends of healthy intestine are then joined together in a procedure called anastomosis.

A bowel resection may offer patients many years of symptom relief. However, the disease can recur at or near the site of the anastomosis.

Removal of the Colon (Colectomy) or Colon and Rectum (Proctocolectomy)

For some people with severe Crohn’s disease affecting the colon, surgery may be needed to remove the entire colon (colectomy). If the rectum is unaffected by the disease, it may be possible to join the end of the small intestine (called the ileum) to the rectum. This allows the person to continue to pass stool in a bowel movement.

However, some patients may need a proctocolectomy – a procedure involving the removal of both the colon and rectum that is performed along with anileostomy. An ileostomy – performed after the proctocolectomy – involves bringing the end of the small intestine (ileum) through a hole (stoma) in the abdominal wall, allowing drainage of intestinal waste out of the body. The stoma is usually created in the right lower abdomen near the belt line.

An external bag must be worn over the opening to collect the waste, and it must be emptied several times a day. Clothing can be worn normally with minimal adjustments, and no one will know you have an ostomy unless you tell them.

Surgery for Abscesses and Fistulas

About one in four adults with Crohn’s disease will develop a fistula or abscess during their lifetime. An abscess is a tender mass filled with pus from an infection. A fistula is an abnormal tunnel that may lead from an abscess to a hollow organ (like the intestines). A fistula can also connect two adjacent loops of intestine or may connect the intestine to the bladder, vagina, skin, or other organ.

Fistulas are usually initially treated with medication, but surgery may be required if the fistula is causing symptoms that don’t respond to drugs. The surgical procedure is resection of the involved bowel and anastomosis.

An abscess must be drained. This may be done with a needle inserted through the skin, which is guided to the correct location with the help of a CT scanner. In many cases, surgery is required to drain the abscess or to perform a resection.

Disease Recurrence after Surgery

• About 50 percent of adult patients will have a recurrence of symptomatic Crohn’s disease within five years after having a resection. The disease usually recurs at the site of the anastomosis or ileostomy.
• The chances of a recurrence can be reduced by taking medication, such as 5-ASA agents and immunomodulators.
• Recurrent Crohn’s disease often can be successfully treated with medications. However, about half of people with recurrent symptoms will need a second surgery.

Special Considerations

• Many people suffer needlessly because they try to avoid surgery. But if medical therapy no longer keeps your disease under control, surgery should be seriously considered.
• It’s important to gather as much information as possible. Discuss all therapeutic and surgical options with your gastroenterologist and surgeon. Most people benefit, too, from speaking with others who’ve undergone surgery.
• If you decide to have surgery, it’s extremely important to bolster your nutritional status prior to the procedure.
• The combination of medical and surgical therapy can often give people with Crohn’s disease the best possible quality of life.