Surgical treatment of Crohn's disease

Crohn’s disease is a debilitating condition that is a form of inflammatory bowel disease (IBD). It can be hard to live with and difficult to manage. Mr Richard Lovegrove, a top colorectal and general surgeon, explains when Crohn’s disease is treated surgically and how this surgery is performed.

When is surgery required for treating Crohn’s disease?

Surgery for Crohn’s disease is often seen as a failure of medical therapy. This is not the case and should be seen as a treatment strategy that has become necessary, based on the behaviour of the disease at that time.

Surgery for Crohn’s disease of the small bowel is most commonly performed when there is evidence on scans that the disease appears fibrotic (scarred) with narrowing causing a degree of blockage to the bowels. Medical therapy is effective against inflamed tissue and will lose any benefit if the disease is fibrotic. Surgery may also be performed if there are complications of the disease, such as an acute bowel blockage, perforation, fistula, or abscess formation.

Surgery for Crohn’s disease affecting the colon and rectum may be performed for a number of reasons:

1. If there is an acute flare of colitis that does not respond to medical therapy
2. If there are pre-cancerous or cancerous changes on biopsies taken at the time of a colonoscopy
3. If strictures (narrowings) develop in the colon or rectum
4. If the patient has stopped responding to medical treatment
5. To improve quality of life, if there are ongoing loose stools with a frequent need to visit the toilet

Crohn’s disease can also cause abscesses and fistulas to develop around the anus. Patients experiencing this may require examinations under general anaesthetic to allow any abscesses to be drained and setons (threads) to be passed through any fistula tracts. Setons serve to facilitate drainage of fluid through the fistula and reduce the risk of developing abscesses.

What types of surgery are there for Crohn’s disease and when is each type used?

Surgery for Crohn’s disease can be undertaken as a laparoscopic (keyhole) or open procedure. For patients who have not had any previous abdominal surgery, keyhole surgery is normally offered. Patients who have had previous surgery and it is either known that they do not have adhesions (scar tissue inside the abdomen) or this is not known, then keyhole surgery may be offered. With any keyhole operation, there is a risk of converting to an open operation. This occurs in between 10-20% of patients. If patients are known to have extensive adhesions, or for particularly complex procedures involving fistulas from the bowel to the abdominal wall, then an open operation would normally be performed.

What risks and complications are there for Crohn’s disease surgery?

There are risks associated with any operation. These include infection, most commonly in the wound, or a chest infection. Infections can also occur inside the abdomen and may require treatment with either a prolonged course of antibiotics, drainage in the radiology department or a return to theatre.

If some bowel has been removed and a join made, then there is a risk that the join may not heal properly. This occurs in 7-14% of patients and may be influenced by medication you are on prior to surgery, smoking and malnutrition. With any operation in which the abdomen is entered, there is a risk of developing a hernia in the wound sites. This is common around stoma sites. Unfortunately, Crohn’s disease cannot be cured at present, and there is a risk of the disease returning and you needing further surgery.

What post-operative advice to you have for those who have had Crohn’s disease surgery?

For any patient with Crohn’s disease, I would strongly advocate them to stop smoking. Smoking increases the risk of complications associated with surgery. It is also the single biggest risk factor for disease recurrence and for complications of the disease.

Following surgery, it is important to try and keep active. Initially, you may not be able to do much, but by about six weeks post-operatively, you should find that you are getting back to normal activity and energy levels are returning. At this stage, it would normally be suitable to return to work. I would normally recommend a phased return to work, starting on half your normal hours and gradually increasing to full time over a 2-4 week period. It can take between three and six months to feel completely back to normal.

After bowel surgery, it is often more comfortable to maintain a low residue diet (low fibre) for a few weeks and to avoid red meat. As you feel more comfortable, you can gradually return to a more normal diet. Many patients with Crohn’s disease look forward to having meals they had not been able to tolerate prior to surgery!

If you suffer from Crohn’s disease and are finding your condition difficult to manage, make an appointment with an expert to discuss further treatment options.