Key Considerations for Managing IBD with Surgery

Announcer:
Welcome to Crohn’s and Colitis Perspectives on ReachMD. The following program is produced in collaboration with the Crohn’s & Colitis Foundation and the American Gastroenterological Association. Here’s Dr. Amy Lightner, Assistant Professor of Surgery and Immunology at the Cleveland Clinic, sharing her insights on surgical considerations for inflammatory bowel disease.

Dr. Lightner:
Part of the IBD Home is you have gastroenterology, you have nutrition, you have psychiatry, and you bring in stoma therapy, and then you also bring in the surgeons, so there’s a lot of different treatment options, a lot of different treatment pathways.

We now have a lot of very good medical options that work quite well, and we have more biologics that have been approved. There are small molecules that have been approved. And so I think surgeons are not particularly aggressive when it comes to operating in IBD especially in Crohn’s patients.

In the setting Crohn’s, colitis, and maybe some perianal disease, I think it depends on what medical therapy they’ve been on.

I think for patients that have been on a number of biologics and they have failed or lost response to those biologics, then when you do a temporary ileostomy, it’s really hard to expect that you’re going to achieve healing and maintain that healing upon reversal. So the studies that have looked at that really have shown that when you reverse or restore intestinal continuity by taking down the ileostomy, the disease typically comes right back, including the perianal disease. Usually, those temporary diversions are really more of a permanent diversion in that setting, so I think it really depends on where they’re at in the spectrum of medical therapy.

Crohn’s and UC are very different, so for Crohn’s patients, we can optimize preoperatively to really affect our postoperative outcomes, so things like anemia, nutrition, drainage of sepsis. Weaning off of corticosteroids is a big one. So there’s a lot of things that we can do to affect our perioperative and postoperative outcomes.

Now when we use a 3-stage approach to making a pouch, which just means that the first stage we just take out the colon, second stage, when they’re healthy we make a pouch and then we reverse it—by using that approach, we really don’t need to try to get them off the steroids and give them IV nutrition and do all these things. It’s best to simply proceed with the colectomy and then allow the patients to get healthier until their pouch surgery.

I think the biggest hang-up for most patients is they’re really scared of having a stoma. I’ve tried to connect them with someone who also had surgery and had a stoma and was really scared before and had a good outcome., and allowing them to contact other patients to say, “Hey, what was this like?” “How did it affect your quality of life?” and kind of go through the process of trying to alleviate some of the concern around having a stoma.

I think it’s great because it is a curative operation. . A pouch is not perfect, but it’s a really satisfying operation to do surgically because you really feel like you’re giving them a long-term, good quality of life.

Crohn’s disease is a little bit trickier because we are really addressing the symptoms. We’re not really treating the underlying disease. So, while we certainly can help the patients by addressing their worst symptoms, we know as surgeons we’re not curing their disease. So we’re there to help, but it’s a little bit different I would say.

Announcer:
That was Dr. Amy Lightner from the Cleveland Clinic. This program was produced in collaboration with the Crohn’s & Colitis Foundation and the American Gastroenterological Association. If you missed any part of this discussion, or to find others in this series, visit ReachMD.com/foundation, where you can be part of the knowledge.