Official reprint from UpToDate® www.uptodate.com
©2012 UpToDate®
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use (click here) ©2012 UpToDate, Inc.
Surgical management of inflammatory bowel disease
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Apr 2012. | This topic last updated: Aug 25, 2011.

INTRODUCTION — Medical therapy is central to the management of inflammatory bowel disease (IBD). (See "Overview of the medical management of mild to moderate Crohn's disease in adults" and "Medical management of ulcerative colitis".) However, appropriate surgical treatment is an important part of therapy since it can alleviate symptoms, address serious complications, improve quality of life, and, in some settings, be lifesaving [1]. As many as one-half of patients with IBD require at least one surgical procedure during the course of their disease, however, due to earlier diagnosis and medical management, the need for surgical intervention within the first two years of diagnosis has decreased [2].

The need for and timing of an operation are best determined by interaction among the gastroenterologist, surgeon, and patient. Guidelines for the surgical treatment of ulcerative colitis have been proposed by the American Society of Colon and Rectal Surgeons [3].

PREOPERATIVE CARE — The best results from surgery occur in patients who have been well prepared medically and psychologically, who undergo the surgery in a timely and expert fashion, and who receive careful postoperative care. Although the majority of patients with IBD are young, they are often seriously ill when surgery is contemplated. Complications are more likely in patients who are malnourished, immunosuppressed, depressed, or have infection. Thus, these features must be anticipated and recognized. The adequacy of nonsurgical therapy, the extent of IBD, and previous operative and pathology reports must be reviewed.

Optimization of medical status — The patient's medical status should be optimized. Correction of anemia, fluid depletion, electrolyte and acid-base disorders, and nutritional assessment are mandatory. Many patients require total parenteral nutrition (TPN) and bowel rest because eating may worsen symptoms. However, long intervals of preoperative TPN are rarely justified, because it is difficult to demonstrate a significant impact on the ultimate outcome [4]. The simplest surgical corrective procedure should be performed in such severely compromised patients. (See "Nutritional issues in the surgical patient".)

Specific complications related to medications or coexisting diseases should be sought (table 1). Disability from medications such as cyclosporine is a source of concern for most surgeons. Coagulopathy due to malnutrition or malabsorption should be corrected. The severity of liver disease should be assessed in patients with sclerosing cholangitis to assess surgical risk and optimize perioperative care. (See "Assessing surgical risk in patients with liver disease".) Complications of specific medications are discussed in detail elsewhere. (See "Overview of the medical management of mild to moderate Crohn's disease in adults".)

Immunosuppressive therapy — Most immunosuppressive drugs can be discontinued just before surgery without sequelae, with the exception of corticosteroids, which must be tapered after surgery. (See "Glucocorticoid withdrawal".) Continuation of immunosuppressive therapy may also be desirable in some patients with Crohn's disease to prevent postoperative recurrence. (See "Immunomodulator therapy in Crohn's disease".)

Postoperative complications do not appear to be increased in patients with Crohn's disease treated with infliximab [5-8], although in one study the use of infliximab during the first three postoperative months after ileocolonic resection was associated with increased risk of sepsis, intra-abdominal abscess, and readmission [9]. The effects of infliximab combined with other immunomodulators are also not well studied. One study found that patients with ulcerative colitis who received infliximab and cyclosporin before colectomy had increased morbidity compared with those who received infliximab alone [10]. A multivariate analysis found infliximab to be the only factor independently associated with infectious complications in patients undergoing IPAA for chronic ulcerative colitis [11]. Preoperative use of infliximab may delay a potentially curative surgical procedure and increase the risk of serious postoperative complications. Therefore, a three-stage ileal pouch-anal canal anastomosis (IPAA) is the optimal approach for patients on combination immunosuppressive therapy that includes infliximab and requires surgical intervention.

Prospective controlled trials with high quality data are needed to support the safety of immunosuppressive therapy in the perioperative period.

Patient education — An honest, straightforward discussion of the risks and benefits of the proposed operation with the patient and family is mandatory to avoid the frustrations of unrealistic expectations. (See "Patient information: Ulcerative colitis (Beyond the Basics)".)

The patient should understand the indications for surgery, the remaining medical options, the surgical alternatives (see below), the expected outcome, including the risk of recurrence, and the potential for immediate and long-term complications of surgery. In patients who will receive an ostomy, a consultation with a stomal therapist is useful for selecting the ostomy site and reducing anxiety. (See "Management of patients with a colostomy or ileostomy".)

Prevention of infection — Adequate antibiotic prophylaxis or antibiotic therapy should be given. The mechanical bowel preparation has to be adapted to the patient's condition; as an example, it is contraindicated in patients with an acute abdomen or obstruction.

Prophylaxis for venous thrombosis — Patients with IBD are at increased risk for thromboembolic venous and arterial complications [12,13]. Thus, intermittent pneumatic compression and/or low dose heparin should be used prophylactically. (See "Prevention of venous thromboembolic disease in surgical patients".)

DISTINGUISHING BETWEEN CROHN'S DISEASE AND ULCERATIVE COLITIS — Surgical decisions and expected outcomes are influenced by the distinction between the ulcerative colitis and Crohn's disease [14,15].

  • Patients with ulcerative colitis may be eligible for sphincter preserving operations. In such patients, it is important to avoid proctectomy whenever possible.
  • Segmental resections are sometimes performed for limited areas of Crohn's colitis [16], but are inappropriate for patients with ulcerative colitis because of the risk of recurrent active inflammation or cancer developing in the remaining colon.
  • Ileal pouch-anal canal anastomosis is usually avoided in patients with Crohn's disease because of poorer functional outcomes and a higher failure rate [17].

Ulcerative colitis and Crohn's colitis can usually be distinguished based upon clinical presentation, radiography, endoscopy (eg, continuous colitis in ulcerative colitis compared to patchy involvement in Crohn's disease), and biopsy [14,15]. (See "Clinical manifestations, diagnosis, and prognosis of ulcerative colitis in adults" and "Clinical manifestations, diagnosis and prognosis of Crohn's disease in adults".) However, the colitis is indeterminate in 8 to 20 percent of patients; the distinction may be particularly difficult in patients with fulminant colitis [18]. The course of these patients tends to resemble that of patients with ulcerative colitis more than it does Crohn's disease, although there may be an increased risk of perineal complications and pouch failure [19,20]. Thus, many surgeons consider patients with indeterminate colitis to be candidates for the same surgical options as those with ulcerative colitis [1,21], although some prefer ileoproctostomy [22]. In a proportion of patients with colitis who do not require surgery, it can also be difficult to distinguish between ulcerative colitis and Crohn’s disease. The term inflammatory bowel disease unclassified is proposed for these cases. Further evaluation may reveal the exact type of disease in these patients [23].

INDICATIONS FOR SURGERY — Advances in medical therapy (including use of infliximab) have reduced the need for emergency surgery due to catastrophic complications such as massive hemorrhage, perforation, fulminant colitis, and acute colonic obstruction [24]. (See "Infliximab in Crohn's disease" and "Toxic megacolon".) On the other hand, the development of continence-preserving procedures such as the ileal pouch anal-canal anastomosis has made surgery a more attractive option in patients in whom medical therapy has been unsuccessful or undesirable. The treatment of choice for acute severe steroid refractory ulcerative colitis is controversial [25]. Gastroenterologists advocate a trial of infliximab [26], while surgeons favor colectomy [27]. A longer duration of in-hospital ineffective medical therapy (8 versus 5 days) that delays surgical therapy in patients with acute severe ulcerative colitis is associated with an increased risk of postoperative complications [28].

The most common indication for elective surgery is disease activity that has been intractable to medical therapy. However, "intractable" is often hard to define. Some authorities have suggested that disease should be considered intractable when it or its treatment is associated with severe and persistent impairment in the quality of life [1,29]. However, these parameters are difficult to measure and are variable among individual patients. We recommend that surgery should be considered for the following indications:

  • Persistent symptoms despite high-dose corticosteroid therapy
  • Dependence upon steroids to maintain remission
  • Progression of disease with worsening of the symptoms or new onset of complications while on maximal medical therapy
  • Significant treatment-related complications such as severe steroid side effects (see "Major side effects of systemic glucocorticoids")
  • Detection of unequivocal dysplasia in patients with long-standing colitis during endoscopic surveillance (see "Colorectal cancer surveillance in inflammatory bowel disease")
  • Suspicion of a malignant stricture or fistula in patients with Crohn's disease

The threshold for performing surgery may be lowered by a number of other factors such as the presence of anemia or hypoproteinemia, and growth retardation in children. On the other hand, the threshold may be increased in patients with severe comorbid illnesses, or those in whom prior intestinal resection place them at risk for the development of the short bowel syndrome. (See "Pathophysiology of the short bowel syndrome".)

Extraintestinal manifestations — The relationship between extracolonic manifestations of IBD and surgery is not well defined. Extraintestinal complications alone seldom require operation but often contribute to the decision to operate. However, healing of pyoderma gangrenosum after intestinal resection is uncertain, ankylosing spondylitis and arthritis may not regress after surgery, and progression of sclerosing cholangitis appears to bear no relation to the presence or absence of the inflammatory process in the colon. A rare extracolonic indication for colectomy and splenectomy is massive hemolytic anemia that is unresponsive to medical treatment [1,30]. Thromboembolic complications that are life threatening, erythema nodosum, and arthralgia of the small and large joints appear to benefit the most from proctocolectomy [31]. Colorectal cancer is an uncommon but important complication in patients who have undergone liver transplantation for primary sclerosing cholangitis. Such patients require ongoing surveillance. (See "Colorectal cancer and primary sclerosing cholangitis".)

SURGICAL OPTIONS FOR ULCERATIVE COLITIS — There are five surgical procedures performed in single or multiple stages that can be offered to patients with ulcerative colitis who are referred for elective colectomy (table 2 and figure 1):

  • Proctocolectomy with permanent ileostomy (Brooke ileostomy)
  • Proctocolectomy with continent ileostomy (Kock pouch)
  • Abdominal colectomy with ileorectal anastomosis
  • Colectomy, mucosal proctectomy, and ileal pouch-anal canal anastomosis (IPAA)
  • Colectomy and stapled ileal pouch distal rectal anastomosis (IPDRA)

Each technique can improve the quality of life and reduce the risk of colonic malignancy, and each has its advantages [32,33]. Optimal results depend upon surgical expertise, the clinical setting, and careful patient selection. The patient's age, previous intestinal or anal surgery, obesity, patient occupation, liver disease, and cancer risk should all be considered. A number of specific surgical issues remain controversial, particularly the merits of avoiding a loop diverting ileostomy [34,35] and the safety and efficacy of laparoscopic approaches [36-39]. One study showed that, compared with the open procedures, laparoscopic assisted restorative proctocolectomy had a long-lasting positive impact on body image and cosmesis, particularly for women [40]. In patients with coexisting primary sclerosing cholangitis, complications from surgical management appear mostly to be related to the severity of the liver disease [41].

In emergency situations (such as toxic megacolon), abdominal colectomy with ileostomy and closure of the rectum or mucous fistula is the procedure of choice. Leaving the rectum in place permits subsequent proctectomy with ileal pouch-anal anastomosis. (See "Toxic megacolon".) Emergency proctocolectomy may also be required for uncontrollable hemorrhage. However, per anal suturing of a bleeding rectal ulcer or leaving a short Hartmann pouch can also be considered in this setting [42]. IPAA should not be performed on patients with toxic colitis due to excessively high complication rates. In addition, patients who are on combination immunosuppressive therapy that includes Infliximab may benefit from a three-stage IPAA [11].

Proctocolectomy with permanent ileostomy is curative for ulcerative colitis. However, patients with IBD wish to avoid a permanent ileostomy. Patients should be advised that an ileostomy may be required if a continence preserving procedure fails or is not technically possible. Furthermore, continence performing procedures are associated with a small risk of urinary and sexual dysfunction; the risk is greatest in patients who require reoperative pelvic surgery. Postoperative impotence and retrograde ejaculation are observed in approximately 1.5 and 4 percent of men, respectively, while transient dyspareunia occurs in about 7 percent of women. Decreased fertility is also frequent in women after IPAA. The surgeon is occasionally faced with the need to abandon the ileal pouch-anal canal anastomosis intraoperatively because of technical reasons or evidence of Crohn's disease or cancer [43,44]. In a review of almost 1800 IPAA attempts from the Mayo Clinic, abandonment was required in 4.1 percent of cases [43].

The stapled ileal pouch-distal rectal anastomosis is technically easier to perform than the ileal pouch-anal canal anastomosis and, in theory, preservation of the anal transitional mucosa should maintain anal sensation and better continence, especially at night. However, this operation leaves diseased anal and distal rectal mucosa behind. Preservation of the distal rectal mucosa should clearly be avoided in patients with cancer or severe dysplasia in the colorectal mucosa and in those with severe extraintestinal manifestations. On the other hand, it should be strongly considered in older patients, and in those in whom mobilization of the pouch to perform a tension-free anastomosis is difficult.

At our institution, an ileorectal anastomosis (IRA) has been used in fewer than 10 percent of patients undergoing surgery for ulcerative colitis, even in the era when ileal pouch-anal anastomosis (IPAA) was not available, because the IRA procedure does not excise the diseased section and thus leaves patients at risk for persistence of symptoms and future malignancy. A retrospective analysis of the functional results after IRA for ulcerative colitis or indeterminant colitis in 86 patients found that the rectum was eventually resected in 46 patients diagnosed with rectal dysplasia (17 percent), rectal cancer (8 percent), and refractory proctitis (28 percent) [45]. The cumulative probability of developing rectal dysplasia at 5, 10, 15, and 20 years was 7, 9, 20, and 25 percent, respectively. The cumulative probability of developing rectal cancer at 5, 10, 15, and 20 years was 0, 2, 5, and 14 percent, respectively. The cumulative probability of having a functioning IRA at 10 and 20 years was 74 and 46 percent, respectively.

Some patients with minimal rectal involvement may be suitable candidates such as those who are not suitable for IPAA but who refuse an ileostomy or those who have medical conditions in which a stoma is relatively contraindicate (eg, portal hypertension or ascites). Some authors have advocated the operation in women of childbearing age because of the risk of infertility. The operation may also be a good choice for patients in whom Crohn's disease cannot be excluded or for patients with colitis complicated by advanced colonic malignancy.

Satisfactory rectal function varies greatly depending upon the selections of patients and length of follow-up. The risk of cancer in the residual rectum has been reported to be 6 percent at 20 years and 15 percent at 30 years. The risk is significant considering that most patients are young and have many years to live.

Complications — Several complications and ileal pouch disorders have been recognized (table 3) [46]. Early complications are common after restorative proctocolectomy. The most frequent are bowel obstruction, pouch bleeding, pelvic and wound sepsis, transient urinary dysfunction, and dehydration from temporary loop ileostomy with high output. Most of these complications can be addressed without the need for reoperation or long-term sequelae. Exceptions are patients who develop a pelvic abscess after surgery who are at increased risk for a poor functional outcome and quality of life, and eventual pouch failure [47,48]. This was illustrated in a series from the Mayo Clinic in which 73 of 1508 (5 percent) patients who underwent ileal pouch-anal anastomosis for chronic ulcerative colitis developed a pelvic abscess [47]. The long-term impact of pelvic abscess was illustrated by the following observations:

  • Transabdominal salvage surgery was required in 55 percent and local surgery in 8 percent.
  • Pouch failure occurred in 26 percent, usually within two years.
  • Daytime incontinence or the need for a protective pad or for constipating or bulking medications was significantly more common in the patients who kept their reservoir. These patients also had significantly more restricted ability to perform work, domestic, and recreational activities compared to patients in whom an abscess had not developed.

Portal vein thrombosis can occur after IPAA. Clinical manifestations may include pain, fever, vomiting, leukocytosis, and unexplained postoperative ileus [49]. Some patients have a subtle clinical presentation and can go undiagnosed until the thrombosis is seen incidentally on computed tomography. Treatment with anticoagulation has been associated with complete recovery.

Late complications include stricture of the anastomosis, anal fistula and abscess, poor postoperative anorectal function, reduced fertility [50,51], and pouchitis [52]; of these, pouchitis is the most frequent. In one series, the cumulative probability of suffering at least one episode of clinical pouchitis was 18 and 48 percent at 1 and 10 years, respectively [52]. (See "Pouchitis".) Several other pouch disorders have been recognized such as irritable pouch syndrome and anismus (anorectal dysfunction) (figure 2) [46].

Fortunately, the majority of pouch-related complications can be addressed without surgical intervention. In one series of almost 1000 patients who had undergone IPAA, reoperation for complications was necessary in only 12 percent [53]. Local measures often suffice, but pouch revision or excision is occasionally required [53-55]. As an example, ileal pouch fistulas and strictures refractory to dilatation are difficult to treat and may require revision of the pouch if Crohn's disease can be excluded. A transvaginal repair is favored for a pouch-vaginal fistula [56]. A combined abdominal perineal repair may offer better results compared with a local procedure [57].

A controlled septic condition does not preclude salvage surgery. Although pouch failure occurs more often than with primary IPAA, high patient satisfaction and quality of life can be achieved [58]. Furthermore, excision of the pouch is associated with a high risk of complications, especially delayed perineal wound healing [59,60].

A number of unusual late complications have been described including [61-63]:

  • Superior mesenteric artery syndrome
  • Solitary ileal ulcer
  • Traumatic ileal ulcer perforation
  • Fibroid polyps
  • Mucosal prolapse with outlet obstruction
  • Puborectal spasm
  • Sacral osteomyelitis
  • Volvulus
  • Pharmacobezoar

Long-term results — As discussed in the preceding section, the long-term success of surgery depends upon the type of operation, the clinical setting, and surgical expertise. Several studies have suggested that functional results are poor during the long-term follow-up in patients who had adverse personality factors before surgery (such as problems with sexual satisfaction, difficulty expressing emotions, perfectionistic body ideals, and poor frustration tolerance) [64]. The following results were described in some of the largest series:

  • One series included 1885 patients who underwent an ileal pouch-anal anastomosis for ulcerative colitis and were followed for an average of 11 years [52]. The mean number of stools was 5.7 per day at one year and 6.4 at 20 years, and also increased at night from 1.5 to 2.0. The incidence of frequent fecal incontinence increased from 5 to 11 percent during the day and from 12 to 21 percent at night. The overall rate of pouch success at 5, 10, 15, and 20 years was 96, 93, 92, and 92 percent, respectively. Quality of life remained unchanged and 92 percent remained in the same employment.
  • In another report that included 486 patients who had undergone proctocolectomy and ileoanal anastomosis for ulcerative colitis or familial adenomatous polyposis, the cumulative probabilities of pouch failure were 1, 5, and 7 percent at 1, 5, and 10 years, respectively [65]. The most common cause of pouch failure was fistula formation.
  • A third report focused on 634 patients who underwent restorative proctocolectomy for IBD between 1976 and 1997 [48]. Patients were followed for a mean of 85 months. Failure (defined as removal of the pouch or the need for an ileostomy) was divided into early (occurring within one-year) or late (occurring more than one-year postoperatively). Three patients died postoperatively while an additional 23 died (of a variety of causes) during follow-up. Of the remaining patients, there were a total of 61 failures (10 percent) of which 15 were early and 46 late. Failures were due to pelvic sepsis (52 percent), poor function (30 percent), pouchitis (11 percent), and miscellaneous causes (four patients, all early failures). Predictors of failure included a final diagnosis of Crohn's disease, a type J or S reservoir, female gender, postoperative pelvic sepsis, and a one-stage procedure. Failure rates rose with time from 9 percent at five years to 13 percent at 10 years.
  • Another series demonstrated that results in older patients (>65) are not as good; however, appropriate case selection conferred acceptable function and quality of life to patients of all ages [66].
  • Anal canal strictures were described in up to 11 percent of 213 patients [67]. Non fibrotic strictures generally responded well to anal dilation while fibrotic strictures were more commonly associated with intra- or postoperative complications and frequently required surgical therapy.
  • A systematic review of 43 observational studies (with a total of 9317 patients) found a pouch failure rate of 6.8 percent, increasing to 8.5 percent in those with more than five-year follow-up [68]. Pelvic sepsis occurred in 9.5 percent. Severe, mild, and urge fecal incontinence was reported in 3.7, 17, and 7.3 percent, respectively. These results suggest that current techniques are associated with non-negligible complication rates and leave room for improvement and continued development of alternative procedures.

IPAA may have long-term effects on female reproductive health [69]. Some women experience increased dyspareunia [70], although the ability to experience orgasm and coital frequency remain unchanged. Female fertility is significantly decreased [71], possibly due to pelvic adhesions, although successful pregnancies occur regularly [72]. Patients may experience a transient increase in stool frequency (including incontinence) during pregnancy, which resolves after delivery.

Pregnancy and delivery are safe in patients with IPAA. Patients should not be discouraged from childbearing because of the pouch. Whether vaginal or Cesarean delivery is better for women with a pelvic pouch remains controversial. The type of delivery should be influenced by obstetric consideration [73] but also the potential risk of sphincter injury [74]. Cesarean sections have been favored at some institutions.

Satisfactory long-term functional outcome and excellent quality of life have also been described after stapled restorative proctocolectomy. In a series of 977 patients, quality of life increased for two years after surgery, with no deterioration thereafter [75]. The prevalence of perfect continence increased from 76 percent before surgery to 82 percent after surgery and, although continence deteriorated somewhat more than two years after surgery, it was no worse than preoperative values. Ninety-eight percent of patients would have recommended the surgery to others. In another prospective, observational study, patients who had a stapled anastomosis had higher rates of daytime, nighttime, and complete continence compared with patients who underwent a hand-sewn anastomosis [76].

Postoperative monitoring — All patients who undergo surgical procedures for ulcerative colitis should be monitored regularly for the development of long-term complications [77]. In addition to functional problems, complications can occur at any stage, including the development of dysplasia and possibly cancer [78-84]. However, in a study of potentially high-risk patients (eg, Kock pouch for ≥14 years, a pelvic pouch for ≥12 years, a history of dysplasia or cancer in the proctocolectomy specimen or troublesome pouchitis), the development of dysplasia was rare [81]. These results are reassuring for both patients and surgeons [82].

Dysplasia — The presence of inflammatory changes in a retained rectal cuff, anal transitional zone, and ileal reservoir after stapled pouch-anal anastomosis is a cause of concern because of the long-term risk of dysplasia [83,85,86]. A systematic review of 23 observational and case control studies estimated that the prevalence of confirmed dysplasia in the pouch, anal transitional zone, or rectal cuff was 1.13 percent (range 0 to 19 percent) [83]. The prevalence of high-grade, low-grade, or indefinite dysplasia was 0.15, 0.98, and 1.23 percent, respectively. Dysplasia was equally frequent in the pouch and rectal cuff or anal transitional zone. Dysplasia and cancer identified before or at operation were significant predictors of the development of dysplasia postoperatively [87].

In fact, the risk of neoplasia is not completely eliminated by colectomy and mucosectomy. A retrospective review of 3203 patients with a preoperative diagnosis of IBD who underwent restorative proctocolectomy found that the cumulative incidence for pouch neoplasia at 5, 10, 15, 20 and 25 years were 0.9, 1.3, 1.9, 4.2, and 5.1 percent, respectively [87]. Eleven patients developed adenocarcinoma of the pouch or at the anal transitional zone, one developed lymphoma in the pouch, three developed squamous cell carcinoma at the anal transitional zone, and 23 developed pouch dysplasia. The prognosis of pouch adenocarcinoma appeared to be poor.

If the rectal cuff becomes symptomatic or develops dysplasia, the retained rectal mucosa from the restorative proctocolectomy can be removed by a transanal completion mucosectomy and reconstructing the ileal pouch-anal anastomosis as an alternative to a complete anal rectal resection and permanent ileostomy [88]. The mucosectomy removes all rectal mucosa, confers a highest likelihood of a surgical cure, and reduces the risk of future dysplasia. However, a mucosectomy removes the highly innervated region of cuboidal epithelium within the anal canal, with possible damage to the anal sphincter complex. Short term results in a series of 27 patients included reduced pouchitis symptoms and 90 percent of patients were moderately to very satisfied with the procedure. Incontinence was reduced by 70 percent at 12 months of observation.

These data support surveillance in patients with retained colonic mucosa. However, the optimal frequency of pouch endoscopy and biopsy is not well established. One authority recommends performing an initial screening five years after creation of an ileal pouch in children or when the total disease duration exceeds seven years [79]. It is reasonable to increase the frequency of surveillance in patients with chronic pouchitis who have severe villous atrophy and in patients who had dysplasia in the resected colon or rectum. Resection of the ileal pouch and anal canal should be considered in patients with pouch or anal high-grade dysplasia detected during surveillance.

Unrecognized Crohn's disease — A consideration in patients with pouch inflammation is whether they have unrecognized Crohn's disease. Establishing the diagnosis in patients who have undergone an IPAA can be difficult. The presence of inflammatory disease affecting other parts of the gastrointestinal tract can provide an important clue, but is not always present. One study suggested that the presence of afferent limb ulcers (in patients not taking nonsteroidal antiinflammatory drugs) was suggestive of Crohn's disease [89].

Crohn's disease involving the ileal pouch is generally associated with a high failure rate and pouch-related fistulas [17]. The complications associated with failure are extensive and the options for reconstructive surgery in patients with Crohn's disease should be questioned [90]. On the other hand, in a series of 204 patients with Crohn's disease who underwent primary IPAA overall 10 year pouch retention was 71 percent [91]. Pouch retention rates were higher and functional results were most favorable when the diagnosis of Crohn's disease was established preoperatively or immediately following surgery (85 to 87 percent 10 year pouch retention). Outcomes in patients with delayed diagnosis were worse, but half still retain their pouch at 10 years.

A systematic clinical approach to the "diseases" of the ileal pouch anal anastomosis is useful in the management of inflammatory and non-inflammatory conditions that can develop after surgery (eg, pouchitis, Crohn's disease, cuffitis, and irritable bowel syndrome) [92].

SURGICAL OPTIONS FOR CROHN'S DISEASE — Crohn's disease can potentially involve the entire gastrointestinal tract and is a chronic, diffuse, recurring disease that is not curable by surgery. As a result, surgery is usually reserved for patients in whom a complication develops or who have symptoms refractory to medical therapy [93]. The major indications for surgery are obstruction and perforation in small intestinal Crohn's disease, and chronic disability and failure to respond to medical therapy in those with colonic involvement. However, in some settings, surgery may be the most efficient means to restore health and improve quality of life, particularly in patients with short-segment stricturing or fistulizing disease [94,95]. The quality of life in patients medically treated for short segment distal ileal disease needs to be compared to surgical resection. The effectiveness of infliximab in preventing the need for surgery for Crohn’s disease at the population level has been questioned [96].

The surgical approach should focus on symptomatic areas of involvement causing complications, such as obstruction, bleeding, or perforation. Resection is performed when segments of bowel are actively or subacutely inflamed or perforated, or when there is an abscess or fistula to an adjacent organ. The disease-free margins are established by gross inspection. The presence of a few aphthous ulcers does not mandate further resection, and extensive resection margins are not necessary since microscopic disease at the margins is not associated with an increased rate of recurrence [97]. On occasion, intraoperative enteroscopy provides useful information for surgical decision making [98].

Some surgeons recommend creating a side-to-side anastomosis after ileocolonic resection because its large width may impede the development of symptomatic recurrence. However, other studies have failed to confirm this benefit [99]. A meta-analysis of eight comparative studies found that a side-to-side anastomosis was associated with fewer anastomotic leaks and postoperative complications, a shorter hospital stay and a lower perianastomotic recurrence rates compared to end-to-end anastomosis [100]. However, the authors suggested that further randomized controlled trials were needed to confirm these associations.

Laparoscopic approaches have been used increasingly for well-selected patients, even in those with recurrent disease [101-105]. They have the potential of decreasing morbidity, speeding recovery, and reducing costs, while decreasing the incidence of small bowel obstruction and ventral (abdominal wall) hernias [105-107]. A randomized controlled trial from a single institution compared laparoscopic-assisted versus open ileocolonic resection in 60 patients with Crohn's disease [108]. Morbidity, hospital stay, and costs were lower in the laparoscopic group, although there were no significant differences in quality-of-life at three months follow-up. The surgeons involved in this study were considered expert laparoscopists.

Optimal selection of patients and outcomes of laparoscopic approaches continue to be studied. One report found that the need for conversion to an open procedure was predicted by the severity of disease; independent predictors of conversion included a history of recurrent medical episodes of Crohn's disease and the presence of intra-abdominal abscess or fistula at the time of laparoscopy [109]. In a long-term follow-up study, the recurrence rates in laparoscopic ileocolic resection compared favorably with conventional surgery [110]. A policy of starting most suitable cases laparoscopically may offer patients the potential benefit of a laparoscopic approach without increased morbidity [111]. For selected patients with Crohn’s colitis, laparoscopic colectomy was found to be safe and effective in the hands of experienced surgeons [112].

Duodenal disease — Duodenal Crohn's disease seldom requires surgery. The major indications for surgery are obstruction and less often perforation or fistula formation. Gastrojejunostomy rather than resection is typically performed. Strictureplasty, duodenojejunostomy, and endoscopic balloon dilation have also been described [113].

Intra-abdominal abscess and perforation — The conventional approach to intra-abdominal pyogenic complications has been initial surgical drainage followed by resection of the diseased segment of bowel. However, the introduction of interventional procedures, new immunosuppressive agents, and laparoscopy has altered the surgical approach [114,115]. CT or ultrasound guided percutaneous drainage is safe and successful in approximately 70 percent of patients. The benefits of preoperative drainage include time to improve the patient’s nutritional status, convert the operative field into a noninfected area, and decrease use of steroids. An established abscess should preferentially be drained nonoperatively using a percutaneous approach if possible [116]. A transgluteal or transabdominal percutaneous approach to drainage can be performed depending on the location of the abscess. The procedure may need to be repeated to completely drain the abscess.

If percutaneous drainage is unsuccessful, surgical drainage should be performed. The timing of surgery following percutaneous abscess drainage, when clinically indicated, occurs after clinical resolution of sepsis. Controversy exists regarding the need for subsequent operation after adequate abscess drainage as intractable disease or recurrent abscess occurs in at least 30 percent of these patients within a year. (See 'Recurrence' below.)

Fortunately, free perforation occurs rarely in Crohn's disease. Emergent surgery is necessary to control sepsis in the presence of peritonitis. Exploratory laparotomy with construction of a stoma is most commonly required. The decision to resect bowel depends upon the operative findings and the patient's condition [116].

Abdominal wall abscesses (psoas and rectus sheath) are less common and more difficult to control locally than intra-abdominal abscesses. In a retrospective review of 13 patients with an abdominal wall abscess treated by percutaneous and/or open operative drainage, all 13 required resection of the diseased segment even after successful drainage of the abscess [115].

Fistulas — After resection and anastomosis of the diseased segment, fistulas to adjacent organs (such as the stomach, duodenum, bladder, vagina, and sigmoid colon) can be closed by suturing the site of entrance. Resection of the adjacent segment is necessary only when it is primarily involved with Crohn's disease. Bypasses should be avoided because persistent disease in the bypassed segment can lead to abscess formation, bleeding, perforation, bacterial overgrowth, and malignancy. Optimal management of perianal fistulas depends upon their anatomy. (See "Perianal complications of Crohn's disease".)

Interestingly, in one report, infliximab did not eliminate the need for surgery in the majority of patients with fistulizing Crohn's disease [117]. However, it appeared to be more effective in patients with perianal disease compared with abdominal enterocutaneous disease.

Strictures — Intestinal strictures can be relieved by resection; synchronous small bowel resection in patients with multiple strictures is common [118]. Strictureplasty or balloon dilation may be a suitable alternative for selected patients.

Strictureplasty — Strictureplasty can relieve obstruction, and is often performed with synchronous small bowel resection [118,119]. It can also be performed without excision of bowel [120,121]. Strictureplasty involves creation of a longitudinal incision through the narrowed area while closing transversely, which widens the lumen. Strictureplasty is particularly well-suited for patients who have short, localized areas of chronic stenosis, and who are at increased risk for short bowel syndrome due to previous intestinal resection [120]. It should not be performed in acutely inflamed bowel. For extensive and/or strictures occurring sequentially over long intestinal segments, a side-to-side isoperistaltic or other type of nonconventional strictureplasty is safe and effective [122-125].

Strictureplasty has been associated with excellent results, including relief of obstruction, the ability to withdraw steroids, and improvement in symptoms [120,121,126,127]. The risk of fistula or recurrent stricture formation is low and comparable to resection. Whether preservation of diseased bowel increases the long-term risk of malignancy is unknown, although case reports have documented adenocarcinoma arising from sites of previous strictureplasty [128].

The following examples illustrate the range of findings in two of the largest series [129,130]. In a report that included a total of 314 patients who underwent 1124 strictureplasty procedures [129]:

  • A synchronous bowel resection was performed in 66 percent of patients
  • Overall morbidity was 18 percent (septic complications occurred in 5 percent of patients)
  • Significant risk factors for morbidity were preoperative weight loss and older age
  • Surgical recurrence rate was 34 percent during a median follow-up of 7.5 years
  • Younger age was a significant predictor of recurrence

Another study included 479 strictureplasty performed in 100 patients over a period of 25 years (1978 to 2003), who were followed for an average of 7 years [130]. Overall morbidity was 22 percent (sepsis 11 percent, obstruction 4 percent, and hemorrhage 4 percent) and procedure-related mortality was 3 percent. The reoperation rates were 52 percent at a mean of 40 months after a first strictureplasty, 56 percent at 26 months after a second, 86 percent at 27 months after a third, and 63 percent at 26 months after a fourth. The major risk factor for reoperation was young age. The early relaparotomy rate was 8 percent. One patient developed cancer after many years of disease. The authors biopsied suspicious lesions, rather than routinely biopsying all lesions.

Balloon dilation — Another method to dilate intestinal strictures is with a hydrostatic balloon [131]. Experience is relatively limited compared with strictureplasty or resection, and the long-term efficacy and safety is therefore less well-established. A meta-analysis of 13 studies (with a total of 347 patients) reported overall technical success in 86 percent of cases and long-term efficacy in 58 percent, with up to 33 months of follow-up [132]. On multivariate analysis, a stricture length of ≤4 cm was associated with better surgery-free outcomes. The outcome of balloon dilatation to relieve obstruction from intestinal strictures in Crohn’s disease is not influenced by the type of concomitant medical therapy [133].

An illustrative report included 55 patients with 59 ileocolonic strictures who underwent 78 dilation procedures [134]. The procedures were performed endoscopically with patients under general anesthesia. Seventy procedures (90 percent) were technically successful. Perforation occurred in six patients (11 percent), two of whom required surgery and four of whom recovered with medical treatment. Obstructive symptoms were relieved in 62 percent of patients up to 11 months after the procedure.

Stricture injection with steroids after balloon dilatation to reduce the need for redilation or surgery may be an effective strategy for children [135] but may not be effective for adults [136]. A randomized trial that included 29 pediatric patients undergoing balloon dilatation for strictures from Crohn’s disease found significantly fewer redilations in the patients treated with corticosteroid injections compared to those who received a placebo injection (1 of 15 versus 5 of 14 patients) [135]. Injection of corticosteroids into the stricture (a method used for refractory peptic esophageal strictures) did not improve outcomes in a pilot randomized controlled trial [136].

Balloon dilation may be useful in situations in which it is desirable to postpone surgery. However, the significant risk of perforation, which substantially increases morbidity, must be considered.

Stenting — Placement of an expandable metal stent within colonic strictures has been described, but experience is limited, and the safety of this approach is uncertain [137].

Colorectal disease — Several alternatives are available for patients requiring elective surgery for colorectal Crohn's disease, ranging from temporary diverting ileostomy to resection of segments of diseased colon or even the entire colon and rectum. Although controversial, it appears that the conservative principles applied to disease involving the small intestine should also be applied to the surgical management of Crohn's colitis [138].

The optimal procedure depends in part upon the extent of the disease and the clinical setting:

  • Segmental colectomy may be adequate for isolated areas of colonic involvement [139]. An Ileorectal anastomosis can be carried out if the rectum is spared. However, approximately one-half of such patients require a subsequent proctectomy [140]. The presence of perianal disease and an anastomosis increases the risk of relapse and reoperation [141,142]. While no prospective randomized study has been undertaken to compare segmental colectomy and total colectomy with ileorectal anastomosis, both procedures appear to be equally effective as treatment options for colonic Crohn's disease. However, patients undergoing segmental resection may have earlier recurrence [143]. The choice of operation depends upon the extent of colonic disease; there may be better outcomes with ileorectal anastomosis in those who have two or more involved colonic segments.
  • Total proctocolectomy is indicated for patients with extensive, diffuse colorectal disease.
  • Subtotal colectomy with ileostomy is usually performed in emergency situations.
  • An abdominoperineal resection with a permanent end-colostomy is appropriate for patients with severe Crohn's disease confined to the anorectum. An intersphincteric proctectomy is recommended to minimize the risk of a nonhealing wound and sexual or urinary dysfunction [144,145]. In one series using this technique, postoperative retrograde ejaculation and impotence occurred in only 4 percent of patients [145]. A low Hartmann procedure should be considered in the presence of severe anorectal disease and ongoing sepsis; this can be followed by perineal proctectomy at a later date [146].

Postoperative monitoring — Patients who have a retained rectum should undergo surveillance regularly after operation because of a small risk of cancer [147]. The optimal surveillance strategy remains controversial, although annual surveillance has been recommended. (See "Colorectal cancer surveillance in inflammatory bowel disease".)

Patients with severe Crohn's colitis requiring surgery are at increased risk of developing dysplasia and adenocarcinoma in the retained rectum [148]. In a retrospective review of 222 patients who required operative intervention for Crohn's colitis, there were five cases of dysplasia (2.3 percent) and six cases of adenocarcinoma (2.7 percent). In this small cohort, the risk factors for the development of dysplasia or adenocarcinoma included longer disease duration (over 17 years), extensive disease, and older age at diagnosis (38 years of age or older). These findings support colonoscopic screening and surveillance of patients with Crohn's colitis. (See "Colorectal cancer surveillance in inflammatory bowel disease".)

Recurrence — The postoperative recurrence rate for patients undergoing a resection and anastomosis is high. Endoscopic recurrence approaches 80 percent at one year, while the clinical recurrence rate is 10 to 15 percent per year [149-152]. However, in most series up to 20 percent of patients will not have a clinical recurrence even at 15 years after surgery [153]. Those with severe endoscopic or radiologic findings are at increased risk to have or develop symptoms (72 versus 42 percent in those with minimal disease in one series) [154]. An increased risk for reoperation has been associated with perforating disease and smoking [155].

A laparoscopic approach does not appear to decrease the risk of recurrence. A retrospective review of 89 patients undergoing laparoscopically resected primary ileocolonic Crohn’s colitis found recurrent disease in 61 percent [156]. The median time to recurrence was 13 months (range 1.3 months to 8.7 years). Only the presence of granulomas in the resected specimen was identified as a risk factor for time to recurrence, and these patients were almost three times more likely to develop a recurrence.

The recurrence rate is lower in patients with Crohn's colitis who undergo a total colectomy and ileostomy compared to those with disease involving other segments of the digestive tract. Such patients have only a 10 percent recurrence rate in the small intestine at 10 years [150]. A number of medical options are available that may reduce the risk of recurrence. (See "Medical prophylaxis of postoperative Crohn's disease".) A relatively aggressive approach should be considered in patients with diffuse and distal Crohn's colitis. Total proctocolectomy in properly selected patients is associated with low morbidity, a decreased risk of recurrence, and a longer time to recurrence [157].

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, “The Basics” and “Beyond the Basics.” The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on “patient info” and the keyword(s) of interest.)

SUMMARY AND RECOMMENDATIONS — Surgical treatment is an important component of inflammatory bowel disease therapy since it can alleviate symptoms, address serious complications, improve quality of life, and, in some settings, be lifesaving. Surgery may be performed in both the emergent and elective setting.

  • Preoperative management includes optimizing medical status (eg, correction of anemia, fluid, and electrolyte balances), addressing nutritional status, discontinuing immunosuppressive therapy, and addressing the psychologic aspects of the disease and surgery. (See 'Preoperative care' above.)
  • Patients with ulcerative colitis may be eligible for a colectomy with a sphincter preserving procedure, but not a segmental resection. (See 'Distinguishing between Crohn's disease and ulcerative colitis' above.)
  • Patients with Crohn's colitis can be treated surgically with a limited segmental resection of the affected bowel, but an ileal pouch-anal canal anastomosis is usually avoided in patients with Crohn's disease because of poorer functional outcomes and a higher failure rate. (See 'Distinguishing between Crohn's disease and ulcerative colitis' above.)
  • Emergency surgery for colitis is performed for catastrophic complications such as massive hemorrhage, perforation, fulminant colitis, and acute colonic obstruction. (See 'Indications for surgery' above.)
  • Abdominal colectomy with ileostomy and rectal sparing is the surgical procedure recommended for emergent surgery for patients with ulcerative colitis (eg, toxic megacolon, uncontrollable hemorrhage). (See 'Surgical options for ulcerative colitis' above.)
  • The most common indication for elective surgery is disease activity that has been intractable to medical therapy. (See 'Indications for surgery' above.) We recommend that surgery should be considered for the following indications: persistent symptoms despite high dose steroid therapy, steroid dependence for remission, progression of disease, serious treatment related complications, dysplasia in patients with long-standing ulcerative colitis, malignant stricture, or fistula in patients with Crohn’s disease.
  • In the elective setting following failed medical therapy, we recommend that a restorative proctocolectomy with an ileal pouch and anal anastomosis for patients with ulcerative colitis be performed in a specialized center. This is usually performed as a two step operative procedure with a temporary protective loop ileostomy in most centers. (See 'Surgical options for ulcerative colitis' above.) For patients who are elderly, have poor sphincter function, significant comorbid disease, and/or concurrent rectal cancer, a total proctocolectomy with an end ileostomy may be the best option. 
  • For patients with Crohn’s disease, the major indications for surgery are obstruction and perforation in small intestinal Crohn's disease, and chronic disability and failure to respond to medical therapy in those with colonic involvement. (See 'Surgical options for Crohn's disease' above.)
  • For patients with Crohn’s disease, we recommend that the surgical approach focus on symptomatic segmental areas of involvement causing complications, such as obstruction, bleeding, an abscess or fistula to an adjacent organ or perforation. (See 'Surgical options for Crohn's disease' above.)
  • For patients with colitis and a retained rectum, we recommend endoscopic surveillance for rectal cancer annually. (See 'Postoperative monitoring' above.)

Use of UpToDate is subject to the Subscription and License Agreement.

REFERENCES

  1. Cima RR, Pemberton JH. Medical and surgical management of chronic ulcerative colitis. Arch Surg 2005; 140:300.
  2. Nguyen GC, Nugent Z, Shaw S, Bernstein CN. Outcomes of patients with Crohn's disease improved from 1988 to 2008 and were associated with increased specialist care. Gastroenterology 2011; 141:90.
  3. Cohen JL, Strong SA, Hyman NH, et al. Practice parameters for the surgical treatment of ulcerative colitis. Dis Colon Rectum 2005; 48:1997.
  4. Dayton, MT. Preoperative and postoperative care of patients with inflammatory bowel disease. Problems in General Surgery 1999; 16:40.
  5. Subramanian V, Pollok RC, Kang JY, Kumar D. Systematic review of postoperative complications in patients with inflammatory bowel disease treated with immunomodulators. Br J Surg 2006; 93:793.
  6. Colombel JF, Loftus EV Jr, Tremaine WJ, et al. Early postoperative complications are not increased in patients with Crohn's disease treated perioperatively with infliximab or immunosuppressive therapy. Am J Gastroenterol 2004; 99:878.
  7. Marchal L, D'Haens G, Van Assche G, et al. The risk of post-operative complications associated with infliximab therapy for Crohn's disease: a controlled cohort study. Aliment Pharmacol Ther 2004; 19:749.
  8. Gaertner WB, Decanini A, Mellgren A, et al. Does infliximab infusion impact results of operative treatment for Crohn's perianal fistulas? Dis Colon Rectum 2007; 50:1754.
  9. Appau KA, Fazio VW, Shen B, et al. Use of infliximab within 3 months of ileocolonic resection is associated with adverse postoperative outcomes in Crohn's patients. J Gastrointest Surg 2008; 12:1738.
  10. Schluender SJ, Ippoliti A, Dubinsky M, et al. Does infliximab influence surgical morbidity of ileal pouch-anal anastomosis in patients with ulcerative colitis? Dis Colon Rectum 2007; 50:1747.
  11. Selvasekar CR, Cima RR, Larson DW, et al. Effect of infliximab on short-term complications in patients undergoing operation for chronic ulcerative colitis. J Am Coll Surg 2007; 204:956.
  12. Schapira M, Henrion J, Ravoet C, et al. Thromboembolism in inflammatory bowel disease. Acta Gastroenterol Belg 1999; 62:182.
  13. Irving PM, Pasi KJ, Rampton DS. Thrombosis and inflammatory bowel disease. Clin Gastroenterol Hepatol 2005; 3:617.
  14. Sanders DS. The differential diagnosis of Crohn's disease and ulcerative colitis. Baillieres Clin Gastroenterol 1998; 12:19.
  15. Tanaka M, Riddell RH, Saito H, et al. Morphologic criteria applicable to biopsy specimens for effective distinction of inflammatory bowel disease from other forms of colitis and of Crohn's disease from ulcerative colitis. Scand J Gastroenterol 1999; 34:55.
  16. Andersson P, Olaison G, Hallböök O, Sjödahl R. Segmental resection or subtotal colectomy in Crohn's colitis? Dis Colon Rectum 2002; 45:47.
  17. Reese GE, Lovegrove RE, Tilney HS, et al. The effect of Crohn's disease on outcomes after restorative proctocolectomy. Dis Colon Rectum 2007; 50:239.
  18. Swan NC, Geoghegan JG, O'Donoghue DP, et al. Fulminant colitis in inflammatory bowel disease: detailed pathologic and clinical analysis. Dis Colon Rectum 1998; 41:1511.
  19. Yu CS, Pemberton JH, Larson D. Ileal pouch-anal anastomosis in patients with indeterminate colitis: long-term results. Dis Colon Rectum 2000; 43:1487.
  20. Delaney CP, Remzi FH, Gramlich T, et al. Equivalent function, quality of life and pouch survival rates after ileal pouch-anal anastomosis for indeterminate and ulcerative colitis. Ann Surg 2002; 236:43.
  21. Stark, ME, Tremaine, WJ. Medical care of the inflammatory bowel disease patients. In: The Gastrointestinal Surgical Patient: Preoperative and Post Operative Care, Quigley, EM, Sorrell, MR (Eds), Williams & Williams, Baltimore 1994. p.411.
  22. Bodzin JH, Klein SN, Priest SG. Ileoproctostomy is preferred over ileoanal pull-through in patients with indeterminate colitis. Am Surg 1995; 61:590.
  23. Geboes K, Colombel JF, Greenstein A, et al. Indeterminate colitis: a review of the concept--what's in a name? Inflamm Bowel Dis 2008; 14:850.
  24. Goudet P, Dozois RR, Kelly KA, et al. Changing referral patterns for surgical treatment of ulcerative colitis. Mayo Clin Proc 1996; 71:743.
  25. Cohen RD. How should we treat severe acute steroid-refractory ulcerative colitis? Inflamm Bowel Dis 2009; 15:150.
  26. Halfvarson J, Järnerot G. Treatment of choice for acute severe steroid-refractory ulcerative colitis is remicade. Inflamm Bowel Dis 2009; 15:143.
  27. Becker JM, Stucchi AF. Treatment of choice for acute severe steroid-refractory ulcerative colitis is colectomy. Inflamm Bowel Dis 2009; 15:146.
  28. Randall J, Singh B, Warren BF, et al. Delayed surgery for acute severe colitis is associated with increased risk of postoperative complications. Br J Surg 2010; 97:404.
  29. Michelassi, F. Indications for surgical treatment in ulcerative colitis and Crohn's disease. In: Operative Strategies in Inflammatory Bowel Disease, Michelassi, F, Milson, JW (Eds), Springer, 1997. p.151.
  30. Heyries L, Bernard JP, Perrier H, et al. [Hemorrhagic rectocolitis and autoimmune hemolytic anemia]. Gastroenterol Clin Biol 1998; 22:741.
  31. Goudet P, Dozois RR, Kelly KA, et al. Characteristics and evolution of extraintestinal manifestations associated with ulcerative colitis after proctocolectomy. Dig Surg 2001; 18:51.
  32. Hultén L. Proctocolectomy and ileostomy to pouch surgery for ulcerative colitis. World J Surg 1998; 22:335.
  33. McLeod, RS. Quality of life after surgery for ulcerative colitis. Problems in General Surgery 1999; 16:158.
  34. Dolgin SE, Shlasko E, Gorfine S, et al. Restorative proctocolectomy in children with ulcerative colitis utilizing rectal mucosectomy with or without diverting ileostomy. J Pediatr Surg 1999; 34:837.
  35. Remzi FH, Fazio VW, Gorgun E, et al. The outcome after restorative proctocolectomy with or without defunctioning ileostomy. Dis Colon Rectum 2006; 49:470.
  36. Larson DW, Dozois EJ, Piotrowicz K, et al. Laparoscopic-assisted vs. open ileal pouch-anal anastomosis: functional outcome in a case-matched series. Dis Colon Rectum 2005; 48:1845.
  37. Wexner SD, Johansen OB, Nogueras JJ, Jagelman DG. Laparoscopic total abdominal colectomy. A prospective trial. Dis Colon Rectum 1992; 35:651.
  38. Shore G, Gonzalez QH, Bondora A, Vickers SM. Laparoscopic vs conventional ileocolectomy for primary Crohn disease. Arch Surg 2003; 138:76.
  39. Marceau C, Alves A, Ouaissi M, et al. Laparoscopic subtotal colectomy for acute or severe colitis complicating inflammatory bowel disease: a case-matched study in 88 patients. Surgery 2007; 141:640.
  40. Polle SW, Dunker MS, Slors JF, et al. Body image, cosmesis, quality of life, and functional outcome of hand-assisted laparoscopic versus open restorative proctocolectomy: long-term results of a randomized trial. Surg Endosc 2007; 21:1301.
  41. Poritz LS, Koltun WA. Surgical management of ulcerative colitis in the presence of primary sclerosing cholangitis. Dis Colon Rectum 2003; 46:173.
  42. Yokoyama T, Masaki T, Ono M, et al. Per anal suturing of a bleeding ulcer to achieve successful hemostasis of massive hemorrhage associated with ulcerative colitis: report of two cases. Surg Today 1998; 28:1179.
  43. Browning SM, Nivatvongs S. Intraoperative abandonment of ileal pouch to anal anastomosis--the Mayo Clinic experience. J Am Coll Surg 1998; 186:441.
  44. Chun HK, Smith LE, Orkin BA. Intraoperative reasons for abandoning ileal pouch-anal anastomosis procedures. Dis Colon Rectum 1995; 38:273.
  45. da Luz Moreira A, Kiran RP, Lavery I. Clinical outcomes of ileorectal anastomosis for ulcerative colitis. Br J Surg 2010; 97:65.
  46. Shen B, Remzi FH, Lavery IC, et al. A proposed classification of ileal pouch disorders and associated complications after restorative proctocolectomy. Clin Gastroenterol Hepatol 2008; 6:145.
  47. Farouk R, Dozois RR, Pemberton JH, Larson D. Incidence and subsequent impact of pelvic abscess after ileal pouch-anal anastomosis for chronic ulcerative colitis. Dis Colon Rectum 1998; 41:1239.
  48. Tulchinsky H, Hawley PR, Nicholls J. Long-term failure after restorative proctocolectomy for ulcerative colitis. Ann Surg 2003; 238:229.
  49. Remzi FH, Fazio VW, Oncel M, et al. Portal vein thrombi after restorative proctocolectomy. Surgery 2002; 132:655.
  50. Olsen KO, Joelsson M, Laurberg S, Oresland T. Fertility after ileal pouch-anal anastomosis in women with ulcerative colitis. Br J Surg 1999; 86:493.
  51. Tiainen J, Matikainen M, Hiltunen KM. Ileal J-pouch--anal anastomosis, sexual dysfunction, and fertility. Scand J Gastroenterol 1999; 34:185.
  52. Hahnloser D, Pemberton JH, Wolff BG, et al. Results at up to 20 years after ileal pouch-anal anastomosis for chronic ulcerative colitis. Br J Surg 2007; 94:333.
  53. Galandiuk S, Scott NA, Dozois RR, et al. Ileal pouch-anal anastomosis. Reoperation for pouch-related complications. Ann Surg 1990; 212:446.
  54. Foley EF, Schoetz DJ Jr, Roberts PL, et al. Rediversion after ileal pouch-anal anastomosis. Causes of failures and predictors of subsequent pouch salvage. Dis Colon Rectum 1995; 38:793.
  55. Cohen Z, Smith D, McLeod R. Reconstructive surgery for pelvic pouches. World J Surg 1998; 22:342.
  56. Burke D, van Laarhoven CJ, Herbst F, Nicholls RJ. Transvaginal repair of pouch-vaginal fistula. Br J Surg 2001; 88:241.
  57. Johnson PM, O'Connor BI, Cohen Z, McLeod RS. Pouch-vaginal fistula after ileal pouch-anal anastomosis: treatment and outcomes. Dis Colon Rectum 2005; 48:1249.
  58. Baixauli J, Delaney CP, Wu JS, et al. Functional outcome and quality of life after repeat ileal pouch-anal anastomosis for complications of ileoanal surgery. Dis Colon Rectum 2004; 47:2.
  59. Karoui M, Cohen R, Nicholls J. Results of surgical removal of the pouch after failed restorative proctocolectomy. Dis Colon Rectum 2004; 47:869.
  60. Prudhomme M, Dehni N, Dozois RR, et al. Causes and outcomes of pouch excision after restorative proctocolectomy. Br J Surg 2006; 93:82.
  61. Taylor WE, Wolff BG, Pemberton JH, Yaszemski MJ. Sacral osteomyelitis after ileal pouch-anal anastomosis: report of four cases. Dis Colon Rectum 2006; 49:913.
  62. Jain A, Abbas MA, Sekhon HK, Rayhanabad JA. Volvulus of an ileal J-pouch. Inflamm Bowel Dis 2010; 16:3.
  63. Mmeje C, Bouchard A, Heppell J. Image of the month. Pharmacobezoar: a rare complication after ileal pouch-anal anastomosis for ulcerative colitis. Clin Gastroenterol Hepatol 2010; 8:A28.
  64. Weinryb RM, Gustavsson JP, Barber JP. Personality predictors of dimensions of psychosocial adjustment after surgery. Psychosom Med 1997; 59:626.
  65. Lepistö A, Luukkonen P, Järvinen HJ. Cumulative failure rate of ileal pouch-anal anastomosis and quality of life after failure. Dis Colon Rectum 2002; 45:1289.
  66. Delaney CP, Fazio VW, Remzi FH, et al. Prospective, age-related analysis of surgical results, functional outcome, and quality of life after ileal pouch-anal anastomosis. Ann Surg 2003; 238:221.
  67. Prudhomme M, Dozois RR, Godlewski G, et al. Anal canal strictures after ileal pouch-anal anastomosis. Dis Colon Rectum 2003; 46:20.
  68. Hueting WE, Buskens E, van der Tweel I, et al. Results and complications after ileal pouch anal anastomosis: a meta-analysis of 43 observational studies comprising 9,317 patients. Dig Surg 2005; 22:69.
  69. Wax JR, Pinette MG, Cartin A, Blackstone J. Female reproductive health after ileal pouch anal anastomosis for ulcerative colitis. Obstet Gynecol Surv 2003; 58:270.
  70. Cornish JA, Tan E, Teare J, et al. The effect of restorative proctocolectomy on sexual function, urinary function, fertility, pregnancy and delivery: a systematic review. Dis Colon Rectum 2007; 50:1128.
  71. Johnson P, Richard C, Ravid A, et al. Female infertility after ileal pouch-anal anastomosis for ulcerative colitis. Dis Colon Rectum 2004; 47:1119.
  72. Hahnloser D, Pemberton JH, Wolff BG, et al. Pregnancy and delivery before and after ileal pouch-anal anastomosis for inflammatory bowel disease: immediate and long-term consequences and outcomes. Dis Colon Rectum 2004; 47:1127.
  73. Juhasz ES, Fozard B, Dozois RR, et al. Ileal pouch-anal anastomosis function following childbirth. An extended evaluation. Dis Colon Rectum 1995; 38:159.
  74. Remzi FH, Gorgun E, Bast J, et al. Vaginal delivery after ileal pouch-anal anastomosis: a word of caution. Dis Colon Rectum 2005; 48:1691.
  75. Fazio VW, O'Riordain MG, Lavery IC, et al. Long-term functional outcome and quality of life after stapled restorative proctocolectomy. Ann Surg 1999; 230:575.
  76. Michelassi F, Lee J, Rubin M, et al. Long-term functional results after ileal pouch anal restorative proctocolectomy for ulcerative colitis: a prospective observational study. Ann Surg 2003; 238:433.
  77. Horgan, AF, Pemberton, JH. Long-term follow-up for ulcerative colitis. Problems in General Surgery 1999; 16:139.
  78. Goldman H. Pouch dysplasia: a new challenge. Inflamm Bowel Dis 1998; 4:259.
  79. Sarigol S, Wyllie R, Gramlich T, et al. Incidence of dysplasia in pelvic pouches in pediatric patients after ileal pouch-anal anastomosis for ulcerative colitis. J Pediatr Gastroenterol Nutr 1999; 28:429.
  80. Veress B, Reinholt FP, Lindquist K, et al. Long-term histomorphological surveillance of the pelvic ileal pouch: dysplasia develops in a subgroup of patients. Gastroenterology 1995; 109:1090.
  81. Thompson-Fawcett MW, Marcus V, Redston M, et al. Risk of dysplasia in long-term ileal pouches and pouches with chronic pouchitis. Gastroenterology 2001; 121:275.
  82. Börjesson L, Willén R, Haboubi N, et al. The risk of dysplasia and cancer in the ileal pouch mucosa after restorative proctocolectomy for ulcerative proctocolitis is low: a long-term term follow-up study. Colorectal Dis 2004; 6:494.
  83. Scarpa M, van Koperen PJ, Ubbink DT, et al. Systematic review of dysplasia after restorative proctocolectomy for ulcerative colitis. Br J Surg 2007; 94:534.
  84. Bell SW, Parry B, Neill M. Adenocarcinoma in the anal transitional zone after ileal pouch for ulcerative colitis: report of a case. Dis Colon Rectum 2003; 46:1134.
  85. Thompson-Fawcett MW, Mortensen NJ, Warren BF. "Cuffitis" and inflammatory changes in the columnar cuff, anal transitional zone, and ileal reservoir after stapled pouch-anal anastomosis. Dis Colon Rectum 1999; 42:348.
  86. Ziv Y, Fazio VW, Sirimarco MT, et al. Incidence, risk factors, and treatment of dysplasia in the anal transitional zone after ileal pouch-anal anastomosis. Dis Colon Rectum 1994; 37:1281.
  87. Kariv R, Remzi FH, Lian L, et al. Preoperative colorectal neoplasia increases risk for pouch neoplasia in patients with restorative proctocolectomy. Gastroenterology 2010; 139:806.
  88. Litzendorf ME, Stucchi AF, Wishnia S, et al. Completion mucosectomy for retained rectal mucosa following restorative proctocolectomy with double-stapled ileal pouch-anal anastomosis. J Gastrointest Surg 2010; 14:562.
  89. Wolf JM, Achkar JP, Lashner BA, et al. Afferent limb ulcers predict Crohn's disease in patients with ileal pouch-anal anastomosis. Gastroenterology 2004; 126:1686.
  90. Tekkis PP, Heriot AG, Smith O, et al. Long-term outcomes of restorative proctocolectomy for Crohn's disease and indeterminate colitis. Colorectal Dis 2005; 7:218.
  91. Melton GB, Fazio VW, Kiran RP, et al. Long-term outcomes with ileal pouch-anal anastomosis and Crohn's disease: pouch retention and implications of delayed diagnosis. Ann Surg 2008; 248:608.
  92. Shen B, Fazio VW, Remzi FH, Lashner BA. Clinical approach to diseases of ileal pouch-anal anastomosis. Am J Gastroenterol 2005; 100:2796.
  93. Fichera A, Michelassi F. Surgical treatment of Crohn's disease. J Gastrointest Surg 2007; 11:791.
  94. Laine L, Hanauer SB. Considerations in the management of steroid-dependent Crohn's disease. Gastroenterology 2003; 125:906.
  95. Delaney CP, Kiran RP, Senagore AJ, et al. Quality of life improves within 30 days of surgery for Crohn's disease. J Am Coll Surg 2003; 196:714.
  96. Jones DW, Finlayson SR. Trends in surgery for Crohn's disease in the era of infliximab. Ann Surg 2010; 252:307.
  97. Fazio VW, Marchetti F, Church M, et al. Effect of resection margins on the recurrence of Crohn's disease in the small bowel. A randomized controlled trial. Ann Surg 1996; 224:563.
  98. Hotokezaka M, Jimi SI, Hidaka H, et al. Role of intraoperative enteroscopy for surgical decision making with Crohn's disease. Surg Endosc 2007; 21:1238.
  99. Scott NA, Sue-Ling HM, Hughes LE. Anastomotic configuration does not affect recurrence of Crohn's disease after ileocolonic resection. Int J Colorectal Dis 1995; 10:67.
  100. Simillis C, Purkayastha S, Yamamoto T, et al. A meta-analysis comparing conventional end-to-end anastomosis vs. other anastomotic configurations after resection in Crohn's disease. Dis Colon Rectum 2007; 50:1674.
  101. Canin-Endres J, Salky B, Gattorno F, Edye M. Laparoscopically assisted intestinal resection in 88 patients with Crohn's disease. Surg Endosc 1999; 13:595.
  102. Milsom JW, Lavery IC, Böhm B, Fazio VW. Laparoscopically assisted ileocolectomy in Crohn's disease. Surg Laparosc Endosc 1993; 3:77.
  103. Bauer JJ, Harris MT, Grumbach NM, Gorfine SR. Laparoscopic-assisted intestinal resection for Crohn's disease. Dis Colon Rectum 1995; 38:712.
  104. Hasegawa H, Watanabe M, Nishibori H, et al. Laparoscopic surgery for recurrent Crohn's disease. Br J Surg 2003; 90:970.
  105. Tan JJ, Tjandra JJ. Laparoscopic surgery for Crohn's disease: a meta-analysis. Dis Colon Rectum 2007; 50:576.
  106. Bergamaschi R, Pessaux P, Arnaud JP. Comparison of conventional and laparoscopic ileocolic resection for Crohn's disease. Dis Colon Rectum 2003; 46:1129.
  107. Young-Fadok TM, HallLong K, McConnell EJ, et al. Advantages of laparoscopic resection for ileocolic Crohn's disease. Improved outcomes and reduced costs. Surg Endosc 2001; 15:450.
  108. Maartense S, Dunker MS, Slors JF, et al. Laparoscopic-assisted versus open ileocolic resection for Crohn's disease: a randomized trial. Ann Surg 2006; 243:143.
  109. Alves A, Panis Y, Bouhnik Y, et al. Factors that predict conversion in 69 consecutive patients undergoing laparoscopic ileocecal resection for Crohn's disease: a prospective study. Dis Colon Rectum 2005; 48:2302.
  110. Lowney JK, Dietz DW, Birnbaum EH, et al. Is there any difference in recurrence rates in laparoscopic ileocolic resection for Crohn's disease compared with conventional surgery? A long-term, follow-up study. Dis Colon Rectum 2006; 49:58.
  111. Casillas S, Delaney CP. Laparoscopic surgery for inflammatory bowel disease. Dig Surg 2005; 22:135.
  112. Umanskiy K, Fichera A. Health related quality of life in inflammatory bowel disease: the impact of surgical therapy. World J Gastroenterol 2010; 16:5024.
  113. Worsey MJ, Hull T, Ryland L, Fazio V. Strictureplasty is an effective option in the operative management of duodenal Crohn's disease. Dis Colon Rectum 1999; 42:596.
  114. Cellini C, Safar B, Fleshman J. Surgical management of pyogenic complications of Crohn's disease. Inflamm Bowel Dis 2010; 16:512.
  115. Neufeld D, Keidar A, Gutman M, Zissin R. Abdominal wall abscesses in patients with Crohn's disease: clinical outcome. J Gastrointest Surg 2006; 10:445.
  116. Fleshman JW. Pyogenic complications of Crohn's disease, evaluation, and management. J Gastrointest Surg 2008; 12:2160.
  117. Poritz LS, Rowe WA, Koltun WA. Remicade does not abolish the need for surgery in fistulizing Crohn's disease. Dis Colon Rectum 2002; 45:771.
  118. Spencer MP, Nelson H, Wolff BG, Dozois RR. Strictureplasty for obstructive Crohn's disease: the Mayo experience. Mayo Clin Proc 1994; 69:33.
  119. Tjandra JJ, Fazio VW, Lavery IC. Results of multiple strictureplasties in diffuse Crohn's disease of the small bowel. Aust N Z J Surg 1993; 63:95.
  120. Yamamoto T, Keighley MR. Long-term results of strictureplasty without synchronous resection for jejunoileal Crohn's disease. Scand J Gastroenterol 1999; 34:180.
  121. Dietz DW, Fazio VW, Laureti S, et al. Strictureplasty in diffuse Crohn's jejunoileitis: safe and durable. Dis Colon Rectum 2002; 45:764.
  122. Michelassi F, Upadhyay GA. Side-to-side isoperistaltic strictureplasty in the treatment of extensive Crohn's disease. J Surg Res 2004; 117:71.
  123. Sampietro GM, Cristaldi M, Maconi G, et al. A prospective, longitudinal study of nonconventional strictureplasty in Crohn's disease. J Am Coll Surg 2004; 199:8.
  124. Tonelli F, Fedi M, Paroli GM, Fazi M. Indications and results of side-to-side isoperistaltic strictureplasty in Crohn's disease. Dis Colon Rectum 2004; 47:494.
  125. Michelassi F, Taschieri A, Tonelli F, et al. An international, multicenter, prospective, observational study of the side-to-side isoperistaltic strictureplasty in Crohn's disease. Dis Colon Rectum 2007; 50:277.
  126. Yamamoto T, Bain IM, Allan RN, Keighley MR. An audit of strictureplasty for small-bowel Crohn's disease. Dis Colon Rectum 1999; 42:797.
  127. Tonelli F, Fazi M, Di Martino C. Ileocecal strictureplasty for Crohn's disease: long-term results and comparison with ileocecal resection. World J Surg 2010; 34:2860.
  128. Menon AM, Mirza AH, Moolla S, Morton DG. Adenocarcinoma of the small bowel arising from a previous strictureplasty for Crohn's disease: report of a case. Dis Colon Rectum 2007; 50:257.
  129. Dietz DW, Laureti S, Strong SA, et al. Safety and longterm efficacy of strictureplasty in 314 patients with obstructing small bowel Crohn's disease. J Am Coll Surg 2001; 192:330.
  130. Fearnhead NS, Chowdhury R, Box B, et al. Long-term follow-up of strictureplasty for Crohn's disease. Br J Surg 2006; 93:475.
  131. Coffey MJ, Wright RA. Efficacy and safety of hydrostatic balloon dilatation of ileocolonic Crohn's studies: a prospective longterm analysis. Gastrointest Endosc 1996; 43:89.
  132. Hassan C, Zullo A, De Francesco V, et al. Systematic review: Endoscopic dilatation in Crohn's disease. Aliment Pharmacol Ther 2007; 26:1457.
  133. Thienpont C, D'Hoore A, Vermeire S, et al. Long-term outcome of endoscopic dilatation in patients with Crohn's disease is not affected by disease activity or medical therapy. Gut 2010; 59:320.
  134. Couckuyt H, Gevers AM, Coremans G, et al. Efficacy and safety of hydrostatic balloon dilatation of ileocolonic Crohn's strictures: a prospective longterm analysis. Gut 1995; 36:577.
  135. Di Nardo G, Oliva S, Passariello M, et al. Intralesional steroid injection after endoscopic balloon dilation in pediatric Crohn's disease with stricture: a prospective, randomized, double-blind, controlled trial. Gastrointest Endosc 2010; 72:1201.
  136. East JE, Brooker JC, Rutter MD, Saunders BP. A pilot study of intrastricture steroid versus placebo injection after balloon dilatation of Crohn's strictures. Clin Gastroenterol Hepatol 2007; 5:1065.
  137. Matsuhashi N, Nakajima A, Suzuki A, et al. Long-term outcome of non-surgical strictureplasty using metallic stents for intestinal strictures in Crohn's disease. Gastrointest Endosc 2000; 51:343.
  138. Martel P, Betton PO, Gallot D, Malafosse M. Crohn's colitis: experience with segmental resections; results in a series of 84 patients. J Am Coll Surg 2002; 194:448.
  139. Prabhakar LP, Laramee C, Nelson H, Dozois RR. Avoiding a stoma: role for segmental or abdominal colectomy in Crohn's colitis. Dis Colon Rectum 1997; 40:71.
  140. Horgan, AF, Dozois, RR. Management of colonic Crohn's disease. Problems in General Surgery 1999; 16:68.
  141. Lewis JD, Schoenfeld P, Lichtenstein GR. An evidence-based approach to studies of the natural history of gastrointestinal diseases: recurrence of symptomatic Crohn's disease after surgery. Clin Gastroenterol Hepatol 2003; 1:229.
  142. Bernell O, Lapidus A, Hellers G. Recurrence after colectomy in Crohn's colitis. Dis Colon Rectum 2001; 44:647.
  143. Tekkis PP, Purkayastha S, Lanitis S, et al. A comparison of segmental vs subtotal/total colectomy for colonic Crohn's disease: a meta-analysis. Colorectal Dis 2006; 8:82.
  144. Bauer JJ, Gelernt IM, Salk BA, Kreel I. Proctectomy for inflammatory bowel disease. Am J Surg 1986; 151:157.
  145. Leicester RJ, Ritchie JK, Wadsworth J, et al. Sexual function and perineal wound healing after intersphincteric excision of the rectum for inflammatory bowel disease. Dis Colon Rectum 1984; 27:244.
  146. Sher ME, Bauer JJ, Gorphine S, Gelernt I. Low Hartmann's procedure for severe anorectal Crohn's disease. Dis Colon Rectum 1992; 35:975.
  147. Yamamoto T, Keighley MR. Long-term outcome of total colectomy and ileostomy for Crohn disease. Scand J Gastroenterol 1999; 34:280.
  148. Maykel JA, Hagerman G, Mellgren AF, et al. Crohn's colitis: the incidence of dysplasia and adenocarcinoma in surgical patients. Dis Colon Rectum 2006; 49:950.
  149. Rutgeerts P, Geboes K, Vantrappen G, et al. Predictability of the postoperative course of Crohn's disease. Gastroenterology 1990; 99:956.
  150. Goligher JC. The long-term results of excisional surgery for primary and recurrent Crohn's disease of the large intestine. Dis Colon Rectum 1985; 28:51.
  151. Rutgeerts P, Hiele M, Geboes K, et al. Controlled trial of metronidazole treatment for prevention of Crohn's recurrence after ileal resection. Gastroenterology 1995; 108:1617.
  152. Caprilli R, Andreoli A, Capurso L, et al. Oral mesalazine (5-aminosalicylic acid; Asacol) for the prevention of post-operative recurrence of Crohn's disease. Gruppo Italiano per lo Studio del Colon e del Retto (GISC). Aliment Pharmacol Ther 1994; 8:35.
  153. Whelan G, Farmer RG, Fazio VW, Goormastic M. Recurrence after surgery in Crohn's disease. Relationship to location of disease (clinical pattern) and surgical indication. Gastroenterology 1985; 88:1826.
  154. McLeod RS, Wolff BG, Steinhart AH, et al. Risk and significance of endoscopic/radiological evidence of recurrent Crohn's disease. Gastroenterology 1997; 113:1823.
  155. Avidan B, Sakhnini E, Lahat A, et al. Risk factors regarding the need for a second operation in patients with Crohn's disease. Digestion 2005; 72:248.
  156. Malireddy K, Larson DW, Sandborn WJ, et al. Recurrence and impact of postoperative prophylaxis in laparoscopically treated primary ileocolic Crohn disease. Arch Surg 2010; 145:42.
  157. Fichera A, McCormack R, Rubin MA, et al. Long-term outcome of surgically treated Crohn's colitis: a prospective study. Dis Colon Rectum 2005; 48:963.
Topic 1375 Version 10.0

TOPIC OUTLINE

GRAPHICS

RELATED TOPICS

All topics are updated as new information becomes available. Our peer review process typically takes one to six weeks depending on the issue.