Stent for Crohn’s disease strictures: Which one and when?
Colonoscopy revealed a circumferential stricture in the right colon with an To date, only about 50 cases have been reported. The most common clinical presentations are obstructive symptoms and gastrointestinal bleeding after taking Surgery is required to relieve obstruction in 75% of reported cases. (Disclaimer: Surgery information is up to date at the time of printing. Colorectal cancer rarely occurs in the first eight to ten years after initial diagnosis of IBD. Occasionally, a portion of the bowel near a stricture can also. Keywords: Crohn's disease, stricture, colon, thiopurines, biologics, surgery. INTRODUCTION Date of the CD diagnosed; stricture diagnosed; lo- calization of the stricture(s); biopsy results; type of the therapy before and after the stricture.
IBD causes chronic inflammation in the gastrointestinal GI tract. Chronic inflammation impairs the ability of the affected organs to function properly, leading to symptoms such as abdominal cramping, diarrhea, rectal bleeding, and fatigue. While both diseases share many of the same symptoms, there are some important differences. Ulcerative colitis is limited to the large intestine colon and the rectum.
Inflammation occurs only on the surface layer of the intestinal lining. It generally starts in the rectum and expands up the colon in a continuous manner. While they cannot cure the diseases, they can often bring about a state of remission a period where a person is symptom free. Remissions can last for months or years, depending on the individual.
Over time, adjustments in medication dose or type may be needed to maintain remission. Medication may not adequately control symptoms for everyone with IBD, and some people with these conditions develop complications that need more aggressive treatment. In these cases, surgery may be recommended or required. When is surgery necessary? Some people with these conditions have the option to choose surgery, while for others, surgery is an absolute necessity due to complications of their disease.
Reasons for elective surgery Some people with IBD decide to have surgery because they can no longer bear the symptoms of their disease or they are no longer responding to their prescribed medication. Some patients do well on a particular medication for a time, and then, for unknown reasons, they stop responding. Some people experience many side effects from the medications. Colorectal cancer Elective surgery may also be recommended for some people with IBD to eliminate the risk of colorectal cancer.
Colorectal cancer rarely occurs in the first eight to ten years after initial diagnosis of IBD. The risk increases the longer a person lives with the disease. People whose disease affects most of their colon are at the greatest risk for developing colorectal cancer.
In most cases, colorectal cancer starts as a polyp a small lump growing from the wall of the intestine. Polyps start out benign but become cancerous over time. Patients with IBD, however, do not always form precancerous polyps. Instead, abnormal and potentially precancerous tissue called dysplasia may lay flat against the wall of the intestine. In addition, abnormal, precancerous cells can be present in an area of the intestinal wall that appears normal at the time of colonoscopy.
People who have had IBD for more than eight to ten years should have surveillance colonoscopies every one to two years depending on other risk factors, such as family history of colorectal cancer.
The standard colonoscopy is usually accompanied by a series of biopsies—small tissue samples taken for microscopic examination. Conditions that require immediate surgery Ulcerative colitis Sudden, severe ulcerative colitis This is the main reason for emergency surgery for ulcerative colitis.
About 15 percent of people with ulcerative colitis have an attack of the disease so severe that medications, even intravenous steroids, cannot control the symptoms. Surgery may be necessary if medications are unable to bring the attack under control. Sudden, severe ulcerative colitis also includes uncontrolled bleeding in the colon which is quite rare and toxic megacolon. Toxic megacolon is caused by severe inflammation that leads to rapid enlargement of the colon.
Symptoms include pain, distention swelling of the abdomen, fever, rapid heart rate, constipation, and dehydration. This potentially life-threatening complication requires immediate treatment and surgery. Perforation of the colon Chronic inflammation of the colon may weaken the wall to such an extent that a hole occurs. This is potentially life threatening because the contents of the intestine can spill into the abdomen and cause a serious infection called peritonitis.
This can narrow a section of intestine called a stricturewhich may lead to an intestinal blockage. Nausea and vomiting or constipation may be signs of a stricture.
Surgery is performed only if bleeding cannot be controlled by other means. Perforation of the bowel As with ulcerative colitis, chronic inflammation may weaken the wall of the intestine to such an extent that a hole occurs. Occasionally, a portion of the bowel near a stricture can also expand, causing the wall to weaken and a hole to occur. Fistula Inflammation can cause ulcers sores to form in the inside wall of the intestines or other organs.
These ulcers can extend through the entire thickness of the bowel wall and form a tunnel to another part of the intestine, between the intestine and another organ such as the bladder or vagina, or to the skin surface. These are called fistulas. Fistulas can also form around the anal area, and may cause drainage of mucus or stool from an area adjacent to the anus.
Repair of this connection requires surgery. Abscess An abscess is a collection of pus, which can develop in the abdomen, pelvis, or around the anal area. It can lead to symptoms of severe pain in the abdomen, painful bowel movements, discharge of pus from the anus, fever, or a lump at the edge of the anus that is swollen, red, and tender. An abscess requires not only antibiotics, but also surgical drainage of the pus cavity to allow for healing.
Toxic megacolon As with ulcerative colitis, severe inflammation can lead to toxic megacolon and require immediate treatment and surgery. Your health care team Once surgery becomes necessary or is decided on as the course of treatment, a surgeon who specializes in performing surgery on the gastrointestinal tract should be consulted to perform the operation.
Your regular gastroenterologist will also play an essential role in your treatment before and after surgery.
If surgery is elective, spend some time choosing a surgeon and a hospital. In addition to being board certified in general surgery, or board certified in colon and rectal surgery, the surgeon should have a great deal of experience performing the specific procedure you will undergo. Some state health departments publish outcome data about certain procedures performed at specific hospitals.
Common procedures for ulcerative colitis The standard surgical procedure for ulcerative colitis is removal of the colon and rectum, called proctocolectomy. Because ulcerative colitis affects only the colon and rectum, once these organs are removed, the person is cured.
For many years, those who underwent proctocolectomy were required to wear a bag over a small hole in the abdomen to collect stool. This procedure is called total proctocolectomy with end ileostomy. While this procedure is still performed, modifications to the procedure allow many patients to undergo variations that eliminate the need to wear a permanent external bag.
To understand the descriptions of these procedures, it is helpful to know the meaning of these terms: Surgical removal of the colon and rectum. Surgical removal of the colon. The lower portion of the small intestine. A surgically created hole in the abdomen for the elimination of waste. Ileostomy can be permanent or temporary. A hole in the abdomen created during ileostomy. A small plastic pouch worn over the stoma to collect stool.
An ostomy bag is also known as a pouching system, collection pouch, or appliance. Proctocolectomy with ileal pouch-anal anastomosis Proctocolectomy with ileal pouch-anal anastomosis IPAA is the most commonly performed surgical procedure for ulcerative colitis. It is an attractive option for many people because it eliminates the need to permanently wear an ostomy bag pouch, appliance, etc.
The nerves and muscles necessary for continence are preserved and stool is passed through the anus. The procedure can be performed in one, two, or three stages, although it usually is performed in two. In the first surgery, the colon and the rectum are removed, but the anus and anal sphincter muscles are preserved.
- Endoscopic management of Crohn’s strictures
- Stent for Crohn’s disease strictures: Which one and when?
The ileum is then fashioned into a pouch and pulled down and connected to the anus. The pouch may be shaped like a J, S, or W. Because the newly formed pouch needs time to heal, a temporary ileostomy is often performed to divert stool away from the pouch. In this procedure, a loop of the small intestine is pulled through an opening in the abdomen to allow for the elimination of waste.
An ostomy bag is worn continuously during this time, and must be emptied several times a day. Issues related to the temporary ileostomy are similar to those experienced with a permanent ileostomy.
Surgery for Crohn's Disease & Ulcerative Colitis | Crohn’s & Colitis Foundation
About 12 weeks after the initial surgery once the pouch has healedthe temporary ileostomy is closed during a second, smaller operation. The small intestine is reconnected and the continuity of the bowel is re-established.Recurrent Recto-Sigmoid endometriosis in a patient with h/o previous shaving procedure
From this point on, the internal pouch serves as a reservoir for waste, and stool is passed through the anus in a bowel movement. An external ostomy bag is no longer required.
This procedure may also be performed in one stage. In this case, the colon and rectum are removed and the pouch is created and joined to the anus without a temporary ileostomy. Due to an increased risk of infection, the procedure is performed less often than the two-stage procedure. In some cases, IPAA may be performed in three stages. In the first surgery, the colon is removed and an ileostomy is created.
In the second surgery, the rectum is removed and the ileum is formed into the pouch, which is connected to the anus. As with the two-stage procedure, this is done to allow the pouch time to heal.
About eight to 12 weeks later, the third surgery is performed to close the ileostomy and reattach the small intestine to the pouch. The patient can then begin using the newly created pouch and pass stool through the anus.
A three-step procedure may be recommended for people with ulcerative colitis who are in poor physical health, on high doses of steroids, or when emergency surgery for bleeding or toxic megacolon is necessary. Total proctocolectomy with end ileostomy In the traditional proctocolectomy procedure, the colon, rectum, and anus are removed, and an end ileostomy is created.
In this procedure, the end of the small intestine ileum is brought through a hole in the abdominal wall in order to create the stoma, which allows drainage of intestinal waste out of the body. The stoma, which is about the size of a quarter, will protrude slightly. It will be pinkish in color and will be moist and shiny. After the procedure, an external ostomy bag must be worn over the stoma at all times to collect waste.
The bag is a component of a pouching system that also includes a skin barrier. The bag is emptied several times a day. The usual site for an ileostomy is the lower abdomen just below the belt line, to the right of the navel see Figure 1. For more information, visit the United Ostomy Associations of America website at www.
Living with an ileostomy People can live long, active, and productive lives with an ileostomy. In most cases, they can engage in the same activities as before the surgery, including sports, gardening, outdoor activities, water sports, traveling, and work.
An initial period of adjustment should be expected. Several pouching systems are available to choose from and it will be necessary to learn how to use the system, as well as how to care for the skin surrounding the stoma. There are no specific dietary restrictions for a person with an ileostomy, but it is important to drink plenty of fluids to avoid dehydration and loss of electrolytes salts and minerals.
It is also helpful to eat foods high in pectin to thicken your stool output and control diarrhea. These foods include applesauce, bananas, or peanut butter.
The psychological implications of a change in body image may be a problem at first. Many people initially feel self-conscious about wearing an ostomy bag. However, the pouch is fairly flat, under clothing, and is not visible. No one needs to know about it unless you decide to tell them.
Many people are concerned about how the surgery will impact their sexual activity. For most people, sexual function is not impaired. Some men may experience erectile dysfunction and some women may have pain during intercourse, but this usually is only temporary. You and your partner are likely to have questions and concerns.
Post-surgical complications Some complications may occur after the surgery, including infection from the surgery or at the site of the stoma. Additionally, the small intestine may become obstructed from food or from scar tissue. If the obstruction is from food, it should be temporary and ease when the food moves through the intestines. A physician or other health care provider should be immediately notified if you experience these symptoms.
Just as people who have had a limb removed sometimes feel as if the limb is still there, some people who have their rectum removed still feel as if they need to have a bowel movement.
This is called phantom rectum. It is normal to feel this after surgery and does not require any treatment. It often subsides over time. Life after surgery Most people do very well post-surgery, and after recovery are able to return to work and normal activity. An adjustment period of up to one year should be expected after surgery.
Initially, there may be up to 12 bowel movements a day. Stool may be soft or liquid, and there may be urgency and leakage of stool. Patients with concomitant fistula or abscesses were not subjected to EBD at our institution. All dilatations were performed with a standard colonoscope Olympus, Hamburg, Germany with a through-the-scope controlled radial expansion CRE balloon predominantly 12—18 mm diameter Boston Scientific, Cork, Ireland.
The balloon was filled with water under visual control, and was insufflated by a multistep inflation with 2—3 min of inflation time at each of the appropriate diameter In general, the average attempts of EBD per session was 3 range 3—5. Passage of the colonoscope through the stricture was attempted in all patients and was used to define therapeutic success.
All of the procedures were performed under conscious sedation using midazolam and either pethidine or fentanyl. After dilatation, patients were observed for 1—4 h in the recovery room.
Patients were followed up as outpatients with 3—6 monthly interval visits, or sooner if they developed symptoms. Long-term efficacy of EBD was defined as the avoidance of surgical resection for obstructive symptoms and disease recurrence at the anastomosis, either with single or repeated dilatations. If patients' symptoms recurred, time to repeat dilatation or surgery was recorded from the index EBD. Descriptive statistics were used to analyse patient demographics.
Kaplan—Meier analysis with log rank statistics was used to estimate event-free interval and Cox forward conditional proportional hazards regression analysis to assess predictors of disease recurrence including smoking status and medication use. Vincents University Hospital, Dublin.
After excluding patients with CD who had dilatation of non-anastomotic strictures, 31 patients remained who were suitable to analyse. Clinical data and follow-up were verified by detailed review of medical records. Patients' demographics are listed in Table 1.
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Eighty-two per cent of patients were on medical therapy for CD at the time of index dilatation. The reasons for choosing a surgical option were usually a combination of factors such as preference of the treating physician, early recurrence of symptoms post index dilatation and even patient preference to undergo surgery to remove the diseased segment over further colonoscopy and dilatation after weighing the management options.
The median number of subsequent dilatations performed was two range 2—6. Of those 15 patients, 8 Median time from primary surgery to first dilatation was nine years IQR, 2— Median time from first EBD to repeat surgery was Median time from index dilatation to second dilatation was 13 months IQR, 4—60 and median time from second to third dilatation was 10 months IQR, 2— Other potential predictors, such as age, gender, C-reactive protein CRP and disease duration, were not significantly associated with subsequent EBD or surgery Supplementary Table 1.
A minority of patients developed mild abdominal pain post procedure which improved and all patients were discharged home on the same day as the procedure.