Romina Pena, MD
Gastrointestinal Surgery Department
Hospital Clínic de Barcelona, Spain
Ulcerative colitis and Crohn’s Disease are chronic inflammatory conditions of the gastrointestinal tract, with both overlapping and distinct features that have a great impact on quality of life. Despite the advances in medical management of this disease, rates of surgical treatment remain high. 16% of ulcerative colitis patients will need surgery within 10 years of diagnosis. Rate rises to 47% for Crohn’s disease. More specifically, rates of emergency surgery have remained unchanged or slightly decreased over time.
Rectal stump management
Little has changed regarding surgical technique for toxic colitis. A total abdominal colectomy with end ileostomy has been the standard procedure for decades. Nevertheless, the optimal management of the remaining rectum is unclear. Three options are available:
1· A Hartmann’s pouch, or intraperitoneal placement of the rectal stump with a rectal drain. Studies show a higher incidence of pelvic sepsis associated with leakage. Also, a difficult rectal dissection is expected during later reconstructive surgery.
2· A subcutaneous placement of the closed rectosigmoid stump. This option also avoids peritonitis and associates with a low pelvic sepsis rate. Nevertheless, wound infection rate is higher.
3· Mucous fistula, or opening of the rectosigmoid remnant as a stoma. Avoids stump blowout with consequent peritonitis. This strategy might not always be possible, as a longer stump is needed to reach the right or even left iliac fossa.
Due to the advances in the medical treatment and extended use of biological drugs, there has been a slight decrease in the surgical rate for CD patients. This might be due to a number of medication and non-medication related factors, including access to a multidisciplinary care team and closer follow-up. This study also detected a paradigm shift towards elective procedures.
Role of the Surgeon
Minimally invasive surgery has consistently reduced postoperative morbidity rates and studies show that it is a more cost-effective treatment strategy in some cases. Surgery seems to be gaining weight as an effective alternative to medical treatment. The surgeon should be then involved in the multidisciplinary team since the early stages of the disease and not only to perform emergent procedures after treatment failure or acute complications.