Surgical Management of

Inflammatory Bowel Disease

Robert R. Cima, MD
John H. Pemberton, MD
Address
Division of Colon and Rectal Surgery, The Mayo Clinic, 200 First Street,
SW, Rochester, MN, 55905, USA.
Current Treatment Options in Gastroenterology 2001, 4:215–225
Current Science Inc. ISSN 1092-8472
Copyright © 2001 by Current Science Inc.

Opinion statement
Surgery continues to be a central component in the treatment of patients with inflam-
matory bowel disease (IBD). The most important aspect of caring for patients with
IBD is a close and ongoing interaction between the surgeon and gastroenterologist
both before and after surgery. Surgery in patients with chronic ulcerative colitis (CUC)
is curative. In the appropriate patient, we recommend proctocolectomy with ileal pouch
anal anastomosis (IPAA). In contrast, patients with Crohn’s disease cannot be cured
with surgery. Instead, surgery is used in conjunction with maximal medical therapy
to treat symptoms of the disease and improve the patient’s quality of life. Surgical
interventions should be limited in scope. Small bowel disease should be treated with
either limited resection or strictureplasty, if possible, to conserve bowel length.
For limited involvement of the colon, segmental resection yields good results. Minimal
surgical intervention, drainage of abscesses, placing draining setons, and aggressive
medical therapy is recommended as treatment of perianal Crohn’s disease.

Introduction
Surgery remains a mainstay in the treatment of patients
with inflammatory bowel disease (IBD), which encom-
passes chronic ulcerative colitis (CUC) and Crohn’s
disease. The cause of both diseases is unknown. The
differences between CUC and Crohn’s disease are
manifested principally in the extent and location of the
inflammatory process. In patients with CUC, surgery is a
primary treatment of the disease. However, surgery is
more commonly used to manage the complications in
patients with CUC or Crohn’s disease. In general, the
most important aspect of surgical intervention in patients
with IBD is appropriate timing. This requires close and
ongoing interactions with gastroenterologists, who are
familiar with the newer and more intensive medical treat-
ment options for IBD. As we will see, improvements in
medical treatment for patients with IBD (Crohn’s disease
in particular) allow a more conservative surgical
approach. Although there is overlap in the indications for
surgery in CUC and Crohn’s disease, the differences in the
natural history of the diseases prompts different surgical
strategies (Tables 1 and 2).
CHRONIC ULCERATIVE COLITIS
Chronic ulcerative colitis is a mucosal inflammatory
disease limited to the rectum and colon. This process is
characterized by contiguous inflammation of the mucosa,
beginning in the rectum and progressing for variable
distances proximally. The natural history of the disease is
one of a chronic inflammatory state, characterized by
intermittent flares of disease activity. In a small number of
patients, the initial presentation of the disease is of a
fulminant nature, which can be fatal. Fulminant CUC,
however, also is observed in patients with longstanding
disease. Emergency surgical intervention is usually neces-
sary in patients with fulminant disease, toxic megacolon,
and massive hemorrhage. The chronic nature of ulcerative
colitis also leads to a number of complications requiring
surgical intervention. These include 1) failure of medical
management to control the disease; 2) stricture forma-
tion; 3) associated systemic manifestations of the disease;
4) a suspicion of dysplastic change, dysplasia-associated
lesion or mass (DALM), or known malignancy; and
5) growth retardation in pediatric patients.
216 Inflammatory Bowel Disease

Table 1. Choice of operations for patients with ulcerative colitis

Patient presentation Preferred procedures

Fulminant ulcerative colitis, toxic megacolon, acute
intractable colitis, perforation, severe hemorrhage
CUC, CUC with dysplasia
CUC with malignancy
CUC—chronic ulcerative colitis.
Total abdominal colectomy with Hartman pouch or venting mucus
fistula. Subsequent surgery depending upon
clinical condition and circumstance (see below).
Total proctocolectomy with ileal-pouch anal anastomosis
with diverting loop ileostomy for patients under 65 years
in good health and continent.
Total proctocolectomy with end ileostomy in older patients
or in patients with poor continence.
Same as for patients with dysplasia, but oncologic
considerations dictate the operation selected. For mid
to high rectal cancers, mucosectomy is recommended.

Table 2. Choice of operations for selected patients with Crohn’s disease

Patient presentation Preferred procedures

Small bowel strictures Limited resection and strictureplasty.

Enteroenteric fistula
Colitis
Perianal disease
Resect origin of fistula and primary closure of the bowel or the associated organ in abdomen,
if not involved with Crohn’s disease.
Isolated disease should be treated with segmental resection; pancolitis should be treated
with total colectomy and ileorectostomy if there is no rectal or perianal disease, or total
proctocolectomy with end ileostomy if there is severe rectal or perianal disease.
Incision, drainage of abscesses, drainage seton placement, medical (infliximab) therapy

EMERGENCY SURGERY FOR CHRONIC ULCERATIVE COLITIS
Fulminant colitis A l t h o u g h C U C c o m m o n l y i s a
chronic disease that allows deliberate and coordinated
care, occasionally CUC presents fulminantly, which is
the initial presentation in approximately 10% of
patients [1]. Fulminant disease is characterized by the
sudden onset of severe, frequent, bloody bowel move-
ments (more than ten per day); abdominal pain;
dehydration; and anemia. The Truelove and Witts crite-
ria for fulminant colitis include the above criteria and at
least two of the following conditions: tachycardia, body
temperature more than 38.6 °C, leukocytosis (more
than 10,500 K), and hypoalbuminemia [2]. These
patients are extremely ill and require rapid aggressive
medical therapy. Medical therapy consists of aggressive
fluid resuscitation and correction of electrolyte abnor-
malities. Blood transfusions may be necessary. The
patient should be given nothing by mouth. Nasogastric
tube decompression may be required if colonic disten-
sion is a component of the presentation. If the patient is
known to have CUC, then high-dosage intravenous
steroids should be initiated. If no provisional diagnosis
of CUC has been made, the patient should undergo
expeditious evaluation of the gastrointestinal tract and
of the colon in particular. Stool cultures should be
obtained. An experienced endoscopist using minimal
air insufflation should perform the colonic endoscopy.
Because of the risk of perforation, many physicians are
concerned about performing endoscopy during an
episode of acute colitis. However, though there are
scattered reports of perforation occurring after endo-
scopy in this setting, this is actually quite rare. Urgent
endoscopy is meant not to evaluate the entire colon but
only to visualize the rectal and distal colonic mucosa. If
the findings on examination are obviously consistent
with CUC, then the endoscope can be withdrawn
quickly without intubating the entire colon. If the
patient is clinically stable, there is no indication for
antibiotic therapy. However, if the patient is very ill, or
has a high fever or leukocytosis, appropriate broad-
spectrum antibiotics should be initiated after cultures
are obtained. The patient should be observed closely for
24 to 48 hours while on medical therapy. If there is no
improvement, or if the patient’s condition deteriorates,
then surgery is advised. If there is evidence of peritoni-
tis, profound hemodynamic instability, or perforation
the patient should be operated upon immediately.
Toxic megacolon Another surgical emergency in patients
with CUC is toxic megacolon. Fortunately, as cooperation
between gastroenterologists and surgeons has improved,
the incidence of toxic megacolon is quite low. This pro-
cess may be the initial presentation of CUC or may rep-
resent a flare in a patient with longstanding disease. The
entire colon or an isolated segment of the colon (usually
transverse or the left colon) is involved. Toxic megacolon
 Surgical Management of Inflammatory Bowel Disease
is a clinical diagnosis. However, the strict radiographic
definition of toxic megacolon is dilatation of the trans-
verse colon greater than 5.5 cm on a supine abdominal
film. The medical treatment of toxic megacolon is similar
to fulminant colitis, namely, nothing given orally, naso-
gastric tube decompression, correction of fluid deficits
and electrolyte abnormalities, high-dosage steroids, and
antibiotics if there is fever or elevated leukocyte count.
Some physicians advocate rolling the patient from supine
to a prone position every hour to prevent the accumula-
tion of air in the transverse colon. Emergency surgery is
indicated if the patient’s clinical or radiographic status
worsens, if there is evidence of perforation, or if there is
no improvement 24 to 36 hours after beginning aggres-
sive medical therapy. Delaying surgery increases the risk of
perforation, which raises the mortality from less than 5%
to nearly 30% [1].
Other surgical emergencies Other surgical emergencies
in patients with CUC are perforation and severe hemor-
rhage. Perforation outside the setting of toxic mega-
colon occurs infrequently; it should raise concern that
the actual diagnosis is Crohn’s disease, or that the perfo-
ration is from another cause (such as a gastric or duode-
nal ulcer related to chronic steroid use). Whatever the
cause, there is no role for conservative therapy, and the
patient should undergo surgery.
Profuse hemorrhage is another indication for surgi-
cal intervention. Decisions regarding intervention are
made after close consultation with the treating gastro-
enterologist. Initial treatment should be aggressive fluid
and blood-product resuscitation. Correction of any
electrolyte or clotting deficiencies should be under-
taken. Identification of the source of bleeding should be
aggressively sought by endoscopy. Evaluation should
include both upper and lower endoscopy. Upper endo-
scopy should be performed to exclude a possible gastric
or duodenal ulcer as the bleeding source. The timing of
the operation is determined by the clinical situation. If
the patient is hemodynamically unstable even after
effective resuscitation, sugery is indicated, because med-
ical therapy takes too long to decrease the mucosal
inflammation responsible for the bleeding. If there is a
slow but ongoing hemorrhage that does not cause
hemodynamic instability or symptoms, then a trial of
high-dosage steroids may be instituted. If there is no
improvement after 48 to 72 hours of medical therapy,
then surgery should be considered.
ELECTIVE SURGERY FOR CHRONIC ULCERATIVE COLITIS
Elective surgical intervention in patients with CUC is
prompted by intractability of symptoms and the treat-
ment of dysplasia or suspected or known malignancies.
Intractability is a clinical definition occurring in both the
acute and chronic states of CUC. During an acute flare,
intractability refers to the inability to control a patient’s
Cima and Pemberton 217
symptoms; intractability in a patient with longstanding
CUC refers to either the inability to taper steroids to a
reasonable maintenance dosage or the development of
severe side effects. Some centers recommend the initia-
tion of intravenous or oral cyclosporine for patients
suffering from an acute flare of CUC not responding to
intravenous steroid therapy. Several small series on
cyclosporine for patients with intractable CUC had hope-
ful initial results; however, more recent reports with larger
numbers of patients and longer follow-up showed that
nearly 50% of all patients subsequently required colec-
tomy within 1 year [3]. Therefore, our policy is usually to
treat acute flares with intravenous steroid therapy for 7 to
10 days. If there is no improvement, elective surgery is
recommended. The type of surgical procedure recom-
mended depends on a number of patient-related factors
including age and over all medical condition.
The development of malignancy in the setting of
CUC has been well described. The estimated risk of
colon cancer in patients with CUC has been estimated
to be anywhere from 2% at 20 years onset to 43% at 35
years [4]. Most clinicians agree that the risk for develop-
ing colon cancer is between 10% to 20% after 20 years
of disease. A patient’s individual risk for colon cancer is
likely increased if there is evidence of high-grade dys-
plasia on random colon biopsies or if there is a DALM.
If there is a known malignancy, then oncologic prin-
ciples drive the surgical decision making process.
Current recommendations are that a colectomy is indi-
cated if there is either a high-grade dysplasia or a DALM.
In most patients, except for those with low rectal
cancers or metastatic disease, total colectomy with ileal
pouch anal anastomosis (IPAA) is an acceptable
surgical treatment modality. The presence of a low-
grade dysplasia on random biopsy is a more difficult
clinical situation. Most clinicians recommend increas-
ing the frequency of surveillance colonoscopies rather
than surgery; however, there are some preliminary
reports that the presence of any degree of dysplasia not
associated with a mass lesion should be viewed with a
very high degree of suspicion and surgery should be rec-
ommended [5]. There is controversy regarding the need
for a mucosectomy in these patients, the aim of which is
to remove all tissue at risk for dysplasia in the future.
However, there have been reports of both dysplasia and
adenocarcinomas arising at the pouch anastomosis
after either mucosectomy or stapled anastomosis. Our
recommendation is that these patients need to have life-
long surveillance of both the pouch and anastomosis.
CROHN’S DISEASE
Crohn’s disease is a transmural inflammatory process
that is discontinuous along the gastrointestinal tract.
Unlike CUC, this disease process occurs anywhere from
the mouth to the anus in patients. Though many of the
indications for surgical intervention in patients with
218 Inflammatory Bowel Disease
Crohn’s disease are similar to those for CUC, the fact that
Crohn’s disease is a transmural inflammatory process
causes complications unique to patients with Crohn’s
disease, such as fistula formation, intra-abdominal
abscess formation, and spontaneous perforation. The
most commonly involved segments of the gastrointesti-
nal tract include the small bowel (particularly the termi-
nal ileum), and the perianal region. In a large series of
patients with Crohn’s disease requiring surgery over an
11-year period, 41% had disease in the terminal ileum,
16% had perianal disease, and 16% had colonic disease;
18% of patients had multiple sites of disease [6•].
Crohn’s disease of the small bowel C r o h n ’ s d i s e a s e
affects the small bowel in the majority of patients. As
previously noted, terminal ileum disease is seen in
approximately 41% of patients with Crohn’s disease.
These patients often present with abdominal discom-
fort, persistent diarrhea, obstructive symptoms, or a
mass-like lesion in the right lower quadrant. Radio-
graphic or endoscopic evaluation establishes the
presumptive diagnosis. If Crohn’s disease is considered
the likely diagnosis, medical treatment should be
initiated. In general, medical therapy is directed at
reduction of the local inflammation by the use of ste-
roids or 5-aminosalicylic acid preparations. If the dis-
ease burden is not high and the symptoms are relatively
mild, the use of other immunomodulators should be
considered prior to surgical intervention for the relief of
symptoms. Once symptoms prompt surgical resection,
the real surgical issue regarding ileocolic Crohn’s dis-
ease is the extent of resection. Most surgeons now agree
that extensive resection should be avoided. Resection to
grossly normal bowel, which allows a safe anastomosis,
is the standard of care. Previously, some surgeons
extended the resection to microscopically normal bowel
in an attempt to reduce recurrence of the disease at the
neoterminal ileum. In a prospective randomized,
controlled trial, Fazio et al. [7•] evaluated the extent of
resection for patients with focal Crohn’s disease of the
small bowel, and found no statistical difference in clini-
cal recurrences between extended versus limited small
bowel resection. Almost all prior studies have found a
very high rate of recurrence (up to 70%) at the anasto-
mosis as judged by radiologic or endoscopic criteria
within 5 years [8]. In a small group of patients, McLeod
et al. [9] showed that nearly 77% of patients have
recurrence on endoscopy or radiograph by 3 years, but
only 40% have symptomatic recurrence. The use of
postoperative 5-aminosalicylic-acid–based medicines
and immunomodulators may decrease the symptom-
atic recurrence rate after surgery. Indeed, meta-analysis
of available trials of mesalamine use has shown a
decrease in symptomatic recurrence after surgery [10].
Another major surgical issue is related to stricture
formation in the small bowel. These strictures are often
multiple and spread along the length of the small bowel.
Previously, the treatment of such strictures was extensive
resection or intestinal bypass. However, multiple resec-
tions were often accompanied by high complication rates,
and extensive resections occasionally were complicated by
short bowel syndrome. Bypassing long segments of small
intestine leads to problems with bacterial overgrowth and
a risk of malignancy in the bypassed segment. To address
these problems, strictureplasty was adapted from the
surgical experience with intestinal tuberculosis. The
Cleveland Clinic reported a large series of 698 stricture-
plasties performed in 162 patients without any septic
complications or deaths [11]. The reoperation rate for
recurrent strictures at 5 years was similar to patients who
underwent formal bowel resections. When reoperation
was required, the majority of new strictures occurred at
sites remote from the previous strictureplasties. Overall,
strictureplasty is a safe and effective means of relieving
obstructive symptoms in patient’s with Crohn’s small
bowel strictures, without the need for multiple resections
that might result in short bowel syndrome.
Crohn’s disease enteric fistula Because Crohn’s disease is
a transmural inflammatory process, a unique complica-
tion in patients with Crohn’s disease is the formation of
fistulas. These fistulas may be between different regions of
the intestine, adjacent organs, abdominal wall, or perianal
skin. Enteroenteric fistulas may be asymptomatic because
of their location or quite symptomatic if a large length of
intestine is bypassed. Initial treatment should be similar
to the management of any enteric fistula. First, it is essen-
tial to ensure that there are no undrained intra-abdominal
fluid collections. An abdominal CT scan with oral, water-
soluble contrast is the test of choice because it is both
diagnostic and possibly therapeutic. Any fluid collections
not communicating with the fistula should be drained.
The patient should be placed at bowel rest, and fluid and
electrolyte abnormalities need to be corrected. The early
assistance of a wound-care specialist or enterostomal ther-
apist is essential in order to avoid skin breakdown if there
is an enterocutaneous fistula. If the patient’s nutritional
status is poor, parenteral nutrition should be instituted
early in his or her treatment. Aggressive medical manage-
ment probably should include infliximab, a chimeric
monoclonal antibody to tumor necrosis factor alfa. If
surgery is required to relieve symptoms, the portion of
bowel where the fistula originates is resected. In the case
of an enteroenteric fistula, the bowel in which Crohn’s
disease is involved needs to be resected and the non-
involved bowel anastomosed. If both ends are involved
with Crohn’s disease, then both should be resected. Treat-
ment of fistulas to other organs or the skin can be treated
using similar principles of resection and repair.
Crohn’s disease of the colon In some patients, Crohn’s
disease initially may be limited to the colon. The patient
 Surgical Management of Inflammatory Bowel Disease
may present with either a fulminant colitis or a chronic
relapsing colitis similar to CUC. The indications for
elective surgery in patients with Crohn’s colitis are
intractability, fistula formation, chronic anemia, stricture
formation, or severe perianal disease. In fulminant
Crohn’s colitis, the patient should be managed similarly
to a patient with fulminant CUC. If the patient progresses
to emergency surgery, a subtotal colectomy with
ileostomy and Hartmann closure of the rectum is recom-
mended. At a later date, the patient may be converted to
an ileorectostomy if the rectum and perianal region had
not been previously involved with Crohn’s disease. Treat-
ment for patients with pancolonic Crohn’s disease is
proctocolectomy with ileostomy. In patients with
Crohn’s colitis, the recurrence of the disease at extraco-
lonic sites is about 10% to 15% at 10 years. The treatment
of patients with segmental Crohn’s colitis often is
debated. For patients with focal colitis and severe peria-
nal disease, our operation of choice is a total proctocolec-
tomy and ileostomy. Those few patients with limited
colonic disease should undergo a segmental resection.
We have found that 86% of patients with focal Crohn’s
colitis who undergo segmental resection remain stoma-
free for more than 10 years [12]. However, nearly 50% of
patients will experience recurrence of Crohn’s disease in
the colon, and nearly a third will require a second opera-
tion for that recurrence. These high rates of recurrence
have led some authors to suggest total proctocolectomy
as the treatment of choice for segmental disease.
Although this procedure has the lowest recurrence rate, it
does result in a permanent stoma.
Perianal Crohn’s disease One of the most difficult areas
of treatment in Crohn’s disease is the treatment of
perianal disease. Nearly 70% of patients with Crohn’s
disease will have perianal disease at some time in the
course of their disease. Perianal Crohn’s disease
manifests itself in numerous ways. Common clinical
presentations include hypertrophic skin tags, ulcer-
ation, fissures, anal stenosis, anal canal ulcers, fistula,
and perianal abscesses. A patient may have one or
multiple manifestations. Symptoms include pain,
discharge, bleeding, and even fecal incontinence.
Surgery for patients with perianal Crohn’s disease
should be directed toward symptom relief with mini-
mal intervention. In this regard, treatment for perianal
Crohn’s disease usually is limited to the treatment of
fistula and perianal abscesses, which often occur con-
currently. The treatment of such fistulas is difficult, as
they are often complex with high rectal primary open-
ings. Our recommended treatment for a high fistula or
complex fistulous involvement of the perineum is
drainage setons and infliximab. This has been shown to
be effective in controlling perianal sepsis and is an
acceptable treatment modality from the patient’s view-
point [13]. Treatment of a low fistula that does not
Cima and Pemberton 219
incorporate external anal sphincter muscle can be either
with seton placement or fistulotomy. Both the clinician
and patient need to know that wounds made in the set-
ting of perianal Crohn’s disease heal quite slowly and a
fistulotomy wound may take months to close. Similar
to fistula treatment in Crohn’s disease, control of peria-
nal abscesses should be directed at drainage of the
abscess and controlling the abscess cavity. Initial drain-
age may be followed by placement of a seton or a long-
term rubber catheter drainage that allows slow healing
of the abscess cavity. Recent advancements in surgery for
patients with perianal Crohn’s disease include the use
of endoanal ultrasound to identify complex fistula and
occult abscesses. Endoanal magnetic resonance imaging
also can be used to identify fistula and occult abscesses.
Sometimes perianal Crohn’s disease may be
unresponsive to medical and local surgical therapy. In
such patients, the disease process may destroy the sphinc-
ter mechanism and cause fecal incontinence or may
present such a wound healing problem that proctectomy
is the only surgical option. Proctectomy is required in up
to 10% of patients with perianal Crohn’s disease. Fecal
diversion often improves the status of patient with peria-
nal disease, but when reversed the active disease invari-
ably returns. In general, limited surgical intervention
cannot cure perianal Crohn’s disease but it can dramati-
cally improve a patient’s quality of life.
INDETERMINATE COLITIS
In approximately 10% of patients with IBD, the path-
ologist is unable to make a definitive diagnosis of CUC
or Crohn’s disease, even if the entire colon is available
for pathologic evaluation. This entity has been termed
indeterminate colitis (IC). IC should be diagnosed only
in those patients in whom the preoperative diagnosis
was chronic CUC and in whom either intraoperative or
postoperative pathologic evaluation is unable to firmly
establish the diagnosis of CUC. The importance of a
diagnosis of IC is that patients with this diagnosis have
different outcomes after IPAA than patients with a firm
diagnosis of CUC. Between 1981 and 1995, 1519
patients underwent IPAA at the Mayo Clinic for CUC;
82 patients were intraoperatively given the diagnosis of
IC [14]. The complication rate and rate of pouch failure
was significantly higher in the IC group compared with
the CUC group. In addition, after 10 years, the IC group
had significantly higher morbidity than the CUC group,
including episodes of pelvic sepsis (17% vs 7%), pouch
fistulas (31% vs 9%), and pouch failures (27% vs 11%),
which required creation of a permanent ileostomy with
or without the removal of the pouch. There were no
differences in the incidence of pouchitis or in func-
tional results. By 15 years, nearly 15% of the patients
with IC had been diagnosed with Crohn’s disease. The
change in diagnosis from CUC to Crohn’s disease
occurred in only 2% of the CUC patients. Overall, total
220 Inflammatory Bowel Disease

proctocolectomy and IPAA was performed safely in
patients with IC. However, the patient, gastroenterolo-
gist, and surgeon need to be aware that the rate of com-
plications and pouch failure is higher in patients with
IC than in patients with CUC, and that the patient’s
diagnosis subsequently may change to Crohn’s disease.
NEW DIRECTIONS FOR SURGERY IN PATIENTS WITH IBD
As a better understanding of the causes of IBD and
newer medical therapies evolve, the role of surgery may
become more limited. It is unlikely that the indications
for surgery or the type of surgical interventions will
change. However, newer surgical techniques (namely
laparoscopic surgery) hopefully will allow for interven-
tions that carry less morbidity but have similar func-
tional results. The use of laparoscopic surgery in the
surgical treatment of IBD is particularly attractive, at
least in patients with Crohn’s disease, because the
chances of subsequent operations are likely. The use of
laparoscopic surgery may decrease surgical stress in
immunocompromised patients and decrease adhesion
formation, making further operations easier. Laparos-
copy improves comesis and patient perceptions of their
illness and quality of life. Although early studies of lap-
aroscopic surgery for patients with IBD did not show a
significant reduction in hospitalization time or cost, this
was likely due to old techniques used. As surgeons have
become more comfortable with laparoscopic techniques
in general (and for colon surgery in particular), and as
the instrumentation has improved, there are preliminary
data suggesting that hospitalization time and costs are
reduced. In a case-matched series at the Mayo Clinic
comparing open versus laparoscopic ileocolectomy for
Crohn’s disease, there were significant patient benefits
seen: hospital length of stay was reduced from 7 days to
4 days [15]. The impact of laparoscopic ileocolic resec-
tions recently has been examined in a prospective but
nonrandomized fashion at two medical centers in the
Netherlands. Patients who underwent laparoscopic
resections had a significantly shorter hospital stay with
similar morbidity [16]. The use of laparoscopic surgery
for patients with CUC was initially limited because of
the difficulty performing a laparoscopic total colectomy.
The initial experience of laparoscopic total colectomy
and IPAA for patients with CUC did not demonstrate
any significant benefits compared with open surgery.
Again, it appears that the data are affected adversely by
surgeon experience with the technique. Total colectomy
and IPAA has evolved from an operation using multiple
ports and a Pfannenstiel incision to a four-incision tech-
nique that includes two 5-mm port sites, a stoma site,
and a 4-cm periumbilical incision. As surgeons’ experi-
ence with laparoscopic small bowel and colon surgery
increases and instrumentation improves, this approach
to treatment for IBD should be equal to if not better
than conventional open surgery.

Treatment of Chronic Ulcerative Colitis

Supportive care for emergent chronic ulcerative colitis
• Aggressive fluid resuscitation and correction of electrolyte abnormalities
and clotting abnormalities.
• Blood transfusions may be necessary.
• Patients should receive nothing by mouth.
• If the patient is very ill or has a high fever or leukocytosis, broad-spectrum
antibiotics should be initiated.
• If the patient is known to have CUC, then high-dosage intravenous steroids
should be initiated. Our policy is usually to treat acute flares with intra-
venous steroid therapy for 7 to 10 days. If there is no improvement, elective
surgery is recommended. Other pharmacologic therapies are beyond
the scope of this article; the reader is referred to other sources for further
information [17].

Endoscopic therapy
Endoscopic therapy for dysplasia-associated lesion or mass
Recently, the need for surgical intervention has been questioned in the setting
of a patient with a DALM. Preliminary reports indicate that if there is no evidence
of dysplasia elsewhere in the colon other than the dysplastic polyp, then the polyp
can be treated endoscopically and the patient followed [18,19]. These findings are
preliminary and are not our current practice. We recommend colectomy for the
presence of any mass or high-grade dysplasia.
 Surgical Management of Inflammatory Bowel Disease Cima and Pemberton 221

Surgery
• Delaying surgical intervention in a patient with CUC may result in
increased morbidity.
• In the appropriate patient with CUC, total abdominal colectomy and IPAA
is the procedure of choice in the elective setting.

Emergency surgery for ulcerative colitis

• Emergency surgical intervention is usually necessary in patients with
fulminant disease, toxic megacolon, perforation, and massive hemorrhage.

Total abdominal colectomy

Total abdominal colectomy with end ileostomy and a Hartman pouch or venting
mucous fistula is the procedure of choice for emergency surgery. Total abdominal
colectomy with end ileostomy removes the bulk of diseased tissue. Removing
the source of the disease allows the patient to be tapered off of steroids and
nearly always results in an improved clinical condition.
Standard procedure Transection of the colon should be performed at a level that leaves the superior
hemorrhoidal artery intact. Dissection into the presacral space should be avoided,
as this will make subsequent dissection more difficult and may jeopardize the
success of a restorative procedure. The addition of a proctectomy in the setting
of an emergency has a number of disadvantages, including increasing the difficulty
and length of the operation, increasing bleeding, and subsequent restorative
procedures are more difficult or even impossible to perform.
Contraindications None.
Complications Complications in this setting are related to degree of compromise induced by
the emergency nature of the operation. They include bleeding, wound infection,
and rectal stump leak.
Cost/cost-effectiveness Operating emergently does require an additional surgery and hospitalization
that would not be necessary in the elective setting for CUC.

Elective surgery for ulcerative colitis

• Patients with intractable symptoms of CUC, dysplasia, or suspected
or known malignancies should be considered for elective surgery.
• Procedures of choice at our institution are total abdominal proctocolec-
tomy with IPAA or proctocolectomy and end ileostomy. The operation
chosen depends primarily upon the patient’s age, comorbid diseases,
and body habitus.

Total proctocolectomy with ileal pouch anal anastomosis or end ileostomy

Standard procedure Although there is controversy over the type of ileal pouch constructed (J-pouch
vs S-pouch) and the role of anal canal mucosal resection versus double stapled
anastomosis, there are little objective data clearly supporting any one approach
over the other. The most important variables in restorative surgery are the degree
of patient debility and the experience of the surgeon. We prefer to perform a
J-pouch reservoir and double staple the pouch-anal anastomosis. A review of our
experience with IPAA for patients with CUC has shown that 92% of patients have
good to excellent results over the long term [20••]. Rates of occasional fecal
incontinence are slightly higher in patients older than 45, and the incidence of
incontinence does increase with aging.
222 Inflammatory Bowel Disease

Contraindications Although older patients are not denied IPAA based on age alone, we do strongly
recommend to patients older than 65 that total proctocolectomy and an end
ileostomy is the better operation. There are centers reporting that IPAA can
be performed in patients over the age of 70 with results comparable with younger
patients [21].
Complications A diverting loop ileostomy is constructed in nearly all of our patients. The main
concern is that without a diverting ileostomy, a pouch leak and subsequent pelvic
sepsis would be uncontrolled. The rate of pelvic sepsis in patients after IPAA is
between 0% to 15% [22]. Most commonly, the early stage of pelvic sepsis (pelvic
phlegmon) is treated with intravenous antibiotics, alone or in combination with
CT-guided percutaneous drainage. Transabdominal operative drainage represents a
significant marker for future pouch dysfunction and subsequent need for pouch
excision in nearly 50% of patients. Overall, the Mayo Clinic experience has shown
that pelvic sepsis or abscess after IPAA leads to a higher rate of pouch failure
compared with patients who do not have these complications (26% compared with
6%) [23]. For this reason, we prefer to use a diverting ileostomy, which is reversed
10 to 12 weeks after the initial operation.
Late complications of IPAA include anastomotic stricture, pouch fistulas,
and pouchitis. Pathologic anastomotic strictures occur in between 5% and 40%
of patients [21]. The causes of stricture formation include tension at the anasto-
mosis, ischemia, and pouch leak. Some authors have claimed that the use of
a stapled anastomosis results in a higher rate of stricture formation. However,
there is no convincing evidence that that is the case. The initial treatment of
chronic anastomotic stricture is dilatation (which may require anesthesia).
If stricture dilatation is not successful, then operative repair may be undertaken
by transanal advancement of either the pouch mucosa or perianal skin, by transab-
dominal pouch advancement, or pouch reconstruction. If the stricture cannot be
repaired or the repair fails, then pouch excision and construction of a permanent
end ileostomy are required.
Pouch-related fistulas are seen in between 5% and 15% of patients after IPAA
[22]. Most occur within 6 months of surgery or after reversal of the diverting
ileostomy. Late presentation of a fistula in a patient who underwent IPAA for CUC
should raise concern that the primary diagnosis should be Crohn’s disease. The
causes of early fistulas are usually technical or related to abscesses from either the
surgery or to cryptoglandular infections. Initial treatment should be conservative
and includes diverting the fecal stream and drainage of any abscesses. If conserva-
tive measures fail, then local advancement flaps or pouch reconstruction may be
attempted, but the ultimate rate of pouch excision in these patients is 20% [23].
Pouchitis is a clinical syndrome characterized by high stool output, frequent
bloody diarrhea, fever, malaise, and pelvic discomfort. At endoscopy, the pouch
mucosa may appear inflamed and purulence may be present. The cause of pouchitis
is unclear; it appears that it is a manifestation of the patient’s underlying IBD, as
it is extremely rare in patients who underwent IPAA for treatment of familial
adenomatous polyposis. The cumulative risk of pouchitis for patients at the Mayo
Clinic is approximately 60% at 10 years. There is no surgical treatment of pouchitis
other than pouch removal. The treatment consists of supportive measures and the
use of the antibiotics (ciprofloxacin or metronidazole). Most patients respond to
treatment rapidly, usually within 2 to 3 days. Some patients go on to have multiple
recurrent episodes of pouchitis or to have chronic pouchitis, which can be treated
with topical steroids or sulfasalazine. Persistent pouchitis may lead to pouch
excision with end ileostomy, but this occurs in less than 1% of all pouch patients.
Cost/cost-effectiveness There are no data or studies that have addressed the cost-effectiveness of this procedure.

Treatment of Crohn’s Disease

Pharmacologic treatment
• In general, medical therapy for Crohn’s disease is directed at reduction
of the local inflammation by use of steroids or 5-aminocylic acid prepara-
tions. If the disease burden is not high and the symptoms relatively mild,
 Surgical Management of Inflammatory Bowel Disease Cima and Pemberton 223

the use of other immunomodulators should be considered prior to surgical

intervention for relief of symptoms. For further information on immuno-
modulator therapy, the reader is referred to other sources [24]
• Patients with fulminant Crohn’s colitis should be managed similarly to
patients with fulminant CUC [17].
• Patients with enteric fistula should be placed at bowel rest and fluid and
electrolyte abnormalities need to be corrected. The early assistance of a
wound care specialist or enterostomal therapist is essential in order to
avoid skin breakdown if there is an enterocutaneous fistula. If the patients’
nutritional status is poor, parenteral nutrition should be instituted early
in their treatment. Aggressive medical management should include
infliximab, a chimeric monoclonal antibody to tumor necrosis factor alfa.
The addition of infliximab at 5 mg/kg had a 68% closure rate of
enterocutaneous fistulas compared to 13% for placebo [25].
• Infliximab is recommended for high fistulas or complex fistulous disease
involving the perineum.

Surgery
• In a large series, the most common indication for surgery in patients
with Crohn’s disease was the failure of medical management to control a
patient’s symptoms (50% of patients); intestinal obstruction and fistula
formation were indcations for surgery in 20% and 15% of patients,
respectively [6•]. Other indications for surgery are suspected or known
malignancy, fulminant colitis, and massive bleeding (very rare).
• Unlike patients with CUC, surgery is not curative in patients with Crohn’s
disease. In fact, nearly 40% of patients requiring surgery for Crohn’s disease
will have a subsequent operation for recurrent Crohn’s disease within 5
years [26]. These data indicate that surgery in patients with Crohn’s
disease should only be undertaken after maximal medical therapy
has been attempted. The extent of the surgery should be limited to
the specific problem requiring the surgical intervention and not all
of the active Crohn’s disease. In cases of perianal Crohn’s disease, multiple
minor surgical procedures are a more effective treatment scheme than
extensive operations.

Resection
Standard procedure Resection to grossly normal bowel (allowing for safe anastomosis) is the standard
of care. Extensive resection should be avoided.
Contraindications None, after medical therapy has been optimized.
Complications Wound infections, anastomotic leaks, fistula formation, recurrence of the disease.
There are no specific complications unique to Crohn’s disease other than the known
risk of recurrence and need for subsequent surgery. Most of the
complications are related to the medically induced immunosuppressed
state of these patients.
Special points Studies have found a very high rate of recurrence of Crohn’s disease at the anastomo-
sis on radiologic or endoscopic examination within 5 years [8]. McLeod et al. [9]
showed that nearly 77% of patients with Crohn’s disease have endoscopic or
radiologic recurrence by 3 years. However, only 44% of patients had symptomatic
recurrence. The use of postoperative 5-aminosalicylic acid based medicines and
immunomodulators may decrease the symptomatic recurrence rate after surgery [10].
Cost/cost-effectiveness There are no data or studies that have addressed the cost-effectiveness
of this procedure.
224 Inflammatory Bowel Disease

Strictureplasty
Strictureplasty is a safe and effective means of relieving obstructive symptoms
from Crohn’s small bowel strictures without the need for multiple resections
that might result in short bowel syndrome.
Standard procedure Strictureplasty involves longitudinal division of the stricture on the antimesenteric
border. The enterotomy is then closed in a transverse fashion similar to the
Heineke-Mikulicz technique. For longer strictures, a Finney-type strictureplasty
is recommended. In the presence of an extremely long stricture or multiple
strictures grouped together, some authors recommend a side-to-side isoperistaltic
strictureplasty [27].
Contraindications The presence of a malignancy is an absolute contraindication to a strictureplasty.
Complications In the Cleveland Clinic series, the most common postoperative complication
was suture-line bleeding. Some authors recommend angiographic evaluation
and possible infusion of a vasoconstricting agent.
Cost/cost-effectiveness There are no data or studies that have addressed the cost-effectiveness of
this procedure.

Subtotal colectomy with ileostomy

Standard procedure A subtotal colectomy with ileostomy and Hartmann closure of the rectum is
recommended for patients with fulminant Crohn’s disease of the colon.
Contraindications None.
Complications Wound infections, bleeding, small bowel obstruction, peristomal hernias.
Special points At a later date, the patient may be converted to an ileorectostomy if the rectum
and perianal region have not been previously involved with Crohn’s disease.
Cost/cost-effectiveness There are no data or studies that have addressed the cost-effectiveness of
this procedure.

Proctocolectomy with ileostomy

Proctocolectomy is indicated in patients with focal colitis and severe perianal Crohn’s
disease, or pancolonic Crohn’s disease and perianal disease. Patients with focal Crohn’s
colitis with rectal sparing should undergo segmental colonic resection.

Seton placement
Nonreacting setons (nylon, PDS) should be used for perianal fistula and
abscesses. The patient should then undergo intensive medical treatment prior
to any extensive operative procedure directed at these problems.

Fistulotomy
Treatment of a superficial fistula that does not incorporate the external anal
sphincter muscle can be either with seton placement or fistulotomy. Patients
with poor continence should only be treated with seton placement to avoid the
risk of inducing fecal incontinence with any operative procedure that divides
the sphincter muscle. Both the clinician and the patient need to know that wounds
made in the setting of perianal Crohn’s disease heal quite slowly, and a fistulotomy
wound may take months to close.

Proctectomy
In patients where perianal Crohn’s disease is unresponsive to medical therapy
and local surgery, proctectomy may be the only surgical option. Proctectomy
is required in up to 10% of patients with perianal Crohn’s disease. Prior to comple-
tion of proctectomy, it is important to ensure that any proximal disease has either
been removed surgically or treated medically, because doing so may improve the
perianal disease.
 Surgical Management of Inflammatory Bowel Disease Cima and Pemberton 225

Fecal diversion
Fecal diversion often improves the status of patients perianal Crohn’s disease,
but perianal disease invariably returns when intestinal continuity is restored. Our
policy is not to perform fecal diversion as a primary treatment for perianal disease
unless the patient refuses proctectomy or has not had maximal medical therapy.

References and Recommended Reading

Papers of particular interest, published recently, have been highlighted as:
• Of importance
•• Of major importance
1. Becker JM: Surgical therapy for ulcerative colitis and
Crohn’s disease. Gastroenterol Clin N Am 1999,
28:371–390.
2. Truelove SC, Witts LF: Cortisone in ulcerative colitis:
final report on a therapeutic trial. Br Med J 1955,
2:1041–1048.
3. Gurudu SR, Griffel LH, Gialanella RJ, Das RM:
Cyclosporine therapy in inflammatory bowel
disease: short-term and long-term results. J Clin
Gastroenterol 1999, 29:151–154.
4. Lewis JD, Deren JJ, Lichenstein GR: Cancer risk
in patients with inflammatory bowel disease.
Gastroenterol Clin N Am 1999, 28:459–477.
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complicating chronic ulcerative colitis: is immediate
colectomy warranted. Dis Colon Rectum 2000,
43:1575–1581.
6.• Hurst RD, Molinari M, Chung TP, et al.: Prospective
study of the features, indications, and surgical
treatment in 513 consecutive patients affected by
Crohn’s disease. Surgery 1997, 122:661–668.
Good overview of the reasons for operation and reoperation
in patients with Crohn’s disease.
7.• Fazio V, Marchetti F, Chruch JM, Goldblum JR:
Effect of resection margins on recurrence of Crohn’s
disease in small bowel: a randomized controlled trial.
Ann Surg 1996, 224:563–573.
Article on a large series of patients enrolled in a prospective
fashion, designed to address an important clinical question.
8. Borely NR, Mortensen NJ, Jewell DP: Preventing
postoperative recurrence of Crohn’s disease.
Br J Surg 1997, 84:1493–1502.
9. McLeod RS, Wolff BG, Steinhart AH, et al.: Risk and
significance of endoscopic/radiological evidence
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Mesalamine in the maintenance treatment of Crohn’s
disease: meta-analysis adjusted for confounding
variables. Gastroenterology 1997, 113:1465–1473.
11. Ozuner G, Fazio VW, Lavery IC, et al.: Reoperative rates
for Crohn’s disease following strictureplasty: long-
term analysis. Dis Colon Rectum 1996, 39:1199–1203.
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colitis. Curr Treat Option Gastroenterol 2000, 3:217–226.
18. Engelsgjerd M, Farraye FA, Odze RD: Polpectomy may
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20.••Farouk R, Pemberton JH, Wolff BG, et al.: Functional
outcomes after ileal pouch-anal anastomosis for
chronic ulcerative colitis. Ann Surg 2000, 231:919–926.
Largest experience with IPAA discussing functional results
and complications.
21. Tan HT AB, Connolly D, Morton M, Keighley RB:
Results of restorative proctocolectomy in the elderly.
Int J Colorect Dis 1997, 12:319–322.
22. Prudhomme M, Farouk R, Dozois RR: Complications
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Incidence and subsequent impact of pelvic abscess
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Curr Treat Opt Gastroenterol 2000, 3:58–68.
25. Present DH, Rutgeerts P, Targan S, et al.: Infliximab
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