B26. Inflammatory bowel disease, surgical treatment options

Page created on September 16, 2021. Not updated since.


For introduction, epidemiology, etiology, and pathology, see the corresponding pathology 2 topic. For clinical features, diagnosis and evaluation, and medical treatment, see the corresponding internal medicine topic.

Surgical treatment of Crohn disease

In CD, surgery is used in cases where conservative therapy is insufficient. Surgical resection of inflamed bowels is avoided as much as possible, as inflammation will later recur at the area of the anastomosis. Surgery may treat the acute episode, but possible perioperative complications and long-term complications of losing bowel lengths (short bowel syndrome) means that radical resections must be avoided.

Surgery is indicated for the following cases:

  • Perianal abscess or complicated fistula
  • Bowel obstruction due to fibrotic strictures
  • Persistent refractory local acute ileitis

Strictures are treated with stricture plasty.

Perianal fistulas are treated with a clever technique. A seton (a nonabsorbable suture) is guided through the fistula tract and tied together. The seton allows any fluid to drain alongside it, and it prevents the fistula from closing prematurely, potentially forming an abscess. Inflammation close to the anal sphincter may lead to incontinence and is important to avoid.

After some weeks/months, the seton may be removed and the fistula allowed to close, if deemed peaceful. If not, fistulotomy may be necessary.

Surgical treatment of ulcerative colitis

Surgery plays a bigger role in UC than in CD. Total colectomy cures the disease and is therefore a valid option in severe cases.

Surgery is indicated for the following cases:

  • Refractory disease – where no remission can be achieved, or relapse is frequent
  • Colonic dysplasia or carcinoma
  • Severe acute UC (perforation, toxic megacolon)

The preferred surgical procedure for UC is restorative proctocolectomy with ileum pouch and anal anastomosis. This involves resection of the entire colon and rectum, while sparing the anal sphincter. An artificial rectum (the ileum pouch) is created by using loops of ileum to serve as a reservoir for faeces, which is then anastomosed with the anus.

Total colectomy with end ileostomy is a possible alternative.

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