INTESTINAL SURGERY e II
Management of Crohn’s
disease and ulcerative
colitis
Christopher Ray
Peter Sagar
Abstract
Crohn’s disease and ulcerative colitis (UC) are complex, contrasting
disease processes that require multidisciplinary team management.
The treatment modalities in inflammatory bowel disease are varied
and the indications and threshold for surgery quite different in patients
with UC compared with Crohn’s disease. We discuss the panoply of
surgical techniques available to the surgeon and IBD patient while
highlighting the potential sequelae, complimentary medical therapies,
nutritional considerations and innovative techniques for reconstruction
of the gastrointestinal tract.
Keywords Crohn’s disease; inflammatory bowel disease; surgical
management; ulcerative colitis
Ulcerative colitis
Disease process
Ulcerative colitis is an idiopathic relapsing and remitting condi-
tion affecting the rectum and a variable length segment of the
colon. The disease is confluent and involves the mucosa and
lamina propria. It can be thought of as superficial compared with
the transmural nature of Crohn’s.
Indications for surgery in UC
Surgery to excise the colon is curative if the rectum is also
removed. In the emergency setting, a total colectomy is indicated
for severe fulminant colitis, toxic megacolon, intractable
bleeding or colonic perforation. The most popular clinical
scoring systems used to assess the likelihood of failure of med-
ical therapy and need for emergency surgery in acute severe
colitis, are the Travis score and Ho score. Both are applied after
72-hours’ intravenous steroid therapy with high-risk scored
subjects facing a 33e34% risk of requiring surgery by Travis and
the Ho scores.1
In the acute situation a total colectomy and end ileostomy is
most commonly undertaken, leaving the rectum in situ. This
reduces the potential morbidity associated with pelvic dissection.
In particular, the risks of pelvic nerve injury and hazards of
reduced fertility are mitigated.
Christopher Ray MBChB PhD FRCS is a Consultant Colorectal Surgeon
at University Hospital Crosshouse, Kilmarnock, NHS Ayrshire &
Arran, UK. Conflicts of interest: none declared.
Peter Sagar MB ChB MD FRCS is a Consultant Colorectal Surgeon at
The John Goligher Department of Colorectal Surgery, St. James’s
University Hospital, Leeds, UK. Conflicts of interest: none declared.
SURGERY 38:6
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Indications for surgery in the elective setting include colitis
refractory to medical therapy, growth retardation in children,
mucosal dysplasia or malignancy and occasionally in attempt to
ameliorate extra-intestinal manifestations of the disease.2
Surgical options
Laparoscopic surgery is now the standard,3 with reduced hospital
stay, postoperative pain, ileus and wound complications
conferring enhanced recovery and facilitating a laparoscopic
approach to future surgery. In the context of toxic megacolon, or
perforation, open surgery at laparotomy may still be mandated.
The rectal stump
At emergency surgery for UC the rectal stump is usually left in
situ, despite this often being the focus of most severe inflam-
mation. Diversion of the faecal effluent allows the inflammation
to settle. Moribund patients were historically treated by per-
forming a blow hole colostomy and ileostomy e the Turnbull
procedure4 e as a minimally invasive, temporizing measure.
This is seldom used now.
The closed rectal stump is at risk of ‘blow-out’ after emer-
gency subtotal colectomy with consequent pelvic sepsis. For this
reason many surgeons over-sew (reinforce the staple line) the
rectal stump e and place a wide-bore rectal drain for decom-
pression and lavage. Alternatively the rectal stump can be tacked
onto the posterior aspect of the midline wound, or a formal rectal
mucous fistula can be fashioned (Figure 1).
Proctectomy
Excision of the rectum (proctectomy) is ultimately recommended
to prevent recurrence of disease and to remove the risk of rectal
stump malignancy. The lifetime risk of dysplasia or malignancy
in the retained stump is thought to be in the order of 10%;
however, case series report rates ranging from 0 to 25%.5 Sur-
gery to excise the rectum is often deferred until patients have
completed their families.
Panproctocolectomy is the synchronous excision of the colon
and rectum (Figure 2). This may be performed with close exci-
sion of the anal complex or an intersphincteric plane can be
developed during the perineal dissection, thereby preserving the
muscle of the external anal sphincter for closure.
The options for reconstruction are either to perform an ileo-
rectal anastomosis (with the risk of recurrent disease and the
need to survey the rectal stump for resurgent inflammation and
potential neoplastic development), or the creation of an ileal
poucheanal anastomosis (IPAA). Alternately a proctectomy can
be offered without reconstruction if the patient prefers a per-
manent ileostomy (Figures 3 and 4).
IPAA is the gold standard for restorative proctectomy
(Figure 5). A variety of surgical methods may be employed to
create a small bowel reservoir with a poucheanal anastomosis.
The variations in technique largely focus on the configuration of
the small bowel. The J-pouch is the most commonly performed
technique; however, the larger volume S- and W-pouch are alter-
natives. Full bowel mobility may need to be exploited (with careful
mobilization at the DJ flexure, mesentery, and peritoneum) to
allow the small bowel conduit to reach the pelvic floor. The aims
are to return continence, freedom from stoma and an anticipated
bowel frequency on average of four to six motions per day. The
318 Ó 2020 Published by Elsevier Ltd.
 INTESTINAL SURGERY e II
Figure 1 Subtotal colectomy and end ileostomy e preserved rectum
unshaded
procedure is complex with short-term sequelae including anasto-
motic leak, subsequent pelvic sepsis and poor long term pouch
function as a potential result. Even successful pouches face a 50%
risk of intermittent episodes of pouchitis,6 with inflamed pouch
mucosa and diarrhoea resulting from bacterial overgrowth. Oral
antibiotics (ciprofloxacin  metronidazole) and the probiotic
Figure 2 Panproctocolectomy and end ileostomy e resected tissue
shaded red
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VSL-3 are used in the treatment and prophylaxis of this debilitating
sequelae.7 A diagnosis of pouchitis relies on the combination of
clinical symptoms and pathologically graded inflammation. The
pouch can also suffer from cuffitis and irritable pouch symptoms.
Interesting developments: There is evidence that appendicec-
tomy for appendicitis is protective for ulcerative colitis, based on
the hypothesis that the appendix acts as a source of bacteria,
cytokines and mucosal inflammatory mediators. A randomized
trial is underway to appraise appendicectomy and its effect on
subsequent disease recurrence in UC (the ACCURE study,
NTR2883; ISRCTN56523019). There is however potential evi-
dence from animal models that appendicectomy in UC may in-
crease the risk of colorectal neoplasia.8
Crohn’s disease
Disease process
Crohn’s is a pan-enteric, relapsing and remitting condition that
can affect anywhere in the GI tract from mouth to anus. In
contrast to UC the disease process is transmural, with penetrating
disease, fistulation, ulceration, abscess and stricture formation
all possible.
Indications for surgery
Surgery in Crohn’s requires careful consideration since the dis-
ease can recur throughout the patient’s lifetime with multiple
operations as a consequence. Between 70% and 90% of patients
with Crohn’s will require surgery during their lifetime.9 Surgical
intervention must be rationalized and bowel resections mini-
mized e the disease process and repeated resections can render
the patient with insufficient small bowel to meet basic nutritional
requirements. This is termed short-gut syndrome and is a form of
intestinal failure which commits the patient to lifelong parenteral
nutritional support.
Surgery in Crohn’s should be reserved for the complications of
the disease e strictures, abscess and fistula e not as a means for
disease clearance. The length of small bowel resections should be
kept to a minimum and resections with microscopically ‘involved
margins’ of disease do not confer an increased risk of
recurrence.10
Surgical options
The three classical sites of disease involvement in Crohn’s are
ileal, ileocolic and Crohn’s colitis. Perianal fistulating disease
may also coexist with these. The disease process can, how-
ever, affect the stomach and duodenum, and there are a host
of extra-intestinal manifestations that the surgeon should be
aware of.
Modern management of complex inflammatory bowel disease
problems should be co-ordinated through an IBD multidisci-
plinary team. The interplay of medical management, the
requirement for and timing of surgery can pose difficult clinical
decisions and requires careful interplay between the gastroen-
terologist, nurse specialist, radiologist and surgeon. Management
strategies can be complex and the emergence of biologic and
‘biosimilar’ medications have changed the landscape of disease
management. Unlike UC, the disease process can be more com-
plex, with concurrent pathological processes.
319 Ó 2020 Published by Elsevier Ltd.
 INTESTINAL SURGERY e II
Figure 3 Subtotal colectomy, preserved rectal stump, end ileostomy
The planning of surgery in Crohn’s can be guided by the
‘SNAP’ mnemonic11 as a framework for each case e with aims to
control sepsis, nutritional deficiencies, clarify anatomy and
formulate an operative procedure/plan. At all costs, active
Crohn’s should be avoided operatively and sepsis should be
settled with radiological drainage of abscesses  antibiotics and
nutritional status optimized preoperatively. The risk of disease
recurrence is significantly enhanced by continued smoking and
some surgeons refuse to operate on Crohn’s until the patient re-
mains abstinent.
Figure 4 Ileo-rectal anastomosis
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The three main modes of pathology in Crohn’s are strictures,
abscess and fistula formation. The targets of operative inter-
vention should be symptoms and not the treatment of radiolog-
ical abnormalities.
Abscess: Intra-abdominal abscesses can usually be drained by
skilled radiological drainage either under ultrasound or CT
guidance. Perianal sepsis and abscesses are best treated by
drainage during a careful examination under anaesthetic.
Strictures: Small bowel strictures can lead to sub-acute
obstructive symptoms causing intestinal hold up, symptoms of
pain and can have deleterious nutritional consequences. Unre-
solved symptoms are best dealt with by small bowel resection e
this can usually be achieved laparoscopically, unless previous
open surgery has rendered the patient with dense intra-
abdominal adhesions. Ileocaecal disease is classical in Crohn’s
and commits the patient and surgeon to an ileocaecal resection
due to the proximity of the mesenteric arterial supply to both the
terminal ileum and caecum (ileocolic artery).
Strictures of the small bowel (ileal or jejunal) can also be dealt
with by means of surgical stricturoplasty. This treatment for
fibrostenotic disease overcomes the area of stenosis while
avoiding bowel resection and implications of short gut.12 There
are a variety of surgical procedures which achieve this but all are
based on the principle of opening the diseased segment and
reconstructing the lumen to widen the narrowed section. The
most commonly employed technique is the Heineke-Mikulicz
procedure. The perceived benefit e in addition to mechanical
opening of the stricture e is to reduce intraluminal pressure,
with reduced drive of microbes and luminal inflammatory me-
diators into the bowel wall. Contraindications to stricturoplasty
include active sepsis, fistulating disease, perforation, haemor-
rhage and dysplasia at the site.
Fistula: Pathological fistula can develop and channels commu-
nicate between loops of small bowel (entero-enteric fistulae),
bowel and skin (enterocutaneous) bladder, vagina and colon.
These may give rise to sepsis, associated symptoms and can have
nutritional implications. Surgical management usually requires
resection of the source segment of bowel with primary anasto-
mosis, or in the context of severe disease or sepsis, a defunc-
tioning stoma may be required.
In complex cases, with active sepsis, or iatrogenic injury to
small bowel, enterocutaneous fistula can develop e these man-
ifest as enteric or bilious content emanating from the abdominal
wall skin or a surgical wound. The anatomy of such tracks can be
established by contrast radiography, the volume of output is key
and may be predictive of the likelihood the fistula may heal and
close spontaneously. Careful consideration must be given to the
management with resolution of sepsis and attention to nutri-
tional needs being paramount. Re-operating in the acute setting
can result in multiple further enteric injuries and may cause more
harm than good. Therefore careful assessment and planning is
required to salvage these patients expediently.
Perianal disease
Complex disease can develop in Crohn’s disease with a range of
possible findings at EUA ranging from enlarged oedematous skin
320 Ó 2020 Published by Elsevier Ltd.
 INTESTINAL SURGERY e II
Figure 5 Ileal poucheanal anastomosis (IPAA) e (J-pouch)
tags, to complex fistula-associated abscesses and in severe cases
the ‘watering can perineum’. Emergency management of these
patients focuses on control of pain and sepsis. Simple incision
and drainage of a perianal abscess is the simplest intervention e
and if an associated fistula can be safely identified, a draining
loose-seton suture placed. The seton acts as a conduit to help
drain the sepsis fully, keeping the fistula track open and allows
planning of further definitive surgery. The complexity and po-
tential severity of perianal Crohn’s, combined with its propensity
to recur, means that the primary focus in managing perianal
sepsis should be preservation of continence. Repeated attacks of
sepsis, trans-sphincteric fistula and injudicious attempts to lay
the fistula open can cause sequential injuries that may impair the
patient’s continence. Great care must be taken to avoid these
sequelae.
Proctitis associated with severe perianal disease can act as a
driving factor in ongoing13 inflammation and may ultimately
require proctectomy, or at least diversion with a defunctioning
colostomy to regain control of the sepsis and improve quality of
life.
Once active sepsis has been controlled, medical therapy may
be instituted with reported success of monoclonal antibodies to
TNF-a (infliximab) allowing complete healing of all enter-
ocutaneous and perianal fistula in up to 55% of patients treated
in a landmark RCT. The CHOICE study14 demonstrated a 39%
complete healing rate with adalimumab in patients’ refractory to
Infliximab.
Subsequent assessment comprises careful examination under
anaesthetic or increasingly the use of magnetic resonance im-
aging (MRI) of the perineum to delineate anatomy.15 When the
fistula is isolated, and involving minimal sphincter muscle mass,
consideration can be given to ‘laying open the fistula’. When
there are concerns of higher, trans-sphincteric tracks, definitive
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operations aimed at fistula healing may be performed with
techniques such as the endo-anal advancement flaps or the novel
method of ligation of the inter-sphincteric track (LIFT proced-
ure). There are a variety of other methods employed including
collagen and biologic fistula plugs, application of glue to the
track and some now employ fiberoptic examination of the
tracks. A
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