Chronic inflammatory bowel disease: when is surgery needed?

By Cristiano Antonino On Dec 19, 2022

When it comes to chronic inflammatory bowel disease, surgery must be considered as a valid therapeutic alternative, subject to evaluation of the clinical condition of the individual patient and within the framework of multidisciplinary patient management

It may happen, in fact, that pharmacological treatments fail to guarantee remission of the disease or that intestinal tumours develop: this is when surgical treatment comes into play.

So what are the conditions that make surgery necessary in patients with chronic inflammatory bowel disease? And what are the goals?

Chronic inflammatory bowel disease: when to resort to surgery

Chronic inflammatory bowel diseases (IBD) can and should almost always be approached first with medical therapy, because the goal is to try to bring the inflammatory activity of the disease under control.

Sometimes, however, it is not possible to do so because at the time of diagnosis one already has a complication, or because one gradually loses response to medical therapy or fails to achieve clinical remission, i.e. the absence of the clinical manifestations of the inflammation itself. In other cases, more frequently in ulcerative colitis than in Crohn’s disease, tumours of the intestine may develop.

In these cases, where the patient’s quality of life is severely impacted or the occurrence of an adenocarcinoma of the intestine becomes a priority with respect to the quoad vitam prognosis, surgery represents a valid therapeutic approach, which is not only an alternative, but one of the most effective tools to induce remission in Crohn’s disease and as a definitive cure in ulcerative colitis, respectively.

Chronic intestinal diseases, surgery should be reserved for patients for whom it is truly the best option

For more than twenty years, surgery has no longer been considered the only option, the ‘last resort’ after exhausting the available pharmacological treatment options.

In fact, it was customary to go ahead with all possible lines of therapy, and when, at the end, the patient was completely defecated by the symptoms of the disease and the lack of response, immunosuppressed by medical therapies, only at that point did one begin to consider surgery.

This path led, of course, to poor results.

Today, thanks also to the multidisciplinary approach, which places the skills of gastroenterologists and surgeons in synchrony, surgery is a weapon that can also be used at the beginning of the treatment course, or during the latter, if the response to medical therapy is not sufficient.

Surgery in Crohn’s disease

In Crohn’s disease, surgery is mainly considered an optimal solution when complications arise.

An example is intestinal occlusion due to the progressive narrowing of the intestinal lumen in the continuous process of inflammation and resolution of inflammation, which generates fibrosis, the latter being pharmacologically non-reversible.

Fistulising disease (where inflammatory burrows are created from the diseased intestine to other organs or to the skin) is another complication that must be treated by the surgical approach.

More rarely, surgery may also be indicated in cases of massive bleeding or perforation.

Furthermore, in Crohn’s disease, there is also a second, more strategic indication, which is much more recent and innovative: the use of the surgical approach even before considering a more impactful medical approach after the failure of the conventional one.

This type of approach, in a multicentre randomised trial, proved to be not inferior to drug therapy and even, in some aspects, more advantageous.

Ulcerative colitis: surgery for chronic and acute intestinal forms

In ulcerative colitis, the surgical approach may be effective in patients with chronic activity or in acute forms of the disease: in these situations surgery must be considered early, obviously after careful multidisciplinary evaluation, and is considered curative because it completely eliminates the target organ of the disease.

Conversely, in situations of milder activity or in acute forms, which respond to medication, medical therapy is clearly the most appropriate course of action.

Thus, through the continuous dialogue between gastroenterologist, surgeon and patient, a balanced therapeutic alliance is established, allowing the most suitable option to be chosen at the best time.

In ulcerative colitis surgery, in cases of acute and chronic colitis and in cases where an adenocarcinoma of the intestine has arisen, the preservation of the large intestine is, generally, not indicated: when operating, the colon must be removed and, in most cases, also the rectum, with the timing depending on each specific case.

However, over the last forty years, techniques for reconstructing intestinal continuity after removal of the colon and rectum have been developed and progressively refined, enabling many patients to live with a good quality of life.

Chronic intestinal diseases, the importance of the multidisciplinary approach

Some innovative surgical techniques, such as those listed above, are not available in every hospital, because they require a high degree of specialisation, which can only be found in a referral centre.

The other added value of caring for a patient with a chronic inflammatory bowel disease at a Reference Centre is the multidisciplinary approach: the team is like a symphony orchestra, where the two most virtuoso musicians, the gastroenterologist and the surgeon, play their ‘solos’ at the right time, so that the symphony is perfect.

In a referral centre, the patient is followed by several specialists, in addition to these two referrers the immunologist, the rheumatologist, the dermatologist for patients who have extra-intestinal manifestations of the disease; the nutritionist, who plays a fundamental role because chronic inflammation of the intestine can lead to malnutrition; the radiologist, who helps to arrive at the diagnosis but also to treat certain complications of Crohn’s Disease with interventional radiology; but also the psychologist, because a course of psychotherapy can make all the difference in pathologies that have such an impact on quality of life.

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