Chronic inflammatory bowel disease (IBD) can and should almost always be approached with medical therapy first, as the goal is to try to control the inflammatory activity of the disease. Sometimes, however, it is impossible to do so because complications might be already present at the time of diagnosis or because a patient progressively loses response to medical therapy or fails to acquire clinical remission, represented by the absence of the inflammation itself. In other cases, more frequently in ulcerative colitis than in Crohn’s disease, tumors of the intestine may develop.
In this case, where the patient’s quality of life is severely impacted, or the presence of adenocarcinoma in the intestine becomes a priority over merely survival, surgery represents a valuable therapeutic approach. It is not only an alternative but one of the most effective tools to regress Crohn’s disease and a definitive cure for ulcerative colitis. Surgery should be reserved for patients for whom it is the best option.
Surgery has no longer been considered the “last resort” after exhausting available pharmacological treatment options for more than two decades. It was common to move forward with all possible lines of therapy, and when, in the end, the patient was affected entirely by disease symptoms and was unresponsive to medical treatments, only at that point would surgery begin to be considered. This pathway led, of course, to poor results.
Today, thanks to the multidisciplinary approach, which places the skills of gastroenterologists and surgeons in sync, surgery is a weapon that can be used even at the beginning of or during treatment if the response to medical therapy is not satisfactory.
Surgery for Crohn’s Disease
Surgery is mainly considered an optimal solution for Crohn’s disease when complications arise. An example is intestinal occlusion due to the progressive narrowing of the intestinal lumen in the ongoing inflammation process and resolution of inflammation generating fibrosis – which is pharmacologically not reversible. Fistulizing Chron’s disease – where inflammatory burrows are created from the diseased intestine to other organs or the skin – is another complication that must be treated surgically. More rarely, surgery may also be indicated in cases of massive bleeding or perforation.
In addition, in Crohn’s disease, there is a second, more strategic indication that is much more recent and innovative: Surgery, even before considering a more impactful medical approach after the failure of the conventional one. This approach is on the same level as drug therapy or, in some aspects, even more advantageous.
Ulcerative Colitis: Surgery for Chronic and Acute Forms
In ulcerative colitis, surgery may be effective in patients with chronic activity or acute forms of the disease. In these situations, surgery should be considered early after careful multidisciplinary evaluation and is considered curative as it eliminates the organ targeted by the disease.
In contrast, in cases of milder activity or acute forms responding to medication, medical therapy is the most suitable route. Thus, through the continuous dialogue between the gastroenterologist, surgeon, and patient, a balanced therapeutic alliance is established, allowing the most suitable option to be chosen.
In ulcerative colitis surgery, in cases of acute and chronic colitis, and where adenocarcinoma of the intestine has arisen, preservation of the large intestine is not generally indicated. When surgery is performed, the colon and, in most cases, the rectum must be removed as well, with timelines relative to each specific case.
However, over the past four decades, techniques for reconstructing bowel continuity after colon and rectum removal have been developed and progressively refined, allowing many patients to live with a good quality of life.
The Importance of the Multidisciplinary Approach
Some innovative surgical techniques, such as those listed above, are only available in some hospitals because they require intense specialization, which can only be found in a Referral Center. The other benefit of taking a patient with chronic inflammatory bowel disease to a Referral Center is a multidisciplinary approach. The team is like an orchestra, where the two most virtuosic musicians, the gastroenterologist, and the surgeon, perform their “solos” at the right time to perfect the symphony.In a Referral Center, the patient is followed by other specialists as well, such as the immunologist, the rheumatologist, the dermatologist – for patients who have extra-intestinal manifestations of the disease – the nutritionist – who plays a key role as chronic intestine inflammation can lead to malnutrition – the radiologist, who helps obtain a diagnosis but also treats with interventional radiology some complications of Crohn’s Disease. Not to mention the psychologist, who can make a difference in diseases that impact the quality of life.