Crohn's and Surgery Part 3 - Risks, Advantages, Stomas and Laparoscopy

This series of articles is about the types of surgery that may be needed in the treatment of Crohn’s Disease. You may also find other Crohn’s and Colitis UK information useful, especially our booklets, Crohn’s Disease and Living with IBD. Most of our publications are available from our website: www.crohnsandcolitis.org.uk

Laparoscopy

Some of the operations outlined in Crohn's and Surgery Part 2, for example ileo-caecal resections, may now be carried out using laparoscopy (minimally invasive surgery). This is also known as ‘keyhole surgery’. Instead of making one large opening in the wall of the abdomen, the surgeon makes four or five small incisions (cuts), each only about 1cm (half an inch) long. Small tubes are passed through these incisions and a harmless gas is pumped in to inflate the abdomen slightly, and give the surgeon more space. A laparoscope, a thin tube containing a light and a camera, is used to relay images of the inside of the abdomen to a television monitor in the operating theatre. Small surgical instruments can also be passed through the incisions and guided to the right place using the view from the laparoscope. If a section of the intestine needs to be removed, this can be done through a separate larger incision.

Laparoscopic operations tend to take longer than ‘open’ surgery, but can have a number of advantages, such as:
• less pain after the operation
• smaller scars
• faster recovery for example, being able to eat and drink more quickly after the operation
• reduced risk of a wound infection
• a shorter stay in hospital.

However, laparoscopic surgery may not be available in all centres, and may not be appropriate if you have already had abdominal surgery.

Stomas

An ileostomy showing the stoma opening

As described above, sometimes in surgery for Crohn’s the intestine is brought to the surface of the abdomen
and an opening is made so that digestive waste products (liquid or faeces) drain into a bag rather than
through the anus. If the part of the intestine brought to the surface is the ileum, this procedure, and the end of the intestine connected to the opening, is known as an ileostomy. If the large intestine or colon is brought to the surface and connected in a similar way, it is a colostomy. Both types of opening are also called stomas.
Most stomas are about the size of a 50p piece, and pinkish red in colour.

Because the contents of the small bowel are liquid, and might irritate the skin, an ileostomy usually has a short spout of tissue, about 2-3cm in length. Depending on the type of stoma bag used, ileostomy bags usually have to be emptied

A 2 piece stoma bag
(1 piece also available)

four to six times a day, and changed about twice a week. Colostomies pass firmer stool, so colostomy bags are usually emptied slightly less frequently, (about one to three times a day), and may need to be changed each time.

Are there risks to surgery?

Crohn’s Disease is a very individual condition, and the risks and benefits of different types of treatment will vary from person to person. Your IBD team should be able to help you weigh up what will be best for you.
Surgery for Crohn’s, like all surgery, will carry some general risks, such as those linked to having a general anaesthetic. There is also a small risk that some operations may lead to complications such as infections. Particular operations may have other risks: for example, occasionally an anastomosis (join) leaks or the small bowel becomes obstructed. Adhesions, sticky bands of material that form as part of the healing process, can twist the intestine. These usually settle down by themselves, but sometimes need dietary treatment.

Your surgical team will be able to tell you more about complications like these, and how they are usually treated.

Because Crohn’s Disease can develop anywhere in the gut, including in previously healthy sections of the small intestine or colon, surgery cannot ‘cure’ it. So, there is always a chance that symptoms will reoccur after the operation, either close to the operation site or in another part of the gut. It may be possible to treat these symptoms with medication, but it could mean that another operation is necessary. There is some research to show that about half of those who have an ileo-colonic resection need another operation within 10 years. However, recent studies have suggested that the newer biological medical therapies may help to prevent Crohn’s recurring following surgery.

What are the advantages of surgery?

Depending on the operation, surgery can bring real benefits such as:

• relief from pain
• relief from symptoms such as diarrhoea or vomiting
• being able to reduce or even stop taking drugs which may be causing side effects
• the ability to eat a more varied diet and to gain weight more easily
• feeling able to lead a fuller life, for example being able to leave the house in a more relaxed frame of mind.

Many people have found that once they have recovered from their operation their quality of life is much improved. In one study looking at resection surgery from the patient’s point of view a majority of those interviewed said they wish they had had their operation earlier.

Coming up in Part 4 - What to Expect: Before, During and After Surgery