IBD: When to operate and when to punt

Emergencies require quicker decisions. In ulcerative colitis, emergency cases may include toxic megacolon, perforated colon, or obstruction from either a stricture or cancer, as well as bleeding in rare cases. Scenarios in Crohn’s disease include perforation with sepsis, inaccessible abscess, and, most commonly, obstruction resulting from fibrous stricture or acute inflammation.

When surgery is required, what’s the best choice? Dr. Whelan emphasized keeping it simple. Redo ileal pouches and ileal pouch excisions should generally be avoided. “Even if you do [pouches] often. It’s not the smartest way to go. These patients are almost all on immunosuppressive medications … to make an operation that’s already big even bigger often doesn’t work out well,” he said.

In emergency chronic ulcerative colitis cases, the safest choice is total abdominal colectomy plus end ileostomy. Dr. Whelan discourages surgeons from considering proctectomy and ileal pouch in emergency cases. A number of studies have shown that delaying pouch surgery is associated with fewer minor and major adverse events, and lower reoperation rates, he said. “If you do these operations on an immunosuppressed population, they don’t do as well,” said Dr. Whelan.

Crohn’s disease emergencies can often be managed nonsurgically. Most patients have phlegmon, fistulae, or a partial obstruction. Intravenous antibiotics, percutaneous drainage, hydration, and boosting nutritional status are good options. In cases where an obstruction requires surgery, and the surgeon isn’t comfortable performing stricturoplasty, “you want to limit the resection as best you can,” he said.

Dr. Whelan disclosed financial relationships with Ethicon Endosurgery and Olympus Corporation. Global Academy for Medical Education and this news organization are owned by the same parent company.”