Surgical aspects in the treatment of inflammatory bowel disease

Abstract

With the advancements in the development of immunomodulatory drugs (i.e. biologicals) and surgical techniques and equipment, the role of surgical treatment in patients with inflammatory bowel disease has changed significantly over the last 10 years. This thesis focuses on new developments and investigates ways to maximize the benefit to patients with as few complications as possible. First, we focus on the treatment of patients with ulcerative colitis that are eligible for a total proctocolectomy with ileal pouch reconstruction. We show how outcomes of this operation have developed over time and that despite initial improvements it seems that this surgery has reached its biological limitations. Secondly, we perform a Cochrane review on the influence of the laparoscopic approach on this large procedure, and show that it brings certain short-term advantages without compromising the long-term results. We also investigate the treatment of complications of this surgery, with an extensive review and cohort series of patients with a pouch sinus, an infrequent but extremely consequential complication. Based on this study, we develop a treatment algorithm to maximize the chances of successful treatment and prevention of pouch failure. We also investigate and discuss the indications for an ileorectal anastomosis rather than ileal pouch construction in certain subgroups of patients that are poor surgical candidates or favor a less extensive surgery in fear of complications. We provide data on risk of development of cancer in the rectal remnant, and recommendations on surveillance and follow-up of patients. Finally, we describe the results of a pilot study of a novel variation in the performance of this operation. We describe the initial results of performing a close rectal dissection (rather than the standard TME resection), using automated vessel sealers. We show that this technique is safe, feasible and has the potential to reduce nerve related complications associated with extensive pelvic dissection. An important aspect in the treatment of ulcerative colitis is the risk of cancer on the long-term. Most patients undergo colonoscopic surveillance after a certain age or disease duration to identify any potential malignant lesions at an early stage. We investigated the relationship between findings at such colonoscopies and the risk of cancer in the pathologic specimen of the colon after resection. Based on this, we were able to provide estimates of the risk of cancer based on the grade and location of dysplasia observed at colonoscopy, and provide recommendations on when best to perform a proctocolectomy in these patients. We also investigated the influence of immunosuppressants medication preoperatively, on the risk of (infectious) complications in patients with Crohn’s disease. Based on an extensive review of literature, we were able to provide estimates of the risk of such complications for each of the commonly used drugs separately, as well as provide recommendations of the drug free interval needed to normalize these risks.