IBD Drive Time: Rebecca Brown, MD, on Controversies in IBD Surgery

Host Raymond Cross, MD, and colorectal surgeon Rebecca Brown, MD, discuss surgical therapies for Crohn's disease and ulcerative colitis, including controversies about the best approaches.  

Raymond Cross, MD, is Medical Director, The Center for Inflammatory Bowel and Colorectal Diseases​, The Melissa L. Posner Institute for Digestive Health and Liver Disease at Mercy Medical Center​, in Baltimore, Maryland​. Rebecca Brown, MD, is a board-certified colorectal surgeon who specializes in the diagnosis and treatment of colorectal disorders and inflammatory bowel diseases at yhe Melissa L. Posner Institute for Digestive Health and Liver Disease at Mercy Medical Center​

IBD Surgery: Key Clinical Practice Considerations

• IBD stricture: Consider elective short-segment resection when nontraversable; assess meal-related symptoms and biopsy new strictures, especially in ulcerative colitis.

• Crohn’s disease: No ileocolic anastomosis is proven superior. For drained intra-abdominal abscess, optimize nutrition; consider 10–14 days of parenteral nutrition for diet intolerance, weight loss, or malnutrition.

• Perianal Crohn’s disease/IPAA: Control rectal inflammation and favor experienced examination under anesthesia. Avoid IPAA in Crohn’s; cited pouch failure/excision rates were <5% in ulcerative colitis, 8%–10% in indeterminate colitis, and ~30% in Crohn’s.

Any views and opinions expressed are those of the authors and/or participants and do not necessarily reflect the views, policies, or positions of the AIBD Network or HMP Global, its employees and affiliates.

Dr Cross:

Welcome everyone to IBD Drive Time. I'm Raymond Cross from Mercy Medical Center in Baltimore, and I'm delighted to have my friend and colleague here at Mercy, Rebecca Brown, who's one of our colorectal surgeons to talk about controversies in IBD surgery. Rebecca, welcome to IBD Drive Time.

Dr Brown:

Hi, thanks for having me.

Dr Cross:

So I try to come up with some questions in clinical practice that I think there are not definitive answers for. So the first one is a patient with a significant stricture that's asymptomatic. Do you resect that or observe that? So how are we approaching that in our practice?

Dr Brown:

I mean, I think to me the key of that is that if you can't traverse it endoscopically, then you have no way to evaluate the rest of the colon above it. So I think if it's nontraversible, even if it's asymptomatic, probably even a short segment resection is a reasonable approach to allow for endoscopic access to assess for other areas of disease.

Dr Cross:

Yeah, it's very controversial. The one thing that I'll add, and I'm sure you agree with this, is are they truly asymptomatic? So typically we ask them about, I'll give them a typical lunch, sandwich, little bag of chips, piece of fruit, something to drink. Do they have bloating, borborygmi, pain, nausea, vomiting? Many patients that have a stricture will tell you that they can't eat that much. And when you ask them why they feel full, they get some of these symptoms. And then you can ask about raw fruits and vegetables. You can ask about a steak or a burger that's on the well done side. So those are your stricture stress tests to see what happens. And I agree with you, you can't really assess above it for inflammation. And in particularly in middle age and older patients, there's also a risk of malignancy within the strictures. We don't see them that often, but certainly that is in our differential.

So I offer patients with tight strictures a surgical approach. I do give them the option of monitoring, but I also remind them that they could have a sudden acute obstruction where they can't pick the time, they can't pick the surgeon, they can't pick the institution that's going to do it. And those are real issues. So we're definitely aligned there. The other analogy I use is we don't watch an asymptomatic aortic aneurysm rupture. We repair those all the time without any question. So I'm sure the surgeons listening to this will have, there may be some different opinions, but I agree with you that elective resection makes sense.

Dr Brown:

I think you're absolutely right about the patients sometimes don't realize that they're symptomatic, if that's a very kind of loaded question, are you symptomatic from your stricture? And a lot of them probably don't realize that they have become more symptomatic over time. So I really like the approach of giving them a lunch and seeing what they could tolerate or not tolerate.

My question for you is, do you routinely biopsy those during colonoscopy, especially if you're planning to send them to surgery with the knowledge that they may have an underlying malignancy there? Because from my perspective, having a negative biopsy makes me more able to do a short segment stricture resection. I tell patients that it's not a perfect biopsy, that kind of stuff. But if you biopsy and you get a malignancy, then obviously that's going to change the surgical approach for that patient.

Dr Cross:

I think if it's a de novo stricture, I think that certainly for ulcerative colitis, if I see a new stricture in a colon, that's like the dogma is you biopsy those, although we can see those in ulcerative colitis, whether it's a diagnosis change, but we should be biopsying them. Now you're only going to hit the distal end, so are you really going to rule out a malignancy? But you should biopsy a new stricture. And certainly short strictures, we can try to balloon dilate and get through, and that maybe addresses some of the questions about going above it, but sometimes they're so tight that they're really not amenable or you don't really feel like it's going to be a long lasting dilation.

Dr Cross:

So second question. So I just had a patient today who had a prior complicated ileocolic and ileal resection who has anastomotic recurrence right at the two anastomosis with nothing in between or above who you're probably going to be seeing in the office for consultation. So we think that that's a unique form of recurrent Crohn's that affects the anastomosis. So is there a best ileocolic anastomosis? So people talk about hand-sewn, end-to-end, side-to-side, stapled, end-to-side, Kono-s, these mesenteric exclusion where you're taking some of the mesentery. So is the evidence sufficient to say that one anastomosis is better than another?

Dr Brown:

I don't think we have enough data on any of those to say for sure. And I always say if there's 10 ways to do something in surgery, it probably means that none of them are the best. There's not one that has come out that has dominantly in studies across the board has proven to be best, which is why surgeons across the nation are still doing whatever anastomosis they feel most comfortable with. ASCRS actually just sent out a link to do a survey for ileocolic anastomosis kind of configuration. So it'll be interesting to see what the national trends are with that and see if there's been any difference in it. But when the data on the Kono-S first came out a few years ago, it was pretty encouraging, but I think the follow-up data has sort of put it in line with the rest of the anastomosis. So I don't think one is necessarily better than another one. I think that it's really what the surgeon feels most comfortable with, the surgical approach, different laparoscopic versus robotic versus open, all have different approaches. And so I think it's all based on how things come together, that kind of stuff.

Dr Cross:

Yeah. I think also that if you start telling a lot of surgeons that they have to operate differently, even though the data from specialized centers suggests that end-to-ends, hand-sewn, the complication rates are not different, that's in someone who is doing regular hand-sewn end-to-end. I think if everyone went from stapling to sewing immediately, you would definitely have higher complication rates. So I feel like whatever anastomosis a surgeon wants to create, that they feel comfortable creating, is the best because the complication rate is likely going to be lower. And our patients already have a higher complication rate in general. No matter who their surgeon is, the complication rate's higher. For that specific situation, when you see a patient like that with anastomotic recurrence, do you think of doing anything differently in a patient like that?

Dr Brown:

Like doing a different anastomosis in the next surgery or?

Dr Cross:

Yeah, where they're talking about inverting and having the mesentery on the other side, do you think any of that makes a difference?

Dr Brown:

I don't know if there's enough data to convince me of that yet.

Dr Cross:

I agree. So for disease proximal to the anastomosis, and oftentimes people talk about in guidelines about doing stricturoplasty, how do you decide whether you're going to do a stricturoplasty or just do a resection?

Dr Brown:

I mean, I think strictureplasty probably is much less common than it used to be because we're operating on Crohn's patients a lot less. Historically speaking, short gutting Crohn's disease was a much more common thing that we see. And so talking about small bowel preservation was really, really important, especially for young patients and those sorts of situations. I feel like now because we're operating on patients less and there truly are as much as possible optimized before surgery, which minimizes the amount of small intestine you have to do, I'm not sure that there is a huge advantage to doing a strictureplasty versus a small bowel resection. The complication rates are the same, and I would venture to guess that surgeons have all created more anastomosis than done strictureplasty. So it almost gets back to the same conversation that we had about anastomotic setup or configuration is you should do what you feel most comfortable with.

Dr Brown:

Obviously there are some pieces of intestine you can't do strictureplasty on if active inflammation, those kinds of things are not loops of intestine that you want to do that on. But I think generally speaking, if it's a true short segment stricture, doing a short segment small bowel resection is not, you don't end up losing that much intestine. So I'm not sure that there's a huge advantage to leaving this potentially scarred site where they had previous inflammation in the GI tract, unless you're super concerned about short gut.

Dr Cross:

And is there a standard in the surgical world? How many strictureplasties a year do you think you need to do where you say that person is doing enough that you do enough ileocolics, so many that is it like 5? Is it 10? Is it 12? Is there any number out there that makes sense?

Dr Brown:

I mean, I think we all do different components of this type of surgery. Any bowel surgery that you're doing, you're going to be, whether it's for cancer or IBD or diverticulitis, the mobilization and the anastomotic setup are typically the same. So I think that if you're going to be doing intestinal resections, you should be doing them regularly. I'm not sure that there's a particular number that I would say. As far as if you should do a certain number of strictureplasties to be able to do them, I can tell you in my practice of what, 7 years now, I have not done a strictureplasty on a Crohn's patient. If I had a patient who needed one, I feel confident that I would be able to do it. They're not, you sort of cut one way and close it the other way. Obviously it's a little bit more complex than that, but we do repair enterotomies and that kind of stuff all of the time.

So there's components of the different surgeries that we do, even if we're not doing the exact one that we're talking about.

Dr Cross:

And we'll come back and ask about complexity of pouches in a minute. So a patient with, this is a big controversy. We just shared a patient like this 2 weeks ago who came in with a relatively small intra-abdominal abscess that was treated with a percutaneous drain and antibiotics with associated stricture. No question that the patient's going to go to the operating room. So from a nutritional perspective in that patient, regular diet, enteral diet only, short-term bowel rest and TPN, what should we be doing for them?

Dr Brown:

I mean, some of that, again, depends on patient tolerance and how big their fistula is. So I think if they can tolerate a diet, they're not losing a bunch of weight and they have the drain in and it's not putting out frank stool, it's probably fine to let them continue a regular diet and actually try to support them with some protein supplements to really improve their nutritional status. I would probably give that patient a couple weeks with a drain in place and really intense kind of nutrition with protein supplements to operate on them. I actually just operated on that patient yesterday and she ended up having a small bowel resection, ileocolonic resection, and sigmoid resection, but she looks fantastic today. I put everything back together. She was sick from a Crohn's standpoint, but her weight had been stable. And so those are the kind of things that I look at when I talk about doing a proximal diversion versus not.

Dr Cross:

See, for the listeners that maybe aren't understanding the concept of why does that matter, when we're optimizing someone with intra-abdominal abscess, the whole goal is to decrease inflammation and infection so that the anastomosis is going to be in a clean, noninfected, noninflamed bed, so you're going to have less leaks. And if you don't do that, the patient's more likely to have an ileostomy or should have an ileostomy so they don't have a complication. So all of that optimization is to try to prevent that. And this is an area that's completely controversial, and I'm not sure that there's a right answer. I think what you said is, are they able to advance their diet without obstructive type symptoms? And when they're eating, what's coming out of the drain? So if all of a sudden the drain was relatively low output and now the drain is becoming high output, that's probably a sign that it's a big fistula and you're not really cleaning that bed where the drain is. It's going to be a mess when you go in. And that's something where you probably would adjust, either go to enteral or go to short-term TPN. And when we do TPN, we're not talking about more than 2 weeks typically. So this doesn't have to be 6 or 8 weeks of TPN.

Dr Brown:

Right. And you and I have had a couple of patients in the past who have been chronically obstructed and really malnourished from that with low albumin, there's no perfect measure of nutritional status, but if their pre-albumin is in the teens, those would be the patients that I would also. And they can't tolerate a diet and they're losing weight. Those are also patients that I would consider short-term parenteral nutrition on because if we can get their pre-albumin up, I think it decreases their risk of having postoperative complications from the anastomosis and makes me more likely to not divert them in the surgery if I know that they've gotten 10 to 14 days of solid nutrition.

Dr Cross:

Agreed. I just want to remind the listeners that IBD Drive Time is the official podcast of the AIBD Network. We're available on Spotify and Apple Podcasts. Two meetings coming up. There's the AIBD APP meeting that's happening October 17th and October 18th in New York City. Sounds like a lot of fun. Get some learning while you're there. And then of course the annual AIBD meeting is going to be December 7th to December 9th in Orlando, Florida.

So Rebecca, a couple more questions. Let's talk a little bit about surgical interventions for perianal disease. So when should we be referring patients to you to try to close a persistent fistula tract? And what are you looking at when you're making the decision whether you're going to do a lift or an advancement flap?

Dr Brown:

I mean, I don't particularly like doing fistula repairs in patients with a history of Crohn's disease because I think the risk of failure is high in a non-IBD patient. I think it's really much higher in an IBD patient. Really, the only Crohn's patient that I'll consider doing a repair on is somebody that has a rectovaginal fistula because I think those are really symptomatic and hard for patients to deal with. But most of the time I will divert those patients and make sure that they have good disease control before even thinking about doing a fistula repair.

Dr Cross:

So when you are considering doing something definitive for perianal Crohn's, does the status of the rectum, what's going on a rectum, does that influence what you're going to recommend?

Dr Brown:

Yeah, absolutely. I mean, I think in perianal Crohn's disease, we can always make patients worse, and that's kind of the thing that I think happens to them. And so if they have active inflammation in their rectum or if they have the thickened skin tags and all those other things that the perianal Crohn's patients dislike, I think operating on them oftentimes makes them worse because now they have a chronic wound down there or a fissure or something that doesn't heal, and I haven't done them a service to do that for them.

Dr Cross:

Yeah, that was going to be a follow-up question is, patients hate skin tags. They're annoying. They sometimes get inflamed and are painful and patients will have leakage, which is probably they're just not able to get the area clean enough when they're wiping. And I really discourage them from having anything done surgically. And it sounds like you recommend the same thing.

Dr Brown:

In Crohn's patients, definitely. I think they're really hard. Now, I have had a couple patients that have had really long pedunculated kind of skin tags that you see and you're like, "Yeah, I can sort of understand how that's obstructing your ability to maintain hygiene and it's getting inflamed and that kind of stuff." And so as long as those look like normal skin tags, not like Crohn's skin tags, I will consider removing them with having a true discussion with a patient of, "If you have perianal Crohn's disease that's active, this is not going to heal and it could make you worse." And I think allowing the patient to have a say in their care is helpful for them. And then if they decide to have the surgery and we end up there, then at least we're both prepared for that to be the case.

Dr Cross:

And coming back to perianal Crohn's, it's awful. And I think we do a really good job of preventing recurrent abscess and need for IND, and so we get less scarring. And I think if we get to these patients early enough, they get less anal canal stenosis. So we get them better, but we're pretty aggressive with setons and keeping them in until the inflammation's well controlled on imaging. And I feel like I get most people to the point where I just can't quite get the seton out or I'm not comfortable taking it out. And we hoped stem cells, that would be our one more nail in the coffin for perianal disease. We could use that, and it hasn't really borne out. But what we learned from those studies was that in that refractory population in the ADMIRE trial, patients that had a good exam under anesthesia by an experienced surgeon where they closed the internal opening after doing a good debridement, those patients did really well.

Dr Cross:

So maybe the message there is if your patient's not having the outcome that you want, just a good exam under anesthesia by an experienced colorectal surgeon can make a difference.

Dr Brown:

Yeah. I mean, I think fistulas can be some of the most frustrating things in the operating room, especially Crohn's-related fistulas, because it's never a straight tract. The internal opening is hard to find. There's so many different things that can happen. And I think having the experience of having seen all of these things and knowing how to maneuver the fistula probe and that kind of stuff can be super helpful in identifying all of those things. I, again, get a little bit nervous about doing anything in Crohn's patients, but I think if they have true, true resolution or control of their perianal Crohn's disease, I think a simpler sort of approach like closing the internal opening and seeing how they do is much better than talking about doing a flap or an endorectal advancement flap or a lift because that's creating so much trauma in the area that is already prone to inflammation.

That may be part of the reason that they don't respond well to that.

Dr Cross:

And there just is a small chance of having malignancy within the tract. I fortunately have never seen that, but that is for someone who's not responding, just to keep in your differential. All right, 2 more questions, then a fun fact. IPAAs—should they only be done in centers of excellence? And what would that look like as far as a center of excellence?

Dr Brown:

I mean, I think that, again, it's sort of the same thing. If you're going to be doing intestinal surgery and doing anastomotic reconstruction, you should probably be doing them regularly. So if you're going to be managing on or operating on IBD patients and doing pouches, you probably should have done more than 3 or 4 in the last 4 years. Making a good pouch I think is something that comes with appropriate training and those kinds of things. But once you know how to do it, I think just doing it fairly regularly is important. So I don't know if there are folks out there that are doing them after having not done them for 5 or 6 years. I kind of feel like if you're in the IBD world that you're getting referred these patients more regularly. Now, the problem also is that since the medical management of ulcerative colitis has improved so much, we've seen a pretty big decrease in the amount of pouches that are being created across the country, and that's affecting training for colorectal surgeons.

So I think a lot of it is going to be experience and making sure that if you're a young surgeon, having backup of somebody who can help you through those first few cases is going to be super important. But once you've hit the learning curve, I think you sort of remember how to do them.

Dr Cross:

And the one nice thing, if a patient has to have a colectomy, and most of the time they're going to have a subtotal with a Hartmann's pouch and an ileostomy, is they have time. You can refer them to someone, and if they don't have a great experience or don't feel comfortable, you can refer them elsewhere, and it can be a place where they have to get on a plane or a train to get there. So you have time. There's no time expiration on when you create the pouch. So once the colon's out, they can shop around and find who they're comfortable with.

Dr Brown:

Absolutely.

Dr Cross:

And I think no matter what surgery you're getting, that's important to feel comfortable with your surgeon.

Dr Brown:

Absolutely.

Dr Cross:

Alright. Should we do IPAAs for Crohn's?

Dr Brown:

No. I think that there's some of these indeterminate colitis patients that you end up doing them on. And I mean, I feel like we can probably all remember patients that had indeterminate colitis, got a pouch, and then had all of these terrible complications related to their pouch, much more than we can remember an indeterminate colitis patient who got a pouch and did fantastic. And maybe that's because that person is doing fantastic and isn't needing a lot of care and that kind of stuff. But I think that we more frequently will see the patients that kind of fall into the other category.

Dr Cross:

For the listeners, I didn't provide any context for the question, but generally the pouch excision rate or needing to go back to an ileostomy for ulcerative colitis is less than 5%. With indeterminate or IBD type undetermined, it's about 8 or 10%. And for Crohn's disease, it's about 30%. I agree with Rebecca. For me, that's far too high to go through 2 additional surgeries to create a pouch. Now, I know that there are some centers that do it. They're highly select. They're excluding stricturing or penetrating patients. They're excluding those with perianal disease. I think that's all sensible. And if you're an optimist, you could say, well, 70% of people keep their pouch. But also one of the benefits of a colectomy is that you come off meds, and if you're going to get a pouch and still go 4 to 8 times a day plus need to be on meds and you're medically refractory before surgery, does that really make sense? I think most of the time it does not make sense.

Dr Brown:

I will also say that pouch excision surgeries and patients that have Crohn's and have complications like fistula and that kind of stuff, it really makes the pouch excision surgery much more complicated. And I think there are important structures in the pelvis that control urinary and sexual dysfunction. And so now we're talking about doing a redo pelvic operation in a patient with active inflammation and now abnormal anatomy, the risk of them having long-term, even nonsurgical related complications from that procedure is much higher. And so it's not just their Crohn's disease and those kinds of things we should be thinking about. I think it's kind of their long-term overall function.

Dr Cross:

Yeah. Marla Dubinsky and I had a conversation about more issues specific to women beyond pregnancy and fertility, but certainly pelvic floor problems with dyspareunia and then in younger women having another surgery impact on fertility can be significant.

All right, so this has been great. Rebecca, tell us your fun facts. So what's your fun fact?

Dr Brown:

Let's see. I have two fun facts for you. One is I know how to juggle, and two is I have 15 chickens at home.

Dr Cross:

Well, I knew about chickens. I didn't know you could juggle, which I think for your colorectal surgeon to be able to juggle, I think that would be a very positive thing.

Dr Brown:

Good hand-eye coordination.

Dr Cross:

Yeah. Sounds good. All right, this has been great, Rebecca.

Dr Brown:

Thanks, Ray.

Dr Cross:

Hopefully we'll have you back soon.