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In IBD patients, discussion of surgery provides valuable education
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In inflammatory bowel disease, as in most areas of medicine, surgery is reserved as a later option for cases that are unresponsive to less invasive treatments. However, for many patients, the conversation about surgery is best initiated earlier in their management instead of as a last resort.
“When these patients get admitted with a severe flare, surgeons should be consulted sooner rather than later,” Amy L. Lightner, MD, colon and rectal surgeon at the Mayo Clinic, said, referring specifically to ulcerative colitis (UC). “Even if the patient doesn’t need surgery at admission, and they improve and respond to medical therapy, they are still overall at a higher risk of eventually needing surgery. I think, at least, that the education up front doesn’t hurt.”
The timeline for discussing surgery with an IBD patient often depends on whether the patient has UC or Crohn’s disease. Another factor is whether a patient presents electively in an outpatient setting, or whether the patient is admitted to the hospital in an emergent or urgent situation. In these situations, the goal is to arm the patient with knowledge of available options without causing undue alarm.
Lightner talked with Healio Gastroenterology and Liver Disease about the circumstances that warrant a conversation about surgery, and the information that patients need to know when considering surgery.
Healio: The conversation about surgery differs between patients with UC and those with Crohn’s. Can you discuss each condition?
Lightner: With UC, there are three forms that surgery can take. It’s usually colectomy, or a total proctocolectomy with a pouch. The patient is either seen in the elective setting in clinic, or they’re seen as an urgent consultation when they’re admitted as an inpatient for a flare or emergency. An emergent situation is probably the easiest as far as discussing surgery, because this would involve a complication like a perforation or toxic megacolon, and they would need to see a surgeon right away. That’s a more obvious decision.
An urgent consultation would be more of a grey area. If a patient is admitted to the hospital with a flare, a lot of times they’ll receive IV steroids to see if they improve. Then they may or may not get an induction of Remicade (infliximab, Janssen) to see if they can stave off getting a colectomy. When these patients get admitted to the hospital for a flare, maybe half of them will end up having a colectomy or needing surgery in the future if they are admitted as an inpatient.
So, at this point, bringing the surgeons in to discuss the possibility of surgery is a good idea. In this conversation, the surgeons would talk about what it would be like to have surgery if they needed it. They’d explain what a pouch is, and what life would be with a pouch. They would go over the risks of surgery, but also reassure the patients that the outcomes after surgery are very good – in fact, surgery can be curative.
This conversation is better to have earlier in the consultation rather than later. Earlier, generally, the patients are feeling a little bit better. If we don’t get called until the patient has already had 5 days of IV steroids and an induction of Remicade and no improvement, they’re going to be feeling miserable by then. Usually, their health has deteriorated a little bit by then, and it makes the outcomes much worse. There have been studies that have shown that the earlier you take the patient to the operating room when they’re admitted, the better the outcome.
If you’ve had that conversation about surgery, they’re ready for it; they know what to expect. They at least have in their minds what the options are. And with ulcerative colitis, surgery is curative; it’s different than Crohn’s. There’s actually a cure for the disease.
Healio: How would the conversation proceed in an outpatient environment?
Lightner: In the outpatient, elective setting, it’s a bit trickier, because a lot of these patients are being managed with medication. Less of the total group in an outpatient setting is going to need surgery. The way we do it at Mayo is, if an outpatient is on biologic therapy and is going to be switched over to another biologic, we’ll typically be called in for a consultation to start having conversations with that patient. We discuss what they can expect, even if they’re not on the doorstep of surgery.
Once the patient is on biologics and they’ve started failing one or two biologics, it’s important to bring the surgeon in to at least educate the patient, especially because biologics and other medicines are not without side effects. A lot of these patients have chronic disease, and they’re actually quite sick, but they’ve learned to manage the disease. It’s almost like they have a new baseline. The biologics and steroids help to a certain extent, but not entirely; these patients get used to being sick. I find that after we do a colectomy on them, they consistently feel better within the first postoperative day, when they’re still in the hospital. They feel drastically better, and they will ask “Why didn’t I do this sooner?” So, once they’re on biologics and steroids, it’s worth bringing the surgeon in to at least have a conversation with them about this as an option. It’s a really simple treatment option.
I don’t think it’s ever too soon to initiate this conversation. There are a lot of patients who don’t want to start immunosuppressants, or they go on infliximab and they start to have some side effects. So, it’s just presenting it as an option. Many patients will do very well on therapy, and they will never need surgery, and that’s great. But it doesn’t hurt to be educated about it. It’s better to have that information.
Healio: You said the conversation would be somewhat different in patients with Crohn’s. What would that conversation be like?
Lightner: Crohn’s is different because we don’t actually cure the disease with surgery. Surgery helps with the symptoms and can improve quality of life, but it’s not curative.
In addition to that, we have to be careful when we do surgery; we have to keep in mind that this patient may need repeat surgery in the future. We take out as little bowel as we can at the time of surgery. That’s important in regard to timing, because if you have a patient with, say, 60 cm of involvement, you might say, ‘Why don’t we try to medically manage them to get it down to 10 cm to actually be removed?’ That timing is a little bit different.
There are the same three categories of settings of surgery: emergent, urgent and elective.
In terms of the emergent need for surgery, you might have a patient with a perforation, or an acute obstruction, or a bleeding episode. They may need to go to the operating room right away. That’s obvious.
The elective setting is tricky, because our gastroenterologists see a lot of patients with Crohn’s disease and are managing a lot of patients as outpatients who will never have surgery. So again, it becomes a timing issue of when to bring in a surgeon. An appropriate time to bring the surgeon in is when you feel like you’ve tried medical therapy and you’re having to switch or escalate medical therapy due to failure. So, if you’ve put a patient on dual therapy with a biologic and immunomodulator and it’s not effective, and you’re adding steroids or needing to switch the biologic due to persistent symptoms, it’s probably a good time to at least get a surgeon involved.
Healio: Is there a way to predict which patients will or will not respond to medical therapy?
Lightner: With Crohn’s disease, there are three types of disease: inflammatory, fibrostenotic and penetrating disease. Patients who have inflammation alone typically respond better to medical management, and they probably won’t need to see a surgeon. Patients who are fibrostenotic have strictures, and they may start to have obstructive symptoms, meaning they are on a liquid diet, are losing weight, and are feeling bloated when they eat. Those symptoms are probably eventually going to require surgery, despite medical management. So, those patients would benefit from seeing a surgeon sooner rather than later once they have those symptoms.
Penetrating disease is similar, the patient has fistulas. We’ll try to get some of the inflammation and fistulation cooled off with medical therapy, and minimize the burden of that disease medically. However, those patients are likely going to need surgery at some point. So, in that setting, we see medical therapy as a bridge to surgery. Those patients should also probably be seen sooner rather than later by a surgeon.
Typically, the surgeon and the gastroenterologist discuss before talking to the patient. We discuss the case, come up with a plan together, and then talk to the patient together.
Healio: How do you explain what surgery will entail to Crohn’s disease patients?
Lightner: We discuss the most common resection that we do, the ileocecal resection. With this surgery, we take out the last part of the ileum and the first part of the colon and reconnect things. We tell the patient we’re going to try to take out as little intestine as possible. We tell them that their symptoms will likely have a marked improvement right after surgery, but that they may be at risk for needing another surgery in the future. We also tell them they might require further medicine after surgery, that they may be kept on medical therapy. We discuss the risks of surgery and the potential postoperative complications. We talk about anastomotic leaks, which are probably a little more common in Crohn’s patients who are on immunosuppression and malnourished and anemic. We go over their risks of these postoperative complications, and let them know that these risks may be increased for them, especially if they’re on steroids and biologics.
We do also let them know that symptoms and quality of life are markedly improved after surgery, especially if they don’t have any complications. The main difference is simply that we’re not curing the disease.
Healio: So, in this discussion it seems that there would be more of a weighing of pros and cons?
Lightner: Exactly; there’s a lot more of that. With ulcerative colitis we can say, yes, there are risks with surgery; however, we are curing your disease. And with Crohn’s, we can say, yes, you’re going to feel much better as long as you don’t have complications, but your disease is still there. We need to take out as little of the disease as possible. Especially if the patient has had multiple surgeries, in which case they are at risk of having a limited amount of intestine left. We need to be very careful.
Healio: Overall, do these surgeries turn out well?
Lightner: They do, absolutely. The complication rate is low. Patients generally do very well. The leak rate is less than 5% and the superficial infection rates are probably around 10%. So, patients do well. It’s just that no surgery is without risk, and there will be some patients who have a complication, and you just have to educate them about the risk that’s involved. It’s really our responsibility to educate them about that. - by Jennifer Byrne
For more information:
Amy L. Lightner, MD, can be reached at 200 First St, SW, Rochester, MN 55905; email: Lightner.Amy@mayo.edu.
Disclosure: Lightner reports consultancy for Takeda Pharmaceuticals.