Surgeons and GIs: IBD co-management in ‘collaborative spirit’
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Feza Remzi, MD, FACS, FTSS(Hon), director of the Inflammatory Bowel Disease Center and professor of surgery at New York University Robert Grossman School of Medicine and NYU Langone Health, spoke with Healio about the importance of collaboration between surgeons and gastroenterologists, the role of ultrasonography for patients with Crohn’s disease in the United States and surgery’s place in the continuum of care.
What does an average disease management plan look like for a patient with IBD?
The disease plan for a patient with inflammatory bowel disease is dictated by the type of IBD that the patient has; Crohn’s disease or ulcerative colitis. It brings a huge variation.
Whatever the disease plan is, the patient needs to be in the center and we, the physicians and non-physician health professionals, will be a part of the critical team serving the patient.
The average disease plan starts, usually, with medical therapy, unless a patient presents with a surgical emergency. For the medical therapy, surgeons collaborate with gastroenterologists, who specialize in the field of IBD. The disease plans may start with relatively simple medication, such as 5 ASA products, immunomodulators, biologics, non-biologics and many different others. It’s really dictated by the patient: patient demographics, patient severity of presentation and longevity of disease, with significant variation depending on the type of IBD the patient has.
Does timing matter when choosing to pursue surgery for IBD? Is surgery always on the table as a treatment option?
The answer is yes, yes, yes. But we have come a long way to get to that answer. We came a long way in collaborative spirits serving our patients, whereas this was really a very divided field, medicine vs. surgery. We all understood that we, the health care providers, had to unite in serving our patients as gastroenterologists and surgeons. So, as far as I am concerned, in the past, surgery was seen as a failure. We make the case to our patients now, in a collaborative spirit with organizations like the American Gastroenterological Association and the American College of Gastroenterology, that surgery is part of the continuum of care that may come at some point in their lives.
For example, 25% to 40% of patients with ulcerative colitis will need surgery at one point in their lives and that is complemented by approximately 90% of patients with Crohn’s disease who will need surgery at one point in their life. Patients have the right to push their limits and try to avoid the surgery, but this needs to be done in a framework under the leadership of gastroenterologists and complemented by a surgeon. The patient should see the surgeon in a more elective basis, rather than an emergent basis, just to say, “I’m here when you’re ready.” That makes a huge difference, rather than seeing the surgeon in an emergent, and rather acute setting, where the relationships can be very traumatic.
The timing of the surgery matters. The more patients delay their surgery, it becomes more likely they will have an emergency surgery, they will have more complications and they would need a temporary bag for a while. As long as we understand this uncertainty and the potential extra complications that may come, it is very important for us to be on the same page relaying this message to our patients collectively.
What are the risks and benefits of surgery to treat IBD?
For ulcerative colitis, the indication, most of the time, is failed medical therapy. That’s number one. So, these patients, unfortunately, have major social, diet, work and sexual restrictions, with a poor quality of life and years of suffering with what I call “deconditioning.” They are accepting a lesser way of living as a norm, suck it up for the sake of the family and move on – that’s just a part of their life. That does not have to be the case. The J-pouch procedure or restorative proctocolectomy, done most of the time in three stages, can dramatically change the quality of life and eliminate the restrictions the patients were having.
That’s the plea that I have for our patients: if they have suffered long enough from ulcerative colitis, surgery can resolve this problem. Granted, it’s a complex procedure. It must be done in high volume centers with experience to avoid disastrous complications related to surgery that may prolong these patient’s suffering. That’s very important.
Secondly, for the Crohn’s disease, it depends on the location of the disease. For example, the ileocolic, where the small bowel joins the large intestine or the small bowel itself or the large intestine itself. The critical thing in Crohn’s diseases is that patients may need more stoma than patients with ulcerative colitis, so these patients like to come later to the surgery. There is a price to pay in these settings: longer hospitalization, likely emergent surgery, likely need for a temporary bag. But the suffering related to Crohn’s disease, abdominal pain, cramping, weight loss, inability to function properly, will be eliminated with surgery. Most of the time, patients with the Crohn’s disease, patients rightfully ask, “if it’s going to come back in any way, why would I have surgery now?” That’s not fair, because, yes, they are correct. The disease is likely to come back. For example, for ileocolic disease, 20% of patients who have surgery see their disease return in 5 years, 30% to 40% in 10 years and around 50% in 15 years. But, most of the time, these patients will have awesome, healthy, wonderful years rather than the status quo and suffering. Prolonged medical therapy is futile when surgery is indicated.
How important is collaboration and patient co-management between gastroenterologists and surgeons?
It’s everything. In 2020, the IBD patient cases need to be discussed in a multidisciplinary team. Patients must feel that both the gastroenterologist and the surgeon are part of the team that are privileged to serve them. The physicians are there to serve the patient, not to argue, not to fight. Now, they may have differences of opinions, and I tell my patients, “that’s okay, it’s a healthy discussion for your benefit.” Patients, sometimes, listen to one recommendation and then another one and another one and then make their decision about what fits for them the best. The last thing we want to give our patients is a message that we are divided and not agreeing. That’s the time when they not only lose their trust to us as physicians, they also lose their trust to the whole health care profession, overall, with prolonged suffering. That, to me, is very important. As surgeons, you must admit that our patients will be seeing our gastroenterologist colleagues more in their lifetime than us. Their management and plan of care started with the gastroenterologist and we need to respect that our gastroenterologist colleagues have a much more invested interest in the patient’s well-being, in their whole lifespan, than for us being in and out. By no means am I underestimating the surgical merits and skillset of what we are doing to serve our patients, but that needs to be done within this framework that I defined. Everyone needs to understand that our gastroenterologist colleagues need us, and we have the privilege of working together to serve our patients the best way we can, in the patient’s interest.
What role does ultrasonography play in IBD care and how can that impact the need for surgery?
The ultrasonography is something that is very important, specifically for Crohn’s compared with ulcerative colitis. It has been commonly used in Europe and Canada, specifically following the Crohn’s disease fibrostenotic, which means a narrowing of fibrosis and scar tissue in a natural progress.
It’s a very easy test to do. It’s very quick. But I have to admit, in the U.S. we have been really behind due to different dynamics of our radiology systems. As a U.S. health care provider, we have a lot to learn from our colleagues from the north and some of the European groups. That may bring quick, easy access to innovation for our patients with Crohn’s disease. I am very much looking forward to it and open-minded in this topic.
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