Surgical Treatment for Inflammatory Bowel Disease and Its Application

Introduction:

Functional gastrointestinal disorders are the most common gut disorders. These types of disorders reduce the functional capability of the intestinal tract. One of the most common functional gastrointestinal disorders is inflammatory bowel disorder. Around 1.3 percent of the adult population in the United States suffer from this condition. Over the years, several treatment modalities, such as dietary modifications and biological therapeutic agents, have been employed in this case. But, in certain cases, surgical interventions are needed.

What Is Inflammatory Bowel Disease?

Inflammatory bowel disease is a chronic inflammatory disease of the small intestine. This inflammation is caused by the abnormal immune response by the gut microflora. This includes two pathological conditions, which are ulcerative colitis (inflammation of the colon and rectum) and Crohn’s disease (a type of inflammatory bowel disease).The cells of the intestinal mucosa are tightly packed by the intercellular junctions. These tightly packed junctions prevent the migration of antigens and bacteria into the circulation. But in certain cases, these protective mechanisms are lost. Additionally, excessive expression of protective mechanisms like excessive production of mucus by goblet cells and a-defensins by Paneth cells. Excessive expression of the inflammation leads to the destruction of the epithelial lining and causes intrusion of the bacteria antigens, and other substances in the bloodstream.

The pathogenesis of inflammatory bowel disease is multifactorial. These factors are:

1. Genetics:

Genetics plays a crucial role in the pathogenesis of inflammatory bowel disease. The NOD2 gene is associated with Crohn’s disease. Also, genes like IBD5, IL23R, and ATG16L1 are associated with Crohn’s disease. Alteration of the functioning of these genes is responsible for the expression of alteration in the expression of cytokine synthesis, autophagy properties, and phagocytosis.

2. Environmental Factors:

Different environmental factors play major roles in the pathogenesis of inflammatory bowel diseases. Factors like food, diet, drugs, geography, social stress, and psychological problems lead to inflammatory bowel disease. In recent studies, it has been seen that vitamin D deficiency and calcium are associated with inflammatory bowel disease. Fatty food, high protein diet, spicy food, and excessive intake of dairy products are associated with this disorder. Drugs like excessive intake of non-steroidal anti-inflammatory drugs and antibiotics at an early age increase the risk of this type of chronic inflammation. Psychological factors like post-traumatic stress disorder, depression, and anxiety are considered risk factors in such cases. This is regarded as a gut-brain axis abnormality. This causes the difference in the alteration in the brain structure, connectivity, and functional responsiveness. Endocrine, neural, and neuroimmune abnormalities are also associated with visceral abnormalities.

3. Microbial Factors:

The intestinal microbiota is essential in maintaining gut health. Alteration of gut microbiota is seen in inflammatory bowel disorder. Microbiota like Faecalibacterium

Prausnitzii, Ruminococcus albus, and Ruminococcus gnavus are decreased in this condition. On the other hand, an increased amount of microorganisms like Ruminococcus bromii, Roseburia, Escherichia coli, and Eubacterium rectale can be observed.

4. Immune Factors:

Dysfunctioning of innate and adaptive immunity is associated with inflammatory bowel disorder. This alteration in the immune response is associated with altered functioning and differentiation of the T- lymphocytes. As a result, Th1 and Th17 cells are formed due to the differentiation of lymphocytes. The altered functioning of Innate lymphoid cells is also responsible for this condition.

What Are Indications of Surgical Interventions?

Indications for surgical involvement in the cases of ulcerative colitis are:

1. Fulminant colitis, or severe attack of ulcerative colitis, is one of the main causes of surgical interventions. In such cases, aggravated symptoms of abdominal pain, bloody diarrhea, and fever can be observed. In radiographic assessments, colonic and abdominal destinations can be seen.

2. Acute dilation of the segment of the colon is known as a toxic megacolon. In this condition, the greatest dilation is usually seen in the area of the cecum. The diameter of the colon in certain areas is more than 6 centimeters.

3. Colorectal cancer is one of the most common complications of this condition. In an early stage, dysplastic changes in gastrointestinal conditions can be observed. Such cases are also treated by surgical interventions.

4. Patients receiving long-term therapy often show increased duration of symptoms and increased episodes of relapses. Such cases must be treated by surgical interventions.

The indication for surgical interventions in Crohn’s disease are:

1. Formation of fistula tract of different types like enteroenteric, enterovesical, and enterovaginal are the indication of surgical interventions. Along with this, the presence of abscesses at various sites can be treated with the help of surgical treatment protocol.

2. Structuring is one of the main complications of Crohn's disease. Obstruction caused by this can not be treated by medical interventions. In such cases, surgical interventions are required.

3. Acute exacerbation of chronic disease often causes perforation and leads to hemorrhage. Such complications are treated by surgical interventions.

What Are the Surgical Treatment Options?

Different surgical treatment options are:

1. Proctocolectomy With Brooke Ileostomy: In this procedure, removal of the colon, rectum, and anus is done. Also, the intestinal wall is attached to the abdominal wall for passing out stool. This procedure is known as Brooke ileostomy. This is mainly done in elderly patients who are not suitable for restorative procedures.

2. Abdominal Colectomy With Ileorectal Anastomosis: In this procedure, the whole colon is removed, and the ileum is attached to the rectum. This procedure can be performed in patients with intermittent colitis. But, this procedure should not be done on patients suffering from active rectal disease.

3. Proctocolectomy With Kock Pouch: In this technique, removal of the colon, rectum, and anas is done. But, along with this, an ileal pouch with a valve is created. As a result, the stool stays within the body, and one can take it out of his own will. Skin problems associated with ileostomy can be solved by this procedure. This procedure can not be done in patients suffering from Crohn's disease as this may lead to fistula tract formation.

4. Restorative Proctocolectomy With Ileal Pouch-Anal Anastomosis: In this procedure colon and rectum are removed. But the continuity of the gastrointestinal tract is removed by joining two parts. This is called j-pouch surgery. It is mainly done in cases of ulcerative colitis. This is contraindicated in patients older than 60 years.

5. Strictureplasty: This procedure is done for the treatment of intestinal strictures present in Crohn's disease. In this procedure, the bowel length is preserved, and the narrowed portion is widened.

6. Laparoscopic procedures can be performed during the surgical removal of the gastric contents. Procedures like endoscopic submucosal dissection can be done for the removal of small areas with dysplastic changes.

Conclusion:

Inflammatory bowel disease is a common gastrointestinal problem caused by several infections. In such cases, chronic inflammation is caused by several factors, like gut dysbiosis, psychological problems, food habits, nutrition, and genetic factors. Surgical resection in such cases is mainly done in cases with severe symptoms. But such procedures are avoided in elderly patients.