Inflammatory Bowel Diseases : the Surgical Perspective

1 Department of Surgery, „Sf. Pantelimon” Emergency Clinical Hospital, „Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania 2 Department of Surgery, University Clinical Hospital, „Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania 3 Department of Urology, Central Military Clinical Hospital, „Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania 4 Department of Surgery, „Carol Davila” University of Medicine and Pharmacy, „Bagdasar-Arseni” Emergency Clinical Hospital, Bucharest, Romania 5 Department of Surgery, „Carol Davila” University of Medicine and Pharmacy, Emergency University Hospital, Bucharest, Romania Corresponding author: Bogdan Socea, Department of Surgery, „Sf. Pantelimon” Emergency Clinical Hospital, Bucharest, Romania. E-mail: bogdansocea@gmail.com


REVIEW
intentions of surgical treatment in Crohn's disease cannot be curative, as it is a pan-enteric disease.Surgical indications are mainly related to complications (fi brostenotic or perforated disease) and limited exertion surgery is recommended.Seriate interventions can cause short bowel syndrome, with the severe consequence of malnutrition 20,21 .Th us, small bowel resection segments should be limited as much as possible or even avoided.A bowel-sparing surgery as part of philosophy of conservationism becomes the rule, and, in consequence, diff erent techniques of strictureplasties are searched for small bowel fi brous strictures.
Strictureplasty techniques in CD are chosen in order to preserve bowel function, whenever these procedure is feasible and the disease is limited.Nowadays, there are several described techniques for strictureplasty.Th e most common are Heineke-Mikulicz for short strictures, Finney for longer strictures, and Michelassi sideto-side isoperistaltic for multiple sequential strictures 22 .Several authors reported new types of strictureplasties: Fazio and Tjandra 23 and Poggioli 24 .
According to European Crohn's and Colitis Organisation (ECCO) guidelines "Strictureplasty is a safe alternative to resection in jejunoileal Crohn's disease, including ileocolonic recurrence, with similar short-term and long-term results" 25 .
However, resection of a small bowel segment remains the most commonly performed procedure in CD 26 .Recurrence rates tend to increase with the passage of time and CD patients may eventually require multiple resections, each increasing the risk of shortbowel syndrome.No correlation seems to be between the extension of resection and relapse of the disease.Th us, extensive "radical" resections, with healthy tissue margins are not necessary 27,28 .

Ulcerative colitis
Ulcerative colitis aff ects the large bowel in most cases, with infl ammation being restricted to the mucosa.Th e surgical treatment aims to obtain healing, with the possibility of resection of the entire aff ected segment (total rectocolectomy).Th is intervention prevents development of colorectal cancer over time, lowering the risk of malignancy.
Strictureplasties are not recommended for large bowel stenosis.
Th e main emergency indications for surgical intervention in UC include massive hemorrhage, toxic colitis, toxic megacolon, and intestinal perforation.Elective indications include medically refractory UC, intoleran-

INTRODUCTION
Ulcerative colitis (UC) and Crohn's disease (CD) are infl ammatory intestinal diseases, grouped together in the entity of infl ammatory bowel diseases (IBD).Th ese conditions have both overlapping and distinct clinical and pathological features, and pathogenesis is yet incompletely understood.Genetic and environmental factors are suspected to alter intestinal immunity, being promoters of gastrointestinal injury 1-6 .
Surgical morbidity and better functional outcome and quality of life (QOL) are all important objectives of the management of these diseases.
Th e incidence and prevalence of infl ammatory bowel diseases (IBD) are continuously increasing all over the world, indicating a tendency of becoming world spread diseases 7 .Romania is enrolling in the global trend of increasing incidence, although geographically it does not represent an area with high prevalence.Th e incidence of UC has been increasing in previously low-incidence areas i.e.Eastern Europe, Asia, and developing countries 1 .IBD have low incidence in Asia and in Southern Europe 8 .A high incidence of IBD is encountered in the northern areas, such as northern Europe and North America 9 .IBD occur more frequent in Caucasian people 10 .UC is more frequent in men, while CD is more common in women 11 .
Despite the fact that medical treatment has continuously improved during the last decade, 80% of patients with Crohn's disease (CD) 12 and approximately 25-35% of patients with ulcerative colitis (UC) require surgery during their lifetime 13,14 .IBD represent a model of multidisciplinary management.Timing of surgery represents the key issue for proper management of IBD patients.

Surgical indications and options
For acute and some specifi c cases of severe IBD, surgery can be a vital procedure.
Many studies suggest that patients with IBD have an increased risk for developing myocardial infarction and stroke 15,16 .In addition, these patients are at high risk of developing cardiovascular events in the perioperative period, and they are in need for a specifi c anesthesia and intensive care management, especially related to surgery [17][18][19] .

Crohn's disease
Crohn's disease primarily involves the small bowel, infl ammation including the entire intestinal wall.Th e ce or non-adherence to medical therapy, severe malnutrition, the presence of dysplasia, and cancer 27,29,30 .
Total abdominal colectomy and end ileostomy is the procedure of choice in emergency settings 31 .Th e most frequent elective procedure performed for UC is restorative proctocolectomy with (RPC) with ileal pouchanal anastomosis (IPAA), which is considered the gold standard 30 .Total proctocolectomy removes all disease and eliminates the risk of colorectal cancer 32 .Unfortunately, total proctocolectomy with end ileostomy is associated with signifi cant morbidity (complications related to ileostoma, sexual dysfunction, altered bladder function) 33 .
IPAA was fi rst described by Sir Allen Parks at St. Marks Hospital London in the early 1980's.Construction of ileal pouch off ers long-term restoration of intestinal continuity without permanent ileostomy.Th e pouch remains functional for 20 years in 90% of patients 34 .In IPAA, the rectal stump mechanically stapled to ileal pouch remains of minimal lengths (2 cm), so that the risk of subsequent rectal cancer is minimum.
ECCO guidelines state that "If surgery is necessary for localized colonic disease (less than a third of the colon involved), then resection only of the aff ected part is preferable" 25 .Th ey also state that "Two segmental resections can be considered for a patient with an established indication for surgery when macroscopic disease aff ects both ends of the colon" 25 .
Minimal invasive surgery (MIS) proved to have at less same positive results compared to classic surgery in cases of infl ammatory bowel diseases.Th ere are no in-creased risk of complications for MIS, and the advantages of laparoscopy are obvious [35][36][37] .
Recent studies also revealed the role of probiotics in selected patients.Th e outcome of UC patients with restorative proctocolectomy and ileal pouch was by probiotics.

CONCLUSIONS
Surgical management in IBD is mandatory for the further outcome and treatment, as well as for patient's quality of life.It often proves to be complex, because clinical outcomes are diff erent and decision making are challenging and diffi cult.Intraoperative decision of surgical tactics and techniques requires experience.A good multidisciplinary collaboration is necessary for best results, and to decide the best surgical timing.
Recently, laparoscopic surgery proved an increasing role in IBD, especially for elective cases.It is necessary that experienced and dedicated IBD surgeons to perform it, in a multidisciplinary approach.
IBD are proinfl ammatory and hypercoagulable conditions, with high perioperative risks.

Compliance with ethics requirements:
Th e authors declare no confl ict of interest regarding this article.Th e authors declare that all the procedures and experiments of this study respect the ethical standards in the Helsinki Declaration of 1975, as revised in 2008(5), as well as the national law.Informed consent was obtained from all the patients included in the study.