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All But the Surgery |
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An Article written for the CCSG by Professor Graham Hill (Colorectal Surgeon). Although there are a number of different conditions that can be classified as Inflammatory Bowel Disease (IBD) most patients will have either ulcerative colitis (UC) or Crohn's Disease (CD). Surgery may be required for UC patients when there are persisting and disabling symptoms, despite state of the art medical therapy, or there is an acute flare up which may endanger life. In a small number of patients who have had UC for a very long time there may be an increased chance of developing cancer in the inflamed colon. Surgery may be required in patients with CD for the same reasons although bowel obstruction, fistula formation and severe infection characterise CD, and surgery is usually the best way to deal with them. When a gastroenterologist refers a patient to a surgeon he is seeking his opinion as to whether he thinks the time has come for surgery and what type of operation would best suit the patient. The surgeon, after studying the patient's case, and talking to and examining him, will form an opinion as to the appropriateness of surgery. This is then discussed fully and the patient and surgeon together will decide whether they should go ahead and what type of procedure is most appropriate. If it is decided to go ahead a date will be set for the operation. If an ileostomy or pelvic pouch is required it is of enormous help to meet a patient of the same sex and around the same age who has had the same operation. Although the patient is likely to have undergone colonoscopy and X-ray barium studies prior to seeing the surgeon it is possible that some or all of these tests will need to be repeated before surgery to see if the disease has progressed in the interim. In any event, prior to being admitted to hospital, the patient will attend a preadmission clinic to ensure that he is fit for the anaesthetic and the operation. Admission to hospital will be the day before surgery and during this time the stoma nurse will visit and discuss the pros and cons of a stoma before marking out a suitable site on the abdomen for one if that becomes necessary. Some patients may require a bowel clean out prior to the operation the next morning. It is likely that the anaesthetist will visit as well and discuss the various options for the anaesthetic and postoperative pain relief. It is not usual to use epidural anaesthesia in this sort of surgery. Early on the day of surgery the patient is taken to the operating room where he is met by the anaesthetist and surgeon. Prior to going to sleep a number of safety checks are made and it is ensured that the paper work is all in order. Postoperative pain is usually controlled by the patient by the touch of a button. The operation is likely to be quite a long and exacting one for the surgical team. Time in surgery ranges from 90 minutes to 300 minutes, and a blood transfusion maybe required. The first the patient is aware that it is all over is a slow dawning of reality over the hour or two following surgery. Pain is almost always very well controlled and by the time the patient returns to the ward he is relatively pain free and sleeping peacefully. The next morning he is wide awake and conversing with the doctors and nursing staff. He will then notice that he is attached to all sorts of lines and tubes including a bladder catheter, an intravenous line, a stomach tube and plastic drains which are coming from within the abdomen. Although he cannot eat for a few days (the intestine does not function for 2-3 days after surgery) fluids, electrolytes and glucose are supplied via the intravenous line. After 3-4 days, when it is has been shown that fluids can be taken freely, a soft diet is commenced. By the middle of the second week a full diet is being taken, the tubes are out and discharge from hospital is imminent. The first month after surgery is characterised by profound tiredness but this improves week by week and is gone completely by 2-3 months. Several weeks after surgery the patient will be seen again by the surgical team when medications are adjusted, diets are reviewed and any further surgery that may be required is discussed. Day to day medical care is provided by the patients general practitioner. Most patients with UC and CD usually come through their surgery well and can expect a major improvement in their quality of life. Since this sort of surgery is major, complications such as infection and difficulty with wound healing are not uncommon but only rarely are these long lasting or particularly dangerous. Back to Newsletters |
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