Common Complications of Surgery for Crohn’s Disease and Ulcerative Colitis

Postoperative Intraabdominal Septic Complications in Crohn's Disease

In patients with Crohn's disease (CD) undergoing abdominal surgery, the reported postoperative intraabdominal septic complications including abscess and sepsis ranged from 2.7% to 16%. Following bowel resection, the overall incidence of severe intraabdominal septic complications, ranges between 6% and 13%. For ileocecal resections specifically, the rate of postoperative abdominal septic complications increased from 7% to 40%. For ileocolonic resection, postoperative intraabdominal septic complications differ between one-stage and two-stage procedures, rates 9% and 12%, respectively. Postoperative intraabdominal septic complications have a detrimental influence on the long-term outcome after intestinal resection in patients with CD, leading to increased number of reoperation and resulting in up to 50% of postoperative death.

The reported risk factors associated with a higher risk of postoperative intraabdominal septic complication include poor nutritional status, the presence of intraabdominal abscesses at the time of surgery, and systematic inflammatory status. In addition, preoperative use of corticosteroids and anti-TNF biologics are the risk of intraabdominal septic complications in patients with CD. Other reported risk factors of postoperative intraabdominal septic complications include low albumin levels and CD-related surgery history. However, it is controversial whether the preoperative use of anti-TNF biologics is indeed associated with postoperative infectious complications.

A postoperative intraabdominal septic complication can be suspected in patients with CD who have unexplained fever and/or an abdominal mass and could be demonstrated in those with abdominal drainage of abscess. Radiographic studies including computed tomography (CT) and magnetic resonance imaging (MRI) are important not only for the detection of abscesses but also for the identification of any associated fistulas, a finding which can guide the management of postoperative intraabdominal septic complications. CT and MRI are considered as the most sensitive and specific imaging tests for detecting postoperative abscesses. However, CT is preferred to be the initial diagnostic test of choice for detecting intraabdominal abscesses. Abdominal ultrasonography, with its lower cost and the lack of ionizing radiation, may be a reasonable diagnostic alterative for detecting intraabdominal abscesses.

Preoperative management, consisting of nutritional support, intravenous antibiotics, weaning off corticosteroids, immunomodulators, or biologics, and percutaneous drainage of abscess, is important in reducing postoperative intraabdominal septic complications. In patients at risk, construction of diverting stoma may help reduce the risk of postoperative intraabdominal septic complications. Traditionally, treatment of postoperative abdominal abscesses in CD includes use of antibiotic, percutaneous, or surgical drainage. Immunosuppressive therapy, which may be used to prevent recurrence of CD after adequate abscess drainage, should be withheld from patients with postoperative abscesses. After the initiation of antibiotic treatment, we should address the issue that whether abscess can be adequately drained. If abscess requires drainage, percutaneous route should be attempted first . Percutaneous drainage has been reported to be performed successfully in 74%–100% of cases in postsurgical CD-related abscesses, and is increasingly performed. ( Fig. 24.1 ). Anastomotic leak may cause abscess or enterocutaneous fistula ( Fig. 24.2 ). In addition, to percutaneous drainage, endoscopic drainage via placement of a pigtail stent through the leak may be attempted. This can be followed by an attempt of closure of the leak with over-the-scope clip system (please see Chapter 16 ).

For severely ill patients, those who fail percutaneous drainage, or those with acute anastomotic leak, reoperation with anastomosis excision and stoma creation is generally recommended. Therefore, understanding indications and selecting proper patients are important for achieving better results in the treatment of postoperative abscess. A suggested management algorithm for the diagnosis and management of postoperative intraabdominal septic complications in CD patients is presented in Fig. 24.3 .

Postoperative Intraabdominal Septic Complications in Restorative Proctocolectomy With Ileal Pouch

Pelvic septic complications after restorative total proctocolectomy and ileal pouch-anal anastomosis (IPAA) include abscess, sepsis, and fistula, which are the main causes of pouch failure. The high risk of development of sepsis or pelvic abscess remains to be a major challenge for construction of IPAA. The overall incidence of pelvic sepsis in the early postoperative period ranges from 5% to 7%. The incidence would increase from 15% to 24% following the pouch construction. Pelvic abscesses are also seen at a frequency of 4.8%–8% after IPAA. High-dose corticosteroid usage prior to surgery and patients with ulcerative colitis (UC) have been well demonstrated to be risk factors for the development of pelvic sepsis/abscess after undergoing total proctocolectomy and IPAA.

Patient with pelvic septic complications may present with symptoms and signs of sepsis, wound infection, and abdominal pain. CT scan can diagnose abscess and help guide its treatment. Pelvic septic complications can be managed with antibiotic treatment and drainage, including CT-guided interventional techniques and surgical drainage. However, only a minority of patients may be treated nonsurgically, and a majority of patients would require laparotomy for drainage of abscess and control of sepsis. The successful treatment of pelvic sepsis/abscess after IPAA generally requires a combined approach with colorectal surgeon, endoscopist, the interventional radiologist, and patient and family.

Examination under anesthesia (EUA) with endoscopy to identify potential anastomotic breakdown and fistula has been the standard of care for the initial management of pelvic sepsis after IPAA. In most cases, pelvic abscess can be drained by a transgluteal or direct path through the ilea pouch. For perianal drainage, the use of an 18-gauge needle to access the fluid collection, followed by and placement of 0.035-inch J-tip guide wire to thread through the needle, and advancement of a12-Fr pigtail catheter over the wire and into the fluid collection, is recommended. The catheter should be flushed several times a day with small amounts of saline solution to maintain patency. In clinical practice, it should be noted that, even after drainage has ceased or imaging has demonstrated resolution of the fluid collection, complete healing of the source of the leak, commonly a dehiscent suture line, may not occur. Therefore, before removing the catheter, an evaluation for persistent leak with fistulogram is recommended. For an abscess which persists despite repeated treatments with catheter drainage and antibiotics, a nonhealed leak should be considered and a further and more surgical intervention may be required. For patients which CT-guided drainage or minor surgery have failed or for those who deteriorate quickly with signs of generalized peritonitis, laparotomy is ultimately required, and reoperation is reported in approximately 24%–63% of the patients. Our suggested approach to postoperative management of septic complications in IPAA is outlined in Fig. 24.4 .