IBD IBD Surgical Management 1 — Questions and Answers
Question 1: What is the surgical procedure of choice for ulcerative colitis that is refractory to medical therapy?
- Total colectomy with end ileostomy alone (permanent)
- Proctocolectomy with ileal pouch-anal anastomosis (IPAA / J-pouch) (Correct answer)
- Subtotal colectomy with ileorectal anastomosis
- Hartmann's procedure with mucous fistula
Correct answer: Proctocolectomy with ileal pouch-anal anastomosis (IPAA / J-pouch)
Restorative proctocolectomy with IPAA (J-pouch) removes all diseased colorectal mucosa while preserving continence, and is the preferred definitive surgery for UC.
Question 2: In the setting of fulminant colitis or toxic megacolon, which surgical approach is performed emergently?
- Total proctocolectomy with immediate IPAA
- Subtotal colectomy with end ileostomy (Hartmann's pouch) (Correct answer)
- Sigmoid colectomy only
- Diverting loop ileostomy alone
Correct answer: Subtotal colectomy with end ileostomy (Hartmann's pouch)
Emergency subtotal colectomy with end ileostomy stabilizes the critically ill patient while preserving the rectum for future IPAA reconstruction after recovery.
Question 3: Strictureplasty in Crohn's disease is performed to address which problem while preserving bowel length?
- Fistula closure
- Short fibrostenotic strictures without active inflammation or malignancy (Correct answer)
- Perianal abscess drainage
- Resection of dysplastic segments
Correct answer: Short fibrostenotic strictures without active inflammation or malignancy
Strictureplasty widens short fibrostenotic strictures without bowel resection, preserving intestinal length and reducing the risk of short bowel syndrome in Crohn's patients with multiple prior resections.
Question 4: Which perianal Crohn's complication requires examination under anesthesia (EUA) with seton placement?
- Simple anal fissure
- Hemorrhoidal disease
- Complex perianal fistula (Correct answer)
- Rectal prolapse
Correct answer: Complex perianal fistula
Complex perianal fistulas in Crohn's require EUA for accurate mapping and seton placement to drain the tract, prevent abscess formation, and allow anti-TNF therapy to be effective.
Question 5: Which criterion is an absolute surgical indication in IBD management?
- Mild disease refractory to first-line medications
- Perforation, uncontrolled hemorrhage, or malignancy (Correct answer)
- Elevated CRP despite therapy
- Frequent flares managed as outpatient
Correct answer: Perforation, uncontrolled hemorrhage, or malignancy
Perforation, life-threatening hemorrhage, and colorectal malignancy are absolute emergent surgical indications that require immediate operative intervention regardless of other factors.
Question 6: What percentage of UC patients will ultimately require colectomy over their lifetime?
- <5%
- 10–15%
- 30–40% (Correct answer)
- >60%
Correct answer: 30–40%
Approximately 30-40% of UC patients will require colectomy during their lifetime, particularly those with extensive pancolitis, medically refractory disease, or dysplasia.
IBD IBD Surgical Management 1
What is the surgical procedure of choice for ulcerative colitis that is refractory to medical therapy?