Crohn's disease and other forms of inflammatory bowel disease (IBD), including ulcerative colitis (UC) and IBD undefined (IBD-U), are chronic but manageable conditions that can cause pain or discomfort, difficulty gaining weight or maintaining good nutrition, and, in some cases, serious or potentially life-threatening complications, especially when left untreated. Many children with these conditions are successfully treated with medicines and other non-invasive treatments such as nutritional supplements and dietary changes. However, if medical treatments are not effective, or if a child experiences a serious complication, bowel resection surgery may be considered.

What is a bowel resection?

A bowel resection is an operation to remove part of the intestine, including the small intestine or large intestine (colon). Your child's doctor may recommend this type of surgery – particularly in the case of small intestine resection – to treat conditions like Crohn's disease, which can cause a blockage (stricture) of the bowel, serious abdominal infections (abscess), or fistulas (a type of perforation) of the intestine. Resection of the large intestine is also known as a colectomy or hemi-colectomy (when only part of large intestine is removed). This type of surgery is performed more frequently for children with UC, but may also be appropriate for those with Crohn's disease or IBD-U.

Who needs bowel resection surgery?

Even with proper medication and diet, some children will develop a complication of their disease that requires as a bowel resection to relieve symptoms, treat an infection or otherwise improve their quality of life. The decision to proceed with surgery is made in collaboration between the child and their family, their gastroenterologist, and a surgeon who specializes in IBD surgery.

Surgery is used to relieve severe, ongoing symptoms and to help children continue growing and gaining weight when medical management is no longer effective on its own. Surgery may be recommended for a child who has chronic or daily symptoms from a bowel stricture (narrowing), bowel obstruction (blockage), or fistula (an abnormal connection from the intestine to another part of the bowel or another organ).

Clinicians will work closely with your family to determine if surgery is necessary and to determine which procedure is most appropriate. Our expert surgeons who specialize in IBD-related procedures will work closely with the gastrointestinal team – always with the goal of optimizing your child’s quality of life.

Types of bowel resection surgery

Most bowel resections can be performed laparoscopically. A laparoscopic resection involves making several small incisions on the abdomen, inserting a laparoscope (a thin telescope attached to a video camera), and using small surgical tools to remove the damaged portion of intestine. In most cases, the bowel can be connected (with sutures) in such a way that bowel function is normal and an ileostomy or colostomy is not needed.

At CHOP, bowel resections are performed by surgeons from the Division of Pediatric General, Thoracic and Fetal Surgery, who consult closely with doctors from the Division of Gastroenterology, Hepatology and Nutrition. A laparoscopic resection can help children with severe strictures (blockages) and locally severe, medically refractory disease (disease that doesn't respond to medication).

There are rare cases when a laparoscopic resection is not an option because of the size or location of the blockage. In this case, an open operation may be needed. This procedure includes a larger incision on the belly to remove the damaged portion of bowel. This type of surgery is also safe and effective and most patients have an uneventful recovery and excellent outcome.

No matter which surgical approach is used, the goal of surgery remains the same: to improve your child's symptoms, nutrition and quality of life.

Preparing for a bowel resection

Before surgery, your child's doctor's will give you details about:

• The type of procedure your child will receive
• What preparations are needed before surgery (for example, how long your child must not eat or drink before surgery)
• What tests may be performed the day of surgery
• How long the operation is expected to last
• What to expect after surgery In most cases, your child will report to the hospital on the day of surgery.

What happens during surgery

Although bowel resection is a major operation, it is done frequently at CHOP with consistent positive results. Our gastroenterology and general surgery teams work together to determine when surgery is needed and which procedure will produce the best results. Our GI-Surgery team is among the best in the world, and have repeatedly been ranked among the best in the nation by U.S. News & World Report.

Before surgery, your child will be given medication to help them stay calm and pain-free during the procedure. Parents can remain with their child before surgery, and may see them immediately after surgery.

For patients with Crohn's disease, the terminal ileum (where the small bowel meets the large bowel) is often where a blockage has occurred. In these cases, a laparoscopic resection (also known as an Ileocecectomy) is the most common operation performed. The goal of surgery is to remove the diseased, damaged or blocked portion of bowel.

During a laparoscopic resection of the bowel:

• Two to four small incisions are made in your child's abdomen
• A laparoscope is inserted to allow doctors to "see" inside the abdomen
• Long, narrow surgical instruments are precisely guided to remove the damaged portion of intestine
• The healthy portions of intestine are reconnected with sutures or staples

In rare cases, a temporary ileostomy or colostomy may be needed to allow the digestive system time to heal. An ostomy is a small hole in the abdomen that is attached an external bag to collect waste. The ostomy allows the child's body to absorb nutrition from the food they eat, and allows waste to safely and painlessly exit the body. Once the child's bowel heals, a second surgery to reconnect the bowel will close the ostomy and allow waste to resume exiting normally through the anus.

Recovery after bowel resection surgery

After a bowel resection, most children will remain hospitalized for three to four days. During hospitalization, your child will be given medication to ease any pain, and the healthcare team will show you and your child how to care for the wounds and, if needed, the ostomy. Your child will be able to drink liquids and eat foods shortly after surgery. Your child's clinical team will let you know when these are permitted.

Children who receive laparoscopic surgery will recover faster, experience less pain and have smaller scars than those who had open surgery. For your child to be discharged from the hospital, they must:

• Be eating and tolerating their diet
• Be walking without assistance
• Have pain controlled
• Be free of fevers

In addition, children who received a bowel resection should also be having regular bowel movements before they are discharged from the hospital.

Once released, children recovering from a bowel resection should rest at home and limit their activities for one to two weeks. Even after normal activity resumes, do not allow your child to perform intense exercise or lift more than about 10 pounds until they are cleared by a doctor. In most cases, it will take four to six weeks to fully recover from any major operation.

Long-term outcomes from bowel surgery

Most children who undergo bowel resection surgery have good results including significant improvement or even resolution of symptoms, a decreased need for medication, and improvements in their nutrition and quality of life.

Reviewed by Peter Mattei, MD, FACS, FAAP, Andrew B. Grossman, MD, and Danielle Karasko, MSN, BSN, CRNP-AC