IBD Drive Time: Rebecca Brown, MD, on Surgical Treatment for IBD

So I tried to come up with some questions in clinical practice that I think there are not definitive answers for.

So the first one is, a patient with a significant stricture that's asymptomatic, do you reset that or observe that? So how are we approaching that in our practice?

I mean, I think to me, the key of that is that if you can't traverse it endoscopically, then you have no way to evaluate the rest of the colon above it.

I think if it's non-perversible, even if it's asymptomatic, probably even a short segment resection is a reasonable approach to allow for endoscopic access to assess for other areas of disease.

Yeah, it's very controversial.

The one thing that I'll add, and I'm sure you agree with this, is are they truly asymptomatic? So typically we ask them about, I'll give them a typical lunch, sandwich, little bag of chips, piece of fruit, something to drink.

Do they have bloating, borbrygmi, pain, nausea, vomiting? Many patients that have a stricture will tell you that they can't eat that much.

And when you ask them why they feel full, they get some of these symptoms.

And then you can ask about raw fruits and vegetables.

You can ask about a steak or a burger that's on the well-done size.

So those are sort of your stricture stress tests to see what happens.

And I agree with you, you can't really assess above it for inflammation.

And particularly in middle-aged and older patients, there's also a risk of malignancy within the strictures.

We don't see them that often, but certainly that is in our differential.

So I offer patients with tight strictures a surgical approach.

I do give them the option of monitoring, but I also remind them that they could have a sudden acute obstruction where they can't pick the time, they can't pick the surgeon, they can't pick the institution that's going to do it.

And those are real issues.

So we're definitely aligned there.

The other analogy I use is we don't watch an asymptomatic aortic aneurysm rupture, right? We repair those all the time without any question.

So I'm sure the surgeons listening to this will have There may be some different opinions, but I agree with you that elective resection makes sense.

I think you're absolutely right about the, you know, patients sometimes don't realize that they're symptomatic.

You know, if that's a very kind of loaded question, are you symptomatic from your structure? And a lot of them probably don't realize that they have become more symptomatic over time.

So I really like the approach of giving them a lunch and kind of seeing what they could tolerate or not tolerate.

My question for you is, do you routinely biopsy those? during colonoscopy, especially if you're planning to send them to surgery with the knowledge that they may have an underlying malignancy there.

Because from my perspective, having a negative biopsy makes me more able to do a short segment stricture resection.