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In this episode of Wrestling the Octopus IBD, Nigel and Rachel talk with Mr Raj Mankotia, Consultant General and Colorectal Surgeon at Sandwell and West Birmingham Hospitals NHS Trust, to demystify the world of IBD-related surgery. With over 25 years’ experience, Raj talks us through first‑time elective or semi‑elective surgery for Crohn’s disease and ulcerative colitis - why it’s needed, what it involves and how patients can prepare for it.

🔍 Key Topics Covered

1. Why Patients Are Referred for Surgery

Raj explains the two main pathways:

Elective referrals
- Failure of medical therapy
- Persistent symptoms (urgency, bleeding, weight loss, malnutrition)
- Pre‑cancerous changes or cancer found on surveillance colonoscopy
Emergency referrals
- Severe inflammation
- Bleeding
- Perforation

2. “Can I choose surgery instead of medication?”

Some patients doing well on medication may still prefer surgery. Raj explains:

This is not a routine pathway
Decisions are individualised
Crohn’s patients will still need maintenance therapy after surgery

3. Fear of Surgery & Fear of Stomas

A major theme of the episode.

Raj discusses:

How stoma decisions are made before surgery, not as a surprise
The role of stoma nurses, psychologists and IBD teams in preparing patients
Why emergency surgery often requires a temporary stoma

4. Common Misconceptions

The biggest one?

“Everyone who has IBD surgery ends up with a permanent stoma.”

Raj explains why this is not true, and how decisions depend on:

Disease location
Nutritional status
Steroid use

He also notes that many patients ultimately choose to keep their stoma because of the improvement in quality of life.

5. Crohn’s Surgery: Ileal / Ileocaecal Resection

Raj outlines:

Why this is the most common Crohn’s operation
What the surgery involves

He also discusses how recurrence rates have improved with modern biologics.

6. Ulcerative Colitis Surgery

Key points include:

Around 20–30% of UC patients may need surgery
Emergency surgery usually involves total colectomy, leaving the rectum
Reasons for leaving the rectum include protecting pelvic nerves (bladder and sexual function)

7. J‑Pouch Surgery

Raj gives a realistic, balanced overview:

Can be done laparoscopically
A pouch is made from small bowel to mimic rectal function
Outcomes vary:
- ~50% have excellent function
- ~50% have more challenging function

8. Preparing for Elective Surgery

Patients may be advised to:

Optimise nutrition
Taper steroids
Stop smoking

9. Hospital Stay & Recovery

Typical expectations:

Enhanced recovery programme
Drinking on day 1, light food on day 2
Early mobilisation

Raj also explains postoperative ileus - why it happens and how it’s managed.

10. What Patients Wish They’d Known

Raj shares reflections from his clinics:

Many wish they’d had surgery earlier
Many are surprised by how much better they feel
Some who had emergency surgery and complications question the timing

📩 Get in Touch

If you have questions for future surgical episodes or topics you’d like covered:

📧 wrestlingtheoc

Follow Rachel at @bottomlineibd

Follow Nigel at @crohnoid

#24 An introduction to IBD surgery - with consultant colorectal surgeon, Raj Mankotia

Wrestling the Octopus (IBD)