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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:

📧

Follow Rachel at @bottomlineibd

Follow Nigel at @crohnoid