Gender Affirming Surgery

Can People with Crohn’s Disease Have Gender-Affirming Surgery Using the Sigmoid Colon Technique?

For transgender women and transfeminine individuals, Gender-Affirming Surgery (GAS), specifically vaginoplasty, is a profound step towards aligning their physical being with their authentic gender identity. Among the various surgical approaches for creating a neovagina, the sigmoid colon technique is one option, utilizing a segment of the large intestine.

However, when a patient has a chronic inflammatory condition like Crohn’s Disease, the choice of surgical technique becomes significantly more complex. At WIH Hospital, our commitment to patient safety and optimal long-term health guides our approach to every complex case. While the sigmoid colon technique offers certain benefits, its implications for individuals with Crohn’s Disease require careful consideration and often lead to exploring safer alternatives.

What is the Sigmoid Colon Technique in Vaginoplasty?

Colon vaginoplasty is an advanced surgical technique that creates a vagina using a section of the colon. Dr. Chettasak Tulayaphanich has been successfully performing this method for more than 20 years at WIH International Hospital, offering unique advantages, particularly the natural ability to produce lubrication.

Understanding Crohn’s Disease and Its Impact on the Colon

Crohn’s Disease is a type of Inflammatory Bowel Disease (IBD) characterized by chronic inflammation of the gastrointestinal (GI) tract. Understanding its nature is crucial when considering any surgery involving the intestines.

▪ Chronic inflammation
▪ Ulcers or fistulas
▪ Scarring or narrowing of the intestines
▪ Previous surgical resection

These symptoms may limit the availability or health of the sigmoid colon, making it important to assess each patient individually.

What is Crohn’s Disease?

    Crohn’s Disease is a chronic condition causing inflammation anywhere along the digestive tract, from the mouth to the anus, though it most commonly affects the small intestine (ileum) and large intestine (colon). Unlike other forms of IBD, Crohn’s inflammation can occur in patches, affecting multiple areas and penetrating deeply into the bowel wall. The exact cause is unknown but involves genetic predisposition, immune system dysfunction, and environmental factors.

 How Crohn’s disease Affects the Colon and Other GI Tract Areas?

    The inflammation caused by Crohn’s Disease can lead to several pathological changes within the GI tract:

• Ulcerations: Open sores that develop in the lining of the digestive tract.
• Thickening of the Bowel Wall: Chronic inflammation can cause the bowel wall to become abnormally thick and rigid.
• Strictures: Narrowing of the bowel lumen due to inflammation, scar tissue, or muscle spasms, which can impede the passage of food.
• Fistulas: Abnormal tunnels that form from the inflamed bowel to other organs (like the bladder, skin, or vagina) or to other parts of the intestine. These are a hallmark complication of Crohn’s and can be notoriously difficult to treat.
• Abscesses: Pockets of pus that can form near areas of inflammation or fistulas.

Common Symptoms and Potential Complications Relevant to Surgery

    Living with Crohn’s Disease involves managing a range of symptoms and potential complications, many of which directly impact surgical considerations:

• Chronic Diarrhea: Often persistent and sometimes bloody.
• Abdominal Pain and Cramping: Ranging from mild to severe.
• Fatigue and Weight Loss: Due to chronic inflammation and malabsorption.
• Bowel Obstruction: Narrowing of the intestines from inflammation or scar tissue can block the passage of food and waste.
• Perianal Disease: Including painful fistulas, abscesses, and fissures around the anus, which are particularly challenging and can involve infection.
• Flares: Periods of increased disease activity and worsening symptoms, often triggered by stress, infection, or other factors. The stress of major surgery itself can induce a flare.
• Poor Wound Healing: Chronic inflammation and nutritional deficiencies can compromise the body’s ability to heal effectively after surgery, increasing the risk of wound complications and surgical site infections.

Can Patients with Crohn’s Disease Still Undergo Sigmoid Colon Vaginoplasty?

   Given the nature of Crohn’s Disease and its profound impact on intestinal health, the use of the sigmoid colon technique for vaginoplasty in patients with a history of Crohn’s Disease is generally strongly cautioned against and often considered contraindicated by leading medical authorities. At WIH Hospital, renowned expert Dr. Chettasak and our board-certified surgical team specifically recommend the penile inversion (skin graft) technique as a safer, effective, and patient-centric alternative for individuals with Crohn’s Disease, mitigating the risks associated with intestinal involvement.

The Risks of Sigmoid Colon Vaginoplasty for Crohn’s Patients

❖ Anastomotic Leakage
❖ Neovaginal Fistulas
❖ Strictures
❖ Disease Recurrence/Flare-up
❖ Poor Healing
❖ Compromised Long-Term Health

Exploring Safer Alternatives: Penile Inversion (Skin Graft) Vaginoplasty

Recognizing the elevated risks, specialized gender-affirming surgeons, Dr. Chettasak, and board-certified surgeons, including those at WIH Hospital, consider alternative techniques that avoid intestinal tissue for patients with Crohn’s Disease. The penile inversion (skin graft) vaginoplasty is highlighted as a highly effective and significantly safer option.

The Penile Inversion (Skin Graft) Technique

Unlike the traditional Penile Inversion Technique, which rolls penile skin inward to create the vaginal canal (often resulting in insufficient depth or poor aesthetic outcome in patients with small genitalia or prior circumcision), Dr. Chettasak’s NPI technique preserves the penile skin for crafting delicate and natural-looking external genital structures, such as the labia minora and vaginal introitus.

Skin Graft Vaginoplasty in this approach uses only scrotal skin (Total Scrotal Skin Graft), which is trimmed and thinned to an ideal thickness (approximately 0.3–0.45 mm) to form the entire neovaginal lining.

If the scrotal skin is insufficient after designing the outer labia (labia majora), Dr. Chettasak may harvest additional skin from the groin area. This site is chosen over more distant regions, such as the lower abdomen or inner thighs, to avoid large or visible scars.

 Advantages for Patients with Crohn’s Disease:

• Avoids Intestinal Tissue: Crucially, this technique does not involve any segment of the large or small intestine.
• Utilizes Healthy Tissue: The penile and scrotal skin are generally unaffected by Crohn’s Disease, providing healthy, robust tissue for reconstruction.
• Reduced Risk of Flares: Without manipulating the bowel, the risk of triggering a Crohn’s flare directly related to the vaginoplasty procedure is significantly diminished.
• Proven Success: The penile inversion technique is the most commonly performed vaginoplasty worldwide, with decades of proven success in creating functional and aesthetically pleasing neovaginas.

For more detailed information on the penile inversion (skin graft) technique and its benefits.

Real-Life Considerations & Advice for Crohn’s Patients Considering Vaginoplasty

If you have Crohn’s Disease and are considering gender-affirming vaginoplasty, here are crucial considerations:

Importance of Pre-Operative Assessment

A comprehensive pre-operative evaluation by the gastroenterologist is essential. This includes:

• Detailed Disease Activity Assessment: Ensuring your Crohn’s Disease is in remission or optimally controlled.
• Colonoscopy: Often required to assess the health of your colon and rule out active inflammation in areas that might impact any surgical field.
• Nutritional Optimization: Addressing any nutritional deficiencies that could impair healing.

Open Communication with the Healthcare Team

    It is paramount to have open and honest discussions with all healthcare providers – the gender-affirming surgeon, gastroenterologist, primary care physician, and mental health professional – about your Crohn’s Disease history and your gender affirmation goals. This ensures a coordinated and safe approach to your care.

Recovery Tips

     Recovery from vaginoplasty requires dedication to dilation and post-operative care. For patients with Crohn’s disease, paying extra attention to overall health, nutrition, and stress management during recovery is vital to minimize the risk of a Crohn’s flare.

 Quality Care for Crohn’s Disease patients at WIH Hospital

At WIH Hospital, your safety, well-being, and successful gender affirmation are our highest priorities. Our expert multidisciplinary team is dedicated to providing personalized care, guiding you through informed decisions, and ensuring your surgical journey is as safe and positive as possible.

We encourage all patients with Crohn’s Disease considering gender-affirming vaginoplasty to consult with our specialists for a thorough, confidential evaluation tailored to your unique health.

FAQ

The sigmoid colon technique uses a segment of your large intestine to create the vaginal canal. Since Crohn’s Disease causes chronic inflammation of the digestive tract, including the colon, using this tissue carries a significantly higher risk of severe complications. These include post-operative flares of your Crohn’s, poor wound healing, new fistulas (abnormal connections), and strictures (narrowing) at the surgical site, which can severely impact your health and the success of the surgery.

The penile inversion technique utilizes existing genital skin (and sometimes a skin graft from another part of the body, like the thigh) to create the neovaginal lining. This method completely avoids using any intestinal tissue. By doing so, it eliminates the risks associated with Crohn’s Disease flares or complications occurring within the newly constructed vaginal canal, making it a much safer and preferred option for patients with this condition.

Yes, it is highly recommended and often required that your Crohn’s Disease be in remission and well-controlled before undergoing any major surgery, especially vaginoplasty. Our multidisciplinary team, including a gastroenterologist, will thoroughly evaluate your disease activity to ensure optimal conditions for surgery and recovery, minimizing the risk of complications.

While the penile inversion technique significantly reduces Crohn’s specific surgical risks, having a chronic condition like Crohn’s means your overall health and healing capacity need careful management. Our team will work closely with you to optimize your nutritional status and manage your medications to support the best possible recovery. Open communication about any Crohn’s symptoms during your recovery is crucial.

Beyond the standard pre-operative assessments for vaginoplasty, you will undergo a comprehensive evaluation by a gastroenterologist. This may include recent colonoscopies, blood tests to check inflammatory markers, and a detailed review of your current Crohn’s treatment plan to ensure your disease is stable and well-managed before surgery.

Yes. If additional depth is required beyond what the penile skin can provide, a skin graft (often from the thigh or groin) is used to line the deeper portion of the neovagina. This is a standard and effective part of the penile inversion technique, allowing for customized depth. Consistent post-operative dilation is typically needed to maintain this depth.

WIH Hospital, our multidisciplinary team, including Dr. Chettasak and other board-certified surgeons with extensive experience in the penile inversion technique, works in close collaboration with gastroenterologists. This ensures a holistic assessment, precise surgical planning to mitigate risks, and comprehensive pre- and post-operative care tailored to your unique needs as a patient with Crohn’s Disease.