Transcript Surgical Management of Inflammatory Bowel Disease

Surgical Management of
Inflammatory Bowel Disease
Sandra J Beck, M.D.
University of Kentucky
Assistant Professor of Colon & Rectal Surgery
Surgical Management of IBD
• Goal: Improve Quality of Life
– Curative?
– Treatment of Complications
– Palliation of Symptoms
Surgical Management of IBD
Therapeutic goals vary for
different types of IBD
Inflammatory Bowel Disease
• Classification
– Ulcerative Colitits
– Crohn’s Disease
– Indeterminate Colitis
Normal Anatomy
Ulcerative Colitis:
Course and Prognosis
• Prognosis much improved over last half
century
– Improved medications
– Advances in surgical technique
– Better peri-operative care
• After 10 years of disease, colectomy rate = 24%
• Maintenance of ability to work after 10 years of
disease = 93%
Langholz E, et.al. Gastroenterology 1994;107:3
Surgical Management of
Ulcerative Colitis
• Goals:
– Cure disease
– Improve quality of life—relieve symptoms
– Prevent risk of carcinoma
• Indications
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Toxic colitis
Hemorrhage
Medical intractability
Malignant degeneration (cancer, dysplasia)
Surgical Management
Ulcerative Colitis
• Options
– Total Abdominal Colectomy, end
ileostomy
– Total proctocolectomy, end ileostomy
– Total proctocolectomy, ileal pouch anal
anastomosis
Surgical Management of
Ulcerative Colitis
Total Abdominal Colectomy, End Ileostomy
• Used for urgent/emergent indications
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Toxic colitis
Toxic Megacolon + perforation
Hemorrhage
Intractable disease in “unhealthy” patients
• May be used when classification of IBD is
uncertain
Total Abdominal Colectomy with
End Ileostomy
Total Abdominal Colectomy,
End Ileostomy
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Advantages
Can be expeditiously
performed
Avoids pelvic dissection
Allows for a large
specimen for pathologic
evaluation
Allows patient to
discontinue drug therapies
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Disadvantages
Not a definitive operation
Rectum may remain
symptomatic
Pathologic overlap in
toxic state
Delay necessary before
next surgical step
Surgical Management of
Ulcerative Colitis
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Total Proctocolectomy, End Ileostomy
Curative
Relatively uncomplicated
High patient satisfaction
Benchmark procedure for UC
Permanent Ileostomy
Total Proctocolectomy, End
Ileostomy
• Indications
– Poor anal musculature / fecal incontinence
– Suspicion of Crohn’s disease (i.e. perianal disease,
small bowel disease)
– Rectal cancer
– Patient request
• Technique
– Abdominal proctocolectomy
– Intersphincteric perineal dissection
– Brooke Ileostomy
Total proctocolectomy with end
ileostomy
Surgical Management of
Ulcerative Colitis
Total Proctocolectomy, Ileal pouch anal anastomosis
• Curative
• Relatively uncomplicated
• High patient satisfaction
• Maintains intestinal continuity
• Most common surgical procedure performed today
for ulcerative colitis
Total Proctocolectomy, IPAA
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Patient Selection
Functional Outcome
Complications
Overall Results
Total Proctocolectomy, IPAA
• Patient Selection
– Certainty of diagnosis
– Adequate anal function
– Acceptable medical risk
– Informed and motivated patient
Total Proctocolectomy, IPAA
• Adequate anal function
– Can be determined by history, examination, and
manometry
– Both sutured and stapled pouch surgery leads to
a decline in resting and squeeze pressures
– Patients who are continent preoperatively tend
to remain continent postoperatively
Churh J, et.al. DC&R 1993;36:895
J-Pouch with Temporary
Ileostomy
J-Pouch Anal Anastomosis
(with Ileostomy closed)
Function after IPAA
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BM’s per day = 5 to 7
Continence = 65-90%
Seepage = 10%
Overall quality of life rated excellent
by 90% of patients
• Now have 25 year data
Complications of IPAA
• Overall morbidity rate decreasing with increased
experience with procedure
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Anastomotic leak—10-14%
Intestinal Obstruction–16-19%
Pouch-anal, Pouch-vaginal fistulae
Anal stricture--8-14%
Pouchitis—20%
– More common in UC patients than FAP patients
– Overall long term incidence may be 50%
• Pouch failure rate overall= 2%
Surgical Management of
Crohn’s Disease
Surgical Management of Crohn’s
• No medical or surgical cure for Crohn’s at
present
• Surgery generally reserved for patients with
complications of the disease or for patients
whose quality of life is adversely affected
by medical management
• Specter of recurrence is always present
Surgical Management of Crohn’s
• Indications
– Abscess
– Fistula
– Perforation
– Obstruction
– Extraintestinal Manifestations
– Presence or Risk of Malignancy
Surgical Management of Crohn’s
• Most patients require one or more
operations
– Probability after 20 years = 78%
– Probability after 30 years = 90%
Nat’l Coop. Crohn’s Disease Study Gastroenterology 1979
• Ileocolic disease is most common and most
likely to eventually require surgery
– 90% at 10 years of symptomatic disease
Surgical Management of Crohn’s
Guidelines
• Disease is chronic; keep long term outlook
for patient in mind
• Preserve small bowel whenever possible
• Treat only the primary problem
Surgical Management of Crohn’s
Types of Operations
• Intestinal resection with or without
anastomosis
• Bypass procedures
– Internal-e.g. gastroduodenostomy
– External-e.g. ileostomy
• Stricturoplasty
Resection
• Most common operation for Crohn’s
• Usually initial procedure of choice for small
bowel disease
• Procedure of choice for colitis as well
– Segmental colon resection
– Total colon resection
• 50% will require another operation within
15 years
Resection with Handsewn
Anastomosis
Resection with Stapled
Anastomosis
Specific Anatomic Presentations
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Ileocolic
Small Bowel
Segmental Colon
Entire Colon
Perianal Disease
Ileocolic Crohn’s
• Distal Ileum
– Most common presenting site
– Often involves cecum (40%)
– Management consists of ileocolic resection
with anastomosis
• End-to-End or End-to-Side anastomosis have equal
rates of recurrence
Cameron J, et.al. Ann Surg 1992;215:546
• End-to-Side or Side-to-Side anastomosis have equal
rates of recurrence
Scott N, Sue-Ling H, Hughes L. Int J Colorect Dis 1995;10:67
Ileocolic Disease:
Special Circumstances
• Sparing of Ileocecal Valve
– Need 5-7cm of normal ileum proximal to valve to
preserve
– End-to-End anastomosis generally preferred
• Ileal disease with proximal skip lesions
– Need to be concerned with short bowel syndrome
– Options
• Resection with one anastomosis
• Multiple resections with multiple anastomosis
• Resection in conjunction with stricturoplasty(ies)
Stricturoplasty
• Indications
– Multiple short segment strictures
– Recurrent disease in patients with history of
resection(s)
– Rapid recurrence of disease manifested as
obstruction
– Stricture in a patient with Short Bowel
Syndrome
Stricturoplasty
• Contraindications
– Free or contained perforation of small bowel
– Internal or external fistula involving affected
site
– Multiple strictures in a short segment
– Stricture close to area planned for resection
– Colonic strictures
– Low albumin or protein level
Stricturoplasty
• Heineke-Mikulicz
– Employed for strictures < 10 cm
– Extend longitudinal enterotomy 2cm beyond
stricture in either direction
– Close enterotomy transversely
• Finney Stricturoplasty
– Used for longer strictures
– Resection probably superior
Strictureplasty
Stricturoplasty
• Results
– Morbidity low- 15%
• Sepsis
• Hemorrhage
– 98% of patients relieved of obstructive
symptoms
Fazio V, et.al. DC&R 1993;36:355
– 28% reoperative rate
• 78% of these for remote disease (stricturing or
perforative)
Ozuner G, FazioV. DC&R 1996;39:1199
Colonic Crohn’s
• Segmental Disease
– Value of segmental colon resection
controversial
– Preservation of colon decreases diarrhea, avoids
use of ileostomy
• 62-67% of patients have recurrent colitis
• >80% are able to preserve bowel continuity
Longo W, et.al. Arch Surg 1988;123:588
Crohns Colitis
Crohns Colitis
Crohn’s Colitis
• Extensive disease
precludes segmental
resection
• Proctocolectomy with
end ileostomy
procedure of choice
Crohn’s Colitis
• Subgroup of patients with
extensive disease have
anorectal sparing and
adequate continence
• Abdominal colectomy
with ileorectal
anastomosis
– 50% of patients eventually
require rectal excision at 20
years
– Only 1/3 of patients are
“content”
Perianal Crohn’s
• Clinical Features
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Edematous skin tags
Blue discoloration
Fissures or ulceration
Abscesses
Fistulae
Anorectal stricture
• Patients with colonic disease more likely to have
anal disease
– 52% vs. 14% with small bowel disease
Crohns Anal Fissure
Crohns Anal Abscess
Perianal Disease
Treatment
• Individualized to each patient
• Goals
– Ameliorate symptoms
– Prevent complications
• Goals need to be met without impairing
continence
• Generally medical management preferable with
limited surgical intervention when necessary
Perianal Disease
Treatment
• Effect of proximal disease on perianal
disease
– Multiple studies with conflicting results
– Beyond adolescence there is no compelling
proof that treatment of proximal disease lessens
perianal disease
– Treat proximal disease independently
Crohns Perianal Disease
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Control sepsis with drains or setons
Injection of steriods
Diversion of fecal stream
Excision of Anus and Rectum and
Permanent Colostomy
Drainage with Seton
Questions?
Questions??