Transcript Ulcerative colitis Crohn`s disease

Surgical treatment of inflammatory bowel disease
Aleš Tomažič
Dept. of Abdominal Surgery, University Medical Center Ljubljana
Inflammatory bowel disease
Ulcerative colitis
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Inflammation restricted
to mucosal surface of
colon and rectum
Generally extends prox.
20-25% of patients
need surgical therapy
Surgery=definite cure
Substantial short- and
longterm morbidity
Crohn’s disease
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Inflammation can
spread to adjacent
organs, all parts of GIT
Skip lesions
70-80% of patients
need surgical therapy,
half more than once
Surgery=symptomatic
treatment
Department of Abdominal Surgery, University Medical Center Ljubljana
Ulcerative colitis
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Emergency procedures
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Life threatening complications of fulminant colitis
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Toxic megacolon
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Perforation
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Bleeding
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MOF – 73% mortality rate
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Unresponsive fulminant colitis
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Total colectomy with terminal ileostomy
Elective procedures
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Refractoriness or intolerance to longterm treatment
Stricture, high grade dysplasia or colorectal cancer
Growth failure in pediatric population
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Restorative proctocolectomy
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Department of Abdominal Surgery, University Medical Center Ljubljana
Indication
Patient comorbidities
Surgeon expertise
Department of Abdominal Surgery, University Medical Center Ljubljana
Surgical treatment in emergent setting
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Total colectomy with end ileostomy – procedure of
choice
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Majority of diseased bowel removed
Avoid complications associated pelvic dissection and enteric
anastomosis
Histopathologic assesment to confirm diagnosis
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13% altered diagnosis postoperatively
Cohen JL et al. Practice parameters for the surgical treatment of ulcerative colitis. Dis Colon Rectum 2005; 48: 1997-2009
Hyman NH et al. Urgent subtotal colectomy for severe inflammatory bowel disease. Dis Colon Rectum 2005; 48: 70-73
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Exteriorisation of rectal stump not needed
20/52 patients choosed not to revert ileostomy
Department of Abdominal Surgery, University Medical Center Ljubljana
Restorative proctocolectomy in urgent conditions –
why not?
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Nutritional depletion
Anemia
High-dose steroids
Pelvic bleeding
Sepsis
Injury to pelvic nerves
Khubchandani IT et al. Outcome of ileorectal anastomosis in an inflammatory bowel disease surgery experience of three decades. Arch Surg
1994; 129: 866-869
Department of Abdominal Surgery, University Medical Center Ljubljana
Restorative proctocolectomy –
procedure of choice in elective conditions
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One- or two-stage procedure
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Age
Steroids
Malabsorption, malnutrition
Open or laparoscopic
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Faster recovery
Better short-term results
Better cosmesis
Department of Abdominal Surgery, University Medical Center Ljubljana
No disease
No medications
No cancer
Short-term morbidity
Long-term morbidity
Invalidism
BENEFITS
DRAWBACKS
Department of Abdominal Surgery,
University Medical Center Ljubljana
Postoperative complications
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Ileus
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Pelvic inflammation, sepsis
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Anastomotic separation
5-10%
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Enterovaginal fistulae
3-16%
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Anastomotic stricture
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Pouchitis
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24-48%
Cuffitis
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Female infertility
3-4X
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Pouch failure
10%
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Day and night incontinence
31-45%
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Mortality rate
0,2-1%
Fazio VW et al. Ileal pouch-anal anastomoses complications and function in 1005 patients. Ann Surg 1995; 222: 120-127
Huenting WE et al. Results and complications after ileal pouch anal anastomosis: a meta analysis of 43 observational studies comprising 9317
patients. Dig Surg 2005; 22: 69-79
Department of Abdominal Surgery, University Medical Center Ljubljana
Quality of life after restorative proctocolectomy
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11-17% of patients have social, work and sexual
restrictions
98% of patients would have surgery again
Quality of life linked to pouch function
Elderly patients have worse QL and pouch function
Delaney CP et al. Prospective, age related analysis of surgical results, functional outcome, and quality of life after ileal pouch-anal anastomosis.
Ann Surg 2003; 238: 221-228.
Department of Abdominal Surgery, University Medical Center Ljubljana
Hand sewn vs stapled anastomosis
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Mucosectomy to remove last 1-2 cm of mucosa – selective approach
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Circular staplers in 1990’s
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Presence of ATZ dysplasia (degree, location)
 Mucosectomy and hand-sewn IPAA
No dysplasia
 Stapled IPAA
Preserves abundant nerve supply to anal transition zone
Minimizes sphincter injury
Less nocturnal incontinence in stapled anastomosis
Significantly reduced resting and squeeze pressures in hand-sewn
anastomosis
Lovegrove RE et al. A comparison of hand sewn versus stapled ileal pouch anal anastomosis following proctocolectomy: a metaanalysis of 4183
patients. Ann Surg 2006; 244: 18-26.
Department of Abdominal Surgery, University Medical Center Ljubljana
Construction of pouch
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J-pouch
S- and W-pouch
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J-pouch vs. S- or W-pouch
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Higher frequency of bowel movements (7 vs 5 – 1 year)
(6,5 vs 6 – 9 years)
Faster operation (195 vs.215 min)
McCormick PH et al. The ideal ileal-pouch design: a long-term randomized control trial of J- vs W-pouch construction.
Dis Colon Rectum. 2012;55(12):1251.
Total proctocolectomy with end ileostomy
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Procedure of choice
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Impared anal sphincter function
Distal rectal cancer
No wish to undergo restorative procedure
Stoma related morbidity
Similar quality of life compared to age- and sex-matched
patients with restorative procedures
Camilleri-Brennan J et al. Does an ileoanal pouch offer a better quality of life than a permanent ileostomy for patients with ulcerative colitis? J Gastrointest Surg 2003; 7: 814-819.
Department of Abdominal Surgery, University Medical Center Ljubljana
Total colectomy with ileorectal anastomosis
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Rare
Minimal rectal involvement
Indeterminate colitis
50-60% failure rate
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Ongoing rectal inflammation
Diarrhea
Dysplasia
Leijonmarck CE et al. Long-term results of ileorectal anastomosis in ulcerative colitis in Stockholm county. Dis Colon Rectum 1990; 33: 195-200
Department of Abdominal Surgery, University Medical Center Ljubljana
LAPAROSCOPIC SURGERY
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Subtotal colectomy
Total proctocolectomy
Restorative proctocolectomy
Laparoscopic proctocolectomy with IPAA
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Higher satisfaction with cosmetic results
Better body image
Similar functional outcome
Similar quality of life
Faster return of bowel function
Decreased use of narcotics
Concerns regarding operative time
Higher costs
Ahmed Ali U et al. Open versus laparoscopic (assisted) ileo pouch anal anastomosis for ulcerative colitis and familial adenomatous polyposis.
Cochrane Database Syst Rev. 2009;(1):CD006267.
Dunker MS et all. Functional outcome, quality of life, body image, and cosmesis in patients after laparoscopic-assisted and conventional
restorative proctocolectomy: a comparative study.
Dis Colon Rectum. 2001;44:1800–1807.
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Acute colitis - delay in surgery associated with increased risk for
complications
Length of anorectal mucosa < 2cm
Covering loop ileostomy recommended, can be avoided in
selected cases
Fertile female patients – subtotal colectomy with end ileostomy
or ileorectal anastomosis
Pouch failure – no recommendation about pouch excision
Laparoscopic restorative proctocolectomy – aside from
cosmesis no benefit
Crohn’s disease
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Traditionally surgery and medicine – complementary
treatments
New evolving drugs – surgery treatment of the last
resort
Higher risk of septic complications after surgical
treatment
Intestinal failure – consequence of multiple
operations within a short time span after failure of
primary operation, rather than operations over
several years
Department of Abdominal Surgery, University Medical Center Ljubljana
Crohn’s disease – “5 golden rules”
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Panintestinal disease with intermittent activity with potential of focal
exacerbations throughout patients life
Can’t be cured with excision, surgery treats only complications
Repeated operations are often required, conserve as much gut as
possible
All diseased bowels need not be excised, only part with
complications
Stenotic complications should be widened by strictureplasty or
dilatation
Alexander-Williams J, Haynes IG. Up-to-date management of small bowel Crohn's disease. Adv Surg 1987;20: 245-264.
Department of Abdominal Surgery, University Medical Center Ljubljana
Crohn’s disease – indications for surgery
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Emergency
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Delayed emergency
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Perforation
Bleeding
Ileus
Toxic megacolon
Abscess
Elective operations
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Fistulas (anal, enterocutaneous, enterovesical, enterovaginal...)
Chronic ileus
Conglomerate tumor
Carcinoma
Department of Abdominal Surgery, University Medical Center Ljubljana
Abscess in Crohn’s disease
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Life-time risk 25%
Percutaneous vs surgical drainage
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56% vs 12% recurrence rate
33% percutaneously drained were operated in 1 year followup
Controversy about resection of diseased bowel
Garcia JC et al. Abscesses in Crohn’s disease: outcome of medical versus surgical treatment. J Clin Gastroenterol 2001; 32: 409-412.
Gutierrez A et al. Outcome of surgical versus percutaneous drainage of abdominal and pelvic abscesses in Crohn’s disease. Am J Gastroenterol
2006; 101: 2283-2289.
Department of Abdominal Surgery, University Medical Center Ljubljana
Fistulae in Crohn’s disease
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35% of surgically managed patients
40% of non-surgically managed required surgery in 1 year
Different types
Short fistula tracts, exposed mucosa, high output require operative
intervention
Optimizing patient’s nutritional status before surgery
Surgical technique
 Primary site resection
 Secondary site repair
Michelassi F et al. Incidence, diagnosis, and treatment of enteric and colorectal fistulae in patients with Crohn’s disease. Ann Surg 1993; 218: 660-666.
Sands BE et al. Infliximab maintenance therapy for fistulizing Crohn’s disease. N Eng J Med 2004; 350: 876-885
Department of Abdominal Surgery, University Medical Center Ljubljana
Operative procedures
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Bypass
Resection
Strictureplasty
Department of Abdominal Surgery, University Medical Center Ljubljana
Recurrence after resection for Crohn’s disease
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Radical resection – less recurrence
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margin >10 cm vs margin < 10 cm
margin > 2 cm vs margin < 2cm
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Wide anastomoses
Stapled anastomoses
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Recurrence with surgical reintervention
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31% vs 83%
18% vs 25%
25-35% at 5 years
40-70% at 10 years
Bernell O et al. Risk factors for surgery and postoperative recurrence in Crohn’s disease. Ann Surg 2000; 231: 38-45.
Department of Abdominal Surgery, University Medical Center Ljubljana
Stricturoplasty
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Contraindications
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Recurrence rate 28% at 5 years
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Multiple strictures at short segment
Long stricture
Perforation
Fistula
5% at the previous stricturoplasty site
Obstruction rate 4,4%
Septic complications 11,3%
Tichansky D et al. Strictureplasty for Crohn’s disease: meta-analysis. Dis Colon Rectum 2000; 43: 911-919.
Fearnhead NS et al. Long-term follow-up of strictureplasty for Crohn’s disease. Br J Surg 2006; 93: 475-482.
Department of Abdominal Surgery, University Medical Center Ljubljana
Crohn’s colitis
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25% of patients
Baloon dilatations of stricture
Risk factors for development of dysplasia or carcinoma
50-75% of patients with fistulas require surgery
Segmental versus total colectomy: time to recurrence 4,4 years
longer in total colectomy group
Tekkis PP et al. A comparison of segmental vs subtotal/total colectomy for colonic Crohn’s disease: a meta-analysis. Colorectal Dis 2006;
8: 82-90
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Restorative proctocolectomy with IPAA – significantly higher rate of
morbidity
Brown CJ et al. Crohn’s disease and indeterminate colitis and the ileal pouch-anal anastomosis: outcomes and patterns of failure. Dis
Colon Rectum 2005; 48: 1542-1549.
Department of Abdominal Surgery, University Medical Center Ljubljana
Anorectal Crohn’s disease
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10-15% of patients have disease limited to the
anorectal area
90% of patients have some manifestation of
anorectal disease
Fissures
Fistulas
Abscesses
Damage of sphincter muscle – severe morbidity
•Localised ileocoecal disease with obstruction = surgery
•Active Crohn’s with abscess = drainage, later resection if necessary
•Stricturoplasty safe alternative to resection if stricture < 10cm
•Wide lumen stapled side – to side anastomosis preferred technique
•Laparoscopic approach preferred for ileocolonic resections, but not in
complex and recurrent cases
•In localised colonic disease resection only of the affected part, also in two
segments
•Endoscopic dilatation of stenosis is preferred technique in short strictures
•Stricturoplasty in colon is not recommended
•IPAA is not recommended for Crohn’s disease
•In complicated CD, surgery is valid alternative to medical therapy
•Multidisciplinary clinical conference for complicated CD
Department of Abdominal Surgery, University Medical Center Ljubljana
Conclusions
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Indications for surgical treatment are relatively straight forward, but
precise timing and type of procedure can be fraught with controversy
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IPAA is common procedure in ulcerative colitis, but not for all
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Surgical conservatism general rule in Crohn’s disease because of
panenetric nature of disease with significant reccurence rates
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Laparoscopic surgery is associated with faster recovery and better
cosmesis, providing similar functional results to open procedures
Department of Abdominal Surgery, University Medical Center Ljubljana