Transcript - Catalyst
Is there a Superior Anastomosis for Pediatric Crohn’s Disease? Morgan Richards, MD August 23,2012 Outline • Case Presentation • Background – Crohn’s Disease • Indications for Operation • Post-operative recurrence • Hand-sewn vs.. stapled anastomoses • Conclusions WC • 15 y/o boy PMH Crohn’s Disease dx 2009 • Admitted for Crohn’s flare 7/25/2012 • RLQ pain, decreased PO intake, RLQ mass • Workup • Colonoscopy • MRE • CT Ab/Pel • Continued pain after medical management • NPO, TPN, Zosyn CT Abdomen and Pelvis UGI with SBFT WC • 8/1/2012 Robot-assisted ileocecectomy with primary anastomosis for stricture • Primary end to end anastomosis • Interrupted Vicryl sutures, single layer closure Background – Crohn’s • Any portion of GI tract may be involved • Segmental, discontinuous • 60% involve TI • 30% perianal disease Background – Gross Pathology • Gross Pathology • Aphthous ulcers stellate coalesce • Longitudinal ulcers surrounding edematous tissue cobblestone • Transmural • Progressive inflammation leads to fibrotic scaring stricture • Fatty tissue from mesentery extends over serosa creeping fat Background - Micro Pathology • Lymphoid aggregates thicken mucosa • Non-caseating granulomas Clinical Manifestations • Three types of disease • Stricturing • Lumenal narrowing, fibrotic scar • Obstructive symptoms • Require operative intervention • Perforating • Sinus tracts • Incite inflammation, adhesions, lead to fistulae • Inflammatory • Medical management for edema, inflammation Operative Indications • Not curative, palliative, preserve intestinal length • Failure medical management • Intestinal obstruction • Enteric fistulae • Abscess/inflammatory mass • Hemorrhage • Perforation • Cancer • Growth retardation Types of Anastomoses Risk Factors for Operation • Neera et al 2006 • Study design – Retrospective review • • • • 989 consecutive pts. with Crohn’s disease (age 1-17 at diagnosis) 6 centers Jan 2000-Nov 2003 IBD Consortium registry Median follow up 2.8 years (1day-16.7yrs) • 128 pts. underwent surgery • 17% by 5 yrs. from diagnosis • 28% by 10 yrs. from diagnosis • Risk for Surgery • Female, initial dx UC, poor growth, abscess, fistula, stricture • Protective factors • Age 3-12 at diagnosis • Fever at presentation • Tx with infliximab or 5-aminosaliciylic acid Disease Recurrence • Definition • Endoscopic, histologic, clinically symptomatic, radiographic, surgical • Risk factors • Smoking, penetrating disease, prior resection for CD, short duration of disease Endoscopic 1yr 3yrs 20-70% 40-50% Second Operation Clinical Criteria 10% 30% 5yrs 20yrs 25-30% 40-50% 50-60% Rutgeerts Scoring System Pediatric Recurrence • Baldassano et al. 2001 (CHOP) • Retrospective review 79pts 1978-1996 • Inclusion Criteria • Patients CD Dx, initial resective surgery Jan 1978 – Dec 1996 • Exclusion Criteria • >21 at first operation, perianal dz operations, abscess drainage, prior CD operation, strictureplasty • Definition of disease recurrence • Increase in PCDAI 30 over baseline + radiological, histological, endoscopic confirmation • Response to escalation in medical therapy • Study end points • Recurrence of symptoms, death without recurrence, last available f/u • Mean follow up 4.3yrs (range 0-14.39 yrs.) Pediatric Recurrence • Baldassano et al. 2001 • Clinical recurrence rate • 17% at 1 yr • 38% at 3 yrs. • 60% at 5 yrs. • Risk factors for recurrence • Preoperative use of 6-MP (1yr vs. 4.45 yrs., p < 0.005) • Crohn’s disease limited to colon (p < 0.05) • PCDAI (Increase > 30 points above baseline, p < 0.05) • Limitations • Retrospective, single institution • Small patient population (type b error) • Short follow up duration Stapled vs. Hand sewn Anastomoses • Cochran Review 2011 • 7 RCTs, 1125 pts. (441 stapled, 684 HS) • 1980’s-2009 • 4 studies - cancer patients (825 pts.) • 3 studies - non-cancer patients (264 pts.) 2 specifically CD • Primary outcome • Overall anastomotic leak (clinical or subclinical) • Reoperation • Secondary outcomes • 30-day mortality • Clinical anastomotic leak • Intra-abdominal abscess • Radiological anastomotic leak • Wound infection • Anastomotic stricture • LOS • Anastomotic hemorrhage • Time to perform anastomosis Stapled vs. HS in Crohn’s Disease Stapled Leak Rate Hand sewn Leak Rate p - value All (1125 pts.) 2.5% 6% 0.03* Cancer (825 pts.) 1.3% 6.7% < 0.05* Non-cancer (264 pts.) 5% 4% > 0.05 • Other outcomes – no difference in: • Overall anastomotic leak • Clinical anastomotic leak • Re-operation • Operative mortality • Intra-abdominal abscess • Wound Infection Recurrence after Ileocolic Resection • RCT, McLeod et al. 2009: Stapled vs. hand sewn anastomosis in ileocolic resection for crohn’s disease • 170 pts. from 17 sites • Intraoperative randomization, computer generated • Two surgical techniques • Hand sewn end to end with 2-0 PDS • Stapled side to side functional end to end anastomosis • Follow up • 6wks, 3mo, 6mo, 9mo, 1yr (with colonoscopy) Recurrence after Ileocolic Resection Inclusion Criteria Exclusion Criteria • Disease in distal ileum and • Previous disease resection right colon • Scheduled, elective resection • Required defunctioning ileostomy • Unable to discontinue CD medications post-operatively Recurrence after Ileocolic Resection • Primary endpoint • Endoscopic recurrence by Rutgeert’s score (i2, i3, i4) • Secondary endpoint • Symptomatic recurrence, endoscopic disease plus symptoms requiring medical or surgical treatment • Time to construct anastomosis • Duration of operation • Post-operative complications • Reoperative rate Results • Hand sewn • 81pts (94%), hand sewn anastomosis with 2-0 PDS • 60 (70%) in 1 layer, 26 (30%) in 2 layers • Stapled • 49 (58%) side to side • 35 (42%) functional end to end • Statistically significant outcomes • Shorter time for anastomosis in stapled group (p = 0.0001) • Shorter mean duration of surgery in stapled group (p = 0.0009) • No difference in • Median hospital stay • Overall complication rate • Leak rates • Reoperative rates Results • Primary Endpoints: Hand sewn Anastomosis Stapled Anastomosis p - value Endoscopic Recurrence Rate 42.5% (31/73) 37.9% (25/66) 0.55 Symptomatic Recurrence Rate 21.9% 22.7% 0.92 Risk Factors for Recurrent Disease Conclusions • No definitive evidence for stapled or hand sewn anastomosis • Stapled may be faster intraoperatively, but does not decrease overall length of stay or provide a mortality benefit • Data remains inconclusive • Low power • Short duration of follow up • Clinically poor primary endpoint References • Baldassano RN. Pediatric Crohn’s Disease: Risk factors for • • • • Postoperative Recurrence. Am. J Gastroenterology 2001; 962169-2176. Gupta N. Risk Factors for Initial Surgery in Pediatric Patients with Crohn’s Disease. Gastroenterology 2006; 130: 1069-1077. McLeod RS et al. Recurrence of Crohn’s Disease After Ileocolic Resection Is Not Affected by Anastomotic Type: Results of a Multicenter, Randomized, Controlled Trial. Dis Colon Rectum 2009; 52: 919-927. Choy PYG, Bissett IP, Docherty JG, Parry BR, Merrie A, Fitzgerald A. Stapled versus hand sewn methods for ileocolic anastomoses. Cochrane Database of Systematic Reviews 2011, Issue 9. Swoger JM. Evaluation for Postoperative Recurrence of Crohn‘s Disease.Gastroenterology Clin N Am 2012;41:303314.