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When is it time to consider surgery in Inflammatory Bowel Disease Mark J. Koruda, MD Department of Surgery UNC Chapel Hill, NC.

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Presentation on theme: "When is it time to consider surgery in Inflammatory Bowel Disease Mark J. Koruda, MD Department of Surgery UNC Chapel Hill, NC."— Presentation transcript:

1 When is it time to consider surgery in Inflammatory Bowel Disease Mark J. Koruda, MD Department of Surgery UNC Chapel Hill, NC

2 ULCERATIVE COLITIS AND CROHN’S DISEASE

3 GEOGRAPHICAL PREVALENCE OF IBD

4 INCREASING INCIDENCE OF IBD

5 AGE AND SEX DISTRIBUTION OF IBD

6 Surgery for Inflammatory Bowel Disease Timing is everything ! Stack the deck in your favor !

7 Perioperative Complications with Crohn’s Disease Wound Infections % Anastomotic Leak % Death % Risk Factors –Intestinal Obstruction –Preexisting sepsis –Impaired nutritional state –? Immunosuppression –Multiple anatomoses

8 Surgery for Inflammatory Bowel Disease Get your patient in best possible condition for surgery Nutrition – consider intervention Albumin <3.0; 5% wgt 3 mos Sepsis – Drain abscess Bowel Prep/decompression No need to wean steroids/immunes Prepare for ostomy

9 Facts About Surgery Who Undergoes Surgery? Patients with symptoms not relieved by medication Patients with serious complications, eg, abscesses, fistulas, intestinal blockage, or uncontrolled bleeding What Does It Do? Relieves symptoms Does not prevent relapse How Is It Performed? Usually only a small section of the intestine is removed, but entire colon may be removed in some cases

10 INDICATIONS FOR SURGERY IN CROHN’S DISEASE

11 Indications for Surgery Medical Management Failure(34%) Fistula(24%) Obstruction(22%) Mass(12%) Abscess(7%) Ann Surg 214:231, 1991

12 Indications for Surgery

13 Surgery for Inflammatory Bowel Disease Barium Studies +/- Road Map Extent of disease Avoid with high grade obstruction “X-rays lie” and “We don’t operate on x-rays” Preop Evaluation

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15 Surgery for Inflammatory Bowel Disease Colonoscopy: Evaluate colonic disease esp distal activity Evaluate strictures Preop Evaluation

16 Surgery for Inflammatory Bowel Disease CT SCAN – esp with mass or fevers r/o abscess Relation to organs – ureters Plan incision Preop Evaluation

17 Ureter

18 PELVIC ABSCESS

19 Surgery for Crohn’s Disease Fistulas Enteroenteric (EE)- nuisance fistulas do not necessarily require surgery

20 FISTULAE AND SINUS TRACTS

21 Surgery for Crohn’s Disease Fistulas Enteroenteric (EE)- nuisance fistulas do not necessarily require surgery EEs (duodenocolonic, gastrocolonic, ileosigmoid, jejunocolonic)that cause metabolic, nutritional, output Cxs should be repaired Fistulas (ileum or colon) between urinary tract commonly require repair Fistulas (ileum or colon) between vagina commonly require repair

22 SURGICAL OPTIONS FOR INTRA-ABDOMINAL DISEASE IN CROHN’S DISEASE

23 Operative Management Margins of Resection Wide margins are unnecessary Frozen sections unnecessary Do resect gross disease Any suitable anastomosis - OK

24 Laparoscopic Surgery in IBD 4 – 6 ports 5 – 10 cm periumbilcal incision Cosmetics Pain Length of Stay Recuperation Anticipate potential future stoma in incision placement

25 Laparoscopic Surgery Crohn’s Disease Indications should not differ between open (conventional) and laparoscopic surgery Contraindications: Diffuse peritonitis Acute obstruction with distension accompanied by dilated loops of intestine History of multiple previous laparotomies, known dense intra-abdominal adhesions Coagulopathy not correctable Portal HTN with intra-abdominal varices

26 Laparoscopic Surgery Crohn’s Disease – Bottom Line Improved postoperative pulmonary function Slight reduction in duration of postoperative ileus Decreased hospital stay (5 v 6 d) A slight decrease of the cost of direct hospital costs for laparoscopic surgery A moderate decrease of surgical morbidity (minor)

27 Hand-assisted Laparoscopic Surgery (HALS)

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30 STRICTUROPLASTY (HEINEKE-MIKULICZ)

31 STRICTUROPLASTY (FINNEY)

32 Non-conventional Stricturoplasty in Crohn’s Disease

33 Stricturoplasty O.K. to do when... Diffuse involvement with multiple strictures Stricture(s) after previous major resection(s) Fibrotic stricture

34 Perforated Phlegmon / fistula Bleeding Multiple Strx in short segement Strx close to resection site Colonic Stx (Ileo-colonic OK) Poor nutrition Stricturoplasty Don’t do when...

35 Segmental Colectomy Colectomy - colostomy Subtotal colectomy - ileostomy Ileo-rectal anastomosis (IRA) Crohn’s Colitis High Risk of Recurrence

36 Fate of the rectum in patients undergoing total colectomy and IRA for Crohn's disease YearN5 yr CR10 yr CR Fx IRA 5yr Fx IRA 10yr

37 Surgery for Crohn’s Disease RV Fistulas Rectovaginal Fistulas – commonly are nuisance Upwards of 50% heal with medical management (infliximab) Surgical repair - ~70% successful Depends on quality of vaginal and rectal disease Steroids -> negative effect

38 Surgery for Crohn’s Disease RV Fistulas - Surgery Transrectal flap – limited by rectal disease/stenosis Transvaginal flap Transrectal and –vaginal approach +/- Diversion – ileostomy vs colostomy

39 PERIANAL FISTULAE AND ABSCESS

40 Imaging Perianal Fistula in Crohn’s Disease Fistulography

41 Imaging Perianal Fistula in Crohn’s Disease EUS

42 Imaging Perianal Fistula in Crohn’s Disease MRI

43 Perianal Fistula in Crohn’s Disease- NOT! Hydradenitis Suppurativa: chronic, recurrent inflammatory process involving the apocrine glands of the axilla, groin, perineal, and perianal regions

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47 SURGICAL TREATMENT OPTIONS FOR PERINEAL CROHN’S DISEASE

48 The Surgisis AFP plug is made from a complex collagen (protein) scaffold obtained from pigs— which have a collagen structure almost identical to that of human tissue. Closure of Crohn's anorectal fistula tracts using Surgisis® anal fistula plug is safe and successful in 80 percent of patients and 83 percent of fistula tracts. Closure rates were higher with single tracts than complex fistulas with multiple primary openings.

49 INDICATIONS FOR SURGERY IN ULCERATIVE COLITIS

50 TOXIC COLITIS

51 PERFORATION

52 Fulminant Colitis Total abdominal colectomy - ileostomy Safest operation 20% of cases

53 INDICATIONS FOR SURGERY IN ULCERATIVE COLITIS

54 RISK OF COLORECTAL CANCER

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58 Stomal Complications... More common than you think ! 150 ileostomies over 10 yrs with 20 yr f/u U.C. - 76%; Crohn’s - 56% Br. J. Surgery 81:727, 1994

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60 IPAA UNC (675)

61 IPAA UNC (808)

62 IPAA Stages Single Stage Healthy No chronic steroids No chronic immunosupressants Technically sound 5% of cases

63 IPAA Stages Two Stages (IPAA-ileostomy; ileostomy takedown) Elective operation Chronic steriods Chronic immunosuppressants Technical considerations 60% of cases

64 IPAA Stages Two Stages (Colectomy-ileostomy; Completion proctectomy IPAA) Usually an urgent 1 st operation High dose steroids Safest 1 st operation IPAA w/o ileostomy if technically sound 20% of cases

65 IPAA Stages Three Stages ( Colectomy-ileostomy; Completion proctectomy IPAA-ileostomy; Ileostomy TD ) Usually an urgent 1 st operation High dose steroids Safest 1 st operation Technical considerations -> ileostomy 20% of cases

66 Laparoscopic Restorative Proctocolectomy Cochrane Review 2009 Eleven trials patients No significant differences in mortality or complications Operative time was significantly longer in the laparoscopic group No significant differences regarding postoperative recovery parameters. Higher cosmesis scores in the laparoscopic group. (smaller incisions)

67 Laparoscopic Restorative Proctocolectomy Cochrane Review 2009 Authors' conclusions The laparoscopic IPAA is a feasible and safe procedure. Short-term advantages of the laparoscopic approach seem to be limited and their clinical significance is arguable.

68 INDETERMINATE COLITIS

69 Indeterminate Colitis (IC) The real story Fistulas: > IC than UC (26 vs. 10 %; P = 0.02) No IC pt required a permanent ileostomy vs with 6 UC pts. Long-term functional results were similar. Pouchitis: 2/3 developed pouchitis. UC and CD pts >3 episodes of pouchitis (58 and 72 %) vs IC (29 %; P = 0.006). CONCLUSIONS: Although IPAA patients with IC have more postoperative fistulas, long-term function is equal to that of UC and better than CD. IPAA should be offered to patients with IC and those in whom clear differentiation between IC and UC cannot be made. Dis Col Rect 45(11):1525, 2002

70 IPAA Complications Early (30-40%) SBO – 10-30% (4x with ileostomy) Sepsis/Abscess – 3-15% Thrombotic – DVT, PE, SMV or Portal Bleeding – GI vs intra-abdominal Pouch ischemia Pouch leak

71 IPAA Complications Late SBO – 10-30% (4x with ileostomy) Pouch Stricture – 8-14% Pouchitis – 50% Pouch fistula – 3-10% Pouch Loss – 1-4% Hernia

72 IPAA “Novel” COMPLICATIONS Stomal Volvulus

73 IPAA “Novel” COMPLICATIONS Thrombotic complications in IBD - 1% to 6% and as high as 39% in a postmortem study. The cause of hypercoagulability in IBD is unclear –Related to activity of disease and coagulation abnormalities: increased plasminogen activator inhibitor, factors V and VIII, and fibrinogen and decreased factor V Leiden, antithrombin III, proteins C and S – 60% of pts with active IBD had a hypercoagulable state vs 15% with inactive disease

74 IPAA “Novel” COMPLICATIONS SMV – PV Thrombosis 45% of pts who had post op IPAA CTs “The incidence of postoperative SMV-PV thrombosis is likely more frequent than previously reported. “

75 IPAA “Novel” COMPLICATIONS “Pouch Stasis”

76 POUCHITIS

77 BENIGN STRICTURE

78 MALIGNANT STRICTURE

79 PROTOCOL FOR MANAGEMENT OF DYSPLASIA

80 COLORECTAL CANCER RISK IN ULCERATIVE AND CROHN’S COLITIS

81 TRANSVERSE COLON STRICTURE

82 ENTEROVESICAL FISTULA

83 FISTULAE

84 PERINEAL COMPLICATIONS

85 PERIANAL ABSCESS

86 ILEAL POUCH-ANAL ANASTOMOSIS

87 SURGICAL OPTIONS IN ULCERATIVE COLITIS

88 LONG-TERM ADVERSE OUTCOMES OF ILEAL POUCH ANAL ANASTOMOSIS

89 POUCHITIS

90 MEDICAL TREATMENT OPTIONS FOR PERINEAL DISEASE

91 PERCUTANEOUS ABSCESS DRAINAGE FOR CROHN’S DISEASE

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94 Surgery in CD: Indications Failure to respond to medical therapy Management of complications –Strictures –Fistulas –Perforations –Perianal disease –Cancer or precursors

95 Indications for Surgery

96 Types of Operations Intestinal Resection Bypass Procedure Stricturoplasty

97 Surgery in CD ProceduresIndications Resection and Regional enteritis, ileocolitis, anastomosis segmental disease StrictureplastyMultiple segmental strictures in jejunoileitis, proximal skip disease (in conjunction with resection) Colectomy and Pan(ileo)colitis with rectal ileostomy involvement, severe perirectal sepsis

98 Surgery in CD ProceduresIndications Subtotal colectomy Extensive colitis with and ileoproctostomy normal rectum Diverting ileostomyCrohn’s colitis Temporary ileostomy Alternative to anastomosis colostomyor when anastomosis inappropriate

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107 Complications of Crohn’s Disease Fistulas Abscesses Intestinal blockage Extra-intestinal disorders (eg, arthritis and disorders of the skin, eyes, kidneys and liver) Malnutrition Growth failure in children

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111 Inflammatory Bowel Disease Surgical Alternatives Mark J. Koruda, MD Department of Surgery UNC Chapel Hill, NC

112 Stricturoplasty for Crohn’s Disease DateNPlastiesResectCxRecur Average2.7/pt

113 Reasons for Continent Ileostomy Dis Colon Rectum 38:573, 1995

114 Pouch Status Dis Colon Rectum 38:573, 1995

115 Course Following Surgery

116 Reason for Pouch Excisions Slipped Valve - 6 Pouch Fistula - 9 Personal - 1

117 Mucus Production

118 Frequency of Pouch Intubation

119 Types of Operations Intestinal Resection Bypass Procedure Stricturoplasty

120 Crohns is left behind The bowel’s bad Stricturoplasty Remember...

121 Indications for Surgery Ann Surg 214:231, 1991


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