1. M62 Course April 7-8 2005 SURGERY for COLONIC CROHN’S DISEASE RJ NICHOLLS

2. Crohn’s Disease Surgery Indicated for Complications Recurrence Often Long term Relief Minimal Surgery No proven effect of Medical Treatment on Recurrence

3. CROHN’S DISEASE Indications for Surgery Elective Obstruction Fistula/abscess Colitis Carcinoma Anal Disease

4. Avoid Late Surgery Postoperative Complications FasthLindhagenPocard 1980 1982 2000 Preoperative Sepsis NO12 % 22% 5% YES48% 45% 23% Hulten 2001

5. CROHN’S DISEASE The Cancer Risk nfu/yDysCarelative risk Swedish study1655 30* - - SI1 Il/col3.2 LI5.6 Gillen 1994281 12-35 - 8 3.4+ Friedman 2001259 -20 42(16) 5 *20.9 < 30y at onset +18.2 extensive colitis

6. The Defunctioned Rectum 25 Patients Low Hartmann’s Procedure 3 Cases of Cancer Regular surveillance Ciccione 2000

7. CROHN’S COLITIS Urgent Surgery % Failed medical treatment 70 Toxic dilatation 20 Perforation <10 Bleeding < 5

8. ACUTE SEVERE COLITIS CROHN’S DISEASE 20-30% of cases 5 Studies 68 patients Medical Treatment Remission65%(55-94%) Remission maintained54-69% Kornbluth 1999

9. ACUTE CROHN’S COLITIS Choice of Operation 145 Patients Colectomy + IRA47 Proctocolectomy27 Colectomy + Ileostomy13 Ileostomy alone10 Keighley 1993

10. ACUTE SEVERE COLONIC CROHN’S DISEASE Initial Colectomy + Ileostomy Operation Survivors 21 Rectal excision C + IRA 11 1 No surgeryIleal Colostomy 5 resection 1 3 Keighley 1993

11. COLONIC CROHN’S DISEASE Main Indications for Elective Surgery Severe Local Symptoms Obstruction Fistulation Anorectal disease Systemic illnessChronic Proctocolitis

12. Pouches and Crohn’s Disease Authors YearMean F/U Total Crohn’s Pouch Cases Failure(%) Hyman 1991 38 25 32 Grobler 1993 - 20 30 Sagar 1996 - 37 46 Regimbeau 2001 113 41 7 Hartley 2003 - 60 25 Tulchinsky 2003 90 13 46 Total 227 31

13. Restorative Proctocolectomy for Crohn’s Disease 3-5% in large surgical series Failure up to 50% (cf UC 10%) Failure increases with time

14. COLONIC CROHN’S DISEASE Segmental v Total Colectomy + IRA Total Colitis70% Segmental Colitis30% Kornbluth 1999

15. Segmental v Total Colectomy +IRA

16. SEGMENTAL(SC) v TOTAL COLECTOMY + IRA 6 Studies488 Pt 265 SC 223 IRA Meta-analysis Time to Recurrence Longer after IRA by 4.4 y Fewer Operations After IRA where two segments involved Tekkis et al 2005

17. CROHN’S DISEASE Colectomy with IRA Nfu(y)Recurrence(%) Flint 1977 37 6 41 Buchman 1981 105 8 30 Ambrose 1984 63 10 48 Goligher 1988 47 15 49 Allan 1989 63 15 53 Longo 1992 131 10 65

18. Recurrence after Colectomy with IRA and Total Proctocolectomy

19. CROHN’S DISEASE COLECTOMY + IRA 131 Patients Fu 9.5 y 13 Ileostomy never closed 118 ProctectomyFurther ileal No resection 30 Diversion resection 48 16 24 Longo 1992

20. Colectomy with IRA Rectal Sparing in 50% of Large Bowel Crohn’s Indicated where two or more segments are involved Recurrence in ~ 50% over 10 years May be possible to re-resect terminal ileal recurrence to avoid permanent stoma

21. PROCTOCOLECTOMY Indications Severe Rectal Disease Cancer Severe Anal Disease (almost always rectal involvement present) Small Bowel Recurrence 20% at 10 y

22. Perineal Wound Delayed Healing Incidence 30% or more of patients x3 in pre-existing anal sepsis Leave open in the presence of sepsis Medical management ?value Intensive Nursing

23. RESTORATIVE PROCTOCOLECTOMY Close Rectal Dissection with Intersphincteric Anal Removal Avoids pelvic nerve damage Not with dysplasia Not with carcinoma

24. SEVERE ANORECTAL CROHN’S DISEASE SPLIT ILEOSTOMY 29 Patients 36 mo Still defunctioned15 Proctocolectomy 8 Restoration of Continuity 6 Late deaths 2Harper 1982