Surgery on Crohn’s Disease Joint Hospital Surgical Grand Round Dennis KY Ngo Department of Surgery Prince of Wales Hospital

Background Chronic transmural inflammatory process that can affect GI tract anywhere, also associated with extraintestinal manifestation Commonly : ileal, ileocolic, colonic and perianal disease Diagnosis based on macroscopic, histologic and radiological features

Incidence More common in Caucasian Rate is lower in Asia. 5-6 per 100 000 population ( North American, northern Europe ) Rate is lower in Asia. However, there is increasing trend 1 per 100 000 population ( Hong Kong )  3 fold over the past decade Leong at el. Inflammatory Bowel Diseases. 10(5):646-51, 2004 Sep.

What is the surgeons’ role in treating this benign disease ? Increasing incidence of Crohn’s disease annually, more and more people will keep an eye on the treatment modality, esp in these young age group population. Apart from medical therapy, What is the surgeons’ role in treating this benign disease ?

M/22 Good past health Presented in March 2006 with right iliac fossa pain associated with diarrhoea and weight loss for 1 month

Colonoscopy on 8 March 2006 Inflammation and ulcers at caecum and ileocaecal valve Terminal ileum could not be intubated because of swollen ileocaecal valve Biopsy: Crohn’s disease Seen by Gastroenterologists on 10 March 2006; Salofalk 1 g TDS and prednisolone started

Readmission as Emergency Readmission on 12 March 2006 Increased right iliac fossa pain for 1 day Fever 38.5 0C Pulse rate: 100/minute CXR: no infradiaphragmatic free gas WCC: 13.5 x 109/L

Thickened terminal ileum and caecum

Pockets of free gas

Pocket of free gas

Ileocaecal Crohn’s disease with peritonitis and suspected perforation  Emergency laparoscopic-assisted right hemicolectomy

Cobblestone appearance

~ 80% will require surgery irrespective of its site Farmer et al. Gastroenterology 1985; 30:990-5 Bernell et al. Ann Surg 2000; 231:38-45 Surgery  Curative ( potentially involve the entire intestine ) Recurrence (invariable) Potential benefits of surgery Symptoms relief Improved nutritional status Reduced dependence of medication Development of Surgical procedures focus on treating the complications as well as conserving the bowel length

Indications of Surgery Failed medical treatment Growth retardation (Children) Complication of steriod and other medical therapy Complications Obstruction Perforation Fistula formation Abscess formation Bleeding Toxic colitis Malignancy

Management of Stenosis Non-operative Balloon dilatation Operative Bypass Strictureplasty Resection

Balloon dilatation 55 patients, managed by endoscopic dilatation 18mm balloon, followed by 20/25mm Inflated for 2min ( repeat 2-6 inflations) 90% successful dilatation 8% perforation rate Mean FU time : 33.6 months 18 patient need second dilatation at 1.5 year Long term successful rate : 62% Operation rate : 38% Couckuyt H, et al. Gut 1995;36:577-580

Bypass Popular in the past (1930-1950) Problems : Active disease in the retained segment Abscess / Fistula / Perforation / increased rate of malignancy of bypassed segment No place in modern day surgery, Except Gastroduodenal Crohn’s with hostile adhesions to adjacent organs preventing a safe excision

Strictureplasty Mainly used for small bowel Good symptomatic relief and bowel sparing Aim at conserving small bowel for the fear of short bowel Ideal for short stricture Can be performed for single or multiple strictures

Contraindication Perforation of bowel Present of abscess, inflammation and fistula Multiple strictures over a short segment of bowel Inability to perform tension-free suture line Profound hypoalbuminemia Generally not to be performed on large bowel High recurrence rate High risk of malignancy

Technique Longitudinal incision with extension to normal looking bowel Inspection of lumen, biospy of suspicious lesion ( R/O malignancy ) Stricture < 10cm : close in Heineke-Miculicz fashion Stricture 10-20cm : repaired with Finney strictureplasty

Heineke Miculicz Strictureplasty

Recurrence & Reoperation 100 patients included for strictureplasty Mean FU 85.1 months ( 0.2-240.9 months ) Overall reoperation rate : 56% N. S. Fearnhead et al. British Journal of Surgery 2006;93:475-482 162 patients Reoperative rates (5 years) : 31% Ozuner et al Dis Colon Rectum 1996

Majority – new segments of stricture Recurrence at strictureplasty site is rare – 3.7% Stebbing et al Br J Surg 1995

Resection Limited resection to achieve the goal of symptomatic relief, while preserving the bowel length Resect macroscopically diseased bowel without concern for microscopic disease Recurrence is unaffected the width of the margin of resection from marcroscopically involved bowel Recurrence rate not increase when microscopic disease still present in the resection margin Fazio et al. Annals of Surgery 1996;224:563-573

Intestinal Fistula Internal fistula (30-40% CD) Ilijevski et al Eur J Surg 1997 General surgical principle Resect the 10 diseased segment Close the 20 involved organs

Colonic operation Intractable disease ( failed medical therapy ) Severe colitis Bleeding Malignancy Involving entire colon and rectum Gold standard : proctocolectomy and ileostomy

Less extensive resection Subtotal colectomy + mucous fistula Total colectomy + ileorectal anastamosis Segmental colonic resection

Role of laparoscopic surgery Longer operation Higher cost Faster recovery Less scarring

Application of laparoscopic technique to Crohn’s disease Benign disease Relatively young patients (back to normal duty with economic consideration) Better cosmesis  Risk of adhesive intestinal obstruction / incisional hernia Possibility of multiple surgery Ozuner D et al Dis Colon Rectum 1996; 39: 1199-1203

Development Stoma creation (ileostomy / colostomy) Earliest indication Braga M et al Ann Surg 2002; 236: 759-66 Limited segmental SB resection Ileocaecal resection More complex / recurrent disease (fistula, phlegmon, etc) Emergency setting

Meta-analysis for ileocaecal resection in Crohn’s 783 patients (Lap: 338) 15 studies (1995 - 2004) 1 RCT; 6 prospective; 8 retrospective Conversion rate: 6.8% Tilney HS et al Surgical Endos May 2006

Significant difference Lap vs Open OT time (longer in Laparoscopic group) ~30 mins Post-op recovery (faster in Laparoscopic group) Tolerates full diet (1.47 days) First flatus (0.68 days) First bowel motion (0.58 days) Shorter hospital stay (2.97 days)

Similar outcome Blood loss Post-op complications Return to work Anastomotic leakage Wound infection Bowel obstruction Intra-abd abscess Return to work

Issues addressed Technical feasibility Safety Immediate operative outcomes

Postoperative course ( our case ) First bowel motion: D3 Fluid diet resumed: D4 DAT: D6 Full ambulation: D4 Home: D9 No complication Wound length: 8 cm

Conclusion Surgical role in Crohn’s disease is Not to cure the disease treat the complications with improvement of quality of life of these young group of patient Development of laparoscopic surgery Better cosmesis and body image Faster recovery Less adhesion for ease of reoperation latter

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