Surgical Management Inflammatory Bowel Disease Ernesto R. Drelichman, MD, FACS St. John Health Systems.

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Presentation transcript:

Surgical Management Inflammatory Bowel Disease Ernesto R. Drelichman, MD, FACS St. John Health Systems

VARIETIES OF COLITIS

ULCERATIVE COLITIS AND CROHN’S DISEASE

DISTINGUISHING FEATURES OF CROHN’S DISEASE

ANATOMIC DISTRIBUTION

INFLAMMATION

OBSTRUCTION

ENDOSCOPIC APPEARANCES

ENDOSCOPIC FEATURES

COBBLESTONING

Crohn’s Stricture

FISTULIZATION

Enterovesical Fistula

PERIANAL FISTULAE AND ABSCESS

GOALS OF THERAPY

CONVENTIONAL DRUG THERAPIES

“OK, OK, you guys have had your chance – the horses want another shot at it.”

BALLOON DILATION OF CROHN’S DISEASE STRICTURES

Philosophy of Surgical Management There is no Cure for Crohn’s Disease There is no Cure for Crohn’s Disease Surgery only overcomes the complications Surgery only overcomes the complications Potential for pan-intestinal involvement Potential for pan-intestinal involvement

Surgery: Risks and Benefits Symptom relief Improved nutrition Reduced medication Surgical risk Disease recurrence Short bowel syndrome

INDICATIONS FOR SURGERY IN CROHN’S DISEASE

Crohn’s Disease Surgical Indications 75% undergo surgery 50% undergo repeat surgery Collaborative decision Collaborative decision Patient Patient Gastroenterologist Gastroenterologist Surgeon Surgeon

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

Inflammatory Bowel Disease Disease Related Challenges Inflammatory Bowel Disease Disease Related Challenges Immunosuppression Immunosuppression Malnutrition Malnutrition fistulas fistulas abscess abscess phlegmon phlegmon thickened, shortened mesentery thickened, shortened mesentery friable tissues and vessels friable tissues and vessels Extensive disease Extensive disease

Step 5: Exteriorization, Resection, and Anastomosis

Step 4: Externalization

Step 5: Resection and Anastomosis

Crohn’s Disease Laparoscopic Colectomy - Advantages *33 patients with ileocolic Crohn’s underwent laparoscopic ileocectomy were case matched for potential confounders to an open group *33 patients with ileocolic Crohn’s underwent laparoscopic ileocectomy were case matched for potential confounders to an open group * > 60% had undergone previous surgery Young-Fadok et al. Surg Endosc 2001;450-4: Young-Fadok et al. Surg Endosc 2001;450-4: