Surgery for Inflammatory Bowel disease E .Condon Beaumont Hospital/ RCSI, Dublin. Colorectal Department Colorectal Surgery Department

Colorectal Surgery Department Overview Types Diverticular disease Ulcerative colitis Crohns Disease Ischemic colitis Amoebiasis Pseudomembranous colitis Radiation enterocolitis Colorectal Surgery Department

Colorectal Surgery Department Diverticular disease Definition ; Herniation of bowel mucosa through the bowel wall (Blood vessels) Sites sigmoid and descending colon Raised intraluminal pressure Segmental contraction 30% of all patients over 60 in the western world Colorectal Surgery Department

Colorectal Surgery Department Presentations Acute diverticulitis Chronic diverticulitis Complications of diverticulitis Obstruction Abscess formation Diffuse peritonitis Fistula Haemorrhage Colorectal Surgery Department

Colorectal Surgery Department Diagnosis Bloods CT Barium Colonoscopy Colorectal Surgery Department

Indications for surgery Acute diverticulitis- all complications except abscess Chronic diverticulitis – Persistent Pain /anemia 2 episodes of mild diveriticulitis Colorectal Surgery Department

Colorectal Surgery Department Surgical options Laparoscopy Sigmoid colectomy Hartmans Anterior resection Transverse colostomy and peritoneal toilet Colorectal Surgery Department

Colorectal Surgery Department Operating theatre Colorectal Surgery Department

Colorectal Surgery Department Best operation to Do?? Sigmoid colectomy Anterior resection Hartmans Colorectal Surgery Department

Colorectal Surgery Department Ulcerative colitis Definition; disease of unknown cause charecterised by non specific and diffuse inflammatory changes of the mucosa of the rectum and the large bowel Causes Infection Allergy Autoimmunity Colorectal Surgery Department

Colorectal Surgery Department UC Disease is mucosal Serosa – no serositis Segment usually descending colon Mucosa reddened friable Pseudopolyps Microscopic – inflammatory cellular infiltration of mucosa and the submucosa crypt abscesses dysplasia transmural inflammation Colorectal Surgery Department

Colorectal Surgery Department Symptoms Bloody diarrhoea Abdominal discomfort Diagnosis – colonoscopy barium enema Treatment Steroids local systemic NSAIDS Bowel rest Colorectal Surgery Department

Indications for surgery Relative indications Chronic invalidisim- severe colitis few years chronic ill health anemia Relapsing colitis 2 severe episodes in 3years Persistent steroids – the complications of roids Absolute indications Failure of medical therapy in acute severe attack Perforation Toxic megacolon Colorectal Surgery Department

Colorectal Surgery Department Operating theatre Colorectal Surgery Department

Colorectal Surgery Department Surgical Options 1. ileostomy 2.Proctocolectomy- permanent ileosotmy 3.Total colectomy- later ileorectal anastomosis 4.Pouch 2 stage / 3 stage 5. Total colectomy with ileostomy Colorectal Surgery Department

Colorectal Surgery Department Best Surgery Pouch 3 stage Proctocolectomy- permanent ileostomy Colorectal Surgery Department

Colorectal Surgery Department Pouchs J Pouchs Advantages no stoma / continence Complications Infertility Pouchitis Pouch failure 10 years 18 % crohns Colorectal Surgery Department

Colorectal Surgery Department Crohns Definition ; regional enteritis granulomatous entercolitis Unknown cause ( toothpaste) Characterised by discontinuous full thickness inflammation anywhere in the GI tract Common sites ileocaecal skip lesions in the ileum and perianal suppuration Colorectal Surgery Department

Colorectal Surgery Department Crohns Key histological differences Granulomas Fibrosis Full thickness Fistulas Colorectal Surgery Department

Colorectal Surgery Department Presentation Usually regional ileitis Like appendicitis Mass RIF Diarrhoea Obstruction Perforation Fistula Perianal Crohns Anemia Colorectal Surgery Department

Indication for Surgery Surgery nearly always treatment of choice 80-90% of cases ultimately require surgery Perianal disease and fistulas Colorectal Surgery Department

Colorectal Surgery Department Operating theatre Colorectal Surgery Department

Colorectal Surgery Department Surgical options Regional ileitis Ileal resection primary reanastomosis Right Hemicolectomy Colonic crohns Panproctocolectomy and permanent ileostomy Perianal crohns fistulotomy Colorectal Surgery Department

Colorectal Surgery Department

Colorectal Surgery Department

Colorectal Surgery Department

Colorectal Surgery Department Ischemic colitis Inflammatory response in the colon following an ischemic episodeowing to occlusion or narrowing of the inferior mesenteric artery Causes atheroma embolism surgery/ trauma Severity depends on the duration and the patency of the marginal artery Colorectal Surgery Department

Colorectal Surgery Department Presentations 2 phases Mucosal gangrene Secondary invasion with organisims which accelerate the gangerenous process Ischemic colitis with gangerene Transient ischemic colitis Stricture Colorectal Surgery Department

Colorectal Surgery Department Surgical options Transient ischemic colitis –mesenteric angiogram stenting of affected segment – primary vascular repair excision of the affected segment Ischemic colitis with gangarene excision total colectomy with permanent ileosotomy 80% mortality Colorectal Surgery Department

Colorectal Surgery Department Amoebiasis Entamoeba histolytica Cyst water /faecal oral /sexual Colitis Transmural colitis with perforation Infamatory mass Hepatic abscess Stool exam ct scan -flagyl Perforation -resection Colorectal Surgery Department

Pseudomembranous colitis C difficile – cephalosporins Diarrhea Bowel rest / flagyl/ vancomycin ORALLY Toxic dilatation > 6 cm impending perforation PFA CT Proctocoletomy end ielostomy Colorectal Surgery Department

Colorectal Surgery Department Radiation enteritis Usually SB following therapeutic radiation less common now Diarrhoea /obstruction Ileitis /proctitis Treatment NSAIDS steroid rarely resect except for strictures Colorectal Surgery Department

Colorectal Surgery Department General Advise Categorise youre answers eg intestinal obstruction in the lumen outside the lumen in the wall in medical Be logical and organised Colorectal Surgery Department

Colorectal Surgery Department Answer questions Definition Pathology Classification Causes Differential diagnosis Symptoms signs Complications S&S of complications Investigations bloods radiology surgical Management medical/ surgical prognosis Colorectal Surgery Department

Colorectal Surgery Department Questions? Good Luck!! Colorectal Surgery Department

Colorectal Surgery Department Preoperative MRI Preop MRI scanning allows selection of patients who will benefit from a course of preoperative radiotherapy T3 or T4 primary tumour or node positive patients lymph node Colorectal Surgery Department

Colorectal Surgery Department MRI Main indication in rectal cancer T3 or not T3 Every patient with rectal CA should have pre-op MRI to decide whether or not neoadjuvant therapy is indicated Colorectal Surgery Department

Colorectal Surgery Department PET Scanning Local recurrence at the splenic flexure Colorectal Surgery Department

Current indications for PET Scanning FDG PET is approved detection and localisation of recurrent colorectal cancer in patients with rising CEA levels and indeterminate findings on standard imaging studies Indications may expand in the future but its final role is still to be determined Radilogical imaging modalities in the diagnosis and management of colorectal cancer , Heamatology clinics of north america 202 16;90 875-95 Colorectal Surgery Department

Colorectal Surgery Department Virtual Colonoscopy Colorectal Surgery Department

Virtual colonoscopy – how does it work Virtual Colonoscopy is a promising new method for detecting colorectal polyps and cancers. Air is insufflated into a cleansed colon, and high resolution, thinly-collimated spiral CT slices are acquired. The two dimensional slices, as well as the post-processed "fly-through" virtual colonoscopic images, are examined for polyps and tumors. Colorectal Surgery Department

Virtual Colonoscopy- advantages Advantages of Virtual Colonoscopy Virtual Colonoscopy is minimally invasive, and does not carry the low but real (1 in 1500) risk of perforation associated with Conventional Colonoscopy. It is well tolerated by patients and does not require sedation. It is capable of evaluating the colon upstream from obstructing lesions that prevent passage of an endoscope. Virtual Colonoscopy is significantly less expensive than Conventional Colonoscopy. Colorectal Surgery Department

Virtual Colonoscopy-Disadvantages The dose of ionizing radiation is less than that of a conventional abdominal CT, and is comparable to obtaining a supine and upright plain film exam of the abdomen. Colonoscopy by CT does not provide the same information as Conventional Colonoscopy. Mucosal detail and color is not visible which limits the characterization of lesions. In addition, the detection of small polyps is inferior Colorectal Surgery Department

Virtual colonoscopy-disadvantages As with any procedure, including Conventional Colonoscopy, there are no guarantees that all clinically significant growths will be detected. It should be remembered than between 10 and 20% of all polyps, and up to 5% of colon cancers are missed, even on Conventional Colonoscopy. Virtual Colonoscopy (like the Barium Enema) is a diagnostic not therapeutic technique. All patients in whom polyps are identified would need to undergo Conventional Colonoscopy for removal. Colorectal Surgery Department

Virtual Colonoscopy Current indications Frail elderly patients Occlusive cancer for detection of other lesions Previous incomplete colonoscopy Colorectal Surgery Department

Colorectal Surgery Department Surgical Advances LOCAL RESECTION TOTAL MESORECTAL EXCISION(TME) COLOANAL POUCH ANASTOMOSIS LAPAROSCOPIC SURGERY Colorectal Surgery Department

Local Resection of low rectal tumours Transanal resection or TEMS (Trans anal endoscopic microsurgery) allows anal sphincter preservation while avoiding the risks of abdominal surgery - but its oncologic acceptability remains controversial. No randomised trials exist Safe application of this technique requires accurate preoperative staging, careful transanal resection, and meticulous histological examination. Factors that increase the risk of recurrence following local resection include T stage, poor histological grade, lymphovascular invasion, and positive excision margins Colorectal Surgery Department

Local resection for low rectal tumours Recent meta-analysis indicates that local recurrence occurs in 9.7% of patients (range 0%-24%) of patients with T1 tumors 25% (range 0%-67%) of those with T2 tumors 38% (range 0%-100%) of those with T3 tumors Sengupta S,Tjandra JJ. Local excision of rectal cancer: what is the evidence? Dis Colon Rectum. 2001;44:1345-1361. Colorectal Surgery Department

Transanal Endoscopic Microsurgery Colorectal Surgery Department

Total Mesorectal Excision Colorectal Surgery Department

Total Mesorectal Excision Definition; en bloc resection of the rectum and its enveloping mesentery to the level of the pelvic floor with a negative distal and radial resection margin. reduces the incidence of local recurrence to less than 10% without the use of adjuvant treatment. Martling AL, Holm T, Rutqvist LE, et al. Stockholm Colorectal Cancer Study Group, Basingstoke Bowel Cancer Research Project. Lancet. 2000;356:93-96 Colorectal Surgery Department

Total Mesorectal Excision Colorectal Surgery Department

Colorectal Surgery Department Coloanal J pouch Colorectal Surgery Department

Colorectal Surgery Department Criteria necessary for successful sphincter preservation in rectal cancer No pre-operative alteration of sphincter mechanism. TME and nerve sparing surgery. No damage to levator ani. Preservation of at least half of the internal sphincter. Low rate of anastomotic leakage. Low rate of pelvic sepsis. Low rate of anastomotic stricture. Allow good bowel function. Colorectal Surgery Department

Colorectal Surgery Department How can we improve function? Rectal cancer surgery may result in poor post-operative quality of life in survivors as a result of frequency, urgency and faecal soiling. McDonald et al BJS 1983 Postoperative function and continence after low anterior resection are significantly improved by a colonic pouch. Parc et al BJS 1986 Lazorthes et al BJS 1986 Mantyh et al DCR 2001 Colorectal Surgery Department

Coloanal J pouch vs. direct low anastomosis Lower morbidity. Better early function. Improvement of function persists with time. Lazorthes F. et al. Br J Surg 1997 Dehni N. et al. Dis Colon Rectum 1998 Harris G.J.C. et al. Br J Surg 2001 Age not a contra-indication. Dehni N. et al. Am J Surg 1998 Colorectal Surgery Department

Coloanal J pouch: functional results Bowel movements 2.1 per 24 h Continence Perfect or good 82% Soiling 14% Frequent fecal incontinence 4% Protecting PAD Never 71% As a safety 11% Needed 18% Colorectal Surgery Department

Coloanal J pouch: functional results Normal discrimination between 95% flatus and stool Urgency 4% Fragmentation of stools 21% Suppository or enema 20% to elicit evacuation Colorectal Surgery Department

Colorectal Surgery Department Conclusion Preoperative radiotherapy is followed by only minor deterioration in post-op anorectal function if colonic pouch anal anastomosis is performed. Reconstructive technique of choice in preoperatively irradiated patients. transanal rectal mucosectomy exclusion of anal sphincter from field of radiation Colorectal Surgery Department

Colorectal Surgery Department Laparoscopic Surgery *78.9% *27.2% *Nair RG et al. British Journal of Surgery 1997;84:1369-98 Colorectal Surgery Department

Laparoscopic colectomy -Essential Questions Is it safe? Clinically Technically Economically Oncologically Colorectal Surgery Department

Laparoscopic Colorectal Surgery Potential advantages Early mobilisation Shorter ileus Reduced opiate requirement Lower cardiorespiratory morbidity Reduced hospital stay Cosmetically better Colorectal Surgery Department

Laparoscopic Colorectal Surgery Potential disadvantages Technically demanding Difficult orientation Increased operative time Increased tumour dissemination Increased postoperative morbidity Colorectal Surgery Department

Colorectal Surgery Department Patterns of Recurrence and Survival after Laparoscopic and Conventional Resections for Colorectal Carcinoma John E Hartley, et al Annals of Surgery 2001;132:181-186 Colorectal Surgery Department

Colorectal Surgery Department Methods 3 - Lap. Assisted Operative Technique “Laparoscopic principles are Open principles” Laparoscopic Mobilisation Intracoporeal vessel division Intra /Extracorporeal bowel division Extracorporeal stapled anastomosis Colorectal Surgery Department

Results 1 - Demographics Laparoscopic Open n 58 53 Age 70 (51-87) 72 (36-90) Sex M:F 38:20 42:11 Stage Dukes A 12 10 Dukes B 19 15 Dukes C 22 21 Dukes D 5 7 Colorectal Surgery Department

Results 2 - Operative Laparoscopic Open Operative Time 185 (80-330) 122 (70-285)* *p<0.05 Mann Whitney CONVERSIONS n=20 (34%)

Crude Survival - Kaplan-Meier 1 p=0.6264. Log Rank Test .8 Probability of Survival .6 .4 Open .2 Laparoscopic 10 20 30 40 50 60 MONTHS Number at risk 58 47 40 11 2 28 9 2 53 43

Colorectal Surgery Department Recurrence Open Lap. Assisted Rectal Cancer n 27 28 Local + distant recurrence 2 1 Local recurrence in isolation 1 1 Total 3 (11.1%) 2 (7.1%) Wound recurrence (all patients) 3 (5.6%) 1 (1.7%) Colorectal Surgery Department

Colorectal Surgery Department Recurrence Rectal Cancer Local recurrence 3 of 27 open 11.1% 2 of 28 lap. assisted 7.1% Wound recurrence Open 3 of 53 5.6% Lap. assisted 1 of 58 1.7% Colorectal Surgery Department

Colorectal Surgery Department Conclusions Oncological outcome at two years is not compromised by an “all-comers” laparoscopic assisted approach Wound recurrence is a feature of both open and laparoscopic surgery for advanced disease Colorectal Surgery Department

Conclusions - Current status Laparoscopic surgery for cancer is still in the development phase Convincing data that it is safe and new suggestions that survival may be improved Very operator dependant Needs strict control - ongoing audit and supervision. Colorectal Surgery Department

“The Ongoing Randomized Trials” COLOR CLASICC NIH BARCELONA SINGAPORE ? 2003 AD Colorectal Surgery Department

Single Positive Randomised Trial Laparoscopy-assisted colectomy versus open colectomy for treatment of non-metastatic colon cancer: a randomised trial. Lacy AM et al Lancet 2002 Jun 29;359(9325):2224-9 Multicentre trials not yet reported CLASICC etc Colorectal Surgery Department

Colorectal Surgery Department Lacy trial continued 219 patients (111 laparoscopic) Improved short term variables and Improved survival in laparoscopic group particularly for Stage III (ie node +ve) cancers Very significant data if can be replicated. Single centre with enthusiast Small numbers Colorectal Surgery Department

Colorectal Surgery Department Consensus Statements “The use of laparoscopic surgery in the curative treatment of colorectal cancer remains controversial. However, assuming appropriate adherence to the principles of surgical oncology there appears to be no difference in the adequacy of tumour resection and adjacent lymph nodes. In addition, the short term outcome appears comparable to open surgery in respect of morbidity, mortality and cancer recurrence including wound deposits.” ACPGBI & AESGBI Colorectal Surgery Department

Colorectal Surgery Department Laparoscopic Assisted Colectomy Three port technique Laparoscopic identification of anatomy division of vascular pedicle mobilisation of colon, mesentery and relevant flexure Extracorporeal delivery of specimen determination of margins anastomosis closure of mesenteric defect Colorectal Surgery Department

Colorectal Surgery Department

Colorectal Surgery Department Operating theatre Colorectal Surgery Department