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

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

3. 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

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

5. Colorectal Surgery Department
Diagnosis
Bloods CT
Barium
Colonoscopy
Colorectal Surgery Department

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

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

8. Colorectal Surgery Department
Operating theatre
Colorectal Surgery Department

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

10. 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

11. Colorectal Surgery DepartmentUC
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

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

13. 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

14. Colorectal Surgery Department
Operating theatre
Colorectal Surgery Department

15. 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

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

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

18. 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

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

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

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

22. Colorectal Surgery Department
Operating theatre
Colorectal Surgery Department

23. 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

24. Colorectal Surgery Department

25. Colorectal Surgery Department

26. Colorectal Surgery Department

27. 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

28. 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

29. 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

30. 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

31. 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

32. 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

33. 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

34. 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

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

36. 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

37. 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

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

39. 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 ;
Colorectal Surgery Department

40. Colorectal Surgery Department
Virtual Colonoscopy
Colorectal Surgery Department

41. 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

42. 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

43. 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

44. 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

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

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

47. 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

48. 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:
Colorectal Surgery Department

49. Transanal Endoscopic Microsurgery
Colorectal Surgery Department

50. Total Mesorectal Excision
Colorectal Surgery Department

51. 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

52. Total Mesorectal Excision
Colorectal Surgery Department

53. Colorectal Surgery Department
Coloanal J pouch
Colorectal Surgery Department

54. 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

55. 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 Lazorthes et al BJS Mantyh et al DCR 2001
Colorectal Surgery Department

56. 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

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

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

59. 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

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

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

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

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

64. 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:
Colorectal Surgery Department

65. 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

66. Results 1 - Demographics
Laparoscopic Open n
Age (51-87) (36-90)
Sex M:F : :11
Stage
Dukes A
Dukes B
Dukes C
Dukes D
Colorectal Surgery Department

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

68. Crude Survival - Kaplan-Meier1
p= 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

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

70. Colorectal Surgery Department
Recurrence
Rectal Cancer
Local recurrence 3 of 27 open %
2 of 28 lap. assisted 7.1%
Wound recurrence
Open 3 of %
Lap. assisted 1 of %
Colorectal Surgery Department

71. 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

72. 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

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

74. 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

75. 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

76. 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

77. 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

78. Colorectal Surgery Department

79. Colorectal Surgery Department
Operating theatre
Colorectal Surgery Department