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Cedars-Sinai Medical Center Los Angeles, California

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Presentation on theme: "Cedars-Sinai Medical Center Los Angeles, California"— Presentation transcript:

1 Cedars-Sinai Medical Center Los Angeles, California
Clinical Debate A patient with severe Crohn's disease, an ileal stricture and proximal dilation on CTE should have an ileocolonic resection first Cedars-Sinai Medical Center Los Angeles, California C S Phillip Fleshner, MD Shierley, Jesslyne, and Emmeline Widjaja Chair in Colorectal Surgery Program Director, Colorectal Surgery Residency Clinical Professor of Surgery UCLA School of Medicine

2 Therapeutic Alternatives to Treat CD Strictures
Additional medical therapy Endoscopic dilation Surgery

3 Why Medical Therapy Not Useful
Expensive When do you stop, ? lifetime exposure QOL issues in partial responders IV steroids frequently used to assess response Steroids associated with development of stenosis Steroids associated with postoperative morbidity Aggressive medical therapy ↑ surgical morbidity Prestenotic dilation is a negative prognostic factor Disease assessment scores Clinical studies

4 Lehman Score Score measuring the progressive nature or cumulative structural bowel damage, independent of the current and fluctuating disease activity A longitudinal tool currently being developed and validated prospectively Pariente B, et al., IBD 2011

5 Prestenotic Dilation and Clinical Response in CD
% “Patients with intestinal narrowing and prestenotic dilatation … were less likely to respond to medical therapy” (OR = 7.85, 95% CI ,p= 0.008) Lawrance IC, et al., WJG 2009

6 Why Medical Rx Is Not Useful Expert Consensus Opinion

7 Why Medical Rx Is Not Useful Expert Consensus Opinion

8 Laparoscopic Ileocolic Resection
Short term outcomes Minimal scarring Enhanced cosmesis Fast surgical recovery Fast restoration of QOL Complications are low (<10%) Medication can be stopped or limited in prevention mode Small bowel loss is generally small (usually 20–25 cm) Long term outcomes Lower incisional hernia Less adhesions, possibly less SBO

9 Endoscopic Dilation vs Laparoscopic Surgery
Criterion Endoscopic Dilatation Laparoscopic Surgery Average Procedure Length Can be long with deep SB strictures using DBE 120 min Overall complications ̴ 10% <10% Complications requiring surgery ̴ 5% <1% Peritonitis/perforation 2% Potential for leaving CA Present; Biopsy critical None

10 Endoscopic Dilation vs Laparoscopic Surgery
Criterion Endoscopic Dilatation Laparoscopic Surgery Technical success rate 90% 100% Clinical success rate ̴ 50% >95% Patients requiring only 1 procedure ̴ 30% 99 Mean # of procedures needed ̴ 4 1 QOL after procedure Unknown Very high

11 Severe CD, Ileal Stricture and Proximal Dilation

12 Is Endoscopic Dilation Ever Preferable to Surgery?
Multicentric disease Multiple prior resections Adhesions Loss of bowel → short bowel syndrome Poor surgical risk Initial presentation of the disease Stricture location Gastroduodenal Rectosigmoid

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