1. Surgery for Inflammatory Bowel Disease
David E. Stein, M.D.
Division of Colorectal Surgery
Department of Surgery
Drexel University College of Medicine

2. Inflammatory Bowel Disease
Ulcerative Colitis and Crohn’s Disease
Different Disease Entities
Treatment changes based on disease type and pattern of disease

3. Crohn’s Disease

4. Crohn’s Disease Chronic inflammatory condition of uncertain etiology
Patients present with a chronic history of GI complaints
Episodic cramping and diarrhea
May take two years until diagnosis
Incurable

5. Disease Sites Small bowel Ileocolic (40%) Colon and/or rectum Other
Stomach and/or duodenum
Anal canal and/or perineum

6. Operative Incidence Jejunoileitis: 50% at 5 years; 70% at 10 years
Ileocolitis: 75% at 5 years; 70% at 10 years
Colitis: 50% at 5 years; 70% at 10 years
Whelan 1985

7. Treatment Caveats Exclusion of infectious causes
Recognition of disease extent
Presence of complicating disorders

8. Medications 5-ASA compounds Anti-microbials Corticosteroids
Immune-modulating agents

9. Immune-Modulating Agents
Methotrexate
Azathioprine and 6-MP
Cyclosporine

10. Mild or Moderate Disease
Outpatient therapy
5-ASA compounds (topical or oral)
Anti-microbials
Corticosteroids
Immune-modulating agents

11. Severe Disease Inpatient therapy Corticosteroids Anti-microbials
5-ASA compounds (topical or oral)
Immune-modulating agents

12. Operative Indications
Disease complications
Toxic colitis or megacolon
Perforation
Hemorrhage
Cancer risk
Obstruction/Strictures

13. Operative Indications
Failure of medical therapy
Unresponsive disease
Incomplete response
Excessive steroid requirements
Complications due to medications
Noncompliance with medication

14. Operative Options Bypass Resection with/without anastomosis
Strictureplasty

15. Operative Considerations
Crohn’s disease is incurable
Death most common from operative complications
Surgery most often for intestinal complications
Operative options are influenced by a myriad factors

16. Operative Considerations
Asymptomatic disease should be ignored
Non-diseased bowel can be affected
Mesenteric division can be difficult
Resection margins should be conservative
Use effective, long-term drainage of sepsis

17. Patient Preparation Counseling Stoma site marking
Restoration of physiologic deficits
Medication withdrawal
Steroids
Mechanical and antibiotic preparation

18. Resection

19. Resection Procedure of choice Operative principles
Adequate mobilization
Minimal contamination
Suture ligation of mesenteric pedicles
Conservative resection margins (<2-5 cm)

20. Anastomosis Configuration and technique unrelated to recurrence
Operative principles
Inspect mesenteric mucosa for ulceration
Equilibrate lumen size
Tension- and torsion-free anastomosis
Close mesenteric defect

21. Temporary Stoma Incompletely drained sepsis Excessive blood loss
Prolonged operation (>4 hours)
Severe hypoalbuminemia (<2.5 g/dL)

22. Strictureplasty

23. Strictureplasty Indications Multiple strictures in long segment
Existing or impending short bowel syndrome
Non-phlegmonous, fibrotic stricture

24. Strictureplasty Contraindications Multiple strictures in short segment
Phlegmonous or fistula-related stricture
Free or contained perforation
Hypoalbuminemia (<2.0 g/dL)
Colonic strictures

25. Strictureplasty Short (<10 cm) segments Heineke-Mikulicz
Long segments
Finney
Side-to side isoperistaltic
Michelassi 1996

26. Specific Disease Sites
Stomach and/or duodenum
Small bowel
Ileocecal
Colon
Rectum
Anal canal and/or perineum

27. Anoperineal Disease

28. Anoperineal Disease Frequency of lesions: 40-80%
Influence of intestinal disease site:
Colonic disease: 47-92%
Small bowel disease: 26-74%
Fielding 1972, Rankin 1979

29. Anoperineal Disease Classification Skin lesions Anal canal lesions
Fistulae/abscesses
Buchmann and Alexander-Williams 1980

30. Anoperineal Disease Skin lesions Maceration Erosion Ulceration
Skin tags
Anal canal lesions
Fissure
Ulcer
Stenosis
Fistulae/abscesses

31. Hemorrhoids and Skin Tags
Conservative approach
Excision
Poor healing: 12-25%
Proctectomy: 30%
Jeffery 1977, Wolkomir 1993

32. Anal Ulcer Asymptomatic Painful Control sepsis, antibiotics Sitz baths
Regulation of bowel movements
Cortisone suppository or injection

33. Fistulae Operative options Non-cutting seton Fistulotomy
Rectal mucosal advancement flap
Cutaneous advancement flap
Fecal diversion (temporary or permanent)

34. Abscesses High index of suspicion Consider EUA Incision and drainage
Avoid primary fistulotomy
Adjuvant antibiotics
Solomon 1993

35. Specific Problems Abdominal abscess Fistulae Free perforation
Hemorrhage
Colonic stricture
Ileal pouch

36. Conclusions
The treatment of Crohn’s disease focuses on ameli-oration of symptoms while minimizing morbidity and maintaining intestinal continuity through the joint efforts of gastroenterologists and surgeons.
Operative therapy for Crohn’s disease is based upon symptoms, disease extent, and clinical presentation.

37. Ulcerative Colitis

38. Ulcerative Colitis Disease is more common in Caucasians
Incidence is 4/100,000
3rd decade of life
35% incidence in First degree relatives (HLA-B27)
Etiology Unknown
UC is a disorder of the colorectal mucosa

39. Ulcerative Colitis

40. Disease Distribution Proctitis/proctosigmoiditis: 44-49%
Left-sided colitis: 36-41%
Pan-colitis: 14-37%
Hendriksen 1985, Farmer 1993, Langholz 1994, Langholz 1996

41. Disease Severity Mild colitis: 20% Moderate colitis: 71%
Severe colitis: 9%
Langholz 1991

42. Disease Course Proctitis: 50% pan-colitis; 12% colectomy
Left-sided colitis:
9% pan-colitis; 23% colectomy
Pan-colitis:
40% colectomy
Langholz 1996

43. Medications
Routes of delivery
Topical
Oral
Intravenous

44. Medications
5-ASA compounds
Corticosteroids
Immune-modulating agents

45. Immune-Modulating Agents
Azathioprine and 6-MP
Cyclosporine

46. Mild - Moderate Disease
Distal colitis
5-ASA compounds (topical or oral)
Corticosteroids (topical)
Extensive colitis
5-ASA compounds (oral)

47. Moderate - Severe Disease
Distal colitis
5-ASA compounds (topical or oral)
Corticosteroids (topical or oral)
Extensive colitis
Corticosteroids (oral)

48. Severe - Fulminant Disease
Distal or extensive colitis
Corticosteroids (intravenous)
Cyclosporine (intravenous)

49. Maintenance Therapy Distal colitis 5-ASA compounds (topical or oral)
Immune-modulating agents
Extensive colitis
5-ASA compounds (oral)

50. Operative Indications
Acute disease complications
Toxic colitis or megacolon
Perforation
Hemorrhage

51. Operative Indications
Chronic disease complications
Cancer risk
Obstruction
Growth retardation
Extra-intestinal manifestations

52. Operative Indications
Failure of medical therapy
Unresponsive disease
Incomplete response
Excessive steroid requirements
Complications due to medications
Noncompliance with medication

53. Toxic Colitis Subjective appearance Objective criteria: Fever
Tachycardia
Leukocytosis
Hypoalbuminemia

54. Toxic Megacolon

55. Toxic Megacolon Toxic colitis Objective criteria:
Colonic diameter greater than 5 cm
Persistent colonic gas pattern

56. Toxic Colitis and Megacolon
Operative technique
Identify and quarantine perforations
Decompress colon
Minimize handling of bowel
Maintain named vessels
Resect omentum
Plan for definitive resection

57. Cancer Risk Risk after 10 years 0.5-1.0% per year
Uncertain affect on risk
Age of disease onset
Increased risk
Disease duration
Extent of disease
No affect on risk
Severity of disease

58. Dysplasia Dysplasia associated lesion or mass (DALM)
40-60% concomitant cancer
High-grade dysplasia
30-43% concomitant cancer
Low-grade dysplasia
10-19% concomitant cancer

59. Emergent Operative Options
Blow-hole colostomy and loop ileostomy
Subtotal colectomy (STC) and end ileostomy
Total proctocolectomy (TPC) and end ileostomy

60. STC and Ileostomy Contraindications Rectal hemorrhage or perforation
Micro-perforation
Co-morbidity
Pregnancy

61. TPC and Ileostomy Indications Rectal hemorrhage or perforation
Contraindictations
Micro-perforation
Co-morbidity

62. Elective Operative Options
Subtotal colectomy (STC) or total abdominal colectomy (TAC) and end ileostomy
Total proctocolectomy (TPC) and end ileostomy
Total proctocolectomy and ileal pouch-anal anastomosis (IPAA)

63. STC or TAC and End Ileostomy
Indications
Significant co-morbidity
Obesity
Immune-modulating agents
High-dose prednisone (>20 mg/day)
Severe hypoalbuminemia
Severe anemia

64. STC or TAC and End Ileostomy

65. TPC and IPAA: The Pelvic Pouch

66. TPC and IPAA: The Pelvic Pouch

67. TPC and IPAA Contraindications Significant co-morbidity Obesity
Marginal or poor sphincter strength
Stage II-IV upper or middle rectal cancer
Stage I-III low rectal cancer
Stage IV colon cancer

68. TPC and IPAA Early complications Small bowel obstruction: 13%
Pelvic sepsis: 5%
Wound infection: 3%
Sexual dysfunction: 2%
Pemberton 1991, Fazio 1995

69. TPC and IPAA Late complications Small bowel obstruction: 9%
Anastomotic leak: 2%
Anastomotic stricture: 5%
Pouchitis: 31%
Pemberton 1991, Fazio 1995

70. TPC and IPAA Functional outcome Frequency: 5-7 stools/day
Nocturnal seepage: 20-30%
Medication: 30%
Pouch loss: 9% (10 years)
Meagher 1998

71. TPC and IPAA Quality of Life SF 36: Comparable to general population
HRQOL: Comparable to patients in remission with mild disease
HRQOL: Comparable to general population
Fazio 1998, Martin 1998, Thirlby 1998

72. Conclusions
The treatment of ulcerative colitis focuses on eradication of disease while minimizing morbidity and maintaining intestinal continuity through the combined efforts of gastroenterologists and surgeons.
The operative treatment of ulcerative colitis is based upon clinical presentation, sphincter function, and patient motivation.

73. Surgery for Inflammatory Bowel Disease
David E. Stein, M.D.
Division of Colorectal Surgery
Department of Surgery
Drexel University College of Medicine