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Surgical Management of Inflammatory Bowel Disease Sandra J Beck, M.D. University of Kentucky Assistant Professor of Colon & Rectal Surgery Surgical Management of IBD • Goal: Improve Quality of Life – Curative? – Treatment of Complications – Palliation of Symptoms Surgical Management of IBD Therapeutic goals vary for different types of IBD Inflammatory Bowel Disease • Classification – Ulcerative Colitits – Crohn’s Disease – Indeterminate Colitis Normal Anatomy Ulcerative Colitis: Course and Prognosis • Prognosis much improved over last half century – Improved medications – Advances in surgical technique – Better peri-operative care • After 10 years of disease, colectomy rate = 24% • Maintenance of ability to work after 10 years of disease = 93% Langholz E, et.al. Gastroenterology 1994;107:3 Surgical Management of Ulcerative Colitis • Goals: – Cure disease – Improve quality of life—relieve symptoms – Prevent risk of carcinoma • Indications – – – – Toxic colitis Hemorrhage Medical intractability Malignant degeneration (cancer, dysplasia) Surgical Management Ulcerative Colitis • Options – Total Abdominal Colectomy, end ileostomy – Total proctocolectomy, end ileostomy – Total proctocolectomy, ileal pouch anal anastomosis Surgical Management of Ulcerative Colitis Total Abdominal Colectomy, End Ileostomy • Used for urgent/emergent indications – – – – Toxic colitis Toxic Megacolon + perforation Hemorrhage Intractable disease in “unhealthy” patients • May be used when classification of IBD is uncertain Total Abdominal Colectomy with End Ileostomy Total Abdominal Colectomy, End Ileostomy • • • • Advantages Can be expeditiously performed Avoids pelvic dissection Allows for a large specimen for pathologic evaluation Allows patient to discontinue drug therapies • • • • Disadvantages Not a definitive operation Rectum may remain symptomatic Pathologic overlap in toxic state Delay necessary before next surgical step Surgical Management of Ulcerative Colitis • • • • • Total Proctocolectomy, End Ileostomy Curative Relatively uncomplicated High patient satisfaction Benchmark procedure for UC Permanent Ileostomy Total Proctocolectomy, End Ileostomy • Indications – Poor anal musculature / fecal incontinence – Suspicion of Crohn’s disease (i.e. perianal disease, small bowel disease) – Rectal cancer – Patient request • Technique – Abdominal proctocolectomy – Intersphincteric perineal dissection – Brooke Ileostomy Total proctocolectomy with end ileostomy Surgical Management of Ulcerative Colitis Total Proctocolectomy, Ileal pouch anal anastomosis • Curative • Relatively uncomplicated • High patient satisfaction • Maintains intestinal continuity • Most common surgical procedure performed today for ulcerative colitis Total Proctocolectomy, IPAA • • • • Patient Selection Functional Outcome Complications Overall Results Total Proctocolectomy, IPAA • Patient Selection – Certainty of diagnosis – Adequate anal function – Acceptable medical risk – Informed and motivated patient Total Proctocolectomy, IPAA • Adequate anal function – Can be determined by history, examination, and manometry – Both sutured and stapled pouch surgery leads to a decline in resting and squeeze pressures – Patients who are continent preoperatively tend to remain continent postoperatively Churh J, et.al. DC&R 1993;36:895 J-Pouch with Temporary Ileostomy J-Pouch Anal Anastomosis (with Ileostomy closed) Function after IPAA • • • • BM’s per day = 5 to 7 Continence = 65-90% Seepage = 10% Overall quality of life rated excellent by 90% of patients • Now have 25 year data Complications of IPAA • Overall morbidity rate decreasing with increased experience with procedure • • • • • Anastomotic leak—10-14% Intestinal Obstruction–16-19% Pouch-anal, Pouch-vaginal fistulae Anal stricture--8-14% Pouchitis—20% – More common in UC patients than FAP patients – Overall long term incidence may be 50% • Pouch failure rate overall= 2% Surgical Management of Crohn’s Disease Surgical Management of Crohn’s • No medical or surgical cure for Crohn’s at present • Surgery generally reserved for patients with complications of the disease or for patients whose quality of life is adversely affected by medical management • Specter of recurrence is always present Surgical Management of Crohn’s • Indications – Abscess – Fistula – Perforation – Obstruction – Extraintestinal Manifestations – Presence or Risk of Malignancy Surgical Management of Crohn’s • Most patients require one or more operations – Probability after 20 years = 78% – Probability after 30 years = 90% Nat’l Coop. Crohn’s Disease Study Gastroenterology 1979 • Ileocolic disease is most common and most likely to eventually require surgery – 90% at 10 years of symptomatic disease Surgical Management of Crohn’s Guidelines • Disease is chronic; keep long term outlook for patient in mind • Preserve small bowel whenever possible • Treat only the primary problem Surgical Management of Crohn’s Types of Operations • Intestinal resection with or without anastomosis • Bypass procedures – Internal-e.g. gastroduodenostomy – External-e.g. ileostomy • Stricturoplasty Resection • Most common operation for Crohn’s • Usually initial procedure of choice for small bowel disease • Procedure of choice for colitis as well – Segmental colon resection – Total colon resection • 50% will require another operation within 15 years Resection with Handsewn Anastomosis Resection with Stapled Anastomosis Specific Anatomic Presentations • • • • • Ileocolic Small Bowel Segmental Colon Entire Colon Perianal Disease Ileocolic Crohn’s • Distal Ileum – Most common presenting site – Often involves cecum (40%) – Management consists of ileocolic resection with anastomosis • End-to-End or End-to-Side anastomosis have equal rates of recurrence Cameron J, et.al. Ann Surg 1992;215:546 • End-to-Side or Side-to-Side anastomosis have equal rates of recurrence Scott N, Sue-Ling H, Hughes L. Int J Colorect Dis 1995;10:67 Ileocolic Disease: Special Circumstances • Sparing of Ileocecal Valve – Need 5-7cm of normal ileum proximal to valve to preserve – End-to-End anastomosis generally preferred • Ileal disease with proximal skip lesions – Need to be concerned with short bowel syndrome – Options • Resection with one anastomosis • Multiple resections with multiple anastomosis • Resection in conjunction with stricturoplasty(ies) Stricturoplasty • Indications – Multiple short segment strictures – Recurrent disease in patients with history of resection(s) – Rapid recurrence of disease manifested as obstruction – Stricture in a patient with Short Bowel Syndrome Stricturoplasty • Contraindications – Free or contained perforation of small bowel – Internal or external fistula involving affected site – Multiple strictures in a short segment – Stricture close to area planned for resection – Colonic strictures – Low albumin or protein level Stricturoplasty • Heineke-Mikulicz – Employed for strictures < 10 cm – Extend longitudinal enterotomy 2cm beyond stricture in either direction – Close enterotomy transversely • Finney Stricturoplasty – Used for longer strictures – Resection probably superior Strictureplasty Stricturoplasty • Results – Morbidity low- 15% • Sepsis • Hemorrhage – 98% of patients relieved of obstructive symptoms Fazio V, et.al. DC&R 1993;36:355 – 28% reoperative rate • 78% of these for remote disease (stricturing or perforative) Ozuner G, FazioV. DC&R 1996;39:1199 Colonic Crohn’s • Segmental Disease – Value of segmental colon resection controversial – Preservation of colon decreases diarrhea, avoids use of ileostomy • 62-67% of patients have recurrent colitis • >80% are able to preserve bowel continuity Longo W, et.al. Arch Surg 1988;123:588 Crohns Colitis Crohns Colitis Crohn’s Colitis • Extensive disease precludes segmental resection • Proctocolectomy with end ileostomy procedure of choice Crohn’s Colitis • Subgroup of patients with extensive disease have anorectal sparing and adequate continence • Abdominal colectomy with ileorectal anastomosis – 50% of patients eventually require rectal excision at 20 years – Only 1/3 of patients are “content” Perianal Crohn’s • Clinical Features – – – – – – Edematous skin tags Blue discoloration Fissures or ulceration Abscesses Fistulae Anorectal stricture • Patients with colonic disease more likely to have anal disease – 52% vs. 14% with small bowel disease Crohns Anal Fissure Crohns Anal Abscess Perianal Disease Treatment • Individualized to each patient • Goals – Ameliorate symptoms – Prevent complications • Goals need to be met without impairing continence • Generally medical management preferable with limited surgical intervention when necessary Perianal Disease Treatment • Effect of proximal disease on perianal disease – Multiple studies with conflicting results – Beyond adolescence there is no compelling proof that treatment of proximal disease lessens perianal disease – Treat proximal disease independently Crohns Perianal Disease • • • • Control sepsis with drains or setons Injection of steriods Diversion of fecal stream Excision of Anus and Rectum and Permanent Colostomy Drainage with Seton Questions? 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