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Surgical Management of Inflammatory Bowel Disease

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.

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Surgical Management of Inflammatory Bowel Disease

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  1. Surgical Management of Inflammatory Bowel Disease Sandra J Beck, M.D. University of Kentucky Assistant Professor of Colon & Rectal Surgery

  2. Surgical Management of IBD • Goal: Improve Quality of Life • Curative? • Treatment of Complications • Palliation of Symptoms

  3. Surgical Management of IBD Therapeutic goals vary for different types of IBD

  4. Inflammatory Bowel Disease • Classification • Ulcerative Colitits • Crohn’s Disease • Indeterminate Colitis

  5. Normal Anatomy

  6. 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

  7. 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)

  8. Surgical Management Ulcerative Colitis • Options • Total Abdominal Colectomy, end ileostomy • Total proctocolectomy, end ileostomy • Total proctocolectomy, ileal pouch anal anastomosis

  9. 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

  10. Total Abdominal Colectomy with End Ileostomy

  11. 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 Total Abdominal Colectomy, End Ileostomy

  12. Surgical Management of Ulcerative Colitis Total Proctocolectomy, End Ileostomy • Curative • Relatively uncomplicated • High patient satisfaction • Benchmark procedure for UC • Permanent Ileostomy

  13. 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

  14. Total proctocolectomy with end ileostomy

  15. 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

  16. Total Proctocolectomy, IPAA • Patient Selection • Functional Outcome • Complications • Overall Results

  17. Total Proctocolectomy, IPAA • Patient Selection • Certainty of diagnosis • Adequate anal function • Acceptable medical risk • Informed and motivated patient

  18. 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

  19. J-Pouch with Temporary Ileostomy

  20. J-Pouch Anal Anastomosis(with Ileostomy closed)

  21. 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

  22. 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%

  23. Surgical Management of Crohn’s Disease

  24. 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

  25. Surgical Management of Crohn’s • Indications • Abscess • Fistula • Perforation • Obstruction • Extraintestinal Manifestations • Presence or Risk of Malignancy

  26. 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

  27. Surgical Management of Crohn’sGuidelines • Disease is chronic; keep long term outlook for patient in mind • Preserve small bowel whenever possible • Treat only the primary problem

  28. Surgical Management of Crohn’sTypes of Operations • Intestinal resection with or without anastomosis • Bypass procedures • Internal-e.g. gastroduodenostomy • External-e.g. ileostomy • Stricturoplasty

  29. 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

  30. Resection with Handsewn Anastomosis

  31. Resection with Stapled Anastomosis

  32. Specific Anatomic Presentations • Ileocolic • Small Bowel • Segmental Colon • Entire Colon • Perianal Disease

  33. 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

  34. 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)

  35. 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

  36. 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

  37. 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

  38. Strictureplasty

  39. 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

  40. 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

  41. Crohns Colitis

  42. Crohns Colitis

  43. Crohn’s Colitis • Extensive disease precludes segmental resection • Proctocolectomy with end ileostomy procedure of choice

  44. 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”

  45. 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

  46. Crohns Anal Fissure

  47. Crohns Anal Abscess

  48. Perianal DiseaseTreatment • 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

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