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The Evolving Role of Surgery in IBD John Pemberton Advances in IBD, December, 2012

The Evolving Role of Surgery in IBD John Pemberton Advances in IBD, December, 2012. The Evolving Role of Surgery. Safety and effectiveness of strictureplasty Approach to patients with complex perineal CD When is enough medical management of patients with CUC enough?

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The Evolving Role of Surgery in IBD John Pemberton Advances in IBD, December, 2012

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  1. The Evolving Role of Surgery in IBDJohn PembertonAdvances in IBD, December, 2012

  2. The Evolving Role of Surgery • Safety and effectiveness of strictureplasty • Approach to patients with complex perineal CD • When is enough medical management of patients with CUC enough? • Just how well is IPAA performing? • Controversies concerning IPAA • How do biologics impact surgery for IBD?

  3. The Evolving Role of Surgery • How safe is IPAA in IC patients? In CD patients? • When is colectomy indicated for patients with dysplasia? • Can you do IPAA in IBD patients with CRC? • What is the risk of CRC after IPAA • Are enhanced recovery programs helpful?

  4. The Evolving Role of Surgery Is there a potential downside to attempts to control CD or CUC medically over longer and longer periods of time?

  5. Strictureplasty CP1111844-8

  6. Crohn DiseaseRationale for Strictureplasty • Disease involves whole intestine • Impossible to cure by excision • All diseased bowel does not need excision • If only stenotic complications are present, these can be relieved without excision CP1111844-12

  7. Evolution toward more complex strictureplasties

  8. The Evolving Role of SurgeryMichelassiLONG side to side strictureplasty

  9. The Evolving Role of Surgery Strictureplasty Campbell, L; Ambe, R; Weaver, J; et al DCR 2012 55(6):714-726 . 2

  10. The Evolving Role of Surgery Strictureplasty Complications Bellolio, F; Cohen, Z; MacRae, H; et al DCR 55(8):864-869, August 2012. 2

  11. The Evolving Role of Surgery Strictureplasty Surgery-free survival Strictureplasty in Selected Crohn's Disease Patients Bellolio F, Cohen Z, MacRae, H, et al DCR 2012 55:864-869 2

  12. AN APPROACH TO PATIENTS WITH PERINEAL FISTULAS AND CD CP1043353-62

  13. Evolutiontoward upfront aggressive COMBINED medical AND surgical therapyfor perineal Crohn’s Diease

  14. Surgery for Crohn DiseaseCombination Therapy* *Regueiro M & Mardine H. Inflammatory Bowel Diseases, March 2003, 9(2):98-103

  15. Response Based on Type of Fistula Simple fistula Complex fistula EUA and Infliximab EUA and Infliximab infliximab alone infliximab alone n=3 n=9 P n=6 n=14 P Initial response 3 9 1.000 6 10 0.026 100% 100% 100% 71.5% Recurrence rate 1 5 0.232 3 10 0.036 33.3% 56% 50% 100% Mean time to 15 5.2 0.004 13 2.14 0.001recurrence (mo) Regueiro M et al: Inflam Bowel Dis 9(2):98, 2003 CP1112779-4

  16. Surgery for Crohn DiseaseInfliximab& Perineal Fistula “For perianalfistulizing CD, repeat doses of Infliximab improves clinical and radiological outcomes, although complete radiologic healing occurs in a minority of patients”* *Rasul I et al. Am J Gastro 2004;99:82-88

  17. Surgery for Perineal Crohn DiseaseSummary • Perianal fistulous disease is rarely cured • Rather, fistulas are controlled by a combined approach including surgery (seton), immunosuppressives antibiotics and infliximab • Setons are used to keep the tracts open, eliminating accumulation of pus and fostering tract quiescence

  18. Surgery for Perineal Crohn DiseaseSummary • When the tracts are dry, the setons are removed • The perineum is reexamined regularly • Only if fecal incontinence intervenes is proctectomy discussed

  19. Risk factors for Proctectomy5 yr. • Extensive fistula/abscess vs simple • 26% vs. 6% • Severe Proctitis vs none or mild • 37% vs. 10% • Severe proctitis and extensive fistula/abscess • 46% proctectomy rate

  20. Fecal Diversion Patients undergoing diversion for perineal CD have <20% chance of successful restoration of intestinal continuity which is NOT improved with biologic therapy Hong MK et al Colorectal Dis 2011 13 (2); 171-6 However….. Fecal diversion isuseful to quiet the perineum prior to repairing an R-V fistula and to promote healing postoperatively

  21. Chronic Ulcerative Colitis

  22. EvolutionToward reasonable time frames for managing aggressive disease

  23. Surgery for CUC….when is enough, enough? • For outpatients, it seems reasonable to treat with 5 ASA preparations, topical steroids, oral steroids, AZA and biologics until unable to steroid spare effectively • For inpatients, reasonably aggressive treatment includes; IV steroids & IFX for 5 days [bleeding, >10 stools indicates fulminant disease] • For deteriorating inpatients, GI & Surgeon need to decide together when enough is enough • High grade dysplasia signifies enough is enough • Low grade dysplasia probably signifies the same

  24. IPAA

  25. Ileal Pouch-Anal Anastomosis Evolution Straight IPAA S pouch J pouch Long cuff Short cuff Double-stapled Laparoscopic IPAA (LAP, HALS,SILS) CP998061-4

  26. Evolutionof the IPAA data set

  27. IPAAMayo Experience1/8/1981 – 12/31/2011 Total : 3405 CUC : 3048 FAP : 304 “other”: 53

  28. Hahnloser D, Pemberton JH, Wolff BG et alAnn Surg. 2004 Oct;240(4):615-21 • complete annual follow-up for 15 years n=409 • 1981-2001 1,885 IPAA for CUC • annual questionnaire (prospective database) • function and continence • QoL • complications (excluding pouch failure)

  29. IPAA Pouch Success 100 92% at 21 yr Cumulative Probability of Pouch Success 50 20 10 5 Years after IPAA Hahnloser D, Pemberton JH, Wolff,BG et al BJS 2007;94:333-340

  30. Function (n=409) • years follow-up1 5 10 15 • Age (years)33 38 43 49 • Stool frequency • Mean Stools/day 5.5 5.6 5.6 6.2 p<.001 • Mean Stools/night 1.1 1.3 1.5 2.0 p<.001 Hahnloser D, Pemberton JH, Wolff BG Ann Surg 2004;240: 615–623

  31. Complications Pouchitis 100 Pouchitis 80 cumulative probability (%) 60 40 20 0 0 5 10 15 Years after IPAA

  32. improved notaffected mildlyrestricted severlyresticted Quality of Life Social Activities ns 5 10 15 5 10 15 5 10 15 5 10 15 5 10 15 5 10 15 5 10 15 Years after IPAA

  33. improved not affected mildly restricted severly resticted Quality of Life Social Work at Activities Home ns ns 5 10 15 5 10 15 5 10 15 5 10 15 5 10 15 5 10 15 5 10 15 Years after IPAA

  34. improved not affected mildly restricted severly resticted Quality of Life Social Work at Family Activities Home Relationship ns ns ns 5 10 15 5 10 15 5 10 15 5 10 15 5 10 15 5 10 15 5 10 15 Years after IPAA

  35. ns ns ns ns improved affected mildly restricted severly resticted Quality of Life Social Work at Family Travel Sports Recreation Sexual Activities Home Relationship Life ns ns ns

  36. Summary • with ageing… • good functional outcome • good and stable QoL

  37. Conclusion IPAA is a durable operation with a good QoL and stable predictable outcomes over time

  38. Minimally Invasive Surgery and IPAA

  39. Evolutiontoward Minimally Invasive Surgery (MIS) for IBD(Laparoscopy/Hand Assisted Laparoscopy (HALS)

  40. HALS IPAAWt.= 227, BMI= 35.2

  41. IPAA (2007) • Total performed 114 • Open 29 • Minimally Invasive 85 (75%) • LAP/HALS37/48(57%)

  42. Surgical Evolution Age - 32pts >65 y/o matched to 32pts<65y/o Outcomes:older pts. had more readmission for volume depletion but functional results were the same over time (Pinto RA etal Colorectal Dis 2011;13;177-83)

  43. Surgical Evolution • Fertility - Weighted average infertility rate during medical treatment = 15% after IPAA = 48% (Waljee A et al. Gut 2006;55:1575-1580) - Fecundity (probability of conception) is decreased after IPAA (Olsen KO et al br J Surg 1999;86:493-495) - Ability to carry a pregnancy to term is not affected. (Hahnloser et alDis Colon Rectum. 2004 Jul;47(7):1127-35) - Subtotal colectomy and BI or IRA is offered to young women who wish to become pregnant

  44. Surgical Evolution • Fewer pelvic/adnexaladhesions form after laparoscopic pelvic dissection* and • Patients undergoing lap IPAA have a higher fertility rate than open patients** Laparoscopic IPAA may be the POC *Indar AA, Efron JE, Young-Fadok TM Surg. Endosc 2009: 23:174-177 **Bartels S et al Ann Surg. 2012 May 17. [Epub ahead of print]

  45. Biologics and Surgery for IBD

  46. The widespread use of biologics has prompted a change in the surgical management of patients with CUC

  47. Surgical Challenges in IBDIFX and Surgical ComplicationsCD only Author Complication Odds Ratio Marchal* Early Major 1.7 (.3-7.7) Belgium Late Major 1.4(.4-5.0) Colombel** Septic .9 (.4-1.9) Mayo Non septic 1.0 (.5-2.0) Nasir*** All Complic 30.3 (TNF) v 27.9% Mayo Abscess/leak 1.99 (TNF) v 3.4% Appau**** 30 d readmit 2.3 (1-5.3) CCF 30 d sepsis 2.6 (1.1-6.1) 30 d abscess 5.8 (1.7-19.7) * Aliment Pharmacol Ther 2004;19:749-54 ** AM J Gastroenterol 2004;99:878-83 ***J Gastrointes Surg 2010 14:1859-1866 ****J Gastrointes Surg 2008;12:1738-44

  48. Surgical Challenges in IBDIFX and Surgical ComplicationsCUC only Author Complication Odds Ratio Selvasekar Pouch specific 2.6 (09-7.5) MayoInfectious 2.7 (1.1-6.7) Schluender Surgery 1.9 (.6-5.9) Cedars Infectious 2.4 (.6-9.6) Mor Sepsis 13.8 (1.8-105) CCF Ferrante Pouch specific .9 (.8-.9) Belgium Infectious .3 (.07-1.4)

  49. Pharmacokinetics of the Biologics • Half lives • Infliximab(IFX) = 10-12 days • Adalimumab= 14 days • Certolizumab= 14 days • Natalizumab = 11 days • For all , drug is still detectable at 8 weeks with complete clearance by 12 weeks

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