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

Drexel University College of Medicine

Surgery for Inflammatory Bowel Disease

David E. Stein, M.D.

Division of Colorectal Surgery

Department of Surgery



Inflammatory Bowel Disease

• Ulcerative Colitis and Crohn’s Disease

• Different Disease Entities

• Treatment changes based on disease type and pattern of disease


Crohn’s Disease


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


Disease Sites

Small bowel

Ileocolic (40%)

Colon and/or rectum

Other

• Stomach and/or duodenum

• Anal canal and/or perineum


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


Treatment Caveats

Exclusion of infectious causes

Recognition of disease extent

Presence of complicating disorders


Medications

5-ASA compounds

Anti-microbials

Corticosteroids

Immune-modulating agents


Immune-Modulating Agents

Methotrexate

Azathioprine and 6-MP

Cyclosporine


Mild or Moderate Disease

Outpatient therapy

• 5-ASA compounds (topical or oral)

• Anti-microbials

• Corticosteroids

• Immune-modulating agents


Severe Disease

Inpatient therapy

• Corticosteroids

• Anti-microbials

• 5-ASA compounds (topical or oral)

• Immune-modulating agents


Operative Indications

Disease complications

• Toxic colitis or megacolon

• Perforation

• Hemorrhage

• Cancer risk

• Obstruction/Strictures



Failure of medical therapy

• Unresponsive disease

• Incomplete response

• Excessive steroid requirements

• Complications due to medications

• Noncompliance with medication


Operative Options

Bypass

Resection with/without anastomosis

Strictureplasty


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


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


Patient Preparation

Counseling

Stoma site marking

Restoration of physiologic deficits

Medication withdrawal

Steroids

Mechanical and antibiotic preparation


Resection


Resection

Procedure of choice

Operative principles

• Adequate mobilization

• Minimal contamination

• Suture ligation of mesenteric pedicles

• Conservative resection margins (<2-5 cm)


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


Temporary Stoma

Incompletely drained sepsis

Excessive blood loss

Prolonged operation (>4 hours)

Severe hypoalbuminemia (<2.5 g/dL)


Strictureplasty


Strictureplasty

Indications

• Multiple strictures in long segment

• Existing or impending short bowel syndrome

• Non-phlegmonous, fibrotic stricture


Strictureplasty

Contraindications

• Multiple strictures in short segment

• Phlegmonous or fistula-related stricture

• Free or contained perforation

• Hypoalbuminemia (<2.0 g/dL)

• Colonic strictures


Strictureplasty

Short (<10 cm) segments

• Heineke-Mikulicz

Long segments

• Finney

• Side-to side isoperistaltic

Michelassi 1996


Specific Disease Sites

Stomach and/or duodenum

Small bowel

Ileocecal

Colon

Rectum

Anal canal and/or perineum


Anoperineal Disease


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


Anoperineal Disease

Classification

• Skin lesions

• Anal canal lesions

• Fistulae/abscesses

Buchmann and Alexander-Williams 1980


Anoperineal Disease

Skin lesions• Maceration• Erosion• Ulceration• Skin tags

Anal canal lesions• Fissure• Ulcer• Stenosis

Fistulae/abscesses


Hemorrhoids and Skin Tags

Conservative approach

Excision

• Poor healing: 12-25%

• Proctectomy: 30%

Jeffery 1977, Wolkomir 1993


Anal Ulcer

Asymptomatic

Painful

• Control sepsis, antibiotics

• Sitz baths

• Regulation of bowel movements

• Cortisone suppository or injection


Fistulae

Operative options

• Non-cutting seton

• Fistulotomy

• Rectal mucosal advancement flap

• Cutaneous advancement flap

• Fecal diversion (temporary or permanent)


Abscesses

High index of suspicion

Consider EUA

Incision and drainage

Avoid primary fistulotomy

Adjuvant antibiotics

Solomon 1993


Specific Problems

Abdominal abscess

Fistulae

Free perforation

Hemorrhage

Colonic stricture

Ileal pouch


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.


Ulcerative Colitis


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


Ulcerative Colitis


Disease Distribution

Proctitis/proctosigmoiditis: 44-49%

Left-sided colitis: 36-41%

Pan-colitis: 14-37%

Hendriksen 1985, Farmer 1993, Langholz 1994, Langholz 1996


Disease Severity

Mild colitis: 20%

Moderate colitis: 71%

Severe colitis: 9%

Langholz 1991


Disease Course

Proctitis:• 50% pan-colitis; 12% colectomy

Left-sided colitis:• 9% pan-colitis; 23% colectomy

Pan-colitis:• 40% colectomy

Langholz 1996


Medications

Routes of delivery• Topical• Oral• Intravenous


Medications

5-ASA compounds

Corticosteroids

Immune-modulating agents


Immune-Modulating Agents

Azathioprine and 6-MP

Cyclosporine


Mild - Moderate Disease

Distal colitis• 5-ASA compounds (topical or oral)• Corticosteroids (topical)

Extensive colitis• 5-ASA compounds (oral)


Moderate - Severe Disease

Distal colitis• 5-ASA compounds (topical or oral)• Corticosteroids (topical or oral)

Extensive colitis• Corticosteroids (oral)


Severe - Fulminant Disease

Distal or extensive colitis• Corticosteroids (intravenous)• Cyclosporine (intravenous)


Maintenance Therapy

Distal colitis• 5-ASA compounds (topical or oral)• Immune-modulating agents

Extensive colitis• 5-ASA compounds (oral)• Immune-modulating agents



Acute disease complications• Toxic colitis or megacolon• Perforation• Hemorrhage



Chronic disease complications• Cancer risk• Obstruction• Growth retardation• Extra-intestinal manifestations



Failure of medical therapy• Unresponsive disease• Incomplete response• Excessive steroid requirements• Complications due to medications• Noncompliance with medication


Toxic Colitis

Subjective appearance

Objective criteria:• Fever• Tachycardia• Leukocytosis• Hypoalbuminemia


Toxic Megacolon


Toxic Megacolon

Toxic colitis

Objective criteria:

• Colonic diameter greater than 5 cm

• Persistent colonic gas pattern


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


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


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


Emergent Operative Options

• Blow-hole colostomy and loop ileostomy• Subtotal colectomy (STC) and end ileostomy• Total proctocolectomy (TPC) and end ileostomy


STC and Ileostomy

Contraindications• Rectal hemorrhage or perforation• Micro-perforation• Co-morbidity• Pregnancy


TPC and Ileostomy

Indications• Rectal hemorrhage or perforation

Contraindictations• Micro-perforation• Co-morbidity


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)


STC or TAC and End Ileostomy

Indications• Significant co-morbidity• Obesity• Immune-modulating agents• High-dose prednisone (>20 mg/day)• Severe hypoalbuminemia• Severe anemia


STC or TAC and End Ileostomy


TPC and IPAA: The Pelvic Pouch


TPC and IPAA: The Pelvic Pouch


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


TPC and IPAA

Early complications• Small bowel obstruction: 13%• Pelvic sepsis: 5%• Wound infection: 3%• Sexual dysfunction: 2%

Pemberton 1991, Fazio 1995


TPC and IPAA

Late complications• Small bowel obstruction: 9%• Anastomotic leak: 2%• Anastomotic stricture: 5%• Pouchitis: 31%

Pemberton 1991, Fazio 1995


TPC and IPAA

Functional outcome• Frequency: 5-7 stools/day• Nocturnal seepage: 20-30%• Medication: 30%• Pouch loss: 9% (10 years)

Meagher 1998


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


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.


Surgery for Inflammatory Bowel Disease

David E. Stein, M.D.Division of Colorectal Surgery

Department of SurgeryDrexel University College of Medicine

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