M62 CourseApril 7-8 2005

SURGERY for

COLONIC CROHN’S DISEASE

RJ NICHOLLS

Crohn’s DiseaseSurgery

Indicated for Complications

Recurrence

Often Long term Relief

Minimal Surgery

No proven effect of Medical Treatment on Recurrence

CROHN’S DISEASEIndications for Surgery

Elective

ObstructionFistula/abscess

ColitisCarcinoma

Anal Disease

Avoid Late Surgery

Postoperative Complications

Fasth Lindhagen Pocard

1980 1982 2000

Preoperative

Sepsis

NO 12 % 22% 5%

YES 48% 45% 23%

Hulten 2001

CROHN’S DISEASEThe Cancer Risk

n fu/y Dys Ca relative risk

Swedish study 1655 30* - - SI 1 Il/col 3.2 LI 5.6

Gillen 1994 281 12-35 - 8 3.4+Friedman 2001 259 -20 42(16) 5

•*20.9 < 30y at onset•+18.2 extensive colitis

The Defunctioned Rectum

25 Patients

Low Hartmann’s Procedure3 Cases of Cancer

Regular surveillance

Ciccione 2000

CROHN’S COLITISUrgent Surgery

%

Failed medical treatment 70

Toxic dilatation 20

Perforation < 10

Bleeding < 5

ACUTE SEVERE COLITIS

CROHN’S DISEASE 20-30% of cases

5 Studies68 patients

Medical Treatment

Remission 65%(55-94%)

Remission maintained 54-69%

Kornbluth 1999

ACUTE CROHN’S COLITISChoice of Operation

145 Patients

Colectomy + IRA 47

Proctocolectomy 27

Colectomy + Ileostomy 13

Ileostomy alone 10

Keighley 1993

ACUTE SEVERE COLONIC CROHN’S DISEASEInitial Colectomy + Ileostomy

Operation Survivors

21

Rectal excision C + IRA

11 1

No surgery Ileal Colostomy

5 resection 1

3 Keighley 1993

COLONIC CROHN’S DISEASEMain Indications for Elective

Surgery

Severe Local SymptomsObstruction

Fistulation Anorectal disease

Systemic illness Chronic Proctocolitis

Pouches and Crohn’s Disease

Authors Year Mean F/U Total Crohn’s Pouch Cases

Failure(%)

Hyman 1991 38 25 32

Grobler 1993 - 20 30

Sagar 1996 - 37 46

Regimbeau 2001 113 41 7

Hartley 2003 - 60 25

Tulchinsky 2003 90 13 46

Total 227 31

Restorative Proctocolectomy for

Crohn’s Disease

3-5% in large surgical series

Failure up to 50% (cf UC 10%)

Failure increases with time

COLONIC CROHN’S DISEASE

Segmental v Total Colectomy + IRA

Total Colitis 70%

Segmental Colitis 30%

Kornbluth 1999

Segmental v Total Colectomy +IRA

SEGMENTAL(SC) v

TOTAL COLECTOMY + IRA

6 Studies 488 Pt 265 SC 223 IRA

Meta-analysis

Time to Recurrence Longer after IRA by 4.4 y

Fewer Operations After IRA where two segments involved

Tekkis et al 2005

CROHN’S DISEASEColectomy with IRA

N fu(y) Recurrence(%)

Flint 1977 37 6 41

Buchman 1981 105 8 30

Ambrose 1984 63 10 48

Goligher1988 47 15 49

Allan 1989 63 15 53

Longo 1992 131 10 65

Recurrence after Colectomy with IRA and Total Proctocolectomy

CROHN’S DISEASECOLECTOMY + IRA

131 Patients

Fu 9.5 y

13 Ileostomy never closed

118

Proctectomy Further ileal No resection

30 Diversion resection 48

16 24

Longo 1992

Colectomy with IRA

Rectal Sparing in 50% of Large Bowel Crohn’s

Indicated where two or more segments are involved

Recurrence in ~ 50% over 10 years

May be possible to re-resect terminal ileal recurrence

to avoid permanent stoma

PROCTOCOLECTOMY

Indications

Severe Rectal Disease

Cancer

Severe Anal Disease (almost always rectal involvement present)

Small Bowel Recurrence 20% at 10 y

Perineal Wound Delayed Healing

Incidence 30% or more of patients

x3 in pre-existing anal sepsis

Leave open in the presence of sepsis

Medical management ?value

Intensive Nursing

RESTORATIVE PROCTOCOLECTOMY

Close Rectal Dissection

with Intersphincteric Anal Removal

Avoids pelvic nerve damage

Not with dysplasia

Not with carcinoma

SEVERE ANORECTAL CROHN’S DISEASE

SPLIT ILEOSTOMY

29 Patients

36 mo

Still defunctioned 15

Proctocolectomy 8

Restoration of Continuity 6

Late deaths 2 Harper 1982