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

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


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


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


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


• Patient Selection– Certainty of diagnosis

– Adequate anal function

– Acceptable medical risk

– Informed and motivated patient


• 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


• Indications – Abscess– Fistula– Perforation– Obstruction– Extraintestinal Manifestations – Presence or Risk of Malignancy


• 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’sGuidelines

• 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’sTypes 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 recurrenceCameron 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 continuityLongo 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 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

Perianal DiseaseTreatment

• 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?

Questions??

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Surgical Management of Inflammatory Bowel Disease