Surgery for inflammatory bowel disease

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Surgery for inflammatory bowel disease

• By
• Rajeev Suryavanshi
• Dept of General surgery

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Inflammatory bowel disease

• Definition-
• Group of conditions involving whole or part
  of the bowel in the inflammatory process.

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Causes of inflammatory bowel disease.

1. Infective bacterial, viral, parasites
2. Ulcerative colitis
3. Crohns disease
4. Radiation enteritis
5. Ischemic colitis
6. Microscopic colitis
7. Drug induced colitis

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Inflammatory bowel disease

• Ulcerative colitis
• Prevalence 80/100,000 in Europe
• Peak Age 20-35 year
• Characteristic feature- acute mucosal
  inflammation with crypt abscesses.

• Crohns disease
• Prevalence 40/100,000 in Europe
• Incidence is increasing
• Characteristic feature- Patchy transmural
  inflammation with non-caeseating granuloma.

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Pathophysiology-

• Exact Pathophysiology still unclear, both
  diseases have some features in common.
• Inappropriate activation of mucosal immune
  system.
• May have defective barrier function.
• Genetic factor-
• - variable prevalence in different population
• - higher incidence in 1degree relatives
• - ? Concordance in monozygotic twins.
• Environmental factors-
• - Smoking
• - NSAIDs.

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Pathological features

• Ulcerative colitis-
• Lesion continuous superficial.
• Rectum always involved
• Granulated, ulcerated mucosa.
• No fissuring
• Normal serosa
• Muscular shortening of colon
• Malignant change

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Ulcerative colitis

• Bowel showing severe ulcerative colitis with
  Pseudo polyp formation

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Pathological features

• Crohns disease-
• Lesion patchy, penetrating
• 50 no rectal involvement.
• Terminal ileum involved in 30
• Discretely ulcerated mucosa
• Cobblestone appearance and fissuring.
• Serositis common
• Enterocutaneous or intestinal fistulae
• Anal lesions in 75
• Possible malignant change.

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Crohns disease

• Opened specimen of Terminal ileal Crohns disease.

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Crohns disease

• Histological appearance of Crohn's disease
  showing transmural inflammation

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Clinical features of Ulcerative colitis

• 30 confined to rectum.
• 15 develop more extensive disease over 10 years.
• 20 whole colonic involvement at presentation.
• Clinically classified -
• Severe acute colitis
• Intermittent relapsing colitis
• Chronic persistent colitis.
• Asymptomatic disease.

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Disease Severity ulcerative colitis
Grade Number of stools per day Systemic features- (Tachycardia, Fever, Anemia, Hypoalbuminaemia.)
Mild lt 4 Systemically well
Moderate gt 4 Systemically well
Severe gt 6 Systemically unwell
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Endoscopic grading of ulcerative colitis
Grade Features
0 Normal
1 Loss of vascular pattern, granularity
2 Granular mucosa with contact bleeding
3 Spontaneous bleeding
4 ulceration
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Endoscopic view

• Ulcerative colitis at endoscopy

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Endoscopic view

• Crohns disease at endoscopy

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Clinical features Crohn's disease

• Depend on site of involvement
• 50 have ileocecal disease
• 25 present with colitis.
• Systemic features more common.
• Picture showing Crohn's stricture

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Extra intestinal manifestations of IBD.

• Associated with disease activity-
• Skin
• Erythema nodosum, Pyoderma gangrenosum
• Joints
• asymmetrical non - deforming arthopathy.
• Eyes
• anterior uveitis, episcleritis,
  conjunctivitis.
• Hepatobiliary
• Acute fatty liver
• Thromboembolic disease

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Extra intestinal manifestations

• Pyoderma gangrenosum.

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Extra intestinal manifestations -

• 2. Unrelated to disease activity -
• Joints
• Sacroilitis, Ankylosing spondylitis
• Hepatobiliary
• - Primary sclerosing cholangitis
• - Cholangiocarcinoma
• - Chronic active hepatitis
• - Gall stones
• Amyloid
• Nephrolithisis

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Surgery for IBD

• Surgical indication differs in ulcerative colitis
  and Crohn's disease.
• Permanent Cure possible in ulcerative colitis,
  with Panproctocolectomy.
• No cure possible in Crohn's disease, due to
  relapsing nature and tendency to recur anywhere
  in the gut. Surgery limited in treating
  complications.

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Indications for Surgery in Ulcerative Colitis.

• 20 of patients with Ulcerative colitis require
  surgery at some time.
• 30 of those with total colitis require colectomy
  in 5 years.

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Surgery in ulcerative colitis

• Emergency -
• Toxic Megacolon
• Perforation
• Hemorrhage
• Severe colitis not responding to medical
  treatment.

• B. Elective -
• Chronic symptoms despite medical therapy.
• Carcinoma or high grade dysplasia.

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Ulcerative colitis

• Radiograph showing features of toxic dilatation
  of colon in ulcerative colitis.

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Surgical Options

• Emergency -
• Total colectomy with ileostomy and mucus fistula.
• B. Elective -
• Panproctocolectomy and Brooke ileostomy.
• Panproctocolectomy and Kock continent ileostomy.
• Total Colectomy and ileorectal anastomosis.
• Restorative Proctocolectomy with ileal pouch.

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Continent reservoir (Kock pouch)

• Kock 1969 designed a reservoir from terminal
  ileum.
• Indication was narrowed significantly with
  ileoanal pouch surgery as standard in 1980s.
• Indication today-
• Failed ileoanal pouch with poor sphincter
  function
• Past Proctocolectomy with sacrifice of anal
  sphincter and ileostomy but want a continent
  ileostomy.

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Restorative Proctocolectomywith ileal pouch

• Need adequate anal musculature
• If over 60 years, suggested evaluation with anal
  manometric studies.
• Any histological evidence of Crohn's on rectal
  biopsy is absolute contraindication for any pouch
  procedure.
• Need for mucosectomy unclear.
• May need defunctioning ileostomy.

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Pouch design

• ileoanal pouch designs

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ileoanal pouch

• ileoanal pouch during surgery.

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Functional results of ileoanal pouch

• Mean stool frequency is six per day.
• Perfect continence
• During day - 90
• At night - 60
• Gross incontinence 5.

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Proctocolectomy with ileal pouch

• Morbidity
• 50 develop significant complications.
• Small bowel obstruction 20
• Pouchitis 15
• Genitourinary dysfunction 6
• Pelvic sepsis 5
• Fistula 5
• Pouch failure 6
• Anal stenosis 5
• Larger capacity pouches reduce stool frequency.

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Surgical indications Crohn's disease.

• Absolute-
• Perforation with generalized peritonitis.
• Massive hemorrhage
• Carcinoma
• Fulminant or unresponsive acute severe colitis.

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Surgical indications Crohn's disease

• B. Elective -
• Chronic obstructive symptoms.
• Chronic ill health or debilitating diarrhea.
• Intra-abdominal abscess or fistula.
• Complications of Perianal disease.

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Surgical options in Crohn's disease

• Limited resections.
• 30 undergoing ileocecal resection require
  further surgery.
• Stricturoplasty often successful.
• Bypass procedure rarely required.
• Few facts-
• Be conservative as possible.
• No evidence that increased resection margin
  reduces risk of recurrence.
• If possible improve preoperative nutritional
  state.

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Surgery in Crohn's disease

• Small bowel or ileocecal disease-
• Resection-
• - appropriate for single ileocecal lesion
• - if mesentery thickened , transfix vessels.
• - wide anastomosis suggested.
• Detecting distal stenosis-
• - using balloon catheter to detect proximal
  stenosis.

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Surgery in Crohn's disease

• Skip lesions
• - ileocecal lesion with skip lesion, need
  resection of ileocecal region with proximal
  stricturoplasties
• - Stricturoplasty ideal for duodenal
  disease.
• - if multiple stricturoplasties done inflate
  stomach via NG tube with 2L of Co2, saline in
  abdominal cavity and test for leak

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Surgery in Crohns disease

• Technique showing Stricturoplasty in Crohn's
  disease.

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Surgery for Crohn's disease-

• B. Colorectal Disease-
• Evaluation with colonoscopy, Anorectal
  physiological studies.
• Localized area local excision
• Wide distribution with no rectal involvement
  total colectomy with ileo rectal anastomosis.
• If rectum involved- Panproctocolectomy.

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Anal disease Crohn's

• Often painless, and managed conservatively.
• If pain suspect pus pocket in Perianal region.
• EUA deroofing without sphincter division is
  indicated.
• More chances of incontinence with aggressive
  surgery, rather than progressive disease.

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Fistula Crohn's

• Enteroenteric fistula common from ileocecal
  disease (small bowel to sigmoid colon)
• Flexible sigmoidoscopy is helpful.
• Surgical - resection of diseased segment
  anastomosis of healthy segment, interrupted
  repair of fistulous site is indicated.
• Ensure no distal stenosis.

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conclusion

• Disease is very old and nothing about it has
  changed. It is we who change as we learn to
  recognize what was formerly imperceptible.

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Thank you
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• Add servellance for ulcerative colitis .