Surgical Management of Inflammatory Bowel Disease

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Surgical Management of Inflammatory Bowel Disease

• Sandra J Beck, M.D.
• University of Kentucky
• Assistant Professor of Colon Rectal Surgery

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Surgical Management of IBD

• Goal Improve Quality of Life
• Curative?
• Treatment of Complications
• Palliation of Symptoms

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Surgical Management of IBD

• Therapeutic goals vary for different types of IBD

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Inflammatory Bowel Disease

• Classification
• Ulcerative Colitits
• Crohns Disease
• Indeterminate Colitis

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Normal Anatomy
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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 19941073

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Surgical Management of Ulcerative Colitis

• Goals
• Cure disease
• Improve quality of liferelieve symptoms
• Prevent risk of carcinoma
• Indications
• Toxic colitis
• Hemorrhage
• Medical intractability
• Malignant degeneration (cancer, dysplasia)

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Surgical Management Ulcerative Colitis

• Options
• Total Abdominal Colectomy, end ileostomy
• Total proctocolectomy, end ileostomy
• Total proctocolectomy, ileal pouch anal
  anastomosis

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Surgical Management of Ulcerative Colitis

• 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

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Total Abdominal Colectomy with End Ileostomy
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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

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Surgical Management of Ulcerative Colitis

• Total Proctocolectomy, End Ileostomy
• Curative
• Relatively uncomplicated
• High patient satisfaction
• Benchmark procedure for UC
• Permanent Ileostomy

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Total Proctocolectomy, End Ileostomy

• Indications
• Poor anal musculature / fecal incontinence
• Suspicion of Crohns disease (i.e. perianal
  disease, small bowel disease)
• Rectal cancer
• Patient request
• Technique
• Abdominal proctocolectomy
• Intersphincteric perineal dissection
• Brooke Ileostomy

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Total proctocolectomy with end ileostomy
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Surgical Management of Ulcerative Colitis

• Total Proctocolectomy, Ileal pouch anal
  anastomosis
• Curative
• Relatively uncomplicated
• High patient satisfaction
• Maintains intestinal continuity
• Most common surgical procedure performed today
  for ulcerative colitis

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Total Proctocolectomy, IPAA

• Patient Selection
• Functional Outcome
• Complications
• Overall Results

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Total Proctocolectomy, IPAA

• Patient Selection
• Certainty of diagnosis
• Adequate anal function
• Acceptable medical risk
• Informed and motivated patient

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Total Proctocolectomy, IPAA

• 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. DCR 199336895

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J-Pouch with Temporary Ileostomy
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J-Pouch Anal Anastomosis(with Ileostomy closed)
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Function after IPAA

• BMs 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

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Complications of IPAA

• Overall morbidity rate decreasing with increased
  experience with procedure
• Anastomotic leak10-14
• Intestinal Obstruction16-19
• Pouch-anal, Pouch-vaginal fistulae
• Anal stricture--8-14
• Pouchitis20
• More common in UC patients than FAP patients
• Overall long term incidence may be 50
• Pouch failure rate overall 2

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Surgical Management of Crohns Disease
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Surgical Management of Crohns

• No medical or surgical cure for Crohns 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

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Surgical Management of Crohns

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

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Surgical Management of Crohns

• Most patients require one or more operations
• Probability after 20 years 78
• Probability after 30 years 90
• Natl Coop. Crohns Disease Study
  Gastroenterology 1979
• Ileocolic disease is most common and most likely
  to eventually require surgery
• 90 at 10 years of symptomatic disease

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Surgical Management of CrohnsGuidelines

• Disease is chronic keep long term outlook for
  patient in mind
• Preserve small bowel whenever possible
• Treat only the primary problem

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Surgical Management of CrohnsTypes of Operations

• Intestinal resection with or without anastomosis
• Bypass procedures
• Internal-e.g. gastroduodenostomy
• External-e.g. ileostomy
• Stricturoplasty

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Resection

• Most common operation for Crohns
• 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

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Resection with Handsewn Anastomosis
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Resection with Stapled Anastomosis
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Specific Anatomic Presentations

• Ileocolic
• Small Bowel
• Segmental Colon
• Entire Colon
• Perianal Disease

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Ileocolic Crohns

• 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 recurrence
• Cameron J, et.al. Ann Surg 1992215546
• End-to-Side or Side-to-Side anastomosis have
  equal rates of recurrence
• Scott N, Sue-Ling H, Hughes L. Int J Colorect Dis
  19951067

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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)

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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

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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

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Stricturoplasty

• Heineke-Mikulicz
• Employed for strictures lt 10 cm
• Extend longitudinal enterotomy 2cm beyond
  stricture in either direction
• Close enterotomy transversely
• Finney Stricturoplasty
• Used for longer strictures
• Resection probably superior

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Strictureplasty
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Stricturoplasty

• Results
• Morbidity low- 15
• Sepsis
• Hemorrhage
• 98 of patients relieved of obstructive symptoms
• Fazio V, et.al. DCR 199336355
• 28 reoperative rate
• 78 of these for remote disease (stricturing or
  perforative)
• Ozuner G, FazioV. DCR 1996391199

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Colonic Crohns

• Segmental Disease
• Value of segmental colon resection controversial
• Preservation of colon decreases diarrhea, avoids
  use of ileostomy
• 62-67 of patients have recurrent colitis
• gt80 are able to preserve bowel continuity
• Longo W, et.al. Arch Surg 1988123588

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Crohns Colitis
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Crohns Colitis
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Crohns Colitis

• Extensive disease precludes segmental resection
• Proctocolectomy with end ileostomy procedure of
  choice

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Crohns 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

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Perianal Crohns

• 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

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Crohns Anal Fissure
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Crohns Anal Abscess
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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

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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

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Crohns Perianal Disease

• Control sepsis with drains or setons
• Injection of steriods
• Diversion of fecal stream
• Excision of Anus and Rectum and Permanent
  Colostomy

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Drainage with Seton
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Questions?
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Questions??