Criteria for Surgical Decision Making in Crohn’s Disease Dr Sanjay De Bakshi MS; FRCS (Eng;...
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Transcript of Criteria for Surgical Decision Making in Crohn’s Disease Dr Sanjay De Bakshi MS; FRCS (Eng;...
Criteria for Surgical Decision Makingin Crohn’s Disease
Dr Sanjay De Bakshi MS; FRCS (Eng; Edin{ad eundem})Head of Division of Surgical GastroenterologyCalcutta Medical Research Institute
Crohn’s Disease
• A disease that the knife will not CURE!!
• The Crohn’s Diaries:- “I wake up every
morning wondering if this is the day my journey to lasting remission will end?”
Burril Bernard CrohnDamocles
Recurrence after Surgery
• Post-operative recurrence rates defined by clinical symptoms are:-
• are follows:-YEARS AFTER SURGERY CLINICAL SYMPTOMS
5 years after 17-55%
10 years after 32-76%
15 years after 72-73%
Factors affecting recurrence after surgery for Crohn’s diseaseTakayuki Yamamoto World J Gastroenterol 2005;11(26):3971-3979
Recurrence after Surgery
• Recurrence rates requiring re-operations are:-
YEARS AFTER SURGERY CLINICAL SYMPTOMS
5 years after 11-32%
10 years after 20-44%
15 years after 46-45%
Factors affecting recurrence after surgery for Crohn’s diseaseTakayuki Yamamoto World J Gastroenterol 2005;11(26):3971-3979
Chance of Surgery
• The chance of surgery at 5-year intervals after diagnosis is as follows:-
YEARS AFTER DIAGNOSIS
NO SURGICAL PROCEDURE
1 SURGICAL PROCEDURE
2 SURGICAL PROCEDURE
5 years after diagnosis 51% 37% 12%
10 years after diagnosis 39% 39% 23%
15 years after diagnosis 30% 34% 36%
Jess T, Loftus EV Jr, Harmsen WS, Zinsmeister AR, Tremaine WJ, Melton LJ 3rd, et al. Survival and cause specific mortality in patients with inflammatory bowel disease: a long term outcome study in Olmsted County, Minnesota, 1940-2004. Gut. 2006 Sep. 55(9):1248-54.
Cumulative risk of Recurrence after Surgery
Risk Factors for Surgery and Postoperative Recurrence in Crohn’s DiseaseOlle Bernell, MD, Annika Lapidus, MD, and Göran Hellers, MD Ann Surg. 2000 Jan; 231(1): 38.
Cumulative risk of Recurrence after Surgery
Risk Factors for Surgery and Postoperative Recurrence in Crohn’s DiseaseOlle Bernell, MD, Annika Lapidus, MD, and Göran Hellers, MD Ann Surg. 2000 Jan; 231(1): 38.
Multiple risk factors, both modifiable and disease-related, have been evaluated in an attempt to predict postoperative Crohn's
disease recurrence
STRONGER LEVEL OF EVIDENCEPATIENT FACTOR
• SmokingDISEASE FACTOR• Penetrating disease(?)• Multiple site involvement(?)• Presence of Granulomas(?)TREATMENT FACTOR• History of prior resection
LESS STRONG LEVEL OF EVIDENCE
• Family history of IBD• Age at disease onset• Anatomical site of disease• Type of anastomosis• Nutritional status• Disease extent
Factors affecting recurrence after surgery for Crohn’s disease. Takayuki Yamamoto World J Gastroenterol 2005;11(26):3971-3979Predictors of recurrence of Crohn’s disease after ileocolectomy: A review. Tara M Connelly and Evangelos Messaris World J Gastroenterol. 2014 Oct 21; 20(39)http://www.medscape.com/viewarticle/772973_5
Recommended indications for surgical intervention include the following
• Persistent symptoms despite high-dose corticosteroid therapy
• Treatment-related complications, including intra-abdominal abscesses
• Medically intractable fistulae• Fibrotic strictures with obstructive symptoms• Toxic megacolon• Intractable haemorrhage• Perforation• Cancer
ASCRS Indications for Surgical Management of Crohn Disease (2007)
Operative Indication
Factors for Considering Surgery
Failed medical therapy
•Presence of disease-related symptoms not responsive to medical management; condition demonstrates an inadequate response
•When first- and second-line therapies do not induce remission safely in severe disease
•Before escalating medical therapy in severe or steroid-dependent disease with limited extent (eg, disease with stricturing behavior, patients who have contraindications or risk factors for further medical therapy)
ASCRS Indications for Surgical Management of Crohn Disease (2007)
Operative Indication
Factors for Considering Surgery
Perforation
Presence of symptoms or signs of free perforationImmediate resection of perforated segment (has a relatively high mortality)After small bowel resection or perforation, other procedures can be performed, as needed (eg, end stoma, diverted or nondiverted anastomosis)
When large anteroparietal, interloop, intramesenteric, or retroperitoneal abscesses cannot be or are unsuccessfully managed with antibiotics and percutaneous drainageSurgical drainage in such cases, with or without resection can be performed
Persistent enteric fistulae and symptoms or signs of localized or systemic sepsis despite appropriate medical managementPersistent sepsis warrants excision of the diseased bowel, whether or not an abscess is present (Surgery may be avoided for internal fistulae)
ASCRS Indications for Surgical Management of Crohn Disease (2007)
Operative Indication
Factors for Considering Surgery
Obstruction
Presence of symptomatic strictures in regions not amenable or responsive to medical therapy
Presence of asymptomatic colonic strictures that cannot be adequately surveyed by biopsy or cytology brushing
ASCRS Indications for Surgical Management of Crohn Disease (2007)
Operative Indication
Factors for Considering Surgery
Inflammation
Presence of acute colitis and symptoms or signs of impending or actual perforation (eg, transverse colon distention > 6 cm on abdominal x-ray or persistent gaseous colonic distention indicate toxic megacolon, pneumatosis coli, evolving local peritonitis, multiple organ failure)
Presence of severe or fulminant colitis
Worsening acute colitis or failure to significantly improve despite 48-96 hours of appropriate medical therapy
ASCRS Indications for Surgical Management of Crohn Disease (2007)
Operative Indication
Factors for Considering Surgery
Hemorrhage
Presence of massive haemorrhaging of any origin that •cannot be or fails to be managed with interventional or endoscopic techniques and •occurs in hemodynamically unstable patients
To identify the lesion:-•Mesenteric angiography with embolization•Laparotomy with or without intra operative endoscopy
ASCRS Indications for Surgical Management of Crohn Disease (2007)
Operative Indication
Factors for Considering Surgery
Neoplasia
Presence of chronic Crohn’s disease of the ileocolon or colon (suspicion on endoscopic surveillance)Presence of adenomatous-appearing polyps (excision)
Presence of carcinoma, Dysplasia associated lesion or mass (DALM), high-grade dysplasia, multifocal colonic or rectal low-grade dysplasia (resection)
Presence of chronic Crohn’s of the upper GI region
Cancer risks in Crohn disease patients. K. Hemminki, X. Li, J. Sundquist and K. Sundquist
Annals of Oncology Volume 20, Issue 3Pp. 574-580.
Swedish trial involving21.788 CD patients
ASCRS Indications for Surgical Management of Crohn Disease (2007)
Operative Indication
Factors for Considering Surgery
Growth retardation and Extra Intestinal Manifestations
Presence of significant growth retardation in prepubertal patients despite appropriate medical therapy
Presence of symptomatic dermatologic, oral, ophthalmologic, or joint disorders refractory to medical therapy (resection of diseased intestine)
Montreal classification system• The Montreal revision of the Vienna system is based on the following 3 variables:• Age at diagnosis/ Disease distribution& location/Disease behavior• Age at diagnosis (A) has 3 categories, as follows :
– A1 – ≤ 16 years– A2 – 17-40 years– A3 – > 40 years
• Disease distribution/location (L) has the following 4 categories, 1 of which is a modifier for upper GI involvement:– L1 – Ileal– L2 – Colonic– L3 – Ileocolonic– L4 – Isolated upper GI disease; L4 is a modifier that can be added to L1-L3 when
there is concomitant upper GI involvement• Disease behavior (B) has 1 interim category (B1) and 2 specified categories, with an
additional modifier for perianal diseases (p), as follows :– B1 – Nonstricturing, nonpenetrating; B1p: nonstricturing, nonpenetrating with
perianal involvement– B2 – Stricturing; B2p: stricturing with perianal involvement– B3 – Penetrating; B3p: penetrating with perianal involvement
Complications of Surgery
Possible Use of Predictors for Long- and Short-Term Disease Course in Crohn’s Disease.
MARKER NAME CLINICAL OUTCOME
CLINICAL MARKERS
Young age at onset (Paediatric/<40 years)
Disabling disease, Surgery
Small bowel disease
Perianal disease
Weight loss > 5kg
Steroid needed for first flare at diagnosis
Early immunosuppression and/ biological Rx
Possible Use of Predictors for Long- and Short-Term Disease Course in Crohn’s Disease.
MARKER NAME CLINICAL OUTCOME
ENDOSCOPY MARKERS
Complete or partial mucosal healing (protective) according to CDEIS or SES-CD
Clinical flares, hospitalization, Surgery
CDEIS= Crohns Disease Endoscopic Index of SeveritySES-CD= Simple endoscopic score for Crohns Disease
Rutgeerts Endoscopic ScoreRutgeerts Endoscopic Recurrence Scoring System.
Endoscopic Score Definition
i0 No lesions
i1 ≤5 aphthous lesions
i2>5 aphthous lesions with normal mucosa between the lesions or skip areas of larger lesions or lesions confined to the ileocolonic anastomosis
i3 Diffuse aphthous ileitis with diffusely inflamed mucosa
i1 i2 i3 i4
Recurrence Rates :- 5% 15-20% 40% 90% -at 3 years
Possible Use of Predictors for Long- and Short-Term Disease Course in Crohn’s Disease.
MARKER NAME CLINICAL OUTCOME
BIOMARKERS
LABORATORY MARKERS
Clinical flares, endoscopic activity, Surgery?CRP
ESR
Calprotectin
SEROLOGY MARKERS
ASCA, pANCA, glycans Complicated disease, Surgery
GENETIC MARKERS NOD2/CARD15 Disease location/behavior/Surgery in CD
TPMT (Thiopurine S-methyltransferase) Azathioprine toxicity
Suggested Treatment to prevent Recurrence after Surgery
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