Crohn’s Colitis SR Brown Colorectal Surgeon Sheffield Teaching Hospitals.
-
Upload
valentine-leonard -
Category
Documents
-
view
224 -
download
0
Transcript of Crohn’s Colitis SR Brown Colorectal Surgeon Sheffield Teaching Hospitals.
![Page 1: Crohn’s Colitis SR Brown Colorectal Surgeon Sheffield Teaching Hospitals.](https://reader035.fdocuments.in/reader035/viewer/2022062301/5697bfa51a28abf838c97f28/html5/thumbnails/1.jpg)
Crohn’s Colitis
SR Brown
Colorectal Surgeon
Sheffield Teaching Hospitals
![Page 2: Crohn’s Colitis SR Brown Colorectal Surgeon Sheffield Teaching Hospitals.](https://reader035.fdocuments.in/reader035/viewer/2022062301/5697bfa51a28abf838c97f28/html5/thumbnails/2.jpg)
BSG guidelines
Gut 2004;53(suppl V):v1-v16
![Page 3: Crohn’s Colitis SR Brown Colorectal Surgeon Sheffield Teaching Hospitals.](https://reader035.fdocuments.in/reader035/viewer/2022062301/5697bfa51a28abf838c97f28/html5/thumbnails/3.jpg)
European Consensus Statement (ECCO)
Gut 2006;55(suppl 1):i16-i35
![Page 4: Crohn’s Colitis SR Brown Colorectal Surgeon Sheffield Teaching Hospitals.](https://reader035.fdocuments.in/reader035/viewer/2022062301/5697bfa51a28abf838c97f28/html5/thumbnails/4.jpg)
Objectives
• Discussion of– Primary surgery in localised Ileocaecal disease– Method of anastomosis– Segmental resections– Stricturoplasty – IPAA
![Page 5: Crohn’s Colitis SR Brown Colorectal Surgeon Sheffield Teaching Hospitals.](https://reader035.fdocuments.in/reader035/viewer/2022062301/5697bfa51a28abf838c97f28/html5/thumbnails/5.jpg)
Primary surgery for localised ileocolic disease
• ECCO recommendations
‘ Localised ileocaecal Crohn’s disease with obstructive symptoms can be treated by primary surgery’
![Page 6: Crohn’s Colitis SR Brown Colorectal Surgeon Sheffield Teaching Hospitals.](https://reader035.fdocuments.in/reader035/viewer/2022062301/5697bfa51a28abf838c97f28/html5/thumbnails/6.jpg)
Evidence for early surgery
• Whilst medical therapy will bring remission, surgery is almost inevitable
• Some long term data on results of resection
• Up to 50% ‘cured’
![Page 7: Crohn’s Colitis SR Brown Colorectal Surgeon Sheffield Teaching Hospitals.](https://reader035.fdocuments.in/reader035/viewer/2022062301/5697bfa51a28abf838c97f28/html5/thumbnails/7.jpg)
Long term outcomes after ileocaecal resection
Study Year Number Follow up (median)
Reoperation (%)
Graadel 1994 58 18 years 54
Nordgren 1994 136 17 years 45
Weston 1996 10 14 years 50
Kim 1997 181 14 years 31
Landsend 2006 53 24 years 64
Total 438 17 years 43%
![Page 8: Crohn’s Colitis SR Brown Colorectal Surgeon Sheffield Teaching Hospitals.](https://reader035.fdocuments.in/reader035/viewer/2022062301/5697bfa51a28abf838c97f28/html5/thumbnails/8.jpg)
Evidence against early surgery
• Minimal long term data on medical therapy
• ?surgical studies out of date– No AZA or Infliximab
![Page 9: Crohn’s Colitis SR Brown Colorectal Surgeon Sheffield Teaching Hospitals.](https://reader035.fdocuments.in/reader035/viewer/2022062301/5697bfa51a28abf838c97f28/html5/thumbnails/9.jpg)
Long term outcome of medical management
• Bemelman 2001
• Consecutive severe ileocaecal Crohn’s
• 1985-1994
• Follow up 8 years
• 76 patients
• 62% surgery
![Page 10: Crohn’s Colitis SR Brown Colorectal Surgeon Sheffield Teaching Hospitals.](https://reader035.fdocuments.in/reader035/viewer/2022062301/5697bfa51a28abf838c97f28/html5/thumbnails/10.jpg)
Quality of life NA Scott, LE Hughes Gut 1994
• 80 patients who had ileocolic resections questioned
• ¾ wanted op sooner• Reasons
– Severe symptoms –97%– Ability to eat properly –86%– Feeling well – 62%– No need for drugs –43%
![Page 11: Crohn’s Colitis SR Brown Colorectal Surgeon Sheffield Teaching Hospitals.](https://reader035.fdocuments.in/reader035/viewer/2022062301/5697bfa51a28abf838c97f28/html5/thumbnails/11.jpg)
Quality of life Tillinger et al. Dig Dis Sci 1999
• 16 patients surveyed prospectively
• HRQOL improved up to 24 months after op.
![Page 12: Crohn’s Colitis SR Brown Colorectal Surgeon Sheffield Teaching Hospitals.](https://reader035.fdocuments.in/reader035/viewer/2022062301/5697bfa51a28abf838c97f28/html5/thumbnails/12.jpg)
Scenario
• Young male• Presumed appendicitis• Found to have
terminal ileitis
![Page 13: Crohn’s Colitis SR Brown Colorectal Surgeon Sheffield Teaching Hospitals.](https://reader035.fdocuments.in/reader035/viewer/2022062301/5697bfa51a28abf838c97f28/html5/thumbnails/13.jpg)
Options
• Do nothing
• Appendicectomy
• Right hemicolectomy
![Page 14: Crohn’s Colitis SR Brown Colorectal Surgeon Sheffield Teaching Hospitals.](https://reader035.fdocuments.in/reader035/viewer/2022062301/5697bfa51a28abf838c97f28/html5/thumbnails/14.jpg)
Traditional teaching
• Appendicectomy if caecum normal– Ileitis may be Yersinia– Removing appendix reduces future confusion– Minimal resection in Crohn’s due to short
bowel– Consent
![Page 15: Crohn’s Colitis SR Brown Colorectal Surgeon Sheffield Teaching Hospitals.](https://reader035.fdocuments.in/reader035/viewer/2022062301/5697bfa51a28abf838c97f28/html5/thumbnails/15.jpg)
Ileocolic resection for acute presentation of crohn’s disease
• Weston 1996
• 36 patients with ?appendicitis found to have ileocaecal Crohn’s– 10 surgery
• 5 reoperations
– 26 no surgery/appendicectomy• 24 reoperations
![Page 16: Crohn’s Colitis SR Brown Colorectal Surgeon Sheffield Teaching Hospitals.](https://reader035.fdocuments.in/reader035/viewer/2022062301/5697bfa51a28abf838c97f28/html5/thumbnails/16.jpg)
Recommendations ECCO
‘ It is up to the judgement of the surgeon whether to resect a terminal ileum affected with Crohn’s disease found at laparotomy for suspected appendicitis’
![Page 17: Crohn’s Colitis SR Brown Colorectal Surgeon Sheffield Teaching Hospitals.](https://reader035.fdocuments.in/reader035/viewer/2022062301/5697bfa51a28abf838c97f28/html5/thumbnails/17.jpg)
Method of Anastomosis
• Functional end-to-end or conventional end-to-end
• Stapled or hand-sewn
![Page 18: Crohn’s Colitis SR Brown Colorectal Surgeon Sheffield Teaching Hospitals.](https://reader035.fdocuments.in/reader035/viewer/2022062301/5697bfa51a28abf838c97f28/html5/thumbnails/18.jpg)
![Page 19: Crohn’s Colitis SR Brown Colorectal Surgeon Sheffield Teaching Hospitals.](https://reader035.fdocuments.in/reader035/viewer/2022062301/5697bfa51a28abf838c97f28/html5/thumbnails/19.jpg)
Factors affecting recurrence
• Host related factors– Smoking etc
• Type of Crohn’s– Fistulating– Obstructing
• Type of anastomosis
![Page 20: Crohn’s Colitis SR Brown Colorectal Surgeon Sheffield Teaching Hospitals.](https://reader035.fdocuments.in/reader035/viewer/2022062301/5697bfa51a28abf838c97f28/html5/thumbnails/20.jpg)
What influences recurrence at the anastomosis?
• Faecal content
• Ischaemia
• Size
• Tissue reaction to suture/staples
![Page 21: Crohn’s Colitis SR Brown Colorectal Surgeon Sheffield Teaching Hospitals.](https://reader035.fdocuments.in/reader035/viewer/2022062301/5697bfa51a28abf838c97f28/html5/thumbnails/21.jpg)
Functional end-to-end versus end-to-end
![Page 22: Crohn’s Colitis SR Brown Colorectal Surgeon Sheffield Teaching Hospitals.](https://reader035.fdocuments.in/reader035/viewer/2022062301/5697bfa51a28abf838c97f28/html5/thumbnails/22.jpg)
Stapled functional end-to-end versus handsewn end-to-end
![Page 23: Crohn’s Colitis SR Brown Colorectal Surgeon Sheffield Teaching Hospitals.](https://reader035.fdocuments.in/reader035/viewer/2022062301/5697bfa51a28abf838c97f28/html5/thumbnails/23.jpg)
Problems with meta-analysis
• Retrospective
• Follow-up
• Needs RCT
![Page 24: Crohn’s Colitis SR Brown Colorectal Surgeon Sheffield Teaching Hospitals.](https://reader035.fdocuments.in/reader035/viewer/2022062301/5697bfa51a28abf838c97f28/html5/thumbnails/24.jpg)
ECCO recommendations
‘ There is some evidence that a wide lumen functional end to end anastomosis is the preferred technique’
![Page 25: Crohn’s Colitis SR Brown Colorectal Surgeon Sheffield Teaching Hospitals.](https://reader035.fdocuments.in/reader035/viewer/2022062301/5697bfa51a28abf838c97f28/html5/thumbnails/25.jpg)
Segmental resections
• Proctocolectomy versus sphincter preserving surgery
• Segmental resection versus colectomy and ileorectal anastomosis
![Page 26: Crohn’s Colitis SR Brown Colorectal Surgeon Sheffield Teaching Hospitals.](https://reader035.fdocuments.in/reader035/viewer/2022062301/5697bfa51a28abf838c97f28/html5/thumbnails/26.jpg)
Proctocolectomy versus sphincter preserving surgery
• Advantages proctocolectomy– Reduced recurrence
• Advantages segmental resection– Less morbidity
– No stoma
QuickTime™ and aTIFF (Uncompressed) decompressor
are needed to see this picture.
![Page 27: Crohn’s Colitis SR Brown Colorectal Surgeon Sheffield Teaching Hospitals.](https://reader035.fdocuments.in/reader035/viewer/2022062301/5697bfa51a28abf838c97f28/html5/thumbnails/27.jpg)
Indications for proctocolectomy
Avoidance of a stoma is convenient and appreciated by the patient but the risk of relapse and reoperation is more than doubled. In case with perianal disease further precaution is recommended.
![Page 28: Crohn’s Colitis SR Brown Colorectal Surgeon Sheffield Teaching Hospitals.](https://reader035.fdocuments.in/reader035/viewer/2022062301/5697bfa51a28abf838c97f28/html5/thumbnails/28.jpg)
Segmental or total colectomy
• Advantages segmental resection– Preservation bowel and
function
• Advantages total colectomy– Reduced recurrence
![Page 29: Crohn’s Colitis SR Brown Colorectal Surgeon Sheffield Teaching Hospitals.](https://reader035.fdocuments.in/reader035/viewer/2022062301/5697bfa51a28abf838c97f28/html5/thumbnails/29.jpg)
Segmental versus total colectomy
![Page 30: Crohn’s Colitis SR Brown Colorectal Surgeon Sheffield Teaching Hospitals.](https://reader035.fdocuments.in/reader035/viewer/2022062301/5697bfa51a28abf838c97f28/html5/thumbnails/30.jpg)
Segmental versus total colectomy
![Page 31: Crohn’s Colitis SR Brown Colorectal Surgeon Sheffield Teaching Hospitals.](https://reader035.fdocuments.in/reader035/viewer/2022062301/5697bfa51a28abf838c97f28/html5/thumbnails/31.jpg)
Limitations to meta-analysis
• Retrospective– Selection bias
• Publication bias
![Page 32: Crohn’s Colitis SR Brown Colorectal Surgeon Sheffield Teaching Hospitals.](https://reader035.fdocuments.in/reader035/viewer/2022062301/5697bfa51a28abf838c97f28/html5/thumbnails/32.jpg)
ECCO recommendations
‘If surgery is necessary for localised colonic disease then resection only of the affected part is preferable’
![Page 33: Crohn’s Colitis SR Brown Colorectal Surgeon Sheffield Teaching Hospitals.](https://reader035.fdocuments.in/reader035/viewer/2022062301/5697bfa51a28abf838c97f28/html5/thumbnails/33.jpg)
Stricturoplasty
• Endoscopic • Surgical
![Page 34: Crohn’s Colitis SR Brown Colorectal Surgeon Sheffield Teaching Hospitals.](https://reader035.fdocuments.in/reader035/viewer/2022062301/5697bfa51a28abf838c97f28/html5/thumbnails/34.jpg)
Advantages over resection
• Preservation of bowel and function
• ?Improved QOL
• Avoidance of surgery (endoscopy group)
![Page 35: Crohn’s Colitis SR Brown Colorectal Surgeon Sheffield Teaching Hospitals.](https://reader035.fdocuments.in/reader035/viewer/2022062301/5697bfa51a28abf838c97f28/html5/thumbnails/35.jpg)
Disadvantages
• ?Safe
• Recurrence
• Adenocarcinoma risk
![Page 36: Crohn’s Colitis SR Brown Colorectal Surgeon Sheffield Teaching Hospitals.](https://reader035.fdocuments.in/reader035/viewer/2022062301/5697bfa51a28abf838c97f28/html5/thumbnails/36.jpg)
Endoscopic balloon dilatation
• 8 studies
• Technical success >90%
• Often repeat dilations necessary
• Avoidance surgery in 41-72%
• Complication rate 10% (perforations 8/230)
![Page 37: Crohn’s Colitis SR Brown Colorectal Surgeon Sheffield Teaching Hospitals.](https://reader035.fdocuments.in/reader035/viewer/2022062301/5697bfa51a28abf838c97f28/html5/thumbnails/37.jpg)
Surgical stricturoplasty
• Retrospective• Plasty vs resection• 58 patients (29 vs 35)• Surgical recurrence
– 36% vs 24%
• Complications– 16% vs 22%
• QOL same
![Page 38: Crohn’s Colitis SR Brown Colorectal Surgeon Sheffield Teaching Hospitals.](https://reader035.fdocuments.in/reader035/viewer/2022062301/5697bfa51a28abf838c97f28/html5/thumbnails/38.jpg)
ECCO statement
‘ Endoscopic dilatation of a stenosis in Crohn’s disease is a preferred technique for the management of accessible short strictures. It should only be attempted in institutions with surgical back up.’
![Page 39: Crohn’s Colitis SR Brown Colorectal Surgeon Sheffield Teaching Hospitals.](https://reader035.fdocuments.in/reader035/viewer/2022062301/5697bfa51a28abf838c97f28/html5/thumbnails/39.jpg)
IPAA for colonic Crohn’s
QuickTime™ and aTIFF (Uncompressed) decompressor
are needed to see this picture.
![Page 40: Crohn’s Colitis SR Brown Colorectal Surgeon Sheffield Teaching Hospitals.](https://reader035.fdocuments.in/reader035/viewer/2022062301/5697bfa51a28abf838c97f28/html5/thumbnails/40.jpg)
Initial data on IPAA for Crohn’s
• 3 papers (UK,US)• Misdiagnosis UC• 44 patients
– Pouch excision in 33%
– Good function in 26 (59%)
![Page 41: Crohn’s Colitis SR Brown Colorectal Surgeon Sheffield Teaching Hospitals.](https://reader035.fdocuments.in/reader035/viewer/2022062301/5697bfa51a28abf838c97f28/html5/thumbnails/41.jpg)
![Page 42: Crohn’s Colitis SR Brown Colorectal Surgeon Sheffield Teaching Hospitals.](https://reader035.fdocuments.in/reader035/viewer/2022062301/5697bfa51a28abf838c97f28/html5/thumbnails/42.jpg)
Panis 1996
• 31 patients with Crohn’s– Rectal disease requiring excision– No perianal disease– No small bowel disease
• 71 patients with UC
• Follow up mean 72 +/-23 months
![Page 43: Crohn’s Colitis SR Brown Colorectal Surgeon Sheffield Teaching Hospitals.](https://reader035.fdocuments.in/reader035/viewer/2022062301/5697bfa51a28abf838c97f28/html5/thumbnails/43.jpg)
Panis 1996
• 6/31 Crohn’s related complications– 4 fistulas treated surgically– 1 abscess – 1 crohn’s pouch recurrence
• 2/31 pouch excision (6%)
• Function = UC patients
![Page 44: Crohn’s Colitis SR Brown Colorectal Surgeon Sheffield Teaching Hospitals.](https://reader035.fdocuments.in/reader035/viewer/2022062301/5697bfa51a28abf838c97f28/html5/thumbnails/44.jpg)
Meta-analysis of the literature
• 10 studies• 3,103 IPAA• 225 IPAA for Crohn’s
![Page 45: Crohn’s Colitis SR Brown Colorectal Surgeon Sheffield Teaching Hospitals.](https://reader035.fdocuments.in/reader035/viewer/2022062301/5697bfa51a28abf838c97f28/html5/thumbnails/45.jpg)
IPAA for Crohn’s
• Crohn’s IPAA– More strictures (OR 2.12)– More pouch failure (32 vs 4.8%)– More Urgency (19 vs 11%)– More incontinence (19 vs 10%)
![Page 46: Crohn’s Colitis SR Brown Colorectal Surgeon Sheffield Teaching Hospitals.](https://reader035.fdocuments.in/reader035/viewer/2022062301/5697bfa51a28abf838c97f28/html5/thumbnails/46.jpg)
IPAA for Crohn’s
• Note selection bias– 9/10 studies identified patients because of
complications
• Patients with isolated colonic Crohn’s– Complication and pouch failure equal
![Page 47: Crohn’s Colitis SR Brown Colorectal Surgeon Sheffield Teaching Hospitals.](https://reader035.fdocuments.in/reader035/viewer/2022062301/5697bfa51a28abf838c97f28/html5/thumbnails/47.jpg)
ECCO statement
‘ At present an IPAA is not recommended in a patient with Crohn’s colitis’