Phillip Fleshner, MD Shierley , Jesslyne , and Emmeline Widjaja Chair in Colorectal Surgery
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Phillip Fleshner, MD Shierley, Jesslyne, and Emmeline Widjaja Chair in Colorectal Surgery Program Director, Colorectal Surgery Residency Clinical Professor of Surgery UCLA School of Medicine Cedars-Sinai Medical Center Los Angeles, California CS Clinical Debate A patient with severe Crohn's disease, an ileal stricture and proximal dilation on CTE should have an ileocolonic resection first
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Clinical Debate A patient with severe Crohn's disease, an ileal stricture and proximal dilation on CTE should have an ileocolonic resection first. S. C. Cedars-Sinai Medical Center Los Angeles, California. Phillip Fleshner, MD - PowerPoint PPT Presentation
Transcript of Phillip Fleshner, MD Shierley , Jesslyne , and Emmeline Widjaja Chair in Colorectal Surgery
Phillip Fleshner, MD
Shierley, Jesslyne, and Emmeline Widjaja Chair in Colorectal Surgery
Program Director, Colorectal Surgery ResidencyClinical Professor of Surgery
UCLA School of Medicine
Cedars-Sinai Medical CenterLos Angeles, California
C S
Clinical DebateA patient with severe Crohn's disease, an ileal
stricture and proximal dilation on CTE should have an ileocolonic resection first
Therapeutic Alternatives to Treat CD Strictures
• Additional medical therapy
• Endoscopic dilation
• Surgery
Why Medical Therapy Not Useful• Expensive• When do you stop, ? lifetime exposure• QOL issues in partial responders• IV steroids frequently used to assess response
Steroids associated with development of stenosisSteroids associated with postoperative morbidity
• Aggressive medical therapy ↑ surgical morbidity• Prestenotic dilation is a negative prognostic factor
Disease assessment scores Clinical studies
Lehman Score• Score measuring the progressive nature or
cumulative structural bowel damage, independent of the current and fluctuating disease activity
• A longitudinal tool currently being developed and validated prospectively
Pariente B, et al., IBD 2011
Prestenotic Dilation and Clinical Response in CD
No stenosis
Stenosis
; no dila
tion
Stenosis
; yes d
ilation
0
50
100 7561
28
%
“Patients with intestinal narrowing and prestenotic dilatation … were less likely to respond to medical therapy”
(OR = 7.85, 95% CI 1.73-35.6,p= 0.008)
Lawrance IC, et al., WJG 2009
Why Medical Rx Is Not UsefulExpert Consensus Opinion
Why Medical Rx Is Not UsefulExpert Consensus Opinion
Laparoscopic Ileocolic Resection• Short term outcomes
Minimal scarringEnhanced cosmesisFast surgical recoveryFast restoration of QOL Complications are low (<10%)Medication can be stopped or limited in prevention modeSmall bowel loss is generally small (usually 20–25 cm)
• Long term outcomesLower incisional herniaLess adhesions, possibly less SBO
Endoscopic Dilation vs Laparoscopic Surgery
Criterion EndoscopicDilatation
LaparoscopicSurgery
Average Procedure Length Can be long with deep SB strictures using DBE
120 min
Overall complications � 10% <10%
Complications requiring surgery
� 5% <1%
Peritonitis/perforation 2% 2%
Potential for leaving CA Present; Biopsy critical None
Endoscopic Dilation vs Laparoscopic Surgery
Criterion EndoscopicDilatation
LaparoscopicSurgery
Technical success rate 90% 100%
Clinical success rate � 50% >95%
Patients requiring only 1 procedure � 30% 99
Mean # of procedures needed � 4 1
QOL after procedure Unknown Very high
Severe CD, Ileal Stricture and Proximal Dilation
Is Endoscopic Dilation Ever Preferable to Surgery?
• Multicentric disease• Multiple prior resections
AdhesionsLoss of bowel → short bowel syndrome
• Poor surgical risk • Initial presentation of the disease• Stricture location
GastroduodenalRectosigmoid
