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Surgical Management Inflammatory Bowel Disease Ernesto R. Drelichman, MD, FACS St. John Health Systems

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VARIETIES OF COLITIS

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ULCERATIVE COLITIS AND CROHNS DISEASE

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DISTINGUISHING FEATURES OF CROHNS DISEASE

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ANATOMIC DISTRIBUTION

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INFLAMMATION

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OBSTRUCTION

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ENDOSCOPIC APPEARANCES

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ENDOSCOPIC FEATURES

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COBBLESTONING

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Crohns Stricture

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FISTULIZATION

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Enterovesical Fistula

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PERIANAL FISTULAE AND ABSCESS

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GOALS OF THERAPY

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CONVENTIONAL DRUG THERAPIES

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OK, OK, you guys have had your chance the horses want another shot at it.

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BALLOON DILATION OF CROHNS DISEASE STRICTURES

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Philosophy of Surgical Management There is no Cure for Crohns Disease There is no Cure for Crohns Disease Surgery only overcomes the complications Surgery only overcomes the complications Potential for pan-intestinal involvement Potential for pan-intestinal involvement

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Surgery: Risks and Benefits Symptom relief Improved nutrition Reduced medication Surgical risk Disease recurrence Short bowel syndrome

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INDICATIONS FOR SURGERY IN CROHNS DISEASE

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Crohns Disease Surgical Indications 75% undergo surgery 50% undergo repeat surgery Collaborative decision Collaborative decision Patient Patient Gastroenterologist Gastroenterologist Surgeon Surgeon

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SURGICAL OPTIONS FOR INTRA- ABDOMINAL DISEASE IN CROHNS DISEASE

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Inflammatory Bowel Disease Disease Related Challenges Inflammatory Bowel Disease Disease Related Challenges Immunosuppression Immunosuppression Malnutrition Malnutrition fistulas fistulas abscess abscess phlegmon phlegmon thickened, shortened mesentery thickened, shortened mesentery friable tissues and vessels friable tissues and vessels Extensive disease Extensive disease

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Step 5: Exteriorization, Resection, and Anastomosis

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Step 4: Externalization

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Step 5: Resection and Anastomosis

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Crohns Disease Laparoscopic Colectomy - Advantages *33 patients with ileocolic Crohns underwent laparoscopic ileocectomy were case matched for potential confounders to an open group *33 patients with ileocolic Crohns underwent laparoscopic ileocectomy were case matched for potential confounders to an open group * > 60% had undergone previous surgery Young-Fadok et al. Surg Endosc 2001;450-4: Young-Fadok et al. Surg Endosc 2001;450-4: