Dr. DrelichmanSurgical Techniques

Part 2

Crohn’s Disease Laparoscopic Colectomy - Results: Patient

OutcomesLAP (n=33)

Median (range)

OPEN (n=33)

Median (range)

p-value

Days to clearliquids

0 (0-4) 3.0 (2-8) 0.0001

Days to regulardiet

2.0 (1-6) 5.0 (3-12) 0.0001

# Shifts ofnarcotics

6.0 (2-14) 10.0 (3-34) 0.0010

Length of stay(days)

4.0 (2-8) 7.0 (3-14) 0.0001

Conversion Rate 5.9%

Laparoscopy for Ileocolic Crohns

Prospective Randomized Trial 60 pts

Ileo-colic Crohn’s Disease• Results: Lap Open

Incision 5cm

12cmMorphine =

=bowel function 3.0d

3.3dLOS 5d

6dComplications 4 8

Milsom et al. DCR 2001;44:1-9:

Multiple strictures

Strictures & Sacculations

Bowel Sparing techniquesStrictureplasty for Crohn’s Disease

STRICTUROPLASTY (FINNEY)

Jaboulay Strictureplasty

Indication: long stricture

Judd Strictureplasty

Indication: fistula site

Crohn’s Conclusions• Bowel-conserving surgical options

strictureplasty and limited resection • Complication rates are similar in both

• Reoperation rates are 50% at 10

years, and 70% at 15 years

Crohn’s Disease Conclusion

• Absolute Indications for Surgery

• Relative Indications _ QOL

• Laparoscopy has some benefits

• Disease related challenges

• Specialized Medical & Surgical care

• Close Collaboration

Surgery for Ulcerative Colitis

ANATOMIC EXTENT OF ULCERATIVE COLITIS

ENDOSCOPIC SPECTRUM OF SEVERITY

Ulcerative ColitisSymptoms/Signs

• Bright red blood per rectum and diarrhea are the most common symptoms

• Severe disease may evoke crampy abdominal pain and distention*, fever, tachycardia, elevated WBC

• Extraintestinal symptoms in up to 36% of patients

* Toxic megacolon: acute colitis with segmental or total dilation of the colon and accompanying fever, abd pain and tenderness, tachycardia, and leukocytosis

RISK OF COLORECTAL CANCER

Surveillance

• Colonoscopy should begin at 8-10 years duration of disease

• Then at 1-2 year intervals

• Pts with PSC start surveillance at time PSC diagnosed

Eaden J et al. Gastrointestinal Endoscopy 2000

SURVEILLANCE BIOPSY PROTOCOL

PSEUDOPOLYPS

DALMS IN ULCERATIVE COLITIS

Risk of Cancer associated with Dysplasia

• Review of ten prospective studies

Probability of cancer

• DALM 43%

• HGD 42%

• LGD 19%

Bernstein et al. Lancet 1994

INDICATIONS FOR SURGERY IN ULCERATIVE COLITIS

Ulcerative ColitisIndications for Surgery

• Intractability

• Massive hemorrhage

• Toxic megacolon

• Fulminant acute colitis

• Systemic complications

• Cancer or dysplasia

• Growth retardation (in children)

IBD - Toxic MegacolonSurgical Options

• Colectomy/Rectal preservation, Ileostomy:• Ulcerative colitis - 3-stage pouch• Crohns - 2-stage IRA

SURGICAL OPTIONS IN ULCERATIVE COLITIS

IPAA

n Maintains the normal route of defecation

h Increased frequency of stools

n Avoids permanent ostomy

Farouk R, Pemberton JH, Wolff BG, Dozois R. Annals Surg. 2000

1,454 patients IPAA for CUC. 12 yrs f/u• <45 >45 • Stool Freq • Day 6 6• Night 1 2 • Incontinence • Never 43% 24%• Occ.(2/wk) 48% 59%• Freq 9% 17%

Functional Outcomes

Quality of Life

n Patients with UC report a lower

quality of life compared to healthy

individuals

n Score similarly to patient with other

chronic illness (Diabetes)

Muir et al. Am J Gastroent. 2001

Post IPAA Quality of Life

n Preoperative scores low in all scales

n Health status questionnaire scores improved and even equal general population at 1 year.

Thirlby, R et al. Archives of Surg 2001

Post IPAA Quality of Life

Ulcerative Colitis Conclusions

• Risk Cancer increases with time in patients with UC and CC

• Surveillance Regimen to prevent Ca

• Colectomy should be offered to patients with Dysplasia

Ulcerative Colitis Conclusions

• Surgery offers definitive cure UC

• 1/3 of patients with UC have surgery

• Post Colectomy Patients have good QOL

• J-Pouch requires Surgical Expertise

Build Your Team• Be Proactive

• Be Educated • What % of practice IBD• Post Graduate training

• Build your Team • Coach or Project manager• IBD specialist, Surgeon• Nutrition • Social and Spiritual Support

• Communicate

St. John Health System IBD Center

Contact Information

Office: (248) 849-6030

Fax: (248)849-6039

Kim Buck, NP: (248)849-5448

“I don’t know where it goes, and I don’t want to know”“I don’t know where it goes, and I don’t want to know”