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Dr. DrelichmanSurgical Techniques
Part 2
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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%
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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:
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Multiple strictures
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Strictures & Sacculations
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Bowel Sparing techniquesStrictureplasty for Crohn’s Disease
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STRICTUROPLASTY (FINNEY)
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Jaboulay Strictureplasty
Indication: long stricture
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Judd Strictureplasty
Indication: fistula site
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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
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Crohn’s Disease Conclusion
• Absolute Indications for Surgery
• Relative Indications _ QOL
• Laparoscopy has some benefits
• Disease related challenges
• Specialized Medical & Surgical care
• Close Collaboration
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Surgery for Ulcerative Colitis
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ANATOMIC EXTENT OF ULCERATIVE COLITIS
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ENDOSCOPIC SPECTRUM OF SEVERITY
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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
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RISK OF COLORECTAL CANCER
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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
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SURVEILLANCE BIOPSY PROTOCOL
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PSEUDOPOLYPS
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DALMS IN ULCERATIVE COLITIS
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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
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INDICATIONS FOR SURGERY IN ULCERATIVE COLITIS
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Ulcerative ColitisIndications for Surgery
• Intractability
• Massive hemorrhage
• Toxic megacolon
• Fulminant acute colitis
• Systemic complications
• Cancer or dysplasia
• Growth retardation (in children)
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IBD - Toxic MegacolonSurgical Options
• Colectomy/Rectal preservation, Ileostomy:• Ulcerative colitis - 3-stage pouch• Crohns - 2-stage IRA
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SURGICAL OPTIONS IN ULCERATIVE COLITIS
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IPAA
n Maintains the normal route of defecation
h Increased frequency of stools
n Avoids permanent ostomy
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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
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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
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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
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Post IPAA Quality of Life
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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
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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
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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
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St. John Health System IBD Center
Contact Information
Office: (248) 849-6030
Fax: (248)849-6039
Kim Buck, NP: (248)849-5448
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“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”