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Surgical Management of IBD

Susan L. Gearhart, M.D Associate Professor of Colorectal Surgery

Which of these individuals were diagnosed with Ulcerative Colitis?

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Which one of these individuals had surgery for their Ulcerative Colitis and is doing well!

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Last Seen with: THIS WOMAN Age: A woman never tells Height: Approx. 1.7 meters Weight: Slim and trim Likes: Gummy bears Date last seen: 4/26/2006

Name: Steve’s Colon DOB: 6/5/1971 Age: 34 Length: Approx. 0.5 meters Sex: M Likes: Oreo cookies Date Missing: 4/26/2006 From: Rockville, MD

If you have any information, or for free prevention tips, please call 1-800-SAVE-A-COLON

Or email SaveAColon@GreatSurgeons.com Zero colons featured here have safely been recovered

Have you seen my colon?

Indications for surgery for Ulcerative Colitis

•  1. Refractory Disease (majority) •  2. Dysplasia (3%)

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Presented by: Name goes here

Staged Procedure: Rate of Intraoperative Inability to perform IPPA ~ 3%

Technique of Restorative Proctocolectomy

Laparoscopic Restorative Proctocolectomy

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What about the ostomy?

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QOL, Health Status, HRQoL following Restorative Proctocolectomy

•  Systemtatic Review of 33 peer-reviewed articles •  HRQoL and HS was equivalent to general

population at 12 months •  Heinken Colorectal Diseases 2011

Fertility and Restorative Proctocolectomy

•  Ability to conceive is decreased (37%) •  The time to conception is longer (5 mo vs. 15 mo) •  The spontaneous pregnancy rate is decreased by

30% •  In-vitro pregnancy more common after surgery.

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Tulchinsky et al. Colorectal Diseases 2013

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Bartels SA, DʼHoore A, Cuesta MA, Bensdorp AJ, Lucas C, Bemelman WA. Significantly increased pregnancy rates after laparoscopic restorative proctocolectomy: a cross-sectional study. Ann Surg. 2012 Dec;256(6):1045-8.

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Reasons for Pouch Failure

•  Most common indication for reoperation following IPAA is pelvic sepsis.

•  Pelvic sepsis on average results in 2 additional operations per patient. – Shawki et al. DCR 2009

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•  445 patients who underwent IPAA •  30-day complication rates were 2x greater in

patients on steroids (OR 1.8, p=0.002) (Lim, DC&R 2007)

Can We Blame the Medications?

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Infliximab and Short-term Complications •  47 IPAA + IFX and 254 IPAA without IFX (Selanski, JACS 2007)

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Recommendations •  Decrease steroid dose to below 30 mg for at least one

month •  Stop Anti-TNF therapy 1 month prior to surgery •  Keep Gastroenterologist in the loop •  Do not hesitate to do a 3 staged procedure

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Which one of these famous persons was diagnosed with Crohn’s Disease?

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Indications for Surgery to Treat Crohn’s Disease •  Refractory symptoms •  Obstruction •  Bleeding •  Fistulization •  Perforation

Key Changes in Surgical Techniques for Crohns Disease

•  Minimal approaches to surgery (laparoscopic and single port site surgery

•  Smaller margins (2 cm) •  Early use of Nutritional Support •  Use of preoperative and postoperative medications

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Management of Intestinal Obstruction

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Endoscopic Balloon Dilation

Van Assche Gut 2010

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Laparoscopic Surgery for Crohns Disease

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Single Incision Laparoscopic Surgery (SILS)

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Summary

•  Surgery can result in good overall quality of life in patients with IBD

•  However there are drawbacks (bowel function can be poor for some time and risk of infertility)

•  Newer methods are beginning to show promise at eliminating these drawbacks!

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