Dr. Drelichman
Surgical Techniques
Part 2
Crohn’s Disease
Laparoscopic Colectomy - Results: Patient
Outcomes
LAP (n=33)
OPEN (n=33)
Median (range)
Median (range)
0 (0-4)
3.0 (2-8)
0.0001
Days to regular
diet
2.0 (1-6)
5.0 (3-12)
0.0001
# Shifts of
narcotics
6.0 (2-14)
10.0 (3-34)
0.0010
Length of stay
(days)
4.0 (2-8)
7.0 (3-14)
0.0001
Days to clear
liquids
Conversion Rate
5.9%
p-value
Laparoscopy for Ileocolic Crohns
Prospective Randomized Trial 60 pts
Ileo-colic Crohn’s Disease
• Results:
Incision
Morphine
bowel function
LOS
Complications
Milsom et al. DCR 2001;44:1-9:
Lap
Open
5cm
=
3.0d
5d
4
12cm
=
3.3d
6d
8
Multiple strictures
Strictures & Sacculations
Bowel Sparing techniques
Strictureplasty 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 Colitis
Symptoms/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 Colitis
Indications for Surgery
• Intractability
• Massive hemorrhage
• Toxic megacolon
• Fulminant acute colitis
• Systemic complications
• Cancer or dysplasia
• Growth retardation (in children)
IBD - Toxic Megacolon
Surgical Options
• Colectomy/Rectal preservation,
Ileostomy:
• Ulcerative colitis - 3-stage pouch
• Crohns - 2-stage IRA
SURGICAL OPTIONS IN
ULCERATIVE COLITIS
IPAA


Maintains the normal route of
defecation
 Increased frequency of stools
Avoids permanent ostomy
Functional Outcomes
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%
Farouk R, Pemberton JH, Wolff BG, Dozois R. Annals Surg.
2000
Quality of Life


Patients with UC report a lower
quality of life compared to healthy
individuals
Score similarly to patient with other
chronic illness (Diabetes)
Muir et al. Am J Gastroent. 2001
Post IPAA Quality of Life


Preoperative scores low in all scales
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”