IBD recent advances in surgery Professor Dr. Med Farouk Safi Department of Surgery Faculty of Medicine & Health Sciences UAE University

Surgery for inflammatory Bowel Disease

Surgery for inflammatory Bowel Disease Incidence rate: 1.4 Million in the US 2.2 Million in Europe UAE ? Lost of Day work Reduced quality of life

Surgery for Crohn’s Disease Intestinal disease in patients with Peri-anal Crohn’s disease Colon 48% Ileocolonic 34% Ileum 18%

Case presentation 31 y female U C since 1998 – Exacerbation & Remission 2008 : Disabling symptoms PMH: Dural sinus thrombosis – 2007 DVT - 2008

Surgery for inflammatory Bowel Disease Surgery can be cured in Ulcerative colitis Albeit an imperfect one

Feb 4, 2009: Laparoscopic assisted total proctocolectomy

Feb 4, 2009: Laparoscopic assisted total proctocolectomy

Surgery for inflammatory Bowel Disease

Feb 4, 2009: Laparoscopic assisted total Proctocolectomy Construction of “J” Pouch – Ileoanal anastomosis

Surgery for inflammatory bowel disease Ulcerative Colitis Curative Crohn’s disease Recurrences (5-90%) Complications Failure of medical treatment Improvement of quality of life

Surgery for inflammatory Bowel Disease Mortality in patients with and without colectomy admitted for UC and Crohn’s: Elective colectomy Ulcerative colitis 3.7% Crohn’s disease 3.3% No colectomy Ulcerative colitis 13.6% Crohn’s disease 10.1% Emergency colectomy Ulcerative colitis 13,2% Crohn’s disease 9.9% Stephan E etal; BMJ; January 2008;

Prevalence of Failure According to Diagnosis, Type of Reservoir and Occurrence of Pelvic Sepsis After the Initial Restorative Proctocolectomy Hagit Tulchinsky, MD,* Peter R. Hawley, MS,† and John Nicholls, MChir† Ann Surg 2003;238: 229–234)n=631

Prevalence of Failure According to Diagnosis, Type of Reservoir and Occurrence of Pelvic Sepsis After the Initial Restorative Proctocolectomy Hagit Tulchinsky, MD,* Peter R. Hawley, MS,† and John Nicholls, MChir† Ann Surg 2003;238: 229–234) n=631

Incidence of common postoperative complications after ileal pouch–anal anastomosis P. M. Sagar1 and J. H. Pemberton2 British Journal of Surgery 2012; 99: 454–468

Portal vein thrombi after restorative proctocolectomy PVT was diagnosed in 42 of the 94 patients (45%).via CT Scan Synptoms: abdominal pain, fever, leukocytosis, and delayed bowel function. Feza H. Remzi, MD, et al; Portal vein thrombi after restorative proctocolectomy Surgery 2002;132:655-62.

Surgery for inflammatory Bowel Disease Surgery can be highly effective in Crohn’s disease but is offset

Surgery for Crohn’s Disease n=412 90% need surgery 50% second surgery Indication Stenosis 58.4% Fistula 38.5% Rate of recurrences 5 years 17.4% 10 years 36.7% 15 years 52.8% Mirow et al; zentrablat chir. 2008; april; 133; 182-7

Surgery for inflammatory Bowel Disease Discussion between Physicians & Surgeons No Consensus Exact timing of Surgery To improve symptoms & quality of life To resolve complications Salvage of acute severe disease

Operative procedures for diffuse jejunoileal Crohn’s disease Takayuki Yamamoto, MD, et al Long-term outcome of surgical management for diffuse jejunoileal Crohn’s disease; Surgery January 2001; Volume 129, Number 1

Contra-indication for strictureplasty Perforating disease Fistula Abscess Perforation Long stricture more than 20 cm

Strictureplasty P. Roy and D Strictureplasty P. Roy and D. Kumar British Journal of Surgery 2004; 91: 1428–1437

Median follow-up 46 months 21 patients (35%) reccure Analysis of the outcome of ileal pouch anastomosis in CD patients Hartey et al; dis,colon,rectum, 2004;47; (11):1808-15 60 patient with CD Median follow-up 46 months 21 patients (35%) reccure The overall pouch loss rate: 12% in all patients 33% in the recurred group

Immediate versus tailored prophylaxis to prevent symptomatic recurrences after surgery for ileocecal Crohn’s disease? Liliana Bordeianou, MD, (Surgery 2011;149:72-8.)

A total of 240 IBD patients (64 CD and 176 UC) with CRC Colorectal Cancer Complicating Inflammatory Bowel Disease Ravi P. Kiran, MD, Wisam Khoury, MD, James M. Church, MD, Ian C. Lavery, MD, Victor W. Fazio, MD, and Feza H. Remzi, MD Ann Surg 2010;252: 330–335) A total of 240 IBD patients (64 CD and 176 UC) with CRC 68% UC and 26% CD

Colorectal Cancer Complicating Inflammatory Bowel Disease Ravi P Colorectal Cancer Complicating Inflammatory Bowel Disease Ravi P. Kiran, MD, Wisam Khoury, MD, James M. Church, MD, Ian C. Lavery, MD, Victor W. Fazio, MD, and Feza H. Remzi, MD Ann Surg 2010;252: 330–335

Summary Laparoscopic or Open Surgery Crohn disease level A2 evidence UC no evidence

Thank you for your attention

Prevalence of Failure According to Diagnosis, Type of Reservoir and Occurrence of Pelvic Sepsis After the Initial Restorative Proctocolectomy Hagit Tulchinsky, MD,* Peter R. Hawley, MS,† and John Nicholls, MChir† Ann Surg 2003;238: 229–234) n=631

Prevalence of Failure According to Diagnosis, Type of Reservoir and Occurrence of Pelvic Sepsis After the Initial Restorative Proctocolectomy Hagit Tulchinsky, MD,* Peter R. Hawley, MS,† and John Nicholls, MChir† Ann Surg 2003;238: 229–234) n=631

Multivariate analysis suggests improved perioperative outcome in Crohn’s disease patients receiving immunomodulator therapy after segmental resection and/or strictureplasty IASC developed in 11 of 100 (11%) operations. Immunomodulator use was associated with fewer IASC (4/72 procedures; 5.6%), compared with 7/28 (25%) cases with patients not on therapy (P < .01). Grace S. Tay, MD,; et al; Surgery 2003;134:565-73.)

Laparoscopic resection with transcolonic specimen extraction for ileocaecal Crohn’s disease British Journal of Surgery 2010; 97: 569–574 Conclusion: Transcolonic removal of the specimen in ileocolic Crohn’s disease is feasible in the absence of a large inflammatory mass but infection may be a problem. It is unclear whether the technique offers benefit compared with conventional laparoscopic surgery

Surgery for inflammatory Bowel Disease

Additionally, long, high-grade strictures resulting from extremely thickened and rigid intestinal wall are often not amenable to strictureplasty and therefore require resection

Surgery for Crohn’s disease 50% maintain inactive during years after selected surgical treatment (medical ??) Risk to specify surgical procedures in CD : 75% of Payees 50% in the first year 100% during years who Why When

Reccurence of Crohn’s disease after surgery Nirow L et al;; Zentralblat Chir; April , 2008, 133(2):182 412 patient required operative treatment: 58.4% stenosis; 38.5% fistula 218 primary surgery 194 reoperation Rate of recurrences: 17.5% after 5 Years 36% after 10 years 52% after 15 Years

Surgery for Crohn’s disease Retard the surgery increase morbidity Induction of biological therapy Aging of patient to face bigger surgical risks Retractile mesenteritis Hypercoagilability Appearance of malignancy (colon 3%, 16-33% small intestine) GI Bleeding, megacolon; perforation Stenosis (Inflammatory; fibrotic) Fistulas (penetrating, coloenteric, colovaginal) Anal crohn’s: simple; simple with proctitis, complex fistula

Surgery for inflammatory Bowel Disease Advanced Medical Treatment 20%-30% of patients with Ulcerative Colitis (15% EM admission, 40% surgical treatment; 60% response to corticoid therapy) Lifetime of risk of surgery for Crohn’s disease 80% Long term effect of medical treatment does not exceed 40% Smart N; BMJ; 2006; 333: 501

Surgery for Crohn’s Disease Indication modern conservative treatment Reduce signs & symptoms Inducing and maintaining clinical; remission Reducing the number of enterocutaneous and recto-vaginal fistulas Maintaining Fistula closure

Surgery for Crohn’s Disease Post-surgical remission 40% Medical remission 24%

Factors affecting recurrence after surgery for Crohn’s disease Takayuki Yamamoto; World J Gastroenterology 2005;11(26):3971-3979 Age at onset of disease Sex Family history of Crohn’s Anatomical site of disease Length of resected bowel Presence of granuloma Blood transfusion Post-op. complication Smoking

Surgery for inflammatory Bowel Disease

Surgery for inflammatory Bowel Disease

Case Presentation 31 y female U C since 1998 – Exacerbation & Remission 2008 : Disabling symptoms PMH: Dural sinus thrombosis – 2007 DVT - 2008

Surgery for inflammatory Bowel Disease

August 2008 August 2006 Jan 2009

Surgery for inflammatory Bowel Disease Normal standardised mortality ratio: US Minissota n= 692 Crohn’s 1.3% Ulcerative colitis 0.8% Europe n= 796 Men 0.69% Women 1.18% Travis et al; Gut; 1996;38; 905-10