Challenges in Surgery for Severe, Refractory Ulcerative Colitis: Case Studies Phillip R. Fleshner,M.D. Shierley,Jesslyne,and Emmeline Widjaja Chair in Colorectal Surgery Chairman Division of Colorectal Surgery Cedars-Sinai Medical Center Clinical Professor of Surgery UCLA School of Medicine, Los Angeles, CA Feza H. Remzi, M.D.Chairman Department of Colorectal Surgery Rupert B. Turnbull Jr., MD Chair in Colorectal Surgery Professor of Surgery Digestive Disease Institute Cleveland Clinic Cleveland, OH

Disclosures None for both speakers

Terminology in Ulcerative Colitis Surgery One Stage, two stage, three stage J pouch, S, pouch, and W pouch Double Stapled anastomosis Mucosectomy

TPC and IPAA

Subtotal Colectomy and Ileostomy

23 yo male with fulminant UC Not responsive to IV steroids Not responsive to infliximab (10mg/kg; 3 wks ago) Physical Exam: mild LLQ tenderness Labs: WBC 15K, Hct 29, CRP 17, IFX level 5 Stool cultures normal Flex sig shows severe disease, no CMV CTE normal Options ? Biologics and UC Surgery

Give IFX every 6 weeks Change to another biologic Subtotal colectomy and ileostomy (3 stage) Ileal pouch-anal anastomosis (2 stage) ?

Postoperative Outcomes and Serum anti-TNF Levels (Cut-off at 3 ug/ml)

Double Stapled vs. Handsewn IPAA 34 yo female 15 yr hx of left sided ulcerative colitis Colonoscopic surveillance reveals high grade dysplasia at the splenic flexure PMHx: otherwise negative PSHx: none Meds: Asacol ?

TPC and IPAA Mucosectomy vs stapled anastomosis Function Anastomotic complications Symptomatic anal canal inflammation “cuffitis” Risk of dysplasia and cancer

Stapler vs Mucosectomy Function CCF N >4000 Patients functional outcome and QOL were evaluated at 1,3,5,10 years after their IPAA surgery No difference in QOL Nighttime BM,daily and nocturnal seepage and pad usage and incontinens were better in stapled group Septic Complications were less in stapled group Kirat 2009 Surgery

Cancer N=11 Two ( 18.2%) patients were diagnosed with Crohn’s Three ( 27.2%) patients were diagnosed with chronic pouchitis Six patients (54.6%) were diagnosed with cuffitis Eight patients had yearly survelliance ;3 had no lesion Six (54.6%) patients had mucosectomy Seven ( 63.6 % ) had poorly diff adenoca Three (27.3 %) patients died within a year of dx Kariv,Remzi, Bennet, Kariv, Fazio, Lavery, Shen Gastro

Clinical Confounders Family history of colorectal cancer Colon cancer in the descending colon Upper rectum High grade dysplasia vs cancer Mid rectum High grade dysplasia vs cancer Low rectum High grade dysplasia vs cancer Advanced local cancer spread at surgery Liver metastasis at surgery

23 yo female with steroid dependent pancolitis Biologic drug refractory (last dose 3 months ago) PE: mild LLQ tenderness Labs: WBC 10K, Hct 37, CRP 11 Flex sig shows severe disease, no CMV MRE normal ? Indeterminate Colitis and IPAA

Clinical Confounders Family history of Crohn’s disease SBFT showing jejunal thickening Wireless capsule shows ulcers Endoscopic sparing of the TC on last C-scope Backwash ileitis Anal abscess 5 years ago..no further episodes Anal fistula repair 5 years ago Elevated ASCA IgG and IgA levels Wants to have children in the future

Microscopic Confounders Gastric inflammation on EGD Crypt associated granulomas Non caseating granulomas in the descending colon Ileal pyloric gland metaplasia