Dr. Drelichman Surgical Techniques Part 2

Crohn’s Disease Laparoscopic Colectomy - Results: Patient Outcomes Conversion Rate 5.9%

Laparoscopy for Ileocolic Crohns Prospective Randomized Trial 60 pts Ileo-colic Crohn’s Disease Results:Lap Open Results:Lap Open Incision 5cm12cm Morphine = = bowel function3.0d3.3d LOS 5d 6d Complications 4 8 Milsom et al. DCR 2001;44:1-9:

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 Bowel-conserving surgical options strictureplasty and limited resection Complication rates are similar in both Complication rates are similar in both Reoperation rates are 50% at 10 years, and 70% at 15 years Reoperation rates are 50% at 10 years, and 70% at 15 years

Crohn’s Disease Conclusion Absolute Indications for Surgery Absolute Indications for Surgery Relative Indications _ QOL Relative Indications _ QOL Laparoscopy has some benefits Laparoscopy has some benefits Disease related challenges Disease related challenges Specialized Medical & Surgical care Specialized Medical & Surgical care Close Collaboration Close Collaboration

Surgery for Ulcerative Colitis 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 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 Severe disease may evoke crampy abdominal pain and distention*, fever, tachycardia, elevated WBC Extraintestinal symptoms in up to 36% of patients 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 Colonoscopy should begin at 8-10 years duration of disease Then at 1-2 year intervals Then at 1-2 year intervals Pts with PSC start surveillance at time PSC diagnosed 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 Review of ten prospective studies Probability of cancer DALM43% DALM43% HGD 42% HGD 42% LGD 19% LGD 19% Bernstein et al. Lancet 1994

INDICATIONS FOR SURGERY IN ULCERATIVE COLITIS

Ulcerative Colitis Indications for Surgery Intractability Intractability Massive hemorrhage Massive hemorrhage Toxic megacolon Toxic megacolon Fulminant acute colitis Fulminant acute colitis Systemic complications Systemic complications Cancer or dysplasia Cancer or dysplasia Growth retardation (in children ) Growth retardation (in children )

IBD - Toxic Megacolon Surgical Options Colectomy/Rectal preservation, Ileostomy : Colectomy/Rectal preservation, Ileostomy : Ulcerative colitis - 3-stage pouch Ulcerative colitis - 3-stage pouch Crohns - 2-stage IRA Crohns - 2-stage IRA

SURGICAL OPTIONS IN ULCERATIVE COLITIS

IPAA Maintains the normal route of defecation Maintains the normal route of defecation  Increased frequency of stools Avoids permanent ostomy Avoids permanent ostomy

Farouk R, Pemberton JH, Wolff BG, Dozois R. Annals Surg ,454 patients IPAA for CUC. 12 yrs f/u Stool Freq Stool Freq Day 6 6 Day 6 6 Night 1 2 Night 1 2 Incontinence Incontinence Never 43% 24% Never 43% 24% Occ.(2/wk)48% 59% Occ.(2/wk)48% 59% Freq 9% 17% Freq 9% 17% Functional Outcomes Functional Outcomes

Quality of Life Patients with UC report a lower quality of life compared to healthy individuals Patients with UC report a lower quality of life compared to healthy individuals Score similarly to patient with other chronic illness (Diabetes) 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 Preoperative scores low in all scales Health status questionnaire scores improved and even equal general population at 1 year. 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 Risk Cancer increases with time in patients with UC and CC Surveillance Regimen to prevent Ca Surveillance Regimen to prevent Ca Colectomy should be offered to patients with Dysplasia Colectomy should be offered to patients with Dysplasia

Ulcerative Colitis Conclusions Surgery offers definitive cure UC Surgery offers definitive cure UC 1/3 of patients with UC have surgery 1/3 of patients with UC have surgery Post Colectomy Patients have good QOL Post Colectomy Patients have good QOL J-Pouch requires Surgical Expertise J-Pouch requires Surgical Expertise

Build Your Team Be Proactive Be Proactive Be Educated Be Educated What % of practice IBD What % of practice IBD Post Graduate training Post Graduate training Build your Team Build your Team Coach or Project manager Coach or Project manager IBD specialist, Surgeon IBD specialist, Surgeon Nutrition Nutrition Social and Spiritual Support Social and Spiritual Support Communicate Communicate

St. John Health System IBD Center St. John Health System IBD Center Contact Information Contact Information  Office: (248)  Fax: (248)  Kim Buck, NP: (248)

“I don’t know where it goes, and I don’t want to know”