General Principles of Medical and Surgical Management of Inflammatory Bowel Disease Jeraldine S. Orlina Colorectal Conference December 22, 2005

Medical Therapy of Ulcerative Colitis  5-Aminosalicyclic acid agents  Corticosteroids  Cyclosporine  6-Mercaptopurine  Azathioprine

5-Aminosalicylic Acid Agents  Sulfasalazine - 5-ASA linked to sulfapyridine by an azo bond - poorly absorbed in upper GI tract - principle use to maintain remission

Operative Indications  Failure of medical therapy  Obstruction  Fistula or abscess  Hemorrhage  Growth retardation (in pediatric population)  Perforation of carcinoma  Extraintestinal manifestations

Preparation of the Patient  Endoscopic and Radiologic studies  Correction of dehydration, electrolyte deficiencies, coagulation deficits, and anemia  Optimization of comorbid conditions  Nutritional optimization  Pre-op marking for stoma (if needed)  Bowel prep

Preparation of patient  Withdrawal of immunosuppressives  Perioperative antibiotics  Stress dose steroids  DVT prophylaxis

Strategic Planning for Surgery  Midline incision to preserve potential stoma sites  Preservation of small bowel  Resection margins—extended resection margins are unnecessary  Use of temporary stoma

Management of Small Bowel Crohn’s Diesease  Chronic obstruction (35%)  Internal fistulas (30%)  Intractability (22%)  Abscess formation (11%)

Types of Operations  Small bowel resection  Multiple small bowel resections (with enteroenterorostomy, diversion, or both)  Bypass  Strictureplasty  Balloon dilatation

Resection  Most common surgical procedure  Wide resection unnecessary  Division of inflamed mesentery

Indications for Strictureplasty  Diffuse involvement of small bowel with multiple strictures  Strictures in a pt who has undergone prev major resection of small bowel  Rapid recurrence of disease manifested as obstruction  Stricture in pt with short bowel syndrome  Nonphlegmonous fibrotic stricture

Relative Contraindications for Stictureplasty  Free or contained perforation of the small bowel  Phlegmonous inflammation, internal fistula, or external fistula involving the affected site  Multiple strictures within a short segment  Stricture in close proximity to a site chosen for resection  Colonic strictures  Hypoalbuminemia

Heineke-Mikulicz Strictureplasty

Finney Strictureplasty

Side-to-side isoperistaltic strictureplasty

Stapled Strictureplasty

Complications  Hemorrhage form suture line  Restricture at strictureplasty site  Fistula/Abscess/Leak  Small bowel adenocarcinoma

Take Home Points  Conservative Management  Preservation of small bowel