M62 Course April SURGERY for COLONIC CROHN’S DISEASE RJ NICHOLLS
Crohn’s Disease Surgery Indicated for Complications Recurrence Often Long term Relief Minimal Surgery No proven effect of Medical Treatment on Recurrence
CROHN’S DISEASE Indications for Surgery Elective Obstruction Fistula/abscess Colitis Carcinoma Anal Disease
Avoid Late Surgery Postoperative Complications FasthLindhagenPocard Preoperative Sepsis NO12 % 22% 5% YES48% 45% 23% Hulten 2001
CROHN’S DISEASE The Cancer Risk nfu/yDysCarelative risk Swedish study * - - SI1 Il/col3.2 LI5.6 Gillen Friedman (16) 5 *20.9 < 30y at onset extensive colitis
The Defunctioned Rectum 25 Patients Low Hartmann’s Procedure 3 Cases of Cancer Regular surveillance Ciccione 2000
CROHN’S COLITIS Urgent Surgery % Failed medical treatment 70 Toxic dilatation 20 Perforation <10 Bleeding < 5
ACUTE SEVERE COLITIS CROHN’S DISEASE 20-30% of cases 5 Studies 68 patients Medical Treatment Remission65%(55-94%) Remission maintained54-69% Kornbluth 1999
ACUTE CROHN’S COLITIS Choice of Operation 145 Patients Colectomy + IRA47 Proctocolectomy27 Colectomy + Ileostomy13 Ileostomy alone10 Keighley 1993
ACUTE SEVERE COLONIC CROHN’S DISEASE Initial Colectomy + Ileostomy Operation Survivors 21 Rectal excision C + IRA 11 1 No surgeryIleal Colostomy 5 resection 1 3 Keighley 1993
COLONIC CROHN’S DISEASE Main Indications for Elective Surgery Severe Local Symptoms Obstruction Fistulation Anorectal disease Systemic illnessChronic Proctocolitis
Pouches and Crohn’s Disease Authors YearMean F/U Total Crohn’s Pouch Cases Failure(%) Hyman Grobler Sagar Regimbeau Hartley Tulchinsky Total
Restorative Proctocolectomy for Crohn’s Disease 3-5% in large surgical series Failure up to 50% (cf UC 10%) Failure increases with time
COLONIC CROHN’S DISEASE Segmental v Total Colectomy + IRA Total Colitis70% Segmental Colitis30% Kornbluth 1999
Segmental v Total Colectomy +IRA
SEGMENTAL(SC) v TOTAL COLECTOMY + IRA 6 Studies488 Pt 265 SC 223 IRA Meta-analysis Time to Recurrence Longer after IRA by 4.4 y Fewer Operations After IRA where two segments involved Tekkis et al 2005
CROHN’S DISEASE Colectomy with IRA Nfu(y)Recurrence(%) Flint Buchman Ambrose Goligher Allan Longo
Recurrence after Colectomy with IRA and Total Proctocolectomy
CROHN’S DISEASE COLECTOMY + IRA 131 Patients Fu 9.5 y 13 Ileostomy never closed 118 ProctectomyFurther ileal No resection 30 Diversion resection Longo 1992
Colectomy with IRA Rectal Sparing in 50% of Large Bowel Crohn’s Indicated where two or more segments are involved Recurrence in ~ 50% over 10 years May be possible to re-resect terminal ileal recurrence to avoid permanent stoma
PROCTOCOLECTOMY Indications Severe Rectal Disease Cancer Severe Anal Disease (almost always rectal involvement present) Small Bowel Recurrence 20% at 10 y
Perineal Wound Delayed Healing Incidence 30% or more of patients x3 in pre-existing anal sepsis Leave open in the presence of sepsis Medical management ?value Intensive Nursing
RESTORATIVE PROCTOCOLECTOMY Close Rectal Dissection with Intersphincteric Anal Removal Avoids pelvic nerve damage Not with dysplasia Not with carcinoma
SEVERE ANORECTAL CROHN’S DISEASE SPLIT ILEOSTOMY 29 Patients 36 mo Still defunctioned15 Proctocolectomy 8 Restoration of Continuity 6 Late deaths 2Harper 1982