M62 Course April 7-8 2005 SURGERY for COLONIC CROHN’S DISEASE RJ NICHOLLS.

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Presentation transcript:

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