1. Surgical treatment of inflammatory bowel disease Aleš Tomažič Dept. of Abdominal Surgery, University Medical Center Ljubljana

2. Inflammatory bowel disease Ulcerative colitis Crohn’s disease  Inflammation restricted to mucosal surface of colon and rectum  Generally extends prox.  20-25% of patients need surgical therapy  Surgery=definite cure  Substantial short- and longterm morbidity  Inflammation can spread to adjacent organs, all parts of GIT  Skip lesions  70-80% of patients need surgical therapy, half more than once  Surgery=symptomatic treatment Department of Abdominal Surgery, University Medical Center Ljubljana

3. Ulcerative colitis  Emergency procedures  Life threatening complications of fulminant colitis  Toxic megacolon  Perforation  Bleeding  MOF – 73% mortality rate  Unresponsive fulminant colitis  Total colectomy with terminal ileostomy  Elective procedures  Refractoriness or intolerance to longterm treatment  Stricture, high grade dysplasia or colorectal cancer  Growth failure in pediatric population  Restorative proctocolectomy Department of Abdominal Surgery, University Medical Center Ljubljana

4. Indication Patient comorbidities Surgeon expertise

5. Surgical treatment in emergent setting  Total colectomy with end ileostomy – procedure of choice  Majority of diseased bowel removed  Avoid complications associated pelvic dissection and enteric anastomosis  Histopathologic assesment to confirm diagnosis  13% altered diagnosis postoperatively  Exteriorisation of rectal stump not needed  20/52 patients choosed not to revert ileostomy Department of Abdominal Surgery, University Medical Center Ljubljana Cohen JL et al. Practice parameters for the surgical treatment of ulcerative colitis. Dis Colon Rectum 2005; 48: 1997-2009 Hyman NH et al. Urgent subtotal colectomy for severe inflammatory bowel disease. Dis Colon Rectum 2005; 48: 70-73

6. Restorative proctocolectomy in urgent conditions – why not?  Nutritional depletion  Anemia  High-dose steroids  Pelvic bleeding  Sepsis  Injury to pelvic nerves Department of Abdominal Surgery, University Medical Center Ljubljana Khubchandani IT et al. Outcome of ileorectal anastomosis in an inflammatory bowel disease surgery experience of three decades. Arch Surg 1994; 129: 866-869

7. Restorative proctocolectomy – procedure of choice in elective conditions  One- or two-stage procedure  Age  Steroids  Malabsorption, malnutrition  Open or laparoscopic  Faster recovery  Better short-term results  Better cosmesis Department of Abdominal Surgery, University Medical Center Ljubljana

8. No disease No medications No cancer Short-term morbidity Long-term morbidity Invalidism BENEFITSDRAWBACKS

9. Postoperative complications  Ileus  Pelvic inflammation, sepsis  Anastomotic separation 5-10%  Enterovaginal fistulae3-16%  Anastomotic stricture  Pouchitis24-48%  Cuffitis  Female infertility3-4X  Pouch failure10%  Day and night incontinence31-45%  Mortality rate 0,2-1% Department of Abdominal Surgery, University Medical Center Ljubljana Fazio VW et al. Ileal pouch-anal anastomoses complications and function in 1005 patients. Ann Surg 1995; 222: 120-127 Huenting WE et al. Results and complications after ileal pouch anal anastomosis: a meta analysis of 43 observational studies comprising 9317 patients. Dig Surg 2005; 22: 69-79

10. Quality of life after restorative proctocolectomy  11-17% of patients have social, work and sexual restrictions  98% of patients would have surgery again  Quality of life linked to pouch function  Elderly patients have worse QL and pouch function Department of Abdominal Surgery, University Medical Center Ljubljana Delaney CP et al. Prospective, age related analysis of surgical results, functional outcome, and quality of life after ileal pouch-anal anastomosis. Ann Surg 2003; 238: 221-228.

11. Hand sewn vs stapled anastomosis  Mucosectomy to remove last 1-2 cm of mucosa – selective approach  Presence of ATZ dysplasia (degree, location)  Mucosectomy and hand-sewn IPAA  No dysplasia  Stapled IPAA  Circular staplers in 1990’s  Preserves abundant nerve supply to anal transition zone  Minimizes sphincter injury  Less nocturnal incontinence in stapled anastomosis  Significantly reduced resting and squeeze pressures in hand-sewn anastomosis Department of Abdominal Surgery, University Medical Center Ljubljana Lovegrove RE et al. A comparison of hand sewn versus stapled ileal pouch anal anastomosis following proctocolectomy: a metaanalysis of 4183 patients. Ann Surg 2006; 244: 18-26.

12. Construction of pouch  J-pouch  S- and W-pouch  J-pouch vs. S- or W-pouch  Higher frequency of bowel movements (7 vs 5 – 1 year) (6,5 vs 6 – 9 years)  Faster operation (195 vs.215 min) McCormick PH et al. The ideal ileal-pouch design: a long-term randomized control trial of J- vs W-pouch construction. Dis Colon Rectum. 2012;55(12):1251.

15. Total proctocolectomy with end ileostomy  Procedure of choice  Impared anal sphincter function  Distal rectal cancer  No wish to undergo restorative procedure  Stoma related morbidity  Similar quality of life compared to age- and sex-matched patients with restorative procedures Department of Abdominal Surgery, University Medical Center Ljubljana Camilleri-Brennan J et al. Does an ileoanal pouch offer a better quality of life than a permanent ileostomy for patients with ulcerative colitis? J Gastrointest Surg 2003; 7: 814-819.

16. Total colectomy with ileorectal anastomosis  Rare  Minimal rectal involvement  Indeterminate colitis  50-60% failure rate  Ongoing rectal inflammation  Diarrhea  Dysplasia Department of Abdominal Surgery, University Medical Center Ljubljana Leijonmarck CE et al. Long-term results of ileorectal anastomosis in ulcerative colitis in Stockholm county. Dis Colon Rectum 1990; 33: 195-200

17. LAPAROSCOPIC SURGERY  Subtotal colectomy  Total proctocolectomy  Restorative proctocolectomy

18. Laparoscopic proctocolectomy with IPAA  Higher satisfaction with cosmetic results  Better body image  Similar functional outcome  Similar quality of life  Faster return of bowel function  Decreased use of narcotics  Concerns regarding operative time  Higher costs Dunker MS et all. Functional outcome, quality of life, body image, and cosmesis in patients after laparoscopic-assisted and conventional restorative proctocolectomy: a comparative study. Dis Colon Rectum. 2001;44:1800–1807. Ahmed Ali U et al. Open versus laparoscopic (assisted) ileo pouch anal anastomosis for ulcerative colitis and familial adenomatous polyposis. Cochrane Database Syst Rev. 2009;(1):CD006267.

20.  Acute colitis - delay in surgery associated with increased risk for complications  Length of anorectal mucosa < 2cm  Covering loop ileostomy recommended, can be avoided in selected cases  Fertile female patients – subtotal colectomy with end ileostomy or ileorectal anastomosis  Pouch failure – no recommendation about pouch excision  Laparoscopic restorative proctocolectomy – aside from cosmesis no benefit

21. Crohn’s disease  Traditionally surgery and medicine – complementary treatments  New evolving drugs – surgery treatment of the last resort  Higher risk of septic complications after surgical treatment  Intestinal failure – consequence of multiple operations within a short time span after failure of primary operation, rather than operations over several years Department of Abdominal Surgery, University Medical Center Ljubljana

22. Crohn’s disease – “5 golden rules”  Panintestinal disease with intermittent activity with potential of focal exacerbations throughout patients life  Can’t be cured with excision, surgery treats only complications  Repeated operations are often required, conserve as much gut as possible  All diseased bowels need not be excised, only part with complications  Stenotic complications should be widened by strictureplasty or dilatation Department of Abdominal Surgery, University Medical Center Ljubljana Alexander-Williams J, Haynes IG. Up-to-date management of small bowel Crohn's disease. Adv Surg 1987;20: 245-264.

23. Crohn’s disease – indications for surgery  Emergency  Perforation  Bleeding  Ileus  Toxic megacolon  Delayed emergency  Abscess  Elective operations  Fistulas (anal, enterocutaneous, enterovesical, enterovaginal...)  Chronic ileus  Conglomerate tumor  Carcinoma Department of Abdominal Surgery, University Medical Center Ljubljana

24. Abscess in Crohn’s disease  Life-time risk 25%  Percutaneous vs surgical drainage  56% vs 12% recurrence rate  33% percutaneously drained were operated in 1 year followup  Controversy about resection of diseased bowel Department of Abdominal Surgery, University Medical Center Ljubljana Garcia JC et al. Abscesses in Crohn’s disease: outcome of medical versus surgical treatment. J Clin Gastroenterol 2001; 32: 409-412. Gutierrez A et al. Outcome of surgical versus percutaneous drainage of abdominal and pelvic abscesses in Crohn’s disease. Am J Gastroenterol 2006; 101: 2283-2289.

25. Fistulae in Crohn’s disease  35% of surgically managed patients  40% of non-surgically managed required surgery in 1 year  Different types  Short fistula tracts, exposed mucosa, high output require operative intervention  Optimizing patient’s nutritional status before surgery  Surgical technique  Primary site resection  Secondary site repair Department of Abdominal Surgery, University Medical Center Ljubljana Michelassi F et al. Incidence, diagnosis, and treatment of enteric and colorectal fistulae in patients with Crohn’s disease. Ann Surg 1993; 218: 660-666. Sands BE et al. Infliximab maintenance therapy for fistulizing Crohn’s disease. N Eng J Med 2004; 350: 876-885

26. Operative procedures  Bypass  Resection  Strictureplasty Department of Abdominal Surgery, University Medical Center Ljubljana

27. Recurrence after resection for Crohn’s disease  Radical resection – less recurrence  margin >10 cm vs margin < 10 cm31% vs 83%  margin > 2 cm vs margin < 2cm18% vs 25%  Wide anastomoses  Stapled anastomoses  Recurrence with surgical reintervention  25-35% at 5 years  40-70% at 10 years Department of Abdominal Surgery, University Medical Center Ljubljana Bernell O et al. Risk factors for surgery and postoperative recurrence in Crohn’s disease. Ann Surg 2000; 231: 38-45.

28. Stricturoplasty  Contraindications  Multiple strictures at short segment  Long stricture  Perforation  Fistula  Recurrence rate 28% at 5 years  5% at the previous stricturoplasty site  Obstruction rate 4,4%  Septic complications 11,3% Department of Abdominal Surgery, University Medical Center Ljubljana Tichansky D et al. Strictureplasty for Crohn’s disease: meta-analysis. Dis Colon Rectum 2000; 43: 911-919. Fearnhead NS et al. Long-term follow-up of strictureplasty for Crohn’s disease. Br J Surg 2006; 93: 475-482.

29. Crohn’s colitis  25% of patients  Baloon dilatations of stricture  Risk factors for development of dysplasia or carcinoma  50-75% of patients with fistulas require surgery  Segmental versus total colectomy: time to recurrence 4,4 years longer in total colectomy group  Restorative proctocolectomy with IPAA – significantly higher rate of morbidity Department of Abdominal Surgery, University Medical Center Ljubljana Tekkis PP et al. A comparison of segmental vs subtotal/total colectomy for colonic Crohn’s disease: a meta-analysis. Colorectal Dis 2006; 8: 82-90 Brown CJ et al. Crohn’s disease and indeterminate colitis and the ileal pouch-anal anastomosis: outcomes and patterns of failure. Dis Colon Rectum 2005; 48: 1542-1549.

30. Anorectal Crohn’s disease  10-15% of patients have disease limited to the anorectal area  90% of patients have some manifestation of anorectal disease  Fissures  Fistulas  Abscesses  Damage of sphincter muscle – severe morbidity

31. Department of Abdominal Surgery, University Medical Center Ljubljana Localised ileocoecal disease with obstruction = surgery Active Crohn’s with abscess = drainage, later resection if necessary Stricturoplasty safe alternative to resection if stricture < 10cm Wide lumen stapled side – to side anastomosis preferred technique Laparoscopic approach preferred for ileocolonic resections, but not in complex and recurrent cases In localised colonic disease resection only of the affected part, also in two segments Endoscopic dilatation of stenosis is preferred technique in short strictures Stricturoplasty in colon is not recommended IPAA is not recommended for Crohn’s disease In complicated CD, surgery is valid alternative to medical therapy Multidisciplinary clinical conference for complicated CD

32. Conclusions  Indications for surgical treatment are relatively straight forward, but precise timing and type of procedure can be fraught with controversy  IPAA is common procedure in ulcerative colitis, but not for all  Surgical conservatism general rule in Crohn’s disease because of panenetric nature of disease with significant reccurence rates  Laparoscopic surgery is associated with faster recovery and better cosmesis, providing similar functional results to open procedures Department of Abdominal Surgery, University Medical Center Ljubljana