1. IBD recent advances in surgery
Professor Dr. Med Farouk Safi
Department of Surgery
Faculty of Medicine & Health Sciences
UAE University

2. Surgery for inflammatory Bowel Disease

3. Surgery for inflammatory Bowel Disease
Incidence rate:
1.4 Million in the US
2.2 Million in Europe
UAE ?
Lost of Day work
Reduced quality of life

4. Surgery for Crohn’s Disease
Intestinal disease in patients with Peri-anal Crohn’s disease
Colon 48%
Ileocolonic 34%
Ileum %

5. Case presentation 31 y female
U C since 1998 – Exacerbation & Remission
2008 : Disabling symptoms
PMH: Dural sinus thrombosis – 2007
DVT

8. Surgery for inflammatory Bowel Disease
Surgery can be cured in Ulcerative colitis
Albeit an imperfect one

9. Feb 4, 2009: Laparoscopic assisted total proctocolectomy

10. Feb 4, 2009: Laparoscopic assisted total proctocolectomy

11. Surgery for inflammatory Bowel Disease

12. Feb 4, 2009: Laparoscopic assisted total Proctocolectomy
Construction of “J” Pouch – Ileoanal anastomosis

13. Surgery for inflammatory bowel disease
Ulcerative Colitis Curative
Crohn’s disease Recurrences (5-90%)
Complications
Failure of medical treatment
Improvement of quality of life

14. Surgery for inflammatory Bowel Disease
Mortality in patients with and without colectomy admitted for UC and Crohn’s:
Elective colectomy
Ulcerative colitis 3.7%
Crohn’s disease 3.3%
No colectomy
Ulcerative colitis 13.6%
Crohn’s disease 10.1%
Emergency colectomy
Ulcerative colitis 13,2%
Crohn’s disease 9.9%
Stephan E etal; BMJ; January 2008;

15. Prevalence of Failure According to Diagnosis, Type of Reservoir and Occurrence of Pelvic Sepsis After the Initial Restorative Proctocolectomy Hagit Tulchinsky, MD,* Peter R. Hawley, MS,† and John Nicholls, MChir† Ann Surg 2003;238: 229–234)n=631

16. Prevalence of Failure According to Diagnosis, Type of Reservoir and Occurrence of Pelvic Sepsis After the Initial Restorative Proctocolectomy Hagit Tulchinsky, MD,* Peter R. Hawley, MS,† and John Nicholls, MChir† Ann Surg 2003;238: 229–234) n=631

17. Incidence of common postoperative complications after ileal pouch–anal anastomosis P. M. Sagar1 and J. H. Pemberton2 British Journal of Surgery 2012; 99: 454–468

18. Portal vein thrombi after restorative proctocolectomy
PVT was diagnosed in 42 of the 94 patients (45%).via CT Scan
Synptoms:
abdominal pain,
fever,
leukocytosis, and
delayed bowel function.
Feza H. Remzi, MD, et al; Portal vein thrombi after restorative
proctocolectomy Surgery 2002;132:

19. Surgery for inflammatory Bowel Disease
Surgery can be highly effective in Crohn’s disease but is offset

20. Surgery for Crohn’s Disease n=412
90% need surgery
50% second surgery
Indication
Stenosis 58.4%
Fistula %
Rate of recurrences
5 years 17.4%
10 years 36.7%
15 years 52.8%
Mirow et al; zentrablat chir. 2008; april; 133; 182-7

21. Surgery for inflammatory Bowel Disease
Discussion between Physicians & Surgeons
No Consensus
Exact timing of Surgery
To improve symptoms & quality of life
To resolve complications
Salvage of acute severe disease

22. Operative procedures for diffuse jejunoileal Crohn’s disease
Takayuki Yamamoto, MD, et al Long-term outcome of surgical management for diffuse jejunoileal Crohn’s disease; Surgery January 2001; Volume 129, Number 1

23. Contra-indication for strictureplasty
Perforating disease
Fistula
Abscess
Perforation
Long stricture more than 20 cm

24. Strictureplasty P. Roy and D
Strictureplasty P. Roy and D. Kumar British Journal of Surgery 2004; 91: 1428–1437

25. Median follow-up 46 months 21 patients (35%) reccure
Analysis of the outcome of ileal pouch anastomosis in CD patients Hartey et al; dis,colon,rectum, 2004;47; (11):
60 patient with CD
Median follow-up 46 months
21 patients (35%) reccure
The overall pouch loss rate:
12% in all patients
33% in the recurred group

26. Immediate versus tailored prophylaxis to prevent symptomatic recurrences after surgery for ileocecal Crohn’s disease? Liliana Bordeianou, MD, (Surgery 2011;149:72-8.)

27. A total of 240 IBD patients (64 CD and 176 UC) with CRC
Colorectal Cancer Complicating Inflammatory Bowel Disease Ravi P. Kiran, MD, Wisam Khoury, MD, James M. Church, MD, Ian C. Lavery, MD, Victor W. Fazio, MD, and Feza H. Remzi, MD Ann Surg 2010;252: 330–335)
A total of 240 IBD patients (64 CD and 176 UC) with CRC
68% UC and
26% CD

28. Colorectal Cancer Complicating Inflammatory Bowel Disease Ravi P
Colorectal Cancer Complicating Inflammatory Bowel Disease Ravi P. Kiran, MD, Wisam Khoury, MD, James M. Church, MD, Ian C. Lavery, MD, Victor W. Fazio, MD, and Feza H. Remzi, MD Ann Surg 2010;252: 330–335

29. Summary Laparoscopic or Open Surgery Crohn disease level A2 evidence
UC no evidence

30. Thank you for your attention

31. Prevalence of Failure According to Diagnosis, Type of Reservoir and Occurrence of Pelvic Sepsis After the Initial Restorative Proctocolectomy Hagit Tulchinsky, MD,* Peter R. Hawley, MS,† and John Nicholls, MChir† Ann Surg 2003;238: 229–234) n=631

32. Prevalence of Failure According to Diagnosis, Type of Reservoir and Occurrence of Pelvic Sepsis After the Initial Restorative Proctocolectomy Hagit Tulchinsky, MD,* Peter R. Hawley, MS,† and John Nicholls, MChir† Ann Surg 2003;238: 229–234) n=631

33. Multivariate analysis suggests improved perioperative outcome in Crohn’s disease patients receiving immunomodulator therapy after segmental resection and/or strictureplasty
IASC developed in 11 of 100 (11%) operations. Immunomodulator use was associated with
fewer IASC (4/72 procedures; 5.6%), compared with 7/28 (25%) cases with patients not on therapy
(P < .01).
Grace S. Tay, MD,; et al; Surgery 2003;134: )

34. Laparoscopic resection with transcolonic specimen extraction for ileocaecal Crohn’s disease British Journal of Surgery 2010; 97: 569–574
Conclusion: Transcolonic removal of the specimen in ileocolic Crohn’s disease is feasible in the absence of a large inflammatory mass but infection may be a problem. It is unclear whether the technique offers benefit compared with conventional laparoscopic surgery

35. Surgery for inflammatory Bowel Disease

36. Additionally, long,
high-grade strictures resulting from extremely thickened and
rigid intestinal wall are often not amenable to strictureplasty
and therefore require resection

37. Surgery for Crohn’s disease
50% maintain inactive during years after selected surgical treatment (medical ??)
Risk to specify surgical procedures in CD :
75% of Payees
50% in the first year
100% during years
who
Why
When

38. Reccurence of Crohn’s disease after surgery Nirow L et al;; Zentralblat Chir; April , 2008, 133(2):182
412 patient required operative treatment: 58.4% stenosis; 38.5% fistula
218 primary surgery
194 reoperation
Rate of recurrences:
17.5% after 5 Years
36% after 10 years
52% after 15 Years

39. Surgery for Crohn’s disease
Retard the surgery increase morbidity
Induction of biological therapy
Aging of patient to face bigger surgical risks
Retractile mesenteritis
Hypercoagilability
Appearance of malignancy (colon 3%, 16-33% small intestine)
GI Bleeding, megacolon; perforation
Stenosis (Inflammatory; fibrotic)
Fistulas (penetrating, coloenteric, colovaginal)
Anal crohn’s: simple; simple with proctitis, complex fistula

40. Surgery for inflammatory Bowel Disease
Advanced Medical Treatment
20%-30% of patients with Ulcerative Colitis (15% EM admission, 40% surgical treatment; 60% response to corticoid therapy)
Lifetime of risk of surgery for Crohn’s disease 80%
Long term effect of medical treatment does not exceed 40%
Smart N; BMJ; 2006; 333: 501

41. Surgery for Crohn’s Disease
Indication modern conservative treatment
Reduce signs & symptoms
Inducing and maintaining clinical; remission
Reducing the number of enterocutaneous and recto-vaginal fistulas
Maintaining Fistula closure

42. Surgery for Crohn’s Disease
Post-surgical remission 40%
Medical remission 24%

43. Factors affecting recurrence after surgery for Crohn’s disease Takayuki Yamamoto; World J Gastroenterology 2005;11(26):
Age at onset of disease
Sex
Family history of Crohn’s
Anatomical site of disease
Length of resected bowel
Presence of granuloma
Blood transfusion
Post-op. complication
Smoking

44. Surgery for inflammatory Bowel Disease

45. Surgery for inflammatory Bowel Disease

47. Case Presentation 31 y female
U C since 1998 – Exacerbation & Remission
2008 : Disabling symptoms
PMH: Dural sinus thrombosis – 2007
DVT

49. Surgery for inflammatory Bowel Disease

50. August 2008
August 2006
Jan 2009

51. Surgery for inflammatory Bowel Disease
Normal standardised mortality ratio:
US Minissota n= 692
Crohn’s 1.3%
Ulcerative colitis 0.8%
Europe n= 796
Men 0.69%
Women 1.18%
Travis et al; Gut; 1996;38;