1. When is it time to consider surgery in Inflammatory Bowel Disease
Mark J. Koruda, MD
Department of Surgery
UNC Chapel Hill, NC

2. ULCERATIVE COLITIS AND CROHN’S DISEASE
Ulcerative colitis is a diffuse mucosal inflammation limited to the colon; it almost always affects the rectum, and it may extend proximally in a symmetrical, uninterrupted pattern to involve all or part of the large intestine. Crohn’s disease, by contrast, is a patchy transmural inflammation that may involve any part of the gastrointestinal tract from mouth to anus.

3. GEOGRAPHICAL PREVALENCE OF IBD
Crohn’s disease and ulcerative colitis have their highest prevalence in Western industrialized countries of Europe and North America. Intermediate prevalence is found in developing countries including post World War II Japan, Korea, Hong Kong, South Africa, and Israel. As new areas assume Western cultural practices, increased prevalence of ulcerative colitis usually is found approximately one decade before the observed increase in Crohn’s disease. The influence of environmental factors is also demonstrated by changes in the incidence and prevalence of IBD when populations move from one area to another. For example, Japanese immigrants to Vancouver have an increased prevalence of disease in the first generation born in North America and Eastern European Jewish settlers in Israel have decreased frequencies of disease in their offspring in Israel. Note that areas of low prevalence of IBD have the highest frequency of indigenous intestinal infections, including helminthic infestations.

4. INCREASING INCIDENCE OF IBD
The incidences of ulcerative colitis and particularly Crohn’s disease have risen dramatically in industrialized parts of the world, with excellent population based epidemiologic studies done in Sweden and Denmark. The most complete data in United Stated are derived from Olmstead County, Minnesota where precise epidemiologic records of the population based in the county surrounding Mayo Clinic were studied from 1940 through During this time the incidence of both ulcerative colitis and Crohn’s disease rose from approximately 1 per 100,000 per year to 8 per 100,00 per year. Most of this increase was between 1940 and 1970 with an apparent plateau after A similar plateau has been seen in Scandinavia, but developing countries have displayed a rapidly increasing incidence of IBD similar to the pattern of years ago in more developed industrialized countries.
• Loftus EVJ et al, Crohn's disease in Olmstead County, Minnesota; : incidence, prevalence and survival. Gastroenterology 1998;114:1161
• Loftus EVJ et al, Ulcerative Colitis in Olmstead County, Minnesota; : incidence, prevalence and survival. Gut 2000;46:336.

5. AGE AND SEX DISTRIBUTION OF IBD
Crohn’s disease and ulcerative colitis can have their onset at any age, but the peak incidence is in late adolescence and early adulthood. In some studies there is a second peak of Crohn’s colitis in women during their 6th and 7th decades of life. In general, the frequency of ulcerative colitis and Crohn’s disease is similar in males and females with a very slight female predominance in some studies. Multiple studies demonstrate a correlation of proximal Crohn’s disease (gastric, duodenal and small bowel location) with early onset disease and of colonic inflammation with late onset Crohn’s disease.
• Rogers BH, Clark LM, Kirsner JB. The epidemiologic and demographic characteristics of inflammatory bowel disease: an analysis of a computerized file of 1400 patients. Journal of Chronic Disease 1971;24:743.

6. Surgery for Inflammatory Bowel Disease
Timing is everything !
Stack the deck in your favor !

7. Perioperative Complications with Crohn’s Disease
Wound Infections %
Anastomotic Leak %
Death %
Risk Factors
Intestinal Obstruction
Preexisting sepsis
Impaired nutritional state
? Immunosuppression
Multiple anatomoses

8. Surgery for Inflammatory Bowel Disease
Get your patient in best possible condition for surgery
Nutrition – consider intervention
Albumin <3.0; 5% wgt 3 mos
Sepsis – Drain abscess
Bowel Prep/decompression
No need to wean steroids/immunes
Prepare for ostomy

9. Facts About Surgery Who Undergoes Surgery?
Patients with symptoms not relieved by medication
Patients with serious complications, eg, abscesses, fistulas, intestinal blockage, or uncontrolled bleeding
What Does It Do?
Relieves symptoms
Does not prevent relapse
How Is It Performed?
Usually only a small section of the intestine is removed, but entire colon may be removed in some cases

10. INDICATIONS FOR SURGERY IN CROHN’S DISEASE
As many as 80% of patients with Crohn’s disease will require at least one operation in the course of their disease. Indications for surgery include those that are absolute and those that are relative. In the former group, free perforation into the greater peritoneal cavity and massive uncontrolled hemorrhage due to deep ulceration are rare, but require surgical intervention. As with ulcerative colitis, the finding of cancer or high grade dysplasia mandates surgery while it remains unclear how best to proceed in the setting of low grade dysplasia. Acute obstruction that is not reversing with medical therapy, or a chronic state of symptomatic high-grade obstruction should both lead to surgical intervention, although the timing in the former case is clearly more urgent.
The more common indications for surgery in Crohn’s disease are relative and can usually be done electively. These include intractability to medical therapy with steroid dependency or resistance, complex fistulae, abdominal abscesses, refractory disease, and growth retardation in children.

11. Indications for Surgery
Abscess(7%)
Medical Management Failure(34%)
Mass(12%)
Obstruction(22%)
Fistula(24%)
Ann Surg 214:231, 1991

12. Indications for Surgery

13. Surgery for Inflammatory Bowel Disease
Preop Evaluation
Barium Studies
+/- Road Map
Extent of disease
Avoid with high grade obstruction
“X-rays lie” and “We don’t operate on x-rays”

15. Surgery for Inflammatory Bowel Disease
Preop Evaluation
Colonoscopy:
Evaluate colonic disease esp distal activity
Evaluate strictures

16. Surgery for Inflammatory Bowel Disease
Preop Evaluation
CT SCAN – esp with mass or fevers
r/o abscess
Relation to organs – ureters
Plan incision

17. Ureter

18. PELVIC ABSCESS PELVIC ABSCESS 94. PELVIC ABSCESS
The CT scan shows a large pelvic abscess containing a small amount of air above a large purulent collection. This is seen contiguous to an inflamed loop of small bowel with markedly thickened walls and surrounding mesenteric inflammatory stranding.
PELVIC ABSCESS

19. Surgery for Crohn’s Disease Fistulas
Enteroenteric (EE)- nuisance fistulas
do not necessarily require surgery

20. FISTULAE AND SINUS TRACTS
In the left panel two fistulae arise from a segment of inflamed, nodular ileum with spiculations representing deep ulcers/sinus tracts. In the right panel complex fistulae emanate from the stenotic ileum to the adjacent small intestine and colon(cecum, transverse and sigmoid).

21. Surgery for Crohn’s Disease Fistulas
Enteroenteric (EE)- nuisance fistulas
do not necessarily require surgery
EEs (duodenocolonic, gastrocolonic, ileosigmoid, jejunocolonic)that cause metabolic, nutritional, output Cxs should be repaired
Fistulas (ileum or colon) between urinary tract commonly require repair
Fistulas (ileum or colon) between vagina commonly require repair

22. SURGICAL OPTIONS FOR INTRA-ABDOMINAL DISEASE IN CROHN’S DISEASE
Most patients with Crohn’s disease who require surgery have segmental disease involving the small or large bowel and can be treated by a resection of the involved area with anastomosis. Removal only of grossly involved bowel is adequate because the presence of microscopic disease at surgical margins does not affect recurrence rates. For the patient with rectal involvement who requires colonic resection, the only current option is to remove the rectum with whatever other part of the colon is involved and to construct a colostomy or ileostomy. The ileal pouch-anal anastomosis should not generally be done in patients with established Crohn’s disease because of the high failure rate of the pouches.
For patients who have strictures in a short small bowel, or for those with multiple strictures diffusely involving the small bowel, stricturoplasty should be considered. Stricturoplasty involves a longitudinal enterostomy over the anti-mesenteric aspect of the stricture with closure of the defect transversely.
Patients without phlegmons, complex fistulae, or multiple strictures can usually undergo laparoscopically-assisted resections with good results.
• Glotzer DJ. Surgical therapy for Crohn’s Disease. In: Peppercorn MA (ed). Gastroenterol Clin No Am. WB Saunders, Philadelphia 1995:
• Yamamuto T, Bain IM, Allen RN et al. An audit of stricturoplasty for small bowel Crohn’s disease. Dis Colon Rectum 1999;42:
• Caawin-Endres J, Salky B, Gattorno F et al. Laparoscopically-assisted intestinal resection in patients with Crohn’s disease. Surg Endosc 1999;13:595-9.

23. Operative Management Margins of Resection
Wide margins are unnecessary
Frozen sections unnecessary
Do resect gross disease
Any suitable anastomosis - OK

24. Laparoscopic Surgery in IBD
4 – 6 ports
5 – 10 cm periumbilcal incision
Cosmetics
Pain
Length of Stay
Recuperation
Anticipate potential future stoma in incision placement

25. Laparoscopic Surgery Crohn’s Disease
Indications should not differ between open (conventional) and laparoscopic surgery
Contraindications:
Diffuse peritonitis • Acute obstruction with distension accompanied by dilated loops of intestine • History of multiple previous laparotomies, known dense intra-abdominal adhesions • Coagulopathy not correctable
• Portal HTN with intra-abdominal varices

26. Laparoscopic Surgery Crohn’s Disease – Bottom Line
• Improved postoperative pulmonary function • Slight reduction in duration of postoperative ileus • Decreased hospital stay (5 v 6 d)
• A slight decrease of the cost of direct hospital costs for laparoscopic surgery • A moderate decrease of surgical morbidity (minor)

27. Hand-assisted Laparoscopic Surgery (HALS)

30. STRICTUROPLASTY (HEINEKE-MIKULICZ)
For short strictures (less than or equal to 10 cm), a Heineke-Mikulicz technique is employed. This involves a linear anti-mesenteric incision extending about 2 cm beyond the stricture proximally and distally. The mucosa is biopsied to exclude unrecognized malignancy. Stay sutures and lateral traction are applied to convert the longitudinal enterotomy into a transverse defect. The wound is then closed transversely.
• Strong, SA. Surgery for Crohn’s disease: Stricturoplasty. In: Bayless TM, Hanauer SB. eds. Advanced Therapy of Inflammatory Bowel Disease. London, BC Decker, Inc., 2001;pp:

31. STRICTUROPLASTY (FINNEY)
The side-to-side stricturoplasty (Finney) is utilized for long strictures greater than 10 cm. This procedure requires that the intestine be supple enough to bend into a U-shape and still allow for a tension-free anastomosis. To initiate the Finney stricturoplasty, an incision is made along the anti-mesenteric margin. The intestine is then folded in a U-shape configuration. The posterior portion is closed with continuous sutures as is the anterior layer with inversion of the mucosal layer.
Concerns about bacterial overgrowth in the diverticulum-like sac extending from the intestine, and about recurrent stricturing within the afferent limb just proximal to the diverticulum, have led to several proposed modifications of this technique.
• Strong, SA. Surgery for Crohn’s disease: Stricturoplasty. In: Bayless TM, Hanauer SB. eds. Advanced Therapy of Inflammatory Bowel Disease. London, BC Decker, Inc., 2001;pp:
• Faziio VW, Tjondra J. Stricturoplasty for Crohn’s disease with multiple long strictures. Dis Colon Rectum 1993;36:71-2.
• Hurst RD, Michelassi F. Stricturoplasty for Crohn’s disease: techniques and long-term results. World J Surg 1998;22:

32. Non-conventional Stricturoplasty in Crohn’s Disease

33. Stricturoplasty O.K. to do when...
Diffuse involvement with multiple strictures
Stricture(s) after previous major resection(s)
Fibrotic stricture

34. Stricturoplasty Don’t do when...
Perforated
Phlegmon / fistula
Bleeding
Multiple Strx in short segement
Strx close to resection site
Colonic Stx (Ileo-colonic OK)
Poor nutrition

35. Crohn’s Colitis High Risk of Recurrence
Segmental Colectomy
Colectomy - colostomy
Subtotal colectomy - ileostomy
Ileo-rectal anastomosis (IRA)

36. Fate of the rectum in patients undergoing total colectomy and IRA for Crohn's disease
Year N
5 yr CR
10 yr CR
Fx IRA 5yr
Fx IRA 10yr
1981
105 70
1984 63 64 71
1990 59 34 49
1992
118 86 48
1993 83 47 57 77
1997 42 74 65
2000 78
2001
106 58
2002
144

37. Surgery for Crohn’s Disease RV Fistulas
Rectovaginal Fistulas – commonly are nuisance
Upwards of 50% heal with medical management (infliximab)
Surgical repair - ~70% successful
Depends on quality of vaginal and rectal disease
Steroids -> negative effect

38. Surgery for Crohn’s Disease RV Fistulas - Surgery
Transrectal flap – limited by rectal disease/stenosis
Transvaginal flap
Transrectal and –vaginal approach
+/- Diversion – ileostomy vs colostomy

39. PERIANAL FISTULAE AND ABSCESS
Entirely separate from intra-abdominal Crohn’s disease and from enteric fistulae, an independent focus of disease often arises from the crypts of Morgagni in the anus and spreads through the internal sphincter muscle to give rise to such complications as intersphincteric abscess, ischiorectal abscess, supralevator abscess, and/or rectovaginal or perineal or buttock fistulae. As many as one-third of patients with Crohn’s disease may have a history of anorectal fissures or fistulae or perianal abscesses.
• Buckmann P, Alexander-Williams J. Classification of perianal Crohn’s disease. Clin Gastroenterol 1980;9:

40. Imaging Perianal Fistula in Crohn’s Disease Fistulography

41. Imaging Perianal Fistula in Crohn’s Disease EUS

42. Imaging Perianal Fistula in Crohn’s Disease MRI

43. Perianal Fistula in Crohn’s Disease- NOT!
Hydradenitis Suppurativa: chronic, recurrent inflammatory process involving the apocrine glands of the axilla, groin, perineal, and perianal regions

47. SURGICAL TREATMENT OPTIONS FOR PERINEAL CROHN’S DISEASE
Perianal abscesses are common in Crohn’s disease and require complete surgical drainage. If a symptomatic fistula develops following drainage, fistulotomy often results in satisfactory healing. For complex fistulae involving large portions of the sphincter muscle, the placement of setons to establish long-term drainage should be considered. For patients with progressive anal sepsis despite medical management, a diverting ostomy may improve symptoms and allow perineal healing, but intestinal continuity can only rarely if ever be re-established without relapse. For women with recto-vaginal fistula unresponsive to medical therapy, surgical fistula closure with rectal mucosal advancement flaps can be considered, if there is no important rectal disease. Complex perianal fistulae and persistent perineal sinuses can be treated by wide excision of the perineum with reconstruction using a rectus abdominis or gracilus myocutaneous flap. For patients who fail medical and surgical therapies, a proctocolectomy with permanent ostomy needs to be considered.
• Hull Tl, Fazio VW. Surgical approaches to low ano-vaginal fistula in Crohn’s disease: Am J Surg 1997;173:95-8.
• Brough WA, Schofield PF. The value of the rectus abdominis mycutaneous flap in the treatment of complex perianal fistula. Dis Colon Rectum 1991;34:
• Pikarsky AJ, Wexner SD. Perianal disease. In: Bayless TM, Hanauer SB. eds. Advanced Therapy of Inflammatory Bowel Disease. London, BC Decker Inc., 2001;pp:501-7.

48. The Surgisis AFP plug is made from a complex collagen (protein) scaffold obtained from pigs—which have a collagen structure almost identical to that of human tissue.
Closure of Crohn's anorectal fistula tracts using Surgisis® anal fistula plug is safe and successful in 80 percent of patients and 83 percent of fistula tracts. Closure rates were higher with single tracts than complex fistulas with multiple primary openings.

49. INDICATIONS FOR SURGERY IN ULCERATIVE COLITIS
Approximately 30% of patients with ulcerative colitis undergo surgery within the first ten years of their illness, of which a substantial number have surgery for refractory disease during the initial presentation. Indications for surgery may be divided into those that are absolute and those that are relative. In the former group, exsanguinating hemorrhage, though rare, accounts for about 10% of emergency colectomies performed for ulcerative colitis. Perforation may occur in as many as 10% of all ulcerative colitis patients hospitalized with severe disease, whether or not the colon is manifesting toxic dilation. Patients with established carcinoma and high-grade dysplasia clearly should undergo colectomy. Although some clinicians do not feel that low-grade dysplasia is an absolute indication for surgery unless it is multifocal or recurrent, most experts now believe that finding the lesion in flat mucosa should lead to colectomy. Finally unresponsive severe acute disease with or without megacolon should lead to colectomy.
Intractable chronic disease, usually steroid-dependent or resistant, is the most common relative indication for elective surgery. Growth retardation in the pediatric age group is an uncommon but justifiable reason for surgery. On rare occasions, severe pyoderma gangrenosum has prompted colectomy, but extra-colonic manifestations of ulcerative colitis are generally managed without surgery.
• Becker JM. Indications for colectomy and choice of procedures. In: Bayless TM, Hanauer SB eds. Advanced Therapy of Inflammatory Bowel Disease. London, BC Decker, Inc. 2001;175-78
• Bernstein CN, Weinstein WM, Levine DS et al. Physician’s perceptions of dysplasia and approaches to surveillance colonoscopies in ulcerative colitis. Am J Gastroenterol 1995;90:
• Lindberg B, Persson B, Veress B et al. Twenty years’ colonoscopy surveillance of patients with ulcerative colitis: detection of dysplastic and malignant transformation. Scand J Gastroenterol 1996;31:

50. TOXIC COLITIS TOXIC COLITIS 11. TOXIC COLITIS
The most dangerous acute complication of ulcerative colitis occurs when the ulcerating, inflammatory process dissects deeply through the wall of the colon, producing a serositis and paralytic ileus. An early radiologic sign of this severe “toxic” colitis is an accumulation of gas over a long segment of colon, as seen on plain films of the abdomen (left panel). At this point, the luminal diameter need not be increased; in fact, it may even be narrowed with tubular or scalloped margins due to edema and spasm.
The more classic appearance of toxic dilatation or “megacolon” (right panel) does not usually emerge until late stages of the process, by which time the patient is already in imminent danger of perforation and/or peritonitis. The dilatation is often maximal in the transverse colon because its superior location in the supine patient allows air to collect in this segment of the flaccid bowel. (Rotation of the patient from supine to prone therefore helps redistribute the gas and decompress the colon.) A characteristic radiologic finding demonstrated in this case of toxic dilatation is the protrusion of soft tissue densities into the lumen, representing a combination of pseudopolyps and submucosal edema. The haustra are also abnormal — either obliterated as in this case, or occasionally accentuated. Barium enema and colonoscopy in such patients carry great risks in this situation and are usually contraindicated.

51. PERFORATION PERFORATION 12. PERFORATION
The potentially most lethal complication of toxic colitis is perforation. An early sign of bowel necrosis and impending perforation is subserosal dissection of luminal gas into the bowel wall, visible on this plain film of the abdomen (left panel) as sharply defined linear lucencies paralleling the medial wall of the ascending colon. The CT scan (right panel) demonstrates both a curvilinear air collection in the bowel wall and an adjacent collection of extraluminal air.
Clinical signs and symptoms in such cases may be subtle or absent; even as severe a complication as free perforation of the colon may be clinically silent in patients receiving corticosteroids.

52. Fulminant Colitis Total abdominal colectomy - ileostomy
Safest operation
20% of cases

53. INDICATIONS FOR SURGERY IN ULCERATIVE COLITIS
Approximately 30% of patients with ulcerative colitis undergo surgery within the first ten years of their illness, of which a substantial number have surgery for refractory disease during the initial presentation. Indications for surgery may be divided into those that are absolute and those that are relative. In the former group, exsanguinating hemorrhage, though rare, accounts for about 10% of emergency colectomies performed for ulcerative colitis. Perforation may occur in as many as 10% of all ulcerative colitis patients hospitalized with severe disease, whether or not the colon is manifesting toxic dilation. Patients with established carcinoma and high-grade dysplasia clearly should undergo colectomy. Although some clinicians do not feel that low-grade dysplasia is an absolute indication for surgery unless it is multifocal or recurrent, most experts now believe that finding the lesion in flat mucosa should lead to colectomy. Finally unresponsive severe acute disease with or without megacolon should lead to colectomy.
Intractable chronic disease, usually steroid-dependent or resistant, is the most common relative indication for elective surgery. Growth retardation in the pediatric age group is an uncommon but justifiable reason for surgery. On rare occasions, severe pyoderma gangrenosum has prompted colectomy, but extra-colonic manifestations of ulcerative colitis are generally managed without surgery.
• Becker JM. Indications for colectomy and choice of procedures. In: Bayless TM, Hanauer SB eds. Advanced Therapy of Inflammatory Bowel Disease. London, BC Decker, Inc. 2001;175-78
• Bernstein CN, Weinstein WM, Levine DS et al. Physician’s perceptions of dysplasia and approaches to surveillance colonoscopies in ulcerative colitis. Am J Gastroenterol 1995;90:
• Lindberg B, Persson B, Veress B et al. Twenty years’ colonoscopy surveillance of patients with ulcerative colitis: detection of dysplastic and malignant transformation. Scand J Gastroenterol 1996;31:

54. RISK OF COLORECTAL CANCER
Estimates of colorectal cancer incidence in ulcerative colitis have appeared widely discrepant and controversial on account of varying influences of referral and ascertainment bias (especially in referral centers), short or incomplete periods of follow-up (especially in ambulatory practice), and statistical errors (such as failure to correct for low-risk cases of limited anatomical extent or zero-risk cases post-colectomy). The most reliable estimates suggest an annual colorectal cancer rate in extensive colitis of at least 0.5% per year after the first decade of colitis (upper curve in yellow). This risk is increased at least 20-fold over that of age and sex-matched control populations without colitis (lower curve in blue). It should be noted that the risk is the same in Crohn’s colitis of equal anatomic extent and disease duration (see Fig. 51), but it may be modified by other factors (see Fig. 41).
• Ransohoff DF. Colon cancer in ulcerative colitis (editorial). Gastroenterology 1988;94:
• Ekbom A, Helmick C, Zack M et al. Ulcerative colitis and colorectal cancer: a population-based study. N Engl J Med 1990;323:
• Itzkowitz SH.Inflammatory bowel disease and cancer. Gastroenterol Clin North Am 1997;26:
• Eaden JA, Abrams KR, Mayberry JF. The risk of colorectal cancer in ulcerative colitis: a meta-anaylsis. Gut 2001;48:

58. Stomal Complications... More common than you think !
150 ileostomies over 10 yrs with 20 yr f/u
U.C. - 76%; Crohn’s - 56%
Br. J. Surgery 81:727, 1994

60. IPAA UNC (675)

61. IPAA UNC (808)

62. IPAA Stages Single Stage
Healthy
No chronic steroids
No chronic immunosupressants
Technically sound
5% of cases

63. IPAA Stages Two Stages (IPAA-ileostomy; ileostomy takedown)
Elective operation
Chronic steriods
Chronic immunosuppressants
Technical considerations
60% of cases

64. IPAA Stages Two Stages (Colectomy-ileostomy; Completion proctectomy IPAA)
Usually an urgent 1st operation
High dose steroids
Safest 1st operation
IPAA w/o ileostomy if technically sound
20% of cases

65. IPAA Stages Three Stages (Colectomy-ileostomy; Completion proctectomy IPAA-ileostomy; Ileostomy TD)
Usually an urgent 1st operation
High dose steroids
Safest 1st operation
Technical considerations -> ileostomy
20% of cases

66. Laparoscopic Restorative Proctocolectomy
Eleven trials patients
No significant differences in mortality or complications
Operative time was significantly longer in the laparoscopic group
No significant differences regarding postoperative recovery parameters.
Higher cosmesis scores in the laparoscopic group. (smaller incisions)
Cochrane Review 2009

67. Laparoscopic Restorative Proctocolectomy
Authors' conclusions
The laparoscopic IPAA is a feasible and safe procedure.
Short-term advantages of the laparoscopic approach seem to be limited and their clinical significance is arguable.
Cochrane Review 2009

68. INDETERMINATE COLITIS
It is uncertain to what extent “indeterminate colitis” represents an inevitable subset of cases in which it is simply difficult to establish a clear differential diagnosis between ulcerative and Crohn’s colitis, as opposed to a specific clinicopathological entity or set of entities distinct from either of the other two “classical” forms if IBD. At least part of the confusion, however, stems from an over-reliance on certain features that “conventional wisdom” incorrectly considers absolutely pathognomonic of either ulcerative colitis or Crohn’s disease.
For example, a number of “typical” characteristics of Crohn’s disease that sometimes occur in ulcerative colitis include relative rectal sparing, an isolated patch of inflammation in the cecum over-interpreted as a “skip lesion,” and granulomas that are actually cryptolytic (or “mucinophagic”) rather than truly epithelioid. Likewise, the “typical” ulcerative colitis pattern of inflammation confined to the mucosa may occasionally be seen in Crohn’s disease as well. Moreover, the “typical” appearance of ulcerative colitis may be modified—often sufficiently to resemble Crohn’s disease—as a consequence of treatment-induced alterations.
• Sachar DB. Is indeterminate colitis a problem of classification or is it an entity? Drugs of Today 2001;37(Supplement E): 63-6.

69. Indeterminate Colitis (IC) The real story
Fistulas:
> IC than UC (26 vs. 10 %; P = 0.02)
No IC pt required a permanent ileostomy vs with 6 UC pts.
Long-term functional results were similar.
Pouchitis:
2/3 developed pouchitis.
UC and CD pts >3 episodes of pouchitis (58 and 72 %) vs IC (29 %; P = 0.006).
CONCLUSIONS: Although IPAA patients with IC have more postoperative fistulas, long-term function is equal to that of UC and better than CD. IPAA should be offered to patients with IC and those in whom clear differentiation between IC and UC cannot be made.
Dis Col Rect 45(11):1525, 2002

70. IPAA Complications Early (30-40%)
SBO – 10-30% (4x with ileostomy)
Sepsis/Abscess – 3-15%
Thrombotic – DVT, PE, SMV or Portal
Bleeding – GI vs intra-abdominal
Pouch ischemia
Pouch leak

71. IPAA Complications Late
SBO – 10-30% (4x with ileostomy)
Pouch Stricture – 8-14%
Pouchitis – 50%
Pouch fistula – 3-10%
Pouch Loss – 1-4%
Hernia

72. IPAA “Novel” COMPLICATIONS
Stomal Volvulus

73. IPAA “Novel” COMPLICATIONS
Thrombotic complications in IBD - 1% to 6% and as high as 39% in a postmortem study.
The cause of hypercoagulability in IBD is unclear
Related to activity of disease and coagulation abnormalities: increased plasminogen activator inhibitor, factors V and VIII, and fibrinogen and decreased factor V Leiden, antithrombin III, proteins C and S
60% of pts with active IBD had a hypercoagulable state vs 15% with inactive disease

74. IPAA “Novel” COMPLICATIONS
SMV – PV Thrombosis
45% of pts who had post op IPAA CTs
“The incidence of postoperative SMV-PV thrombosis is likely more frequent than previously reported. “

75. IPAA “Novel” COMPLICATIONS
“Pouch Stasis”

76. POUCHITIS
226. POUCHITIS
A 5-12 year follow-up study of 102 post-colectomy patients at the Mt. Sinai Hospital in New York provided data on the long-term cumulative incidence and classification of pouchitis after colectomy and ileal pouch-anal anastomosis. In consonance with most other long-term follow-up studies, the cumulative incidence of pouchitis was 49%. Most of these cases (70%) were episodic and readily responsive to conventional treatment. Only 20% of the pouchitis cases (i.e, 10% of the total cohort) required continuous therapy to maintain remission and only 8% (4% of the total cohort) remained refractory to medical treatment.
• Aisenberg J, Legnani PE, Ellozoy SH et al. Are p-ANCA, ASCA, or interleukin-1 genes associated with pouchitis? Long-term follow-up in 102 ulcerative colitis (UC) patients [abstract]. Gastroenterology 2000;118:A340.

77. BENIGN STRICTURE 14. BENIGN STRICTURE
Benign strictures may occur in ulcerative colitis as a consequence of muscle hypertrophy and spasm, or less frequently with a component of fibrosis. Their x-ray (left panel) and endoscopic (right panel) appearances, however, may be indistinguishable from malignant strictures. Even biopsies may miss an early cancer, although brush cytology may increase the diagnostic yield. For these reasons, any stricture in ulcerative colitis must be considered malignant until proven otherwise. In this case of benign stricture, the nodularity seen on colonoscopy is due to pseudopolyps; the stricture itself has some pliability (cf. Fig. 15).

78. MALIGNANT STRICTURE 15. MALIGNANT STRICTURE
Strictures in ulcerative colitis, even if they appear benign radiologically and endoscopically, may still harbor foci of carcinoma and must therefore be thoroughly investigated. The carcinoma in this case did not appear as a mass lesion either on barium enema (left panel) or endoscopy (right panel), but it was found on biopsy of the fixed and rigid stricture (cf. Fig. 14). The rigidity of this stricture is suggested visually by the bright yellow light reflection in the left half of the endoscopic photograph, an appearance produced when the colonoscope presses against the inelastic bowel wall as it attempts to traverse the tight narrowing.

79. PROTOCOL FOR MANAGEMENT OF DYSPLASIA
All authorities agree that a simple, readily-excisable adenomatous polyp outside the area of endoscopic or histologic colitis can be managed conservatively. There is also a wide albeit not universal consensus that any degree of definite dysplasia in flat colitic mucosa mandates colectomy, at least in patients with long-standing ulcerative colitis. This same consensus extends generally to colitis patients with multifocal dysplasia or with unresectable adenomatous polypoid lesions within colitic mucosa. A relatively new concept, however, teaches that a completely excisable adenomatous polyp, even in colitic mucosa, can be managed conservatively if there is no other dysplasia found on extensive biopsies throughout the entire colon. (See Fig. 48)
• Riddell RH. Dysplasia and cancer in ulcerative colitis: a soluble problem? Scand J Gastroenterol Suppl 1984;104:
• Lashner BA, Hanauer SB, Silverstein MD. Optimal timing of colonoscopy to screen for cancer in ulcerative colitis. Ann Intern Med 1988;108:274-8.
• Engelsgjerd M, Farraye FA, Odze RD. Polypectomy may be adequate treatment for adenoma-like dysplastic lesions in chronic ulcerative colitis. Gastroenterology 1999;117:
• Rubin PH, Friedman S, Harpaz N et al. Colonoscopic polypectomy in chronic colitis: conservative management after endoscopic resection of dysplastic polyps. Gastroenterology 1999;117:
• Odze RD. Adenomas and adenoma-like DALMs in chronic ulcerative colitis: a clinical, pathological, and molecular review. Am J Gastroenterol 1999;94:

80. COLORECTAL CANCER RISK IN ULCERATIVE AND CROHN’S COLITIS
These graphs from a multicenter study comparing the frequency of colorectal cancer in ulcerative and Crohn’s colitis confirm the long-standing but only recently acknowledged suspicion that the cancer risk in the two diseases is virtually identical, given the same duration and anatomical extent of the colitis. (Cf. Fig. 38)
• Gillen CD, Walmsley RS, Prior P, Andrews HA, Allan RN. Ulcerative colitis and Crohn’s disease: a comparison of the colorectal cancer risk in extensive colitis. Gut 1994;35:
• Sachar DB. Cancer in Crohn’s disease: dispelling the myths. Gut 1994;35:

81. TRANSVERSE COLON STRICTURE
Radiographic (left) and endoscopic (right) views of a benign stricture at the anastomosis of the neoterminal ileum and transverse colon in Crohn’s disease. The ileum proximal to the anastomosis is dilated due to chronic obstruction.
TRANSVERSE COLON STRICTURE

82. ENTEROVESICAL FISTULA
Since the terminal ileum crosses the dome of the bladder as it traverses the pelvis, the most common form of internal Crohn’s disease fistula, after entero-enteric, is enterovesical. The contrast material in the bladder in this small bowel x-ray is barium that has entered via a fistula from diseased ileum. Dysuria is a frequent symptom and urinary tract infections often result, but one of the earliest and most pathognomonic signs of entero-vesical fistulization is pneumaturia.
• Greenstein AJ, Sachar DB, Tzakis A et al. The course of enterovesical fistulas in Crohn’s disease. Am J Surg 1984;147:

83. FISTULAE FISTULAE 97. FISTULAE
A mass effect impinging upon the medial aspect of the cecum with entero-colic fistulae to the transverse colon and sigmoid as well as separation of bowel loops secondary to inflammatory mesenteric changes are noted in the panel on the right. The film on left shows a stellate collection of contrast representing radiating fistulas and sinus tracts involving the sigmoid colon.
FISTULAE

84. PERINEAL COMPLICATIONS
Perianal fistulae and other lesions of the perineum are among the most frustrating and mutilating complications of Crohn’s disease. They include discrete fistulae opening near the scarred anal canal (left panel), undermining fistulae with large external tags (“elephant ears”) of granulation tissue (middle panel) and sometimes—especially following over-aggressive surgery—major slough of the entire perinuem (right panel).

85. PERIANAL ABSCESS PERIANAL ABSCESS 103. PERIANAL ABSCESS
An erythematous, fluctuant area with swelling and tenderness is adjacent to the anal canal. A characteristic anal skin tag (elephant ear) is present overlying a chronic anal fissure.
PERIANAL ABSCESS

86. ILEAL POUCH-ANAL ANASTOMOSIS
The ileal pouch-anal anastomosis (IPAA) has become the conventional operation for ulcerative colitis with 90% of procedures for ulcerative colitis in many series involving IPAA. The operation can be done as a primary two stage procedure, a total procto-colectomy, and IPAA with temporary loop ileostomy, multistage with subtotal colectomy, oversow of rectal stump, and ileostomy followed by completion proctectomy and loop ileostomy closure or as a one stage procedure without loop ileostomy. The procedure can be done by a total mucosal proctectomy with hand suturing of the pouch to the anal canal or by leaving the anal transitional zone with stapling of the pouch to the anal canal. Long-term follow-up of pouch function and quality of life have indicated a high degree of success with an acceptable rate of complications. The standard Brooke ileostomy and in limited situations a straight ileal-rectal anastomosis continue to be important alternative to IPAA for some patients with ulcerative colitis.
• Remzi FH, Fazio VW. Ileal anal pouch anastomosis. In: Bayless TM, Hanauer SB. eds. Advanced Therapy of Inflammatory Bowel Disease. London, BC Decker Inc., 2001;
• Fazio VW, O’Riordon MG, Lavery IC et al. Long-term functional outcome and quality of life after stapled restorative procto-colectomy. Ann Surg 1999;230:
• McIntyre PB, Pemberton JH, Wolff BG et al. Comparing functional results one year and 10 years after ileal pouch anal anastomosis for chronic ulcerative colitis. Dis Colon Rectum 1994;37:303-7.

87. SURGICAL OPTIONS IN ULCERATIVE COLITIS
Until the last one or two decades, the conventional operation for ulcerative colitis was a standard Brooke ileostomy. The operation is curative and requires no anastomosis to heal, but it does result in permanent fecal incontinence and requires the wearing of an external appliance. A continent ileostomy can be fashioned from an ileal-reservoir with a nipple valve (Kock pouch). No external appliance is needed, but emptying requires regular catheterization through the nipple valve. Complications include pouchitis and nipple malfunction leading to incontinence.
The ileal pouch-anal anastomosis (IPAA) is a sphincter-saving operation that allows anal continence with an overall 95% chance of success. Complications of this procedure include anastomotic leaks, stricture formation, pouchitis, and partial incontinence. In a limited group of patients with relatively mild distal disease, a straight ileo-rectal anastomosis can be considered. Such patients require ongoing cancer surveillance of the remaining rectal segment.
• Becker JM. Indications for colectomy and choice of procedures. In: BaylessTM, Hanauer SB. eds. Advanced Therapy of Inflammatory Bowel Disease. London, BC Decker Inc., 2001;
• Pastore RL, Wolff BG, Hodge D. Total abdominal colectomy and ileo- rectal anastomosis for inflammatory bowel disease. Dis Colon Rectum 1997;40:
• Kock NG. Continent ileostomy. Prog Surg 1973;12:180.

88. LONG-TERM ADVERSE OUTCOMES OF ILEAL POUCH ANAL ANASTOMOSIS
The long-term functional outcome of a hand-sewn ileal pouch anal anastomosis was determined in 300 patients. At ten years post-procedure, 27% of patients had some degree of daytime incontinence, 54% still had nocturnal incontinence, and 39% were taking anti-diarrheal medications. Thirteen percent could not distinguish gas from stool and 8% had sexual dysfunction.
• Meagher DP, Farou HR, Dozois RR et al. Ileal pouch anal anastomosis for chronic ulcerative colitis. Complications and long-term outcome in patients. Brit J Surg 1998;85:

89. POUCHITIS
224. POUCHITIS
One hundred forty-nine patients with ulcerative colitis who underwent ileal pouch-anal anastomosis were prospectively evaluated for symptoms of pouchitis. The diagnosis of pouchitis was based on stool frequency, bloody stools, and endoscopic inflammation. The median follow-up time was 54 months (5-152). The cumulative risk of developing mild pouchitis was 21% at six months, 26% at 12 months, and 39% at 48 months. The corresponding risk of developing severe pouchitis was 9, 11, and 14%. The total cumulative risk of developing any form of pouchitis was 51% at four years. Extra-colonic manifestations and early onset of ulcerative colitis were risk factors for developing pouchitis, while former smoking appeared to be protective. Only 1.3% of patients had their pouches removed.
• Stahlberg D, Gullberg K, Liljequist J et al. Pouchitis following pelvic pouch operation for ulcerative colitis: Incidence cumulative risk and risk factors. Dis Colon Rectum 1996;39:

90. MEDICAL TREATMENT OPTIONS FOR PERINEAL DISEASE
Uncontrolled trials suggests efficacy for metronidazole and/or ciprofloxacin in treating active perineal Crohn’s disease, but relapse is frequent upon withdrawal of these agents. In one placebo-controlled trial for active perianal fistula, anti-TNF in the form of infliximab closed half of the perianal fistulae in over 60% of patients and closed all fistulae in over 40%, compared with 26% and 13% for placebo-treated patients respectively. In the only controlled trial of 6-mercaptopurine on Crohn’s disease fistula, complete fistula closure was seen in 31% over six months versus 6% in the placebo group. Methotrexate has been transiently helpful in perianal fistula closure, but not well-studied in this regard. Cyclosporine administration may result in rapid fistula closure, but the relapse rate upon withdrawal of the drug is high. There are enthusiastic but limited reports on the efficacy of tacrolimus and thalidomide in closure of refractory perianal fistulae.
• Brandt LJ, Bernstein LH, Boley SJ et al. Flagyl therapy for perineal Crohn’s disease: a follow-up study. Gastroenterology 1982;83:383-7.
• Present DH, Rutgeerts P, Targen S et al. Infliximab for the treatment of fistulas in patients with Crohn’s disease. N Engl J Med 1999;340:
• Present DH, Corliss BI, Wisch N et al. Treatment of Crohn’s disease with 6-mercaptopurine: a long-term randomized double-blind study. N Engl J Med 1983;2:981-7.
• Hanauer SB, Smith MB. Rapid closure of Crohn’s disease fistulas with continuous intravenous cyclosporine. Am J Gastroenterol 1993;88:646-9.

91. PERCUTANEOUS ABSCESS DRAINAGE FOR CROHN’S DISEASE
Thirty-six patients were identified with intra-abdominal abscesses related to Crohn’s disease. Fifteen of the 36 were considered for initial percutaneous drainage. Drainage was not technically feasible in seven patients who were excluded from the study. In the remaining eight patients, a percutaneous drain was inserted, but in four of them it failed to adequately drain the abscess, so that two patients required early surgery for recurrent abscess and two for enterocutaneous fistula. Four patients had good long-term results, but one of these later had surgery related to the abscess. The authors concluded that in selected cases intra-abdominal abscesses can be drained percutaneously, but overall only three of the original 36 patients were able thus to avoid surgery altogether.
• Jawhari A, Kamm MA, Ong C et al. Intra-abdominal and pelvic abscesses in Crohn’s disease: results of non-invasive and surgical management. Brit J Surg 1998;85:

94. Surgery in CD: Indications
Failure to respond to medical therapy
Management of complications
Strictures
Fistulas
Perforations
Perianal disease
Cancer or precursors

95. Indications for Surgery

96. Types of Operations Intestinal Resection Bypass Procedure
Stricturoplasty

97. Surgery in CD Procedures Indications
Resection and Regional enteritis, ileocolitis, anastomosis segmental disease
Strictureplasty Multiple segmental strictures in jejunoileitis, proximal skip disease (in conjunction with resection)
Colectomy and Pan(ileo)colitis with rectal ileostomy involvement, severe perirectal sepsis

98. Surgery in CD Procedures Indications
Subtotal colectomy Extensive colitis with and ileoproctostomy normal rectum
Diverting ileostomy Crohn’s colitis
Temporary ileostomy Alternative to anastomosis colostomy or when anastomosis inappropriate

107. Complications of Crohn’s Disease
Fistulas
Abscesses
Intestinal blockage
Extra-intestinal disorders (eg, arthritis and disorders of the skin, eyes, kidneys and liver)
Malnutrition
Growth failure in children

111. Inflammatory Bowel Disease Surgical Alternatives
Mark J. Koruda, MD
Department of Surgery
UNC Chapel Hill, NC

112. Stricturoplasty for Crohn’s Disease
Date N Plasties Resect Cx Recur
Average 2.7/pt

113. Reasons for Continent Ileostomy
Dis Colon Rectum 38:573, 1995

114. Pouch Status
Dis Colon Rectum 38:573, 1995

115. Course Following Surgery

116. Reason for Pouch Excisions
Slipped Valve - 6
Pouch Fistula - 9
Personal - 1

117. Mucus Production

118. Frequency of Pouch Intubation

119. Types of Operations Intestinal Resection Bypass Procedure
Stricturoplasty

120. Stricturoplasty Remember...
Crohns is left behind
The bowel’s bad

121. Indications for Surgery
Ann Surg 214:231, 1991