1. Dr. Drelichman Surgical Techniques Part 2

2. Crohn’s Disease Laparoscopic Colectomy - Results: Patient Outcomes Conversion Rate 5.9%

3. Laparoscopy for Ileocolic Crohns Prospective Randomized Trial 60 pts Ileo-colic Crohn’s Disease Results:Lap Open Results:Lap Open Incision 5cm12cm Morphine = = bowel function3.0d3.3d LOS 5d 6d Complications 4 8 Milsom et al. DCR 2001;44:1-9:

4. Multiple strictures

5. Strictures & Sacculations

6. Bowel Sparing techniques Strictureplasty for Crohn’s Disease

7. STRICTUROPLASTY (FINNEY)

8. Jaboulay Strictureplasty Indication: long stricture

9. Judd Strictureplasty Indication: fistula site

10. Crohn’s Conclusions Bowel-conserving surgical options strictureplasty and limited resection Bowel-conserving surgical options strictureplasty and limited resection Complication rates are similar in both Complication rates are similar in both Reoperation rates are 50% at 10 years, and 70% at 15 years Reoperation rates are 50% at 10 years, and 70% at 15 years

11. Crohn’s Disease Conclusion Absolute Indications for Surgery Absolute Indications for Surgery Relative Indications _ QOL Relative Indications _ QOL Laparoscopy has some benefits Laparoscopy has some benefits Disease related challenges Disease related challenges Specialized Medical & Surgical care Specialized Medical & Surgical care Close Collaboration Close Collaboration

12. Surgery for Ulcerative Colitis Surgery for Ulcerative Colitis

13. ANATOMIC EXTENT OF ULCERATIVE COLITIS

14. ENDOSCOPIC SPECTRUM OF SEVERITY

15. Ulcerative Colitis Symptoms/Signs Bright red blood per rectum and diarrhea are the most common symptoms Bright red blood per rectum and diarrhea are the most common symptoms Severe disease may evoke crampy abdominal pain and distention*, fever, tachycardia, elevated WBC Severe disease may evoke crampy abdominal pain and distention*, fever, tachycardia, elevated WBC Extraintestinal symptoms in up to 36% of patients Extraintestinal symptoms in up to 36% of patients * Toxic megacolon: acute colitis with segmental or total dilation of the colon and accompanying fever, abd pain and tenderness, tachycardia, and leukocytosis

16. RISK OF COLORECTAL CANCER

17. Surveillance Colonoscopy should begin at 8-10 years duration of disease Colonoscopy should begin at 8-10 years duration of disease Then at 1-2 year intervals Then at 1-2 year intervals Pts with PSC start surveillance at time PSC diagnosed Pts with PSC start surveillance at time PSC diagnosed Eaden J et al. Gastrointestinal Endoscopy 2000

18. SURVEILLANCE BIOPSY PROTOCOL

19. PSEUDOPOLYPS

20. DALMS IN ULCERATIVE COLITIS

21. Risk of Cancer associated with Dysplasia Review of ten prospective studies Review of ten prospective studies Probability of cancer DALM43% DALM43% HGD 42% HGD 42% LGD 19% LGD 19% Bernstein et al. Lancet 1994

23. INDICATIONS FOR SURGERY IN ULCERATIVE COLITIS

24. Ulcerative Colitis Indications for Surgery Intractability Intractability Massive hemorrhage Massive hemorrhage Toxic megacolon Toxic megacolon Fulminant acute colitis Fulminant acute colitis Systemic complications Systemic complications Cancer or dysplasia Cancer or dysplasia Growth retardation (in children ) Growth retardation (in children )

25. IBD - Toxic Megacolon Surgical Options Colectomy/Rectal preservation, Ileostomy : Colectomy/Rectal preservation, Ileostomy : Ulcerative colitis - 3-stage pouch Ulcerative colitis - 3-stage pouch Crohns - 2-stage IRA Crohns - 2-stage IRA

26. SURGICAL OPTIONS IN ULCERATIVE COLITIS

29. IPAA Maintains the normal route of defecation Maintains the normal route of defecation  Increased frequency of stools Avoids permanent ostomy Avoids permanent ostomy

30. Farouk R, Pemberton JH, Wolff BG, Dozois R. Annals Surg. 2000 1,454 patients IPAA for CUC. 12 yrs f/u 45 45 Stool Freq Stool Freq Day 6 6 Day 6 6 Night 1 2 Night 1 2 Incontinence Incontinence Never 43% 24% Never 43% 24% Occ.(2/wk)48% 59% Occ.(2/wk)48% 59% Freq 9% 17% Freq 9% 17% Functional Outcomes Functional Outcomes

31. Quality of Life Patients with UC report a lower quality of life compared to healthy individuals Patients with UC report a lower quality of life compared to healthy individuals Score similarly to patient with other chronic illness (Diabetes) Score similarly to patient with other chronic illness (Diabetes) Muir et al. Am J Gastroent. 2001

32. Post IPAA Quality of Life Preoperative scores low in all scales Preoperative scores low in all scales Health status questionnaire scores improved and even equal general population at 1 year. Health status questionnaire scores improved and even equal general population at 1 year. Thirlby, R et al. Archives of Surg 2001

33. Post IPAA Quality of Life

34. Ulcerative Colitis Conclusions Risk Cancer increases with time in patients with UC and CC Risk Cancer increases with time in patients with UC and CC Surveillance Regimen to prevent Ca Surveillance Regimen to prevent Ca Colectomy should be offered to patients with Dysplasia Colectomy should be offered to patients with Dysplasia

35. Ulcerative Colitis Conclusions Surgery offers definitive cure UC Surgery offers definitive cure UC 1/3 of patients with UC have surgery 1/3 of patients with UC have surgery Post Colectomy Patients have good QOL Post Colectomy Patients have good QOL J-Pouch requires Surgical Expertise J-Pouch requires Surgical Expertise

36. Build Your Team Be Proactive Be Proactive Be Educated Be Educated What % of practice IBD What % of practice IBD Post Graduate training Post Graduate training Build your Team Build your Team Coach or Project manager Coach or Project manager IBD specialist, Surgeon IBD specialist, Surgeon Nutrition Nutrition Social and Spiritual Support Social and Spiritual Support Communicate Communicate

37. St. John Health System IBD Center St. John Health System IBD Center Contact Information Contact Information  Office: (248) 849-6030  Fax: (248)849-6039  Kim Buck, NP: (248)849-5448

38. “I don’t know where it goes, and I don’t want to know”