1. Inflammatory Bowel Disease
Dr. Hagit Tulchinsky,
Proctology Unit, Surgery B
Tel Aviv Sourasky Medical Center

2. Epidemiology Developed countries
More common in Jewish population (3-5 folds), whites
Equal distribution between genders
Bimodal age distribution: 15-35y, 50-70y

3. Etiology-1 UC and Crohn`s – separate entities ?
10-15% of IBD - Indeterminate colitis
10% - diagnosis is changed
Relatives – more likely to have the same disease as the proband
Cluster within families

4. Etiology-2
Genetic predisposition + environmental factors (dietary intake)
Complex genetic disorder
UC - less significant genetic contribution than in Crohn`s d.
Susceptibility locus, IBD 1, on chromosome 16
Molecular evidence of 2 forms of Crohn`s
pANCA – in most UC patients (75%)

5. Etiology-3 Host – defective mucosal barrier function
NSAID`s exacerbate IBD
Cigarette smoking: protective in UC, aggressive factor in Crohn`s d.

6. Etiology- Summary
These diseases are due to aberrant host response to environmental antigens in genetically susceptible individuals

7. Pathology-UC-1 congested serosa From rectum proximally
Confined to colon and rectum
Disease limited to the mucosa
Macroscopic appearance
congested serosa
contracted and shortened bowel
edema of the mesentery
pseudopolyps
10% backwash ileities

8. Pathology-UC-2 Only the mucosa is affected Microscopic appearance
Cancer and dysplasia
3-5% develop cancer
Increased risk if extensive disease for at least 8
years
Surgery if low grade dysplasia

9. Pathology Crohn`s disease-1
May affect any part of the intestinal tract
Usually affects the terminal ileum and cecum
Small bowel alone – 1/3
Colon alone – 1/3
Perianal region or upper GI tract alone – less common

10. Pathology Crohn`s disease-2
Macroscopic appearance
Skip lesions
Segmental colitis
Stenosis of terminal ileum
Anal lesions in 75%
Wrapping of mesenteric fat
Thickened wall irregularly
Thickened mesentery

11. Pathology Crohn`s disease-3
Microscopic appearance
Patchy distribution
2/3 – noncaseating granulomas,
Transmural chronic inflammation,
Serositis, fibrous adhesions
Deep ulcers into the muscle layers
Cancer and dysplasia
Increased risk in long standing disease

12. Pathology-Summery
Pathologic features – more usually seen in chronic stages of the disease
Cardinal feature of Crohn`s d. - patchiness
The presence of small bowel disease should exclude UC
High or complex perianal fistula / anal ulceration – more likely Crohn`s d.
Crypt distortion – characteristic of UC
Granulomas are less specific

13. Clinical findings Diarrhea, mucous discharge Rectal bleeding- more UC
Obstructive symptoms- more Crohn’s d.
Anal/perianal d.- more Crohn’s d.
Loss of body weight
Anemia

14. Physical findings Reflect the severity of the disease
Abdominal tenderness (left side)
Abdominal distention
Fever, tachycardia
Proctitis- urgency, tenesmus, fecal incontinence

15. Extraintestinal manifestations
Peripheral arthritis, 15-20%, resolve after colectomy
Ankylosing spondylitis
Sacroiliitis
Primary sclerosing cholangitis – more in UC, no resolution post op

16. Surgery-UC 20-45% eventually undergo surgery
Indications – elective / emergency
Pre op. management:
- Correct hypovolemia + electrolytes
- Correct anemia
- If on steroids – Hydrocortisone I.V.
- Counseling and education on the outcome
- Severe malnutrition – TPN
- Prepare as for colon surgery

17. Indications for elective surgery UC
Intractability – most common
Involvement of other organs
Large bowel dysplasia/cancer

18. Indications for elective surgery UC
Intractability
Failure of medical therapy
Chronic complications of the disease
Debilitating symptoms
Poor nutrition
Impaired quality of life
Anemia
Hypoproteinemia
Children- failure to growth
Side effects

19. Indications for elective surgery UC
Presence and risk of cancer
When to consider prophylactic surgery/close surveillance program?
Extensive and long standing colitis
Onset at childhood/teenage + generalized colitis +10
or more yrs of disease – 2% will develop cancer
each year
PSC
Dysplasia

20. Indications for elective surgery UC
Debilitating extra intestinal manifestations
May improve after surgery
Cutaneouos, peripheral arthicular, ocular, hematological,vascular
Ankylosing spondilitis and rheumatoid arthritis will not regress
PSC may progress to cirrhosis or cholangio ca. after surgery

21. Indications for emergency surgery UC
Fulminant colitis
Tachycardia, fever, WBC > 10,500, low albumin
First – aggressive conservative treatment
Failure – surgery
Goal – operate before colonic perforation
Toxic megacolon
Pain, fever, toxicity, abdominal tenderness and distention, transverse colon >7cm
Perforation, hemorrhage and obstruction

22. Choice of Operation-UC
Restorative proctocolectomy
Treatment of choice if elective
CI – Crohn`s, incompetent sphincter,
cancer in distal rectum
Proctectomy with continent ileostomy
Brooke ileostomy, poor sphincter
Proctectomy with Brooke ileostomy
Colectomy and ileorectal anastomosis
Rarely used today
only if relative rectum sparing, young males

23. Normal anatomy

24. Proctocolectomy

25. Colectomy with ileorectal anastomosis

27. Elective treatment of choice
Choice of Operation
Elective treatment of choice
Restorative proctocolectomy with ileal reservoir
The ileal pouch anal anastomosis

28. The pouch procedure Removes all of the colon and rectum
Preserves the anal canal
Aim – to avoid permanent ileostomy
The decision is up to the patient
Information on the pros and cons

29. The pouch procedure WHO IS ELIGIBLE ?
Ulcerative colitis and not Crohn`s disease
Patients who had no operation
Patients who had a colectomy with ileostomy or ileorectal anastomosis
Good anal sphincter control

30. The pouch procedure Technique
Stage 1- The pouch operation
Abdomen opened
Colon and rectum are freed
Rectum is cut above the anal sphincter
Small bowel and anus left in place

31. Abdominal incision

32. Proctocolectomy

33. The pouch procedure Technique
Stage 1- The pouch operation
J pouch
Pouch joined to the anus
Protective loop ileostomy

34. 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.

36. The pouch procedure Technique
Stage 2 – Closure of ileostomy
Relatively minor procedure
Cut around the ileostomy
Bowel closed
The hole in the abdomen closed

37. The pouch procedure Results
Early complications
Obstruction
Infection

38. The pouch procedure Results
Late complications
Obstruction
Pouchitis
Defecation problems
Anal skin soreness
Pouch fistula

39. The pouch procedure Results
Function
Frequency
Urgency
Continence
Anti diarrheal medications

40. The pouch procedure Results
Quality of life
90% - better
Failure
Up to 15%

41. Surgery Crohn`s disease
Typical presenting symptoms:
Abdominal pain, diarrhea, weight loss
Reserved for patients whose quality of life is significantly impaired despite appropriate medical therapy or after disease associated complications develop
The probability of undergoing surgery is 78-90% after 20 and 30 yrs, respectively
Elective / emergent indications

42. Indications for elective surgery Crohn`s disease
Fistula ± abscess
The most common indication
Different types of fistula
Rarely heal with corticosteroids
6-MP will promote closure in 30-40%
Obstruction
Chronic/acute
Single/multiple sites of stricture

43. Indications for elective surgery Crohn`s disease
Failed medical therapy
Incomplete response
Maintenance medications cannot be stopped
Significant side effects
Intra abdominal abscess/fistula
Carcinoma
Growth retardation
15-30% of children with Crohn`s
Op. is indicated only in the pre pubertal child

44. Indications for emergency surgery Crohn`s disease
Fulminant colitis and Toxic megacolon
Acute flare and at least 2 of the following:
Tachycardia >100 , fever >38.6, WBC > 10,500, albumin<3
Initial therapy –correct physiological deficits,
high dose steroids or immunosuppresants, bowel rest, antibiotics
Any worsening during the initial 48h - surgery
Free perforation, massive hemorrhage, peritonitis, septic shock – emergent op.

45. Indications for emergency surgery Crohn`s disease
Perforation
Most are sealed
Massive bleeding
Rare – 1% of patients
of patients

46. Principles of operative treatment Crohn`s disease
PALLIATIVE, CONSERVATISM
Minimal procedure with maximal effect
Mechanical and antibiotic preparation
I.V. Steroids
Stop immunosuppressive therapy
Correction of deficits
Stoma marking
of patients

47. Operative options Crohn`s disease
Bypass
Rarely recommended – high recurrence rate and malignancy risk
Resection
Macroscopic healthy margins
Anastomosis
Stapled or handsewn
Same principles as for any anastomosis
of patients

48. Operative options Crohn`s disease
Stricturoplasty
- Small bowel strictures, fibrotic recurrence at
ileocolic or ileoractal anastomosis
- Not for colonic narrowing
- Indications and contra indications
- Technique
of patients

49. 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:

50. 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:

51. Thank You