1. Crohn’s Colitis SR Brown Colorectal Surgeon Sheffield Teaching Hospitals

2. BSG guidelines Gut 2004;53(suppl V):v1-v16

3. European Consensus Statement (ECCO) Gut 2006;55(suppl 1):i16-i35

4. Objectives Discussion of –Primary surgery in localised Ileocaecal disease –Method of anastomosis –Segmental resections –Stricturoplasty –IPAA

5. Primary surgery for localised ileocolic disease ECCO recommendations ‘Localised ileocaecal Crohn’s disease with obstructive symptoms can be treated by primary surgery’

6. Evidence for early surgery Whilst medical therapy will bring remission, surgery is almost inevitable Some long term data on results of resection Up to 50% ‘cured’

7. Long term outcomes after ileocaecal resection StudyYearNumberFollow up (median) Reoperation (%) Graadel19945818 years54 Nordgren199413617 years45 Weston19961014 years50 Kim199718114 years31 Landsend20065324 years64 Total43817 years43%

8. Evidence against early surgery Minimal long term data on medical therapy ?surgical studies out of date –No AZA or Infliximab

9. Long term outcome of medical management Bemelman 2001 Consecutive severe ileocaecal Crohn’s 1985-1994 Follow up 8 years 76 patients 62% surgery

10. Quality of life NA Scott, LE Hughes Gut 1994 80 patients who had ileocolic resections questioned ¾ wanted op sooner Reasons –Severe symptoms –97% –Ability to eat properly –86% –Feeling well – 62% –No need for drugs –43%

11. Quality of life Tillinger et al. Dig Dis Sci 1999 16 patients surveyed prospectively HRQOL improved up to 24 months after op.

12. Scenario Young male Presumed appendicitis Found to have terminal ileitis

13. Options Do nothing Appendicectomy Right hemicolectomy

14. Traditional teaching Appendicectomy if caecum normal –Ileitis may be Yersinia –Removing appendix reduces future confusion –Minimal resection in Crohn’s due to short bowel –Consent

15. Ileocolic resection for acute presentation of crohn’s disease Weston 1996 36 patients with ?appendicitis found to have ileocaecal Crohn’s –10 surgery 5 reoperations –26 no surgery/appendicectomy 24 reoperations

16. Recommendations ECCO ‘ It is up to the judgement of the surgeon whether to resect a terminal ileum affected with Crohn’s disease found at laparotomy for suspected appendicitis’

17. Method of Anastomosis Functional end-to-end or conventional end- to-end Stapled or hand-sewn

19. Factors affecting recurrence Host related factors –Smoking etc Type of Crohn’s –Fistulating –Obstructing Type of anastomosis

20. What influences recurrence at the anastomosis? Faecal content Ischaemia Size Tissue reaction to suture/staples

21. Functional end-to-end versus end-to-end

22. Stapled functional end-to-end versus handsewn end-to-end

23. Problems with meta-analysis Retrospective Follow-up Needs RCT

24. ECCO recommendations ‘ There is some evidence that a wide lumen functional end to end anastomosis is the preferred technique’

25. Segmental resections Proctocolectomy versus sphincter preserving surgery Segmental resection versus colectomy and ileorectal anastomosis

26. Proctocolectomy versus sphincter preserving surgery Advantages proctocolectomy –Reduced recurrence Advantages segmental resection –Less morbidity –No stoma

27. Indications for proctocolectomy Avoidance of a stoma is convenient and appreciated by the patient but the risk of relapse and reoperation is more than doubled. In case with perianal disease further precaution is recommended.

28. Segmental or total colectomy Advantages segmental resection –Preservation bowel and function Advantages total colectomy –Reduced recurrence

29. Segmental versus total colectomy

31. Limitations to meta-analysis Retrospective –Selection bias Publication bias

32. ECCO recommendations ‘If surgery is necessary for localised colonic disease then resection only of the affected part is preferable’

33. Stricturoplasty Endoscopic Surgical

34. Advantages over resection Preservation of bowel and function ?Improved QOL Avoidance of surgery (endoscopy group)

35. Disadvantages ?Safe Recurrence Adenocarcinoma risk

36. Endoscopic balloon dilatation 8 studies Technical success >90% Often repeat dilations necessary Avoidance surgery in 41-72% Complication rate 10% (perforations 8/230)

37. Surgical stricturoplasty Retrospective Plasty vs resection 58 patients (29 vs 35) Surgical recurrence –36% vs 24% Complications –16% vs 22% QOL same

38. ECCO statement ‘ Endoscopic dilatation of a stenosis in Crohn’s disease is a preferred technique for the management of accessible short strictures. It should only be attempted in institutions with surgical back up.’

39. IPAA for colonic Crohn’s

40. Initial data on IPAA for Crohn’s 3 papers (UK,US) Misdiagnosis UC 44 patients –Pouch excision in 33% –Good function in 26 (59%)

42. Panis 1996 31 patients with Crohn’s –Rectal disease requiring excision –No perianal disease –No small bowel disease 71 patients with UC Follow up mean 72 +/-23 months

43. Panis 1996 6/31 Crohn’s related complications –4 fistulas treated surgically –1 abscess –1 crohn’s pouch recurrence 2/31 pouch excision (6%) Function = UC patients

44. Meta-analysis of the literature 10 studies 3,103 IPAA 225 IPAA for Crohn’s

45. IPAA for Crohn’s Crohn’s IPAA –More strictures (OR 2.12) –More pouch failure (32 vs 4.8%) –More Urgency (19 vs 11%) –More incontinence (19 vs 10%)

46. IPAA for Crohn’s Note selection bias –9/10 studies identified patients because of complications Patients with isolated colonic Crohn’s –Complication and pouch failure equal

47. ECCO statement ‘ At present an IPAA is not recommended in a patient with Crohn’s colitis’