1. MICI: approccio chirurgico
UOC di Chirurgia Pediatrica
Università degli Studi di Napoli Federico II
Dir. Prof. Alessandro Settimi
MICI: approccio chirurgico
Ciro Esposito
Alessandro Settimi
Napoli 2003

2. DIAGNOSIS
A minority (25%) of children with CD present with the classic triad of abdominal pain, diarrhoea and weight loss
The development of standardised diagnostic criteria (the Porto criteria) by the IBD working group of the ESPGHAN has done much to ensure uniformity in diagnosis and management

3. DIAGNOSIS
The gold standard in diagnosis is combined upper and lower gastrointestinal endoscopy, together with small bowel radiology UC CD

4. DIAGNOSIS
Increased experience with MR enterography, the lack of exposure to radiation, and the utility of MRI in the evaluation of perianal CD all favour this study over contrast meal
Capsule endoscopy is showing promise as an adjunct in cases of diagnostic difficulty, but carries the risk of obstruction if the capsule becomes impacted at an occult area of narrowing

5. SURGICAL MANAGEMENT OF ULCERATIVE COLITIS
The objective in both elective and emergency surgical interventions for UC is the removal of the colon
The most common indication for colectomy is:
Failure of medical therapy whether due to frequent
disease activation with short periods of remission
Unacceptability of the side-effects of medical therapy
Inadequate disease control may also be reflected by:
Reduced growth velocity
Delayed puberty, inadequate nutrition, poor bone mineralisation
Loss of time from school
Colonic cancer per se does not feature in the indications for colectomy in childhood since the quoted risk is 2% at 10 years, 8% at 20 years and 18% at 30 years
Eaden JA et al. Gut 2001

6. SURGICAL MANAGEMENT OF ULCERATIVE COLITIS
Colectomy rates at 5 years from diagnosis range between 14% and 24% in children
Gower-Rousseau C et al. Am J Gastroenterol 2009
The Ileal Pouch Anal Anastomosis (IPAA) is now the gold standard for UC surgery
The most conservative approach for elective surgery is a 3-stage procedure:
Total colectomy with end ileostomy
Construction of IPAA with completion of proctectomy and temporary diverting loop ileostomy
Ileostomy closure
In a 2-stage approach, the first stage is:
Total proctocolectomy (TPC) with IPAA and
temporary diverting loop ileostomy
2. Ileostomy closure

7. SURGICAL MANAGEMENT OF UC
Single-stage IPAA may be performed in only very carefully
selected cases:
patients who are not on immunomodulator or biologic therapy
on minimal to no steroids
are not obese and otherwise with favorable body habitus
are without other nutritional derangements or anemia
Clearly single-stage surgery is feasible but is associated with a
higher risk of major complications such as anastomotic dehiscence,
sepsis and late pouch failure (Brown et al, Z Gastroenterol , 2012 )
Advances such as the double-stapled IPAA have been
incorporated into paediatric practice with considerable
reduction in operating time when compared with
traditional hand-sewn IPAA (Annals of Surgery, 2006 )

8. + ILEOSTOMY

9. IPAA offers a definitive cure for the colonic manifestations of UC
without need for permanent ileostomy in the majority,
with pouch survival of > 90% at 20 years (Baillie et al. 2015)
However, IPAA is associated with a high surgical complication rate, mainly related to the pouch:
Alexander F et al. (J Pediatr Surg, 2009 ) reported that one fifth of patients will have at least one complication in the first month after surgery:
Pouchitis (48%)
Chronic refractory pouchitis (7%)
Pouch failure (9%)
In another pediatric series (Koivusalo et al, J Pediatr Surg 2013) the complication rate was as high as 21/37 (57%):
Pouchitis (62%)
Intestinal obstruction (48%)
Recurrent pouchitis (35%)
Pelvic abscess/sepsis (10,8%)
Pouch prolapse (2,7%)
Wound complications (16,2%)
There is very little experience in the paediatric surgical literature of revision pouch surgery which is a further strong argument for close links with high case load adult specialist units
Smith NP, J Pediatr Surg 2007

10. OUTCOME OF SURGERY FOR UC
QoL after surgery was improved or maintained and generally stable over time, consistent with short-term results in children and long-term results in adults
Polites et al. J Pediatr Surg 2015

11. SURGICAL MANAGEMENT OF ULCERATIVE COLITIS
The option of Ileorectal Anastomosis (IRA) for UC is rarely considered in childhood
Potential advantages include:
Reduced stool frequency with improved faecal continence
Improved fertility in females
Reduced likelihood of impaired sexual functioning due to
nerve injury during the pelvic dissection
This has to be balanced with the:
Need for regular endoscopic surveillance
Potential for failure of medical control of the residual disease in the rectum
The ultimate failure rate of IRA for UC is as high as 57% but this does not argue against the procedure in females if time is gained for pregnancy before later restorative proctectomy
Waljee K, Am J Gastrenterol 2011

12. ACUTE SEVERE COLITIS Early introduction of salvage medical therapies
World J Gastroenterol 2012
Early introduction of salvage medical therapies
(cyclosporine, tacrolimus and infliximab) has
reduced the emergency colectomy rate in ASC from
30%-70% to the current 10%- 20% with
concomitant reduction in mortality
Upper limits of normal colonic width in children
with ASC should take age into consideration:
4 cm < 11 years
6 cm in older children
Absolute indicators for surgery in the setting of unresponsive ASC
include perforation and significant haemorrhage
The surgical procedure of choice is colectomy and end ileostomy preserving the rectal stump

13. A- Hand-assisted Laparoscopic Surgery (HALS)
Laparoscopic approaches have therefore increased in prevalence in the population of patients with IBD:
A- Hand-assisted Laparoscopic Surgery (HALS)
B- Laparoscopic-assisted Surgery
C- Laparoscopic «incisionless» surgery

14. ROLE OF MINIMALLY INVASIVE SURGERY
ADVANTAGES
- Small incisions with less pain and improved cosmesis
- More rapid return to full functional status like work and
school
- Adhesion prevention to reduce the risk of adhesive small
bowel obstruction
CONTRAINDICATIONS TO MIS TECHNIQUES IN PATIENTS WITH IBD

15. CD

16. Site involvement in paediatric CD
Terminal ileum and colon (40-60%)
Colonic alone (10-40%)
Proximal small bowel (8-15%)
Entire digestive tract (5-15%)

17. INDICATIONS FOR ELECTIVE SURGERY
Intestinal subocclusion
Internal fistulas
Abdominal abscess or mass
Growth failure
Unsuccessful medical treatment

18. INDICATIONS FOR EMERGENCY SURGERY
Free perforation
Massive bleeding
Toxic megacolon
Bowel obstruction

19. SURGICAL OPTIONS Intestinal resection and primary anastomosis
Strictureplasty
Intestinal diversion

20. SURGICAL MANAGEMENT OF CD
The life time risk of surgery for CD is approximately 80% (Caprilli et al, Gut 2009)
Indications for surgical management of children with CD include:
Failure of medical therapy
Associated extra-intestinal manifestations (especially eye and joint pathology)
Complications of the disease (fistula, obstruction, perforation, abscess formation, and bleeding)
Timely surgical intervention has been demonstrated to improve height velocities in patients refractory to medical therapy (Singh Ranger G, Pediatr Surg Int 2006)
Requirement for surgical resection ranges from 20%-29% at 3 years,
and 34%-50% at 5 years from diagnosis in paediatric practice
World J Gastroenterol 2014

21. STRICTUREPLASTY Repeated resectional surgery in CD is clearly
associated with a risk of short bowel syndrome
Di Abriola GF et al demonstrated that strictureplasty is a good and effective surgical option for sparing bowel length in CD patients with extensive intestinal strictures (J Pediatr Surg 2011)

22. RESECTIONAL SURGERY FOR CD
In accordance with one of the five golden rules
of Alexander-Williams and Haynes:
«resect only symptomatic macroscopic disease»
Children with ileocolic disease (with colonic
involvement proximal to the mid-transverse
colon) are readily managed by right hemicolectomy and primary anastomosis with low associated morbidity
The phenotype associated with left sided
colitis in childhood has been shown to
relapse early following segmental
resection
In this case a subtotal colectomy with
end ileostomy is favoured in children

23. MIS APPROACH IN CD
OPEN
MIS
The small bowel in patients with full-thickness fibrostenotic/inflammatory disease can typically be run during laparoscopy without difficulty, often in high-definition on large monitors (Holder-Murray et al . , Inflamm Bowel Dis 2015)
Primary uncomplicated ileocolic or small bowel CD should not undergo open surgery unless deemed to have an absolute contraindication to MIS
MIS has also to be proven safe for recurrent or fistulizing ileocolic disease

24. SPECIAL SITES - PERIANAL CROHN’S DISEASE (PACD)
Effective management of PACD follow 3 principles:
Prompt drainage of any septic focus
Conservative surgery
Appropriate medical therapy
Most surgeons favor the use of non-cutting setons to
control septic complications from fistulas
Setons are well-tolerated and after drainage of pus
represent the principal adjunctive surgical contribution to medical management
The final application of MIS to patients with IBD is
the palliation of symptoms due to PACD
More complex fistulating disease involving the vagina or
urinary tract is rarely seen in paediatric practice
For these patients, diversion of fecal stream may allow
more optimal conditions for healing

25. PRE-OPERATIVE OPTIMISATION
Risk factors associated with post-operative sepsis include:
Poor nutritional status (albumin < 30 g/L)
Presence of abscess or fistula
Preoperative steroids
Recurrent clinical exacerbations of CD
To date there is little strong evidence supporting delaying surgery to allow for a period of pre-operative hyperalimentation by either enteral or parenteral routes
However medical management of sepsis and percutaneous drainage of intra-abdominal abscesses may reduce post-operative septic complications
Clin Colon Rectal Surg 2007

26. NEW DEVELOPMENTS IN SURGERY IN CHILDREN WITH IBD
Single –incision Laparoscopic Surgery (SILS)
The SILS approach uses only 1 incision through which an
operating platform allows several working instruments in
addition to the laparoscopic camera
It offers improved cosmesis by eliminating several 5- to 12-mm incisions in the abdominal wall as in multiport laparoscopy
The SILS approach has already been used
successfully for colectomy in UC
(Fichera et al, 2011)
Additional long-term studies are needed to clarify the role of this approach in the paediatric population

27. TRANSITIONAL CARE
The separation of adult and paediatric IBD practice may disadvantage children, delaying adaption of innovative treatments and timely transition
Consensus Guidelines , issued jointly by the European Crohn’s and Colitis Organization and the ESPGHAN, state that every adolescent should be included in a transitional care programme which is adapted to fit local paediatric and adult health care models
In addition, within the paediatric setting, adolescents should be encouraged to take increasing responsibility for their treatment and visit the clinic at least once without their parents

28. Int J Colorectal Dis
Adequate management of IBD requires a multidisciplinary team including gastroenterologist, pharmacist, pediatric surgeon, psychiatrics and nutrition therapist; all should be involved for good decision making in that disease spectrum
Key factors for successful outcome are careful patient selection after evaluating the balance between the risk of the disease and the expected surgical complications

29. CONCLUSION -CD CD is a medical disease. The role of surgery:
DOES NOT cure or prevent recurrences
BUT IT CAN BE a life-saving procedure
AND IT CAN HAVE a dramatic effect on improving the patient’s quality of life

30. Conclusions UC Surgery is curative: Total colectomy
Type: J pouch + ileostomia
High incidence of redo surgery
Side effects
IBD Team
Transitional care
Long term follow-up