Dr Drelichman Surgical Techniques Part 2 Crohns Disease

Dr. Drelichman Surgical Techniques Part 2

Crohn’s Disease Laparoscopic Colectomy - Results: Patient Outcomes Conversion Rate 5. 9%

Laparoscopy for Ileocolic Crohns Prospective Randomized Trial 60 pts Ileo-colic Crohn’s Disease • Results: Incision Morphine bowel function LOS Complications Milsom et al. DCR 2001; 44: 1 -9: Lap Open 5 cm = 3. 0 d 5 d 4 12 cm = 3. 3 d 6 d 8

Multiple strictures

Strictures & Sacculations

Bowel Sparing techniques Strictureplasty for Crohn’s Disease

STRICTUROPLASTY (FINNEY)

Jaboulay Strictureplasty Indication: long stricture

Judd Strictureplasty Indication: fistula site

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

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

Surgery for Ulcerative Colitis

ANATOMIC EXTENT OF ULCERATIVE COLITIS

ENDOSCOPIC SPECTRUM OF SEVERITY

Ulcerative Colitis Symptoms/Signs • 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 • 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

RISK OF COLORECTAL CANCER

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

SURVEILLANCE BIOPSY PROTOCOL

PSEUDOPOLYPS

DALMS IN ULCERATIVE COLITIS

Risk of Cancer associated with Dysplasia • Review of ten prospective studies Probability of cancer • DALM • HGD • LGD 43% 42% 19% Bernstein et al. Lancet 1994

INDICATIONS FOR SURGERY IN ULCERATIVE COLITIS

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

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

SURGICAL OPTIONS IN ULCERATIVE COLITIS

IPAA n n Maintains the normal route of defecation h Increased frequency of stools Avoids permanent ostomy

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

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

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

Post IPAA Quality of Life

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

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

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

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

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