Restorative Proctocolectomy Kangaroo Club Information Day Bruce George

Restorative Proctocolectomy Kangaroo Club Information Day Bruce George Oxford 6 th October 2018 Colorectal

Restorative Proctocolectomy • New developments • Treatment options • Personal reflections and predictions Oxford Colorectal

Restorative Proctocolectomy “New” developments SWORD data: Gradual reduction in pouches per year in UK (425 to 340) Gradual increase in laparoscopic (and TATME) approaches Average length of stay 10. 1 days Re-operation 6%, re-admission 27% Tendency to large volume units, especially outside London 26 surgeons > 15 procedures in 5 yrs 126 surgeons: 1 procedure each Oxford Colorectal

Restorative Proctocolectomy Indications for Surgery in UC • Acute attack • Failure of medical therapy • Risk of malignancy • Growth retardation in childhood Oxford Colorectal

Restorative Proctocolectomy Options: Ileostomy IRA Kock pouch Ileo-anal pouch No surgery Oxford Colorectal

Restorative Proctocolectomy Options: Ileostomy IRA Kock pouch Ileo-anal pouch No surgery Oxford Colorectal

Restorative Proctocolectomy • The only reason to do a pouch is to avoid: Oxford Colorectal

Restorative Proctocolectomy Selection and consent • Certainty of diagnosis – ? Indeterminate – ? Crohn’s • • Steroids/anti-TNF drugs Sphincters Co-morbidity Psychology (coping, anxiety, socialising skills) Oxford Would you do better with an ileostomy? Colorectal

Restorative Proctocolectomy The 4 4 2 rule • 40 • 20 Oxford Colorectal

Restorative Proctocolectomy Ileo-rectal anastomosis in UC • Initially described in 1950’s – Fell into disrepute due to high cancer risk • Recent resurgence of interest – selected patients with: • • Mild proctitis No dysplasia No PSC Compliant with surveillance Only an option in a small proportion of patients Oxford Colorectal

Restorative Proctocolectomy Ileo-rectal anastomosis in UC (compared to pouch) • Lower bowel frequency, better continence • Similar urgency • Less complicated procedure , faster return to normal activities • No (or postponed) pelvic surgery • Better preservation of fertility Oxford • Need for surveillance/cancer risk Colorectal

Restorative Proctocolectomy Continent ileostomy Kock pouch Oxford Colorectal

Restorative Proctocolectomy Kock pouch When IPAA not an option – Poor sphincters/incontinence – Perianal sepsis – Low rectal carcinoma Salvage after IPAA Previous panproctocolectomy and ileostomy FAP Crohn’s colitis with no evidence of small bowel involvement for > 5 years Oxford Colorectal

Restorative Proctocolectomy operative procedure Oxford Colorectal

operative procedure Restorative Proctocolectomy Oxford Colorectal

operative procedure Restorative Proctocolectomy Oxford Colorectal

operative procedure Restorative Proctocolectomy Oxford Colorectal

operative procedure Restorative Proctocolectomy Oxford Colorectal

operative procedure Restorative Proctocolectomy Oxford Colorectal

Restorative Proctocolectomy Kock pouch • Frequent revisions – 15 -60% • Nipple valve dysfunction – 9 -41% • Continence – 61 -95% Oxford Need to be highly motivated and engaged in process Only an option if already has good ileostomy Colorectal

Restorative Proctocolectomy Options: Ileostomy IRA Kock pouch Ileo-anal pouch No surgery Oxford Colorectal

Restorative Proctocolectomy • Future: – More patient involvement • Social media • Decision making • Organisation of services • PROMS Oxford Colorectal