Criteria for Surgical Decision Making in Crohn’s Disease Dr Sanjay De Bakshi MS; FRCS (Eng; Edin{ad eundem}) Head of Division of Surgical Gastroenterology.

Criteria for Surgical Decision Makingin Crohn’s Disease

Dr Sanjay De Bakshi MS; FRCS (Eng; Edin{ad eundem})Head of Division of Surgical GastroenterologyCalcutta Medical Research Institute

Crohn’s Disease

• A disease that the knife will not CURE!!

• The Crohn’s Diaries:- “I wake up every

morning wondering if this is the day my journey to lasting remission will end?”

Burril Bernard CrohnDamocles

Recurrence after Surgery

• Post-operative recurrence rates defined by clinical symptoms are:-

• are follows:-YEARS AFTER SURGERY CLINICAL SYMPTOMS

5 years after 17-55%

10 years after 32-76%

15 years after 72-73%

Factors affecting recurrence after surgery for Crohn’s diseaseTakayuki Yamamoto World J Gastroenterol 2005;11(26):3971-3979

Recurrence after Surgery

• Recurrence rates requiring re-operations are:-

YEARS AFTER SURGERY CLINICAL SYMPTOMS

5 years after 11-32%

10 years after 20-44%

15 years after 46-45%

Factors affecting recurrence after surgery for Crohn’s diseaseTakayuki Yamamoto World J Gastroenterol 2005;11(26):3971-3979

Chance of Surgery

• The chance of surgery at 5-year intervals after diagnosis is as follows:-

YEARS AFTER DIAGNOSIS

NO SURGICAL PROCEDURE

1 SURGICAL PROCEDURE

2 SURGICAL PROCEDURE

5 years after diagnosis 51% 37% 12%

10 years after diagnosis 39% 39% 23%

15 years after diagnosis 30% 34% 36%

Jess T, Loftus EV Jr, Harmsen WS, Zinsmeister AR, Tremaine WJ, Melton LJ 3rd, et al. Survival and cause specific mortality in patients with inflammatory bowel disease: a long term outcome study in Olmsted County, Minnesota, 1940-2004. Gut. 2006 Sep. 55(9):1248-54.

Cumulative risk of Recurrence after Surgery

Risk Factors for Surgery and Postoperative Recurrence in Crohn’s DiseaseOlle Bernell, MD, Annika Lapidus, MD, and Göran Hellers, MD Ann Surg. 2000 Jan; 231(1): 38.

Cumulative risk of Recurrence after Surgery

Risk Factors for Surgery and Postoperative Recurrence in Crohn’s DiseaseOlle Bernell, MD, Annika Lapidus, MD, and Göran Hellers, MD Ann Surg. 2000 Jan; 231(1): 38.

Multiple risk factors, both modifiable and disease-related, have been evaluated in an attempt to predict postoperative Crohn's

disease recurrence

STRONGER LEVEL OF EVIDENCEPATIENT FACTOR

• SmokingDISEASE FACTOR• Penetrating disease(?)• Multiple site involvement(?)• Presence of Granulomas(?)TREATMENT FACTOR• History of prior resection

LESS STRONG LEVEL OF EVIDENCE

• Family history of IBD• Age at disease onset• Anatomical site of disease• Type of anastomosis• Nutritional status• Disease extent

Factors affecting recurrence after surgery for Crohn’s disease. Takayuki Yamamoto World J Gastroenterol 2005;11(26):3971-3979Predictors of recurrence of Crohn’s disease after ileocolectomy: A review. Tara M Connelly and Evangelos Messaris World J Gastroenterol. 2014 Oct 21; 20(39)http://www.medscape.com/viewarticle/772973_5

Recommended indications for surgical intervention include the following

• Persistent symptoms despite high-dose corticosteroid therapy

• Treatment-related complications, including intra-abdominal abscesses

• Medically intractable fistulae• Fibrotic strictures with obstructive symptoms• Toxic megacolon• Intractable haemorrhage• Perforation• Cancer

ASCRS Indications for Surgical Management of Crohn Disease (2007)

Operative Indication

Factors for Considering Surgery

Failed medical therapy

•Presence of disease-related symptoms not responsive to medical management; condition demonstrates an inadequate response

•When first- and second-line therapies do not induce remission safely in severe disease

•Before escalating medical therapy in severe or steroid-dependent disease with limited extent (eg, disease with stricturing behavior, patients who have contraindications or risk factors for further medical therapy)

ASCRS Indications for Surgical Management of Crohn Disease (2007)

Operative Indication

Factors for Considering Surgery

Perforation

Presence of symptoms or signs of free perforationImmediate resection of perforated segment (has a relatively high mortality)After small bowel resection or perforation, other procedures can be performed, as needed (eg, end stoma, diverted or nondiverted anastomosis)

When large anteroparietal, interloop, intramesenteric, or retroperitoneal abscesses cannot be or are unsuccessfully managed with antibiotics and percutaneous drainageSurgical drainage in such cases, with or without resection can be performed

Persistent enteric fistulae and symptoms or signs of localized or systemic sepsis despite appropriate medical managementPersistent sepsis warrants excision of the diseased bowel, whether or not an abscess is present (Surgery may be avoided for internal fistulae)

ASCRS Indications for Surgical Management of Crohn Disease (2007)

Operative Indication

Factors for Considering Surgery

Obstruction

Presence of symptomatic strictures in regions not amenable or responsive to medical therapy

Presence of asymptomatic colonic strictures that cannot be adequately surveyed by biopsy or cytology brushing

ASCRS Indications for Surgical Management of Crohn Disease (2007)

Operative Indication

Factors for Considering Surgery

Inflammation

Presence of acute colitis and symptoms or signs of impending or actual perforation (eg, transverse colon distention > 6 cm on abdominal x-ray or persistent gaseous colonic distention indicate toxic megacolon, pneumatosis coli, evolving local peritonitis, multiple organ failure)

Presence of severe or fulminant colitis

Worsening acute colitis or failure to significantly improve despite 48-96 hours of appropriate medical therapy

ASCRS Indications for Surgical Management of Crohn Disease (2007)

Operative Indication

Factors for Considering Surgery

Hemorrhage

Presence of massive haemorrhaging of any origin that •cannot be or fails to be managed with interventional or endoscopic techniques and •occurs in hemodynamically unstable patients

To identify the lesion:-•Mesenteric angiography with embolization•Laparotomy with or without intra operative endoscopy

ASCRS Indications for Surgical Management of Crohn Disease (2007)

Operative Indication

Factors for Considering Surgery

Neoplasia

Presence of chronic Crohn’s disease of the ileocolon or colon (suspicion on endoscopic surveillance)Presence of adenomatous-appearing polyps (excision)

Presence of carcinoma, Dysplasia associated lesion or mass (DALM), high-grade dysplasia, multifocal colonic or rectal low-grade dysplasia (resection)

Presence of chronic Crohn’s of the upper GI region

Cancer risks in Crohn disease patients. K. Hemminki, X. Li, J. Sundquist and K. Sundquist

Annals of Oncology Volume 20, Issue 3Pp. 574-580.

Swedish trial involving21.788 CD patients

ASCRS Indications for Surgical Management of Crohn Disease (2007)

Operative Indication

Factors for Considering Surgery

Growth retardation and Extra Intestinal Manifestations

Presence of significant growth retardation in prepubertal patients despite appropriate medical therapy

Presence of symptomatic dermatologic, oral, ophthalmologic, or joint disorders refractory to medical therapy (resection of diseased intestine)

Montreal classification system• The Montreal revision of the Vienna system is based on the following 3 variables:• Age at diagnosis/ Disease distribution& location/Disease behavior• Age at diagnosis (A) has 3 categories, as follows :

– A1 – ≤ 16 years– A2 – 17-40 years– A3 – > 40 years

• Disease distribution/location (L) has the following 4 categories, 1 of which is a modifier for upper GI involvement:– L1 – Ileal– L2 – Colonic– L3 – Ileocolonic– L4 – Isolated upper GI disease; L4 is a modifier that can be added to L1-L3 when

there is concomitant upper GI involvement• Disease behavior (B) has 1 interim category (B1) and 2 specified categories, with an

additional modifier for perianal diseases (p), as follows :– B1 – Nonstricturing, nonpenetrating; B1p: nonstricturing, nonpenetrating with

perianal involvement– B2 – Stricturing; B2p: stricturing with perianal involvement– B3 – Penetrating; B3p: penetrating with perianal involvement

Complications of Surgery

Possible Use of Predictors for Long- and Short-Term Disease Course in Crohn’s Disease.

MARKER NAME CLINICAL OUTCOME

CLINICAL MARKERS

Young age at onset (Paediatric/<40 years)

Disabling disease, Surgery

Small bowel disease

Perianal disease

Weight loss > 5kg

Steroid needed for first flare at diagnosis

Early immunosuppression and/ biological Rx

Possible Use of Predictors for Long- and Short-Term Disease Course in Crohn’s Disease.

MARKER NAME CLINICAL OUTCOME

ENDOSCOPY MARKERS

Complete or partial mucosal healing (protective) according to CDEIS or SES-CD

Clinical flares, hospitalization, Surgery

CDEIS= Crohns Disease Endoscopic Index of SeveritySES-CD= Simple endoscopic score for Crohns Disease

Rutgeerts Endoscopic ScoreRutgeerts Endoscopic Recurrence Scoring System.

Endoscopic Score Definition

i0 No lesions

i1 ≤5 aphthous lesions

i2>5 aphthous lesions with normal mucosa between the lesions or skip areas of larger lesions or lesions confined to the ileocolonic anastomosis

i3 Diffuse aphthous ileitis with diffusely inflamed mucosa

i1 i2 i3 i4

Recurrence Rates :- 5% 15-20% 40% 90% -at 3 years

Possible Use of Predictors for Long- and Short-Term Disease Course in Crohn’s Disease.

MARKER NAME CLINICAL OUTCOME

BIOMARKERS

LABORATORY MARKERS

Clinical flares, endoscopic activity, Surgery?CRP

ESR

Calprotectin

SEROLOGY MARKERS

ASCA, pANCA, glycans Complicated disease, Surgery

GENETIC MARKERS NOD2/CARD15 Disease location/behavior/Surgery in CD

TPMT (Thiopurine S-methyltransferase) Azathioprine toxicity

Suggested Treatment to prevent Recurrence after Surgery

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