Crohn’s Colitis SR Brown Colorectal Surgeon Sheffield Teaching Hospitals
Jan 09, 2016
Crohn’s Colitis
SR Brown
Colorectal Surgeon
Sheffield Teaching Hospitals
BSG guidelines
Gut 2004;53(suppl V):v1-v16
European Consensus Statement (ECCO)
Gut 2006;55(suppl 1):i16-i35
Objectives
• Discussion of– Primary surgery in localised Ileocaecal disease– Method of anastomosis– Segmental resections– Stricturoplasty – IPAA
Primary surgery for localised ileocolic disease
• ECCO recommendations
‘ Localised ileocaecal Crohn’s disease with obstructive symptoms can be treated by primary surgery’
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’
Long term outcomes after ileocaecal resection
Study Year Number Follow up (median)
Reoperation (%)
Graadel 1994 58 18 years 54
Nordgren 1994 136 17 years 45
Weston 1996 10 14 years 50
Kim 1997 181 14 years 31
Landsend 2006 53 24 years 64
Total 438 17 years 43%
Evidence against early surgery
• Minimal long term data on medical therapy
• ?surgical studies out of date– No AZA or Infliximab
Long term outcome of medical management
• Bemelman 2001
• Consecutive severe ileocaecal Crohn’s
• 1985-1994
• Follow up 8 years
• 76 patients
• 62% surgery
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%
Quality of life Tillinger et al. Dig Dis Sci 1999
• 16 patients surveyed prospectively
• HRQOL improved up to 24 months after op.
Scenario
• Young male• Presumed appendicitis• Found to have
terminal ileitis
Options
• Do nothing
• Appendicectomy
• Right hemicolectomy
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
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
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’
Method of Anastomosis
• Functional end-to-end or conventional end-to-end
• Stapled or hand-sewn
Factors affecting recurrence
• Host related factors– Smoking etc
• Type of Crohn’s– Fistulating– Obstructing
• Type of anastomosis
What influences recurrence at the anastomosis?
• Faecal content
• Ischaemia
• Size
• Tissue reaction to suture/staples
Functional end-to-end versus end-to-end
Stapled functional end-to-end versus handsewn end-to-end
Problems with meta-analysis
• Retrospective
• Follow-up
• Needs RCT
ECCO recommendations
‘ There is some evidence that a wide lumen functional end to end anastomosis is the preferred technique’
Segmental resections
• Proctocolectomy versus sphincter preserving surgery
• Segmental resection versus colectomy and ileorectal anastomosis
Proctocolectomy versus sphincter preserving surgery
• Advantages proctocolectomy– Reduced recurrence
• Advantages segmental resection– Less morbidity
– No stoma
QuickTime™ and aTIFF (Uncompressed) decompressor
are needed to see this picture.
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.
Segmental or total colectomy
• Advantages segmental resection– Preservation bowel and
function
• Advantages total colectomy– Reduced recurrence
Segmental versus total colectomy
Segmental versus total colectomy
Limitations to meta-analysis
• Retrospective– Selection bias
• Publication bias
ECCO recommendations
‘If surgery is necessary for localised colonic disease then resection only of the affected part is preferable’
Stricturoplasty
• Endoscopic • Surgical
Advantages over resection
• Preservation of bowel and function
• ?Improved QOL
• Avoidance of surgery (endoscopy group)
Disadvantages
• ?Safe
• Recurrence
• Adenocarcinoma risk
Endoscopic balloon dilatation
• 8 studies
• Technical success >90%
• Often repeat dilations necessary
• Avoidance surgery in 41-72%
• Complication rate 10% (perforations 8/230)
Surgical stricturoplasty
• Retrospective• Plasty vs resection• 58 patients (29 vs 35)• Surgical recurrence
– 36% vs 24%
• Complications– 16% vs 22%
• QOL same
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.’
IPAA for colonic Crohn’s
QuickTime™ and aTIFF (Uncompressed) decompressor
are needed to see this picture.
Initial data on IPAA for Crohn’s
• 3 papers (UK,US)• Misdiagnosis UC• 44 patients
– Pouch excision in 33%
– Good function in 26 (59%)
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
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
Meta-analysis of the literature
• 10 studies• 3,103 IPAA• 225 IPAA for Crohn’s
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%)
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
ECCO statement
‘ At present an IPAA is not recommended in a patient with Crohn’s colitis’