Surgery in acute colitis timing and technique

1
Surgery in acute colitistiming and technique

• Bruce D George
• John Radcliffe Hospital

2
Acute Severe Colitis

• Truelove and Witts criteria
• Diarrhoea over 6/day
• Macroscopic blood in stool
• and
• Temperature over 37.5 or
• Tachycardia over 90/min or
• Anaemia less than 10.5g/dl or
• ESR over 30mm/hour

3
History of severe UC

• Hardy and Bulmer 1933
• 95 cases, Birmingham
• 75 mortality in first year after first
  presentation

4
210 patients, 109 cortisone, 101 placebo 41 vs
16 remission plt0.01 7 vs 24 mortality
during first attack
5
The Current Position

• High dose steroids (and cyclosporin)
• Joint medical and surgical care
• regular clinical and radiological assessment
• Total colectomy ileostomy
• five day rule
• Very low mortality

6
Predictors of outcome

• Bowel frequency
• Pulsegt100/min
• Max temp gt38
• Albumin lt 30g/l on day 4
• Mucosal islands on AXR
• Toxic dilatation

7
Predicting outcome in severe ulcerative
colitisTravis et al 1996

• If on Day 3
• gt 8 stools per day
• or
• 3-8 stools per day CRP gt45mg/l
• 85 chance of colectomy

8
The standard Operation

• Total colectomy
• End ileostomy
• Rectal stump

9
Key principles

• Joint medical and surgical management
• Early surgery for non-responders
• Very low mortality

10
Colectomy for severe acute colitis(presumed UC)

• John Radcliffe Hospital
• 1994 to 2000
• 81 patients (41 female, 40 male)
• Median age 34 years (range 10-80)
• Median follow-up 5.4 years (range 1.1 to 10)

11
Complications of Acute Colectomy

• Major surgical
• Small bowel obstruction 9
• Rectal stump complications 5
• Wound 2
• Miscellaneous 2
• Major medical 5
• Total 28

12
But that is only the beginning

• Further surgery
• Pouch 57 (70)
• Completion proctectomy 13 (16)
• No restoration/completion 11 (14)

13
Cumulative morbidity in JR series

• Unplanned re-admission 40 (49)
• Major surgical 41 (51)
• Small bowel obstruction 22 (24)
• Requiring re-operation 8 (10)
• Major medical 10
• Mortality 0

14
Complications of acute colectomy

• Alves et al 2003
• 164 patients
• Mortality 0.6 (0)
• Morbidity 33 (28)
• Re-op for SBO 8 (10)

15
Pouch morbidity
16
Small bowel obstruction

• MacLean et al 2002
• 1178 patients undergoing pouch reconstruction
• Median follow-up 8.7 years
• 351 episodes of SBO in 272 patients (23) (24)
• Loop ileostomy identified as risk factor

17
How to do better?

• Blame the drugs
• Operate on fewer patients
• Make the surgery better

18
Odds ratios for major surgical complications of
IBD surgery

• Steroids (any dose) 5.54 (1.12-27)
• lt20mg 6.28 (0.97-40)
• 20-40mg 5.87 (0.9-38)
• gt40mg 18.94 (1.72-207)
• AZA/6MP (any dose) 1.2 (0.37-3.94)
• Aberra et al 2003

19
Does cyclosporin add to surgical morbidity?

• Hyde et al DCR 2001
• 44 patients colectomy for severe UC

20
Operate on fewer patients

• Cyclosporin
• McCormack et al DCR 2002
• 46 patients failed response to 7 days high dose
  steroids
• 14 (30) no effect (colectomy)
• 32 (70) initial response
• Early relapse in 9 (20) colectomy
• Sustained response in 12 (26)

21
Operate on fewer patients

• Non-responders
• Partial responders
• ?improve on pre-attack therapy
• ?convert to elective surgery
• Responders

22
But dont delay inappropriately

• 2001
• British DGH
• 32 episodes in 25 patients (1994-2000)
• Median age 36 years (17-81)
• 6 died (24 mortality)
• 3 post-op, all surgery gt day 10

23
Make the surgery better

• Management of the rectal stump
• Anti-adhesion strategies
• Laparoscopic

24
(No Transcript)
25
Anti-adhesion Strategies

• Tissue separation
• Sodium hyaluronate based bioresorbable membranes
• (Seprafilm)
• Icodextrin 4
• (Adept)

26
Laparoscopic colectomy for acute severe colitis

• Long operating times
• Less pain
• Earlier return of bowel function
• Shorter hospital stay
• Similar morbidity
• Marcello et al (DCR 2001) 16 vs 24
• Bell (Surg Endosc 2002) 33

? Reduced small bowel adhesions
27
Summary

• The current gold standard
• Is it good enough?
• Send fewer patients along surgical path
• Make the surgical path less hazardous