Surgery for Inflammatory Bowel disease

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Surgery for Inflammatory Bowel disease

• E .Condon
• Beaumont Hospital/ RCSI, Dublin.
• Colorectal Department

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Overview

• Types
• Diverticular disease
• Ulcerative colitis
• Crohns Disease
• Ischemic colitis
• Amoebiasis
• Pseudomembranous colitis
• Radiation enterocolitis

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Diverticular disease

• Definition Herniation of bowel mucosa through
  the bowel wall (Blood vessels)
• Sites sigmoid and descending colon
• Raised intraluminal pressure
• Segmental contraction
• 30 of all patients over 60 in the western world

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Presentations

• Acute diverticulitis
• Chronic diverticulitis
• Complications of diverticulitis
• Obstruction
• Abscess formation
• Diffuse peritonitis
• Fistula
• Haemorrhage

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Diagnosis

• Bloods
• CT
• Barium
• Colonoscopy

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Indications for surgery

• Acute diverticulitis- all complications except
  abscess
• Chronic diverticulitis Persistent Pain /anemia
• 2 episodes of mild diveriticulitis

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Surgical options

• Laparoscopy
• Sigmoid colectomy
• Hartmans
• Anterior resection
• Transverse colostomy and peritoneal toilet

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Operating theatre
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Best operation to Do??

• Sigmoid colectomy
• Anterior resection
• Hartmans

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Ulcerative colitis

• Definition disease of unknown cause
  charecterised by non specific and diffuse
  inflammatory changes of the mucosa of the rectum
  and the large bowel
• Causes
• Infection
• Allergy
• Autoimmunity

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UC

• Disease is mucosal
• Serosa no serositis
• Segment usually descending colon
• Mucosa reddened friable
• Pseudopolyps
• Microscopic inflammatory cellular infiltration
  of mucosa and the submucosa crypt abscesses
  dysplasia transmural inflammation

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Symptoms

• Bloody diarrhoea
• Abdominal discomfort
• Diagnosis colonoscopy barium enema
• Treatment
• Steroids local systemic
• NSAIDS
• Bowel rest

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Indications for surgery

• Relative indications
• Chronic invalidisim- severe colitis few years
  chronic ill health anemia
• Relapsing colitis 2 severe episodes in 3years
• Persistent steroids the complications of roids
• Absolute indications
• Failure of medical therapy in acute severe attack
• Perforation
• Toxic megacolon

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Operating theatre
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Surgical Options

• 1. ileostomy
• 2.Proctocolectomy- permanent ileosotmy
• 3.Total colectomy- later ileorectal anastomosis
• 4.Pouch 2 stage / 3 stage
• 5. Total colectomy with ileostomy

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Best Surgery

• Pouch 3 stage
• Proctocolectomy- permanent ileostomy

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Pouchs

• J Pouchs
• Advantages no stoma / continence
• Complications
• Infertility
• Pouchitis
• Pouch failure 10 years 18
• crohns

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Crohns

• Definition regional enteritis granulomatous
  entercolitis
• Unknown cause ( toothpaste)
• Characterised by discontinuous full thickness
  inflammation anywhere in the GI tract
• Common sites ileocaecal skip lesions in the
  ileum and perianal suppuration

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Crohns

• Key histological differences
• Granulomas
• Fibrosis
• Full thickness
• Fistulas

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Presentation

• Usually regional ileitis
• Like appendicitis
• Mass RIF
• Diarrhoea
• Obstruction
• Perforation
• Fistula
• Perianal Crohns
• Anemia

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Indication for Surgery

• Surgery nearly always treatment of choice 80-90
  of cases ultimately require surgery
• Perianal disease and fistulas

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Operating theatre
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Surgical options

• Regional ileitis
• Ileal resection primary reanastomosis
• Right Hemicolectomy
• Colonic crohns
• Panproctocolectomy and permanent ileostomy
• Perianal crohns fistulotomy

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Ischemic colitis

• Inflammatory response in the colon following an
  ischemic episodeowing to occlusion or narrowing
  of the inferior mesenteric artery
• Causes
• atheroma
• embolism
• surgery/ trauma
• Severity depends on the duration and the patency
  of the marginal artery

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Presentations

• 2 phases
• Mucosal gangrene
• Secondary invasion with organisims which
  accelerate the gangerenous process
• Ischemic colitis with gangerene
• Transient ischemic colitis
• Stricture

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Surgical options

• Transient ischemic colitis mesenteric angiogram
  stenting of affected segment primary vascular
  repair
• excision of the affected segment
• Ischemic colitis with gangarene excision total
  colectomy with permanent ileosotomy 80 mortality

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Amoebiasis

• Entamoeba histolytica
• Cyst water /faecal oral /sexual
• Colitis
• Transmural colitis with perforation
• Infamatory mass
• Hepatic abscess
• Stool exam ct scan -flagyl
• Perforation -resection

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Pseudomembranous colitis

• C difficile cephalosporins
• Diarrhea
• Bowel rest / flagyl/ vancomycin ORALLY
• Toxic dilatation gt 6 cm impending perforation
• PFA CT
• Proctocoletomy end ielostomy

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Radiation enteritis

• Usually SB following therapeutic radiation less
  common now
• Diarrhoea /obstruction
• Ileitis /proctitis
• Treatment NSAIDS steroid rarely resect except for
  strictures

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General Advise

• Categorise youre answers
• eg intestinal obstruction
• in the lumen
• outside the lumen
• in the wall
• in medical
• Be logical and organised

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Answer questions

• Definition
• Pathology
• Classification
• Causes
• Differential diagnosis
• Symptoms signs
• Complications SS of complications
• Investigations bloods radiology surgical
• Management medical/ surgical
• prognosis

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Questions?

• Good Luck!!

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Preoperative MRI

• Preop MRI scanning allows selection of patients
  who will benefit from a course of preoperative
  radiotherapy
• T3 or T4 primary tumour or node positive patients

lymph node
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MRI

• Main indication in rectal cancer T3 or not T3
• Every patient with rectal CA should have pre-op
  MRI to decide whether or not neoadjuvant therapy
  is indicated

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PET Scanning
Local recurrence at the splenic flexure
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Current indications for PET Scanning

• FDG PET is approved detection and localisation of
  recurrent colorectal cancer in patients with
  rising CEA levels and indeterminate findings on
  standard imaging studies
• Indications may expand in the future but its
  final role is still to be determined
• Radilogical imaging modalities in the diagnosis
  and management of colorectal cancer , Heamatology
  clinics of north america 202 1690 875-95

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Virtual Colonoscopy
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Virtual colonoscopy how does it work

• Virtual Colonoscopy is a promising new method for
  detecting colorectal polyps and cancers. Air is
  insufflated into a cleansed colon, and high
  resolution, thinly-collimated spiral CT slices
  are acquired. The two dimensional slices, as well
  as the post-processed "fly-through" virtual
  colonoscopic images, are examined for polyps and
  tumors.

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Virtual Colonoscopy- advantages

• Advantages of Virtual Colonoscopy Virtual
  Colonoscopy is minimally invasive, and does not
  carry the low but real (1 in 1500) risk of
  perforation associated with Conventional
  Colonoscopy. It is well tolerated by patients and
  does not require sedation. It is capable of
  evaluating the colon upstream from obstructing
  lesions that prevent passage of an endoscope.
  Virtual Colonoscopy is significantly less
  expensive than Conventional Colonoscopy.

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Virtual Colonoscopy-Disadvantages

• The dose of ionizing radiation is less than that
  of a conventional abdominal CT, and is comparable
  to obtaining a supine and upright plain film exam
  of the abdomen.
• Colonoscopy by CT does not provide the same
  information as Conventional Colonoscopy. Mucosal
  detail and color is not visible which limits the
  characterization of lesions. In addition, the
  detection of small polyps is inferior

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Virtual colonoscopy-disadvantages

• As with any procedure, including Conventional
  Colonoscopy, there are no guarantees that all
  clinically significant growths will be detected.
  It should be remembered than between 10 and 20
  of all polyps, and up to 5 of colon cancers are
  missed, even on Conventional Colonoscopy.
• Virtual Colonoscopy (like the Barium Enema) is a
  diagnostic not therapeutic technique. All
  patients in whom polyps are identified would need
  to undergo Conventional Colonoscopy for removal.

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Virtual Colonoscopy Current indications

• Frail elderly patients
• Occlusive cancer for detection of other lesions
• Previous incomplete colonoscopy

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Surgical Advances

• LOCAL RESECTION
• TOTAL MESORECTAL EXCISION(TME)
• COLOANAL POUCH ANASTOMOSIS
• LAPAROSCOPIC SURGERY

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Local Resection of low rectal tumours

• Transanal resection or TEMS (Trans anal
  endoscopic microsurgery) allows anal sphincter
  preservation while avoiding the risks of
  abdominal surgery
• - but its oncologic acceptability remains
  controversial.
• No randomised trials exist
• Safe application of this technique requires
  accurate preoperative staging, careful transanal
  resection, and meticulous histological
  examination. Factors that increase the risk of
  recurrence following local resection include T
  stage, poor histological grade, lymphovascular
  invasion, and positive excision margins

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Local resection for low rectal tumours

• Recent meta-analysis indicates that local
  recurrence occurs in
• 9.7 of patients (range 0-24) of patients with
  T1 tumors
• 25 (range 0-67) of those with T2 tumors
• 38 (range 0-100) of those with T3 tumors
• Sengupta S,Tjandra JJ. Local excision of rectal
  cancer what is the evidence? Dis Colon Rectum.
  2001441345-1361.

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Transanal Endoscopic Microsurgery
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Total Mesorectal Excision
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Total Mesorectal Excision

• Definition en bloc resection of the rectum and
  its enveloping mesentery to the level of the
  pelvic floor with a negative distal and radial
  resection margin.
• reduces the incidence of local recurrence to less
  than 10 without the use of adjuvant treatment.
  Martling AL, Holm T, Rutqvist LE, et al.
  Stockholm Colorectal Cancer Study Group,
  Basingstoke Bowel Cancer Research Project.
  Lancet. 200035693-96

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Total Mesorectal Excision
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Coloanal J pouch
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Criteria necessary for successful sphincter
preservation in rectal cancer

• No pre-operative alteration of sphincter
  mechanism.
• TME and nerve sparing surgery.
• No damage to levator ani.
• Preservation of at least half of the internal
  sphincter.
• Low rate of anastomotic leakage.
• Low rate of pelvic sepsis.
• Low rate of anastomotic stricture.
• Allow good bowel function.

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How can we improve function?

• Rectal cancer surgery may result in poor
  post-operative quality of life in survivors as a
  result of frequency, urgency and faecal soiling.
  McDonald et al BJS 1983
• Postoperative function and continence after low
  anterior resection are significantly improved by
  a colonic pouch. Parc et al BJS 1986
  Lazorthes et al BJS 1986 Mantyh et al DCR
  2001

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Coloanal J pouch vs. direct low anastomosis

• Lower morbidity.
• Better early function.
• Improvement of function persists with time.
• Lazorthes F. et al. Br J Surg 1997
• Dehni N. et al. Dis Colon Rectum 1998
• Harris G.J.C. et al. Br J Surg 2001
• Age not a contra-indication. Dehni N. et al.
  Am J Surg 1998

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Coloanal J pouch functional results

• Bowel movements 2.1 per 24 h
• Continence
• Perfect or good 82
• Soiling 14
• Frequent fecal incontinence 4
• Protecting PAD
• Never 71
• As a safety 11
• Needed 18

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Coloanal J pouch functional results

• Normal discrimination between 95
• flatus and stool
• Urgency 4
• Fragmentation of stools 21
• Suppository or enema 20
• to elicit evacuation

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Conclusion

• Preoperative radiotherapy is followed by only
  minor deterioration in post-op anorectal function
  if colonic pouch anal anastomosis is performed.
• Reconstructive technique of choice in
  preoperatively irradiated patients.

transanal rectal mucosectomy
exclusion of anal sphincter from field of
radiation
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Laparoscopic Surgery
78.9
27.2
Nair RG et al. British Journal of Surgery
1997841369-98
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Laparoscopic colectomy -Essential Questions

• Is it safe?
• Clinically
• Technically
• Economically
• Oncologically

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Laparoscopic Colorectal Surgery
Potential advantages

• Early mobilisation
• Shorter ileus
• Reduced opiate requirement
• Lower cardiorespiratory morbidity
• Reduced hospital stay
• Cosmetically better

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Laparoscopic Colorectal Surgery
Potential disadvantages

• Technically demanding
• Difficult orientation
• Increased operative time
• Increased tumour dissemination
• Increased postoperative morbidity

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Patterns of Recurrence and Survival after
Laparoscopic and Conventional Resections for
Colorectal CarcinomaJohn E Hartley, et al
Annals of Surgery 2001132181-186
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Methods 3 - Lap. Assisted
Operative Technique

• Laparoscopic principles are Open principles
• Laparoscopic Mobilisation
• Intracoporeal vessel division
• Intra /Extracorporeal bowel division
• Extracorporeal stapled anastomosis

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Results 1 - Demographics

• Laparoscopic Open
• n 58 53
• Age 70 (51-87) 72 (36-90)
• Sex MF 3820 4211
• Stage
• Dukes A 12 10
• Dukes B 19 15
• Dukes C 22 21
• Dukes D 5 7

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Results 2 - Operative

• Laparoscopic Open
• Operative Time 185 (80-330) 122 (70-285)

plt0.05 Mann Whitney
CONVERSIONS n20 (34)
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Crude Survival - Kaplan-Meier
1
p0.6264. Log Rank Test
.8
Probability of Survival
.6
.4
Open
.2
Laparoscopic
0
40
30
20
10
50
60
MONTHS
58

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40
2
11
Number at risk
2
28
9
53
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Recurrence

• Open Lap. Assisted
• Rectal Cancer
• n 27 28
• Local distant recurrence 2 1
• Local recurrence in isolation 1 1
• Total 3 (11.1) 2 (7.1)
• Wound recurrence (all patients) 3 (5.6)
  1 (1.7)

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Recurrence

• Rectal Cancer
• Local recurrence 3 of 27 open 11.1
• 2 of 28 lap. assisted 7.1
• Wound recurrence
• Open 3 of 53 5.6
• Lap. assisted 1 of 58 1.7

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Conclusions

• Oncological outcome at two years is not
  compromised by an all-comers laparoscopic
  assisted approach
• Wound recurrence is a feature of both open and
  laparoscopic surgery for advanced disease

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Conclusions - Current status

• Laparoscopic surgery for cancer is still in the
  development phase
• Convincing data that it is safe and new
  suggestions that survival may be improved
• Very operator dependant
• Needs strict control - ongoing audit and
  supervision.

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The Ongoing Randomized Trials
COLOR
CLASICC
NIH
BARCELONA
SINGAPORE
? 2003 AD
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Single Positive Randomised Trial

• Laparoscopy-assisted colectomy versus open
  colectomy for treatment of non-metastatic colon
  cancer a randomised trial.
• Lacy AM et al
• Lancet 2002 Jun 29359(9325)2224-9
• Multicentre trials not yet reported CLASICC etc

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Lacy trial continued

• 219 patients (111 laparoscopic)
• Improved short term variables and
• Improved survival in laparoscopic group
  particularly for Stage III (ie node ve) cancers
• Very significant data if can be replicated.
• Single centre with enthusiast
• Small numbers

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Consensus Statements

• The use of laparoscopic surgery in the curative
  treatment of colorectal cancer remains
  controversial. However, assuming appropriate
  adherence to the principles of surgical oncology
  there appears to be no difference in the adequacy
  of tumour resection and adjacent lymph nodes.
  In addition, the short term outcome appears
  comparable to open surgery in respect of
  morbidity, mortality and cancer recurrence
  including wound deposits.

ACPGBI AESGBI
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Laparoscopic Assisted Colectomy

• Three port technique
• Laparoscopic
• identification of anatomy
• division of vascular pedicle
• mobilisation of colon, mesentery and relevant
  flexure
• Extracorporeal
• delivery of specimen
• determination of margins
• anastomosis
• closure of mesenteric defect

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Operating theatre