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• ?surgical studies out of date– No AZA or Infliximab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’