crohn’s colitis sr brown colorectal surgeon sheffield teaching hospitals

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  • Crohns ColitisSR BrownColorectal SurgeonSheffield Teaching Hospitals

  • BSG guidelinesGut 2004;53(suppl V):v1-v16

  • European Consensus Statement (ECCO)Gut 2006;55(suppl 1):i16-i35

  • ObjectivesDiscussion ofPrimary surgery in localised Ileocaecal diseaseMethod of anastomosisSegmental resectionsStricturoplasty IPAA

  • Primary surgery for localised ileocolic diseaseECCO recommendations Localised ileocaecal Crohns disease with obstructive symptoms can be treated by primary surgery

  • Evidence for early surgeryWhilst medical therapy will bring remission, surgery is almost inevitableSome long term data on results of resectionUp to 50% cured

  • Long term outcomes after ileocaecal resection

  • Evidence against early surgeryMinimal long term data on medical therapy?surgical studies out of dateNo AZA or Infliximab

  • Long term outcome of medical managementBemelman 2001Consecutive severe ileocaecal Crohns1985-1994Follow up 8 years76 patients62% surgery

  • Quality of life NA Scott, LE Hughes Gut 199480 patients who had ileocolic resections questioned wanted op soonerReasonsSevere symptoms 97%Ability to eat properly 86%Feeling well 62%No need for drugs 43%

  • Quality of life Tillinger et al. Dig Dis Sci 199916 patients surveyed prospectivelyHRQOL improved up to 24 months after op.

  • ScenarioYoung malePresumed appendicitisFound to have terminal ileitis

  • OptionsDo nothingAppendicectomy Right hemicolectomy

  • Traditional teachingAppendicectomy if caecum normalIleitis may be YersiniaRemoving appendix reduces future confusionMinimal resection in Crohns due to short bowelConsent

  • Ileocolic resection for acute presentation of crohns diseaseWeston 199636 patients with ?appendicitis found to have ileocaecal Crohns10 surgery5 reoperations26 no surgery/appendicectomy24 reoperations

  • Recommendations ECCO It is up to the judgement of the surgeon whether to resect a terminal ileum affected with Crohns disease found at laparotomy for suspected appendicitis

  • Method of AnastomosisFunctional end-to-end or conventional end-to-endStapled or hand-sewn

  • Factors affecting recurrenceHost related factorsSmoking etcType of CrohnsFistulatingObstructingType of anastomosis

  • What influences recurrence at the anastomosis?Faecal contentIschaemiaSizeTissue 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-analysisRetrospectiveFollow-upNeeds RCT

  • ECCO recommendations There is some evidence that a wide lumen functional end to end anastomosis is the preferred technique

  • Segmental resectionsProctocolectomy versus sphincter preserving surgerySegmental resection versus colectomy and ileorectal anastomosis

  • Proctocolectomy versus sphincter preserving surgeryAdvantages proctocolectomyReduced recurrenceAdvantages segmental resectionLess morbidityNo stoma

  • Indications for proctocolectomyAvoidance 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 colectomyAdvantages segmental resectionPreservation bowel and functionAdvantages total colectomyReduced recurrence

  • Segmental versus total colectomy

  • Segmental versus total colectomy

  • Limitations to meta-analysisRetrospectiveSelection biasPublication bias

  • ECCO recommendationsIf surgery is necessary for localised colonic disease then resection only of the affected part is preferable

  • Stricturoplasty

    Endoscopic Surgical

  • Advantages over resectionPreservation of bowel and function?Improved QOLAvoidance of surgery (endoscopy group)

  • Disadvantages?SafeRecurrenceAdenocarcinoma risk

  • Endoscopic balloon dilatation8 studiesTechnical success >90%Often repeat dilations necessaryAvoidance surgery in 41-72% Complication rate 10% (perforations 8/230)

  • Surgical stricturoplastyRetrospectivePlasty vs resection58 patients (29 vs 35)Surgical recurrence 36% vs 24%Complications16% vs 22%QOL same

  • ECCO statement Endoscopic dilatation of a stenosis in Crohns 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 Crohns

  • Initial data on IPAA for Crohns3 papers (UK,US)Misdiagnosis UC44 patientsPouch excision in 33%Good function in 26 (59%)

  • Panis 199631 patients with CrohnsRectal disease requiring excisionNo perianal diseaseNo small bowel disease71 patients with UCFollow up mean 72 +/-23 months

  • Panis 19966/31 Crohns related complications4 fistulas treated surgically1 abscess 1 crohns pouch recurrence2/31 pouch excision (6%)Function = UC patients

  • Meta-analysis of the literature10 studies3,103 IPAA225 IPAA for Crohns

  • IPAA for CrohnsCrohns IPAAMore strictures (OR 2.12)More pouch failure (32 vs 4.8%)More Urgency (19 vs 11%)More incontinence (19 vs 10%)

  • IPAA for CrohnsNote selection bias9/10 studies identified patients because of complicationsPatients with isolated colonic CrohnsComplication and pouch failure equal

  • ECCO statement At present an IPAA is not recommended in a patient with Crohns colitis

    Crohns r hemi

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