surgical management of IBD - emergency and elective.ppt

surgical management of IBD

1. Surgical Management of Inflammatory
Bowel Disease (Ulcerative Colitis)

2. •Introduction
•Indications
•Pre-op preparation
•Surgery in emergency
•Elective surgical options
•Controversial issues

3. Introduction
•Contiguous inflammation of the colorectal mucosa
•Confined to the mucosal and sub-mucosa and always start
from and involve the rectum
•Disease distribution
–Proctitis / Procto-sigmoiditis –45-50%
–Left-sided colitis –17-40%
–Pan-colitis –15-35%

4. •Clinically manifests as
–Diarrhoea, abdominal pain, fever, weight loss, rectal
bleeding
•Removal of the affected organ is curative –Surgery has
pivotal position

5. Indications
•Failure of medical management
–Symptoms are not controlled
–Development of side effects or complications
•Cancer risk
–Incidence -6%
–Multiple
–Stricture –Harbor dysplasia or cancer

6. •Toxic megacolon
–Incidence -16%
–In pancolitis
–Surgery –15%
•Hemorrhage
–Uncommon -6%-10%
•Perforation
–In 2-3% of hospitalized UC pts

7. Pre-op Preparation
–Correcting anemia, fluid depletion, electrolyte and
acid-base disorders, and nutritional deficiencies.
–Many pts require TPN and bowel rest –Eating may
worsen symptoms –Difficult to demonstrate a
significant impact on outcome
.
–Most drugs can be discontinued without sequelae
except corticosteroids
–Infliximab + Cyclosporin vs infliximab alone before
surgery –Combination therapy has increased
morbidity

8. –Three-stage IPAA is the optimal approach for pre-op
combination therapy that includes infliximab
.
–Ostomy site selection by stoma therapist
–Mechanical bowel preparation
•Not necessary
–Antimicrobial prophylaxis

9. Surgery in emergency
•Aim
–Treatment of the fulminant state
–Restoration to previous state of health to perform a
future restorative procedure
•The primary procedure
–Total abdominal colectomy + End ileostomy, + Rectal
stump left behind.
•Avoid pouch formation
–High doses of steroids (> 40 mg/day) and nutritionally
depleted
•Able to discontinue all medications

10. •Preserve ileal branches of the ileo-colic vessels
–For pouch construction
•Not necessary to mobilize the rectum
–Decrease pelvic sepsis and preserve planes
•Remaining recto-sigmoind
–Rectal stump closure -hazardous
–A trans-anal rectal drain –To prevent leakage
–Rectal stump –Diseased
•Distal site of transaction
–Matured mucous fistula
–Buried within the abdominal incision

11. Elective surgery
•Total proctocolectomy + Brooke ileostomy
•Total proctocolectomy + Continent ileostomy
•Abdominal colectomy + Ileorectal anastomosis (IRA)
•Ileal pouch–anal anastomosis (IPAA)

13. •Total proctocolectomy + Brooke ileostomy
–Indications
•Older age
•Distal rectal cancer
•Severely compromised anal function
•Patients preference
–Disadvantages
•Loss of fecal continence
•High incidence of SAIO

14. –Complications
•Delayed healing of the perineal wound
•Sexual complications
•Dyspareunia
–As a result of perineal scarring
•Intestinal obstruction
•Ileostomy related
–Skin irritation
–Stomal stenosis
–Stoma prolapse, and herniation

15. •Total proctocolectomy + Continent ileostomy
–Indications
•Rectal cancer
•Poor anal sphincter function
•Occupations that may preclude frequent visits to the
toilet
•Failed Brooke ileostomy
–Avoid in suspicion of Crohn’s disease

16. –Operative principles
•Excision of a very short segment of terminal ileum
•Exclude CD –Essential
•Aperistaltic reservoir
–Terminal 45–60 cm of the ileum –S-pouch
–A wide plastic tube –Into the pouch for drainage in the
early postoperative period.
–Drainage is achieved by intubating the pouch three
times a day.

17. –Complications
•Pouchitis
–Incidence -25%
–Stasis and overgrowth of anaerobic bacteria
–Increased output, fever, weight loss, stomal bleeding
–Pouchoscopy
–Antibiotics + Continuous pouch drainage.
•Intestinal obstruction
–Incidence -5%
•Fistulas
–Incidence -10%.
–Bowel rest, TPN, continuous pouch drainage

18. •Abdominal colectomy + Ileorectal anastomosis
–Indications
•Indeterminate colitis
•Upper rectal disease
–Rectal compliance remains adequate
–Advantages
•Avoid perineal complications of procto-colectomy
•Minimal sexual dysfunction
•May provide perfect control of feces and flatus
–Disadvantages
•Non achievement of total excision of colorectal mucosa.

19. –Frequency of defecation –Semi-liquid stools 2-5 / day
–Conversion to an IPAA
•Poor rectal compliance
•Persistent proctitis
•Upper rectal cancer

20. –Complications
•Nocturnal defecation
•Cancer risk (in remnant rectum)
–The overall risk -6%
–Most cancers appear 15–20 years after operation.
–Early lesions are not easily identified at
sigmoidoscopy –Semi-annual sigmoidoscopy +
Biopsies

21. •Recurrent or persistent inflammation
–Incidence -20%–45%
–Severe diarrhea, tenesmus, bleeding, urgency
–Topical or systemic therapies / Rectal excision if
non responsive

22. •Ileal pouch–anal anastomosis (IPAA)
–Near total procto-colectomy + Ileal reservoir
–Preservation of anal sphincter
–The original operation –Sir Alan Parks
•Complete stripping of the anal mucosa
–Stapled anastomosis
•Between pouch and anal canal cephalad to the dentate
line –Preservation of anal transition zone
–Topical 5-aminosalicylic acid or steroid enemas –
Minimize rectal mucosal inflammation, facilitate
mucosectomy

23. –Mobilisation of rectum
•Ventrally to the level of the prostate / mid-portion of the
vagina
•Posteriorly, past the end of the coccyx
•Mobilization should be flush with fascia propria
–Minimal damage to autonomic nerves to genitals
–Mucosal stripping
•Perineal approach with Lone Star™ retractor –Good
exposure and minimal damage to the sphincter
mechanism
•Inject diluted epinephrine into the submucosal plane –
Minimize bleeding

24. •Ileal reserviour
–The terminal ileum alignment –J configuration,15–
25 cm lengths of both limbs
•Lengthening manoeuvres
–Apex of the pouch must reach beyond the
symphysis pubis
–Superficial mesenteric incision on the anterior and
posterior aspects along the SMA
–Selective ligation of mesenteric arcades

25. •Double-stapled technique
–Anorectum division 2 cm above the dentate line
using a right-angle linear stapler
–Anvil is tied in to the apex of pouch
–Air insufflation test –To check Integrity of the rectal
staple line
–Transanal placement of circular stapler
–Proximal defunctioning loop ileostomy
–Drain placement in the presacral space
–Sphincter strengthening exercises in Post-op period –
Improve functional results after ileostomy closure

26. –Complications
•Small bowel obstruction
–Incidence –20%
•Pelvic sepsis
–Incidence –5%
–Abscess formation, perineal fistula
–Fever, anal pain, tenesmus, and discharge of pus or
secondary hemorrhage
–CT or MRI –For confirmation
–IV antibiotics -Response within 24–36 hours
–Ongoing sepsis / Organized abscess -Endoanal or
imaging-guided percutaneous drainage

27. •I-A anastomotic stricture
–Incidence –5 –38%
–Anastomotic tension –Leakage, infection
–Prevention
•Full mobilization of the mesentery
•Anchoring the pouch to surrounding tissues
–Repeated dilatations under GA ->50%
–Transanal excision of the stricture + advancement of
pouch distally
–If recognized in contrast studies or DRE before
ileostomy closure then ileostomy closure should be
delayed

28. •Poucho-vaginal fistula
–Incidence –3-16%.
–Injury to the vagina or rectovaginal septum
–Anastomotic dehiscence, pelvic sepsis
–CD
–Vaginal discharge
–Demonstration of fistula on examination
–Confirmed by contrast enema
–Seton placement, diverting ileostomy, drainage of
sepsis + pouch repair

29. •Pouchitis
–Nonspecific inflammation
–Overgrowth of anaerobic bacteria
–Abdominal cramps, fever, pelvic pain, and sudden
increase in stool frequency
–Biopsy –Marked inflammatory infiltrates with
villous atrophy and crypt abscesses
–Antibiotics, probiotics(after resolution of the acute
symptoms), steroid enemas, ileostomy±pouch
excision

30. •Incontinence
–Average number of bowel movements after IPAA –
6 / day
–Major incontinence –Unusual
–Minor incontinence –In 30% of pts
–Good perianal hygiene + Perineal pad
–Bulking agent or antidiarrheal medication –50% pts

31. •Diversion ileostomy
–Integral part of the original procedure.
–Mayo Clinic reported –Omission of a stoma didn’t
significantly increase the complication rate
.
–Omission of ileostomy
•Septic complications and functional results are similar
to results after an ileostomy
•Fewer episodes of intestinal obstruction
•Decrease length of hospital stay

32. –Series at Cleveland Clinic, Florida
•110 pts
•No clinical evidence of leaks with diverting ileostomy
•3 of the 36 patients without an ileostomy had leaks
–Ileostomy complications –20%
•High output of enteric fluid, dehydration, skin irritation,
stoma retraction, stoma prolapse
–Pouch-specific complications (without an ileostomy) –
Repeat laparotomy + fecal diversion

33. –The benefits must be weighed against the morbidity of
an ileostomy –benefits > morbidity
–Avoidance of ileostomy
•Experienced surgeon
•Low-dose prednisone (<20 mg/day)
•No immune-modulating agents
•Uneventful operation

34. •Role of laparoscopy
–Early reports –increased morbidity
–Improved techniques and equipment
•Early and late results are comparable to standard
laparotomy
–Lap assisted vs. open restorative proctocolectomy
•Long-lasting positive impact on body image and
cosmesis
•Particularly for women

35. –Meta-analysis of nine cohort or case-matched series
•966 patients, total abdominal colectomy + end
ileostomy,
•Laparoscopical approach = 42
–Fewer wound infections
–Lower rate of intra-abdominal abscess
–Mean shorter length of hospital stay (mean
difference 3.17 days
–Conversion rate –5.5%

36. –IPAA with minimal access
•Single–port and robotic assisted proctocolectomy with
IPAA
•Significantly fewer incisional, abdominal, and pelvic
adhesions
•Safe, feasible, and effective procedure. (54,55)

37. •IRA vs IPAA
–In < 10% -IRA has been used
–Risk for persistence of symptoms and future malignancy.
–Retrospective analysis of the functional results after IRA
for UC or IC
•86 patients
•Rectum was eventually resected in 46 patients
–Refractory proctitis –28%
–Rectal dysplasia –17%
–Rectal cancer –8%

38. –In minimal rectal involvement
•Not suitable for IPAA, who refuse an ileostomy
•May be suitable for IRA
–Reduce the risk of infertility in women of childbearing
age
–Good choice in whom CD can’t be excluded or for
colitis + advanced colonic malignancy

39. •Shape or size of reservoir
–Initial ileal reservoir –in late 1970s
•Triple-loop S pouch
–S-pouches
•Evacuation problems because of long (5-cm or more)
exit conduit
•Frequently requiring pouch catheterization

40. –Three other configurations
•Double-loop J-pouch
•Quadruple-loop W-pouch
•Lateral isoperistaltic H-pouch

41. Summary
•Indications of surgery in UC
–Disease complication
–Failure and side effects of medical treatment
•Restorative proctocolectomy + IPAA –gold standard for elective
surgical treatment
–Safe, curative, and applicable to most patients
–Morbidity still high
•However, transanal mucosectomy with hand-sewn anastomosis vs
double stapling, diversion versus non-diversion, and the indications
for surgery in indeterminate colitis are still debated and remain
under active investigation.

42. •Individualizing approach should be used to decide mucosectomy
•J pouch is the most common reservoir used worldwide
•Diverting ileostomy can be avoided only in selective group of
patients.
•The laparoscopic approach remains to be further evaluated before it
can be routinely recommended.