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Surgery in acute colitis timing and technique

Surgery in acute colitis timing and technique. Bruce D George John Radcliffe Hospital. 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

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Surgery in acute colitis timing and technique

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  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. Hardy and Bulmer 1933 95 cases, Birmingham 75% mortality in first year after first presentation History of severe UC

  4. 210 patients, 109 cortisone, 101 placebo 41% vs 16% remission p<0.01 7% vs 24% mortality during first attack

  5. High dose steroids (and cyclosporin) Joint medical and surgical care regular clinical and radiological assessment Total colectomy + ileostomy five day rule Very low mortality The Current Position

  6. Predictors of outcome • Bowel frequency • Pulse>100/min • Max temp >38 • Albumin < 30g/l on day 4 • Mucosal islands on AXR • Toxic dilatation

  7. If on Day 3 : > 8 stools per day or 3-8 stools per day + CRP >45mg/l 85% chance of colectomy Predicting outcome in severe ulcerative colitisTravis et al 1996

  8. The standard Operation • Total colectomy • End ileostomy • Rectal stump

  9. Joint medical and surgical management Early surgery for non-responders Very low mortality Key principles

  10. 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) Colectomy for severe acute colitis(presumed UC)

  11. Major surgical Small bowel obstruction 9 Rectal stump complications 5 Wound 2 Miscellaneous 2 Major medical 5 Total 28% Complications of Acute Colectomy

  12. Further surgery Pouch 57 (70%) Completion proctectomy 13 (16%) No restoration/completion 11 (14%) But that is only the beginning

  13. Unplanned re-admission 40 (49%) Major surgical 41 (51%) Small bowel obstruction 22 (24%) Requiring re-operation 8 (10%) Major medical 10 Mortality 0 Cumulative morbidity in JR series

  14. Alves et al 2003 164 patients Mortality 0.6% (0%) Morbidity 33% (28%) Re-op for SBO 8% (10%) Complications of acute colectomy

  15. Pouch morbidity

  16. 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 Small bowel obstruction

  17. Blame the drugs Operate on fewer patients Make the surgery better How to do better?

  18. Steroids (any dose) 5.54 (1.12-27) <20mg 6.28 (0.97-40) 20-40mg 5.87 (0.9-38) >40mg 18.94 (1.72-207) AZA/6MP (any dose) 1.2 (0.37-3.94) Aberra et al 2003 Odds ratios for major surgical complications of IBD surgery

  19. Does cyclosporin add to surgical morbidity? • Hyde et al DCR 2001 • 44 patients colectomy for severe UC

  20. 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%) Operate on fewer patients

  21. Non-responders Partial responders ?improve on pre-attack therapy ?convert to elective surgery Responders Operate on fewer patients

  22. 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 > day 10 But don’t delay inappropriately

  23. Management of the rectal stump Anti-adhesion strategies Laparoscopic Make the surgery better

  24. Tissue separation Sodium hyaluronate based bioresorbable membranes (Seprafilm) Icodextrin 4% (Adept) Anti-adhesion Strategies

  25. 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% Laparoscopic colectomy for acute severe colitis ? Reduced small bowel adhesions

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

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