Crohn’s Colitis

1. Crohn’s Colitis SR Brown Colorectal Surgeon Sheffield Teaching Hospitals

2. BSG guidelines Gut 2004;53(suppl V):v1-v16

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

4. Objectives • Discussion of • Primary surgery in localised Ileocaecal disease • Method of anastomosis • Segmental resections • Stricturoplasty • IPAA

5. Primary surgery for localised ileocolic disease • ECCO recommendations ‘ Localised ileocaecal Crohn’s disease with obstructive symptoms can be treated by primary surgery’

6. 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’

7. Long term outcomes after ileocaecal resection

8. Evidence against early surgery • Minimal long term data on medical therapy • ?surgical studies out of date • No AZA or Infliximab

9. Long term outcome of medical management • Bemelman 2001 • Consecutive severe ileocaecal Crohn’s • 1985-1994 • Follow up 8 years • 76 patients • 62% surgery

10. 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%

11. Quality of life Tillinger et al. Dig Dis Sci 1999 • 16 patients surveyed prospectively • HRQOL improved up to 24 months after op.

12. Scenario • Young male • Presumed appendicitis • Found to have terminal ileitis

13. Options • Do nothing • Appendicectomy • Right hemicolectomy

14. 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

15. 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

16. 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’

17. Method of Anastomosis • Functional end-to-end or conventional end-to-end • Stapled or hand-sewn

19. Factors affecting recurrence • Host related factors • Smoking etc • Type of Crohn’s • Fistulating • Obstructing • Type of anastomosis

20. What influences recurrence at the anastomosis? • Faecal content • Ischaemia • Size • Tissue reaction to suture/staples

21. Functional end-to-end versus end-to-end

22. Stapled functional end-to-end versus handsewn end-to-end

23. Problems with meta-analysis • Retrospective • Follow-up • Needs RCT

24. ECCO recommendations ‘ There is some evidence that a wide lumen functional end to end anastomosis is the preferred technique’

25. Segmental resections • Proctocolectomy versus sphincter preserving surgery • Segmental resection versus colectomy and ileorectal anastomosis

26. Proctocolectomy versus sphincter preserving surgery • Advantages proctocolectomy • Reduced recurrence • Advantages segmental resection • Less morbidity • No stoma

27. 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.

28. Segmental or total colectomy • Advantages segmental resection • Preservation bowel and function • Advantages total colectomy • Reduced recurrence

29. Segmental versus total colectomy

30. Segmental versus total colectomy

31. Limitations to meta-analysis • Retrospective • Selection bias • Publication bias

32. ECCO recommendations ‘If surgery is necessary for localised colonic disease then resection only of the affected part is preferable’

33. Stricturoplasty • Endoscopic • Surgical

34. Advantages over resection • Preservation of bowel and function • ?Improved QOL • Avoidance of surgery (endoscopy group)

35. Disadvantages • ?Safe • Recurrence • Adenocarcinoma risk

36. Endoscopic balloon dilatation • 8 studies • Technical success >90% • Often repeat dilations necessary • Avoidance surgery in 41-72% • Complication rate 10% (perforations 8/230)

37. Surgical stricturoplasty • Retrospective • Plasty vs resection • 58 patients (29 vs 35) • Surgical recurrence • 36% vs 24% • Complications • 16% vs 22% • QOL same

38. 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.’

39. IPAA for colonic Crohn’s

40. Initial data on IPAA for Crohn’s • 3 papers (UK,US) • Misdiagnosis UC • 44 patients • Pouch excision in 33% • Good function in 26 (59%)

42. 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

43. 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

44. Meta-analysis of the literature • 10 studies • 3,103 IPAA • 225 IPAA for Crohn’s

45. 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%)

46. 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

47. ECCO statement ‘ At present an IPAA is not recommended in a patient with Crohn’s colitis’