Surgery for inflammatory bowel disease
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Surgery for Inflammatory Bowel disease. E .Condon Beaumont Hospital/ RCSI, Dublin. Colorectal Department. Overview. Types Diverticular disease Ulcerative colitis Crohns Disease Ischemic colitis Amoebiasis Pseudomembranous colitis Radiation enterocolitis. Diverticular disease.

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Surgery for Inflammatory Bowel disease

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Surgery for Inflammatory Bowel disease

E .Condon

Beaumont Hospital/ RCSI, Dublin.

Colorectal Department

Colorectal Surgery Department


Overview

Types

  • Diverticular disease

  • Ulcerative colitis

  • Crohns Disease

  • Ischemic colitis

  • Amoebiasis

  • Pseudomembranous colitis

  • Radiation enterocolitis

Colorectal Surgery Department


Diverticular disease

  • Definition ; Herniation of bowel mucosa through the bowel wall (Blood vessels)

  • Sites sigmoid and descending colon

  • Raised intraluminal pressure

  • Segmental contraction

  • 30% of all patients over 60 in the western world

Colorectal Surgery Department


Presentations

  • Acute diverticulitis

  • Chronic diverticulitis

    Complications of diverticulitis

  • Obstruction

  • Abscess formation

  • Diffuse peritonitis

  • Fistula

  • Haemorrhage

Colorectal Surgery Department


Diagnosis

  • Bloods

  • CT

  • Barium

  • Colonoscopy

Colorectal Surgery Department


Indications for surgery

  • Acute diverticulitis- all complications except abscess

  • Chronic diverticulitis – Persistent Pain /anemia

  • 2 episodes of mild diveriticulitis

Colorectal Surgery Department


Surgical options

  • Laparoscopy

  • Sigmoid colectomy

  • Hartmans

  • Anterior resection

  • Transverse colostomy and peritoneal toilet

Colorectal Surgery Department


Operating theatre

Colorectal Surgery Department


Best operation to Do??

  • Sigmoid colectomy

  • Anterior resection

  • Hartmans

Colorectal Surgery Department


Ulcerative colitis

  • Definition; disease of unknown cause charecterised by non specific and diffuse inflammatory changes of the mucosa of the rectum and the large bowel

  • Causes

  • Infection

  • Allergy

  • Autoimmunity

Colorectal Surgery Department


UC

  • Disease is mucosal

  • Serosa – no serositis

  • Segment usually descending colon

  • Mucosa reddened friable

  • Pseudopolyps

  • Microscopic – inflammatory cellular infiltration of mucosa and the submucosa crypt abscesses dysplasia transmural inflammation

Colorectal Surgery Department


Symptoms

  • Bloody diarrhoea

  • Abdominal discomfort

  • Diagnosis – colonoscopy barium enema

  • Treatment

  • Steroids local systemic

  • NSAIDS

  • Bowel rest

Colorectal Surgery Department


Indications for surgery

  • Relative indications

    • Chronic invalidisim- severe colitis few years chronic ill health anemia

    • Relapsing colitis 2 severe episodes in 3years

    • Persistent steroids – the complications of roids

  • Absolute indications

    • Failure of medical therapy in acute severe attack

    • Perforation

    • Toxic megacolon

Colorectal Surgery Department


Operating theatre

Colorectal Surgery Department


Surgical Options

  • 1. ileostomy

  • 2.Proctocolectomy- permanent ileosotmy

  • 3.Total colectomy- later ileorectal anastomosis

  • 4.Pouch 2 stage / 3 stage

  • 5. Total colectomy with ileostomy

Colorectal Surgery Department


Best Surgery

  • Pouch 3 stage

  • Proctocolectomy- permanent ileostomy

Colorectal Surgery Department


Pouchs

  • J Pouchs

  • Advantages no stoma / continence

  • Complications

  • Infertility

  • Pouchitis

  • Pouch failure 10 years 18 %

  • crohns

Colorectal Surgery Department


Crohns

  • Definition ; regional enteritis granulomatous entercolitis

  • Unknown cause ( toothpaste)

  • Characterised by discontinuous full thickness inflammation anywhere in the GI tract

  • Common sites ileocaecal skip lesions in the ileum and perianal suppuration

Colorectal Surgery Department


Crohns

  • Key histological differences

  • Granulomas

  • Fibrosis

  • Full thickness

  • Fistulas

Colorectal Surgery Department


Presentation

  • Usually regional ileitis

  • Like appendicitis

  • Mass RIF

  • Diarrhoea

  • Obstruction

  • Perforation

  • Fistula

  • Perianal Crohns

  • Anemia

Colorectal Surgery Department


Indication for Surgery

  • Surgery nearly always treatment of choice 80-90% of cases ultimately require surgery

  • Perianal disease and fistulas

Colorectal Surgery Department


Operating theatre

Colorectal Surgery Department


Surgical options

  • Regional ileitis

    • Ileal resection primary reanastomosis

    • Right Hemicolectomy

  • Colonic crohns

    • Panproctocolectomy and permanent ileostomy

    • Perianal crohns fistulotomy

Colorectal Surgery Department


Colorectal Surgery Department


Colorectal Surgery Department


Colorectal Surgery Department


Ischemic colitis

  • Inflammatory response in the colon following an ischemic episodeowing to occlusion or narrowing of the inferior mesenteric artery

  • Causes

    atheroma

    embolism

    surgery/ trauma

    Severity depends on the duration and the patency of the marginal artery

Colorectal Surgery Department


Presentations

  • 2 phases

    • Mucosal gangrene

    • Secondary invasion with organisims which accelerate the gangerenous process

  • Ischemic colitis with gangerene

  • Transient ischemic colitis

  • Stricture

Colorectal Surgery Department


Surgical options

  • Transient ischemic colitis –mesenteric angiogram stenting of affected segment – primary vascular repair

    excision of the affected segment

    Ischemic colitis with gangarene excision total colectomy with permanent ileosotomy 80% mortality

Colorectal Surgery Department


Amoebiasis

  • Entamoeba histolytica

  • Cyst water /faecal oral /sexual

  • Colitis

  • Transmural colitis with perforation

  • Infamatory mass

  • Hepatic abscess

  • Stool exam ct scan -flagyl

  • Perforation -resection

Colorectal Surgery Department


Pseudomembranous colitis

  • C difficile – cephalosporins

  • Diarrhea

  • Bowel rest / flagyl/ vancomycin ORALLY

  • Toxic dilatation > 6 cm impending perforation

  • PFA CT

  • Proctocoletomy end ielostomy

Colorectal Surgery Department


Radiation enteritis

  • Usually SB following therapeutic radiation less common now

  • Diarrhoea /obstruction

  • Ileitis /proctitis

  • Treatment NSAIDS steroid rarely resect except for strictures

Colorectal Surgery Department


General Advise

  • Categorise youre answers

    eg intestinal obstruction

    in the lumen

    outside the lumen

    in the wall

    in medical

    Be logical and organised

Colorectal Surgery Department


Answer questions

  • Definition

  • Pathology

  • Classification

  • Causes

  • Differential diagnosis

  • Symptoms signs

  • Complications S&S of complications

  • Investigations bloods radiology surgical

  • Management medical/ surgical

  • prognosis

Colorectal Surgery Department


Questions?

Good Luck!!

Colorectal Surgery Department


Preoperative MRI

  • Preop MRI scanning allows selection of patients who will benefit from a course of preoperative radiotherapy

  • T3 or T4 primary tumour or node positive patients

lymph node

Colorectal Surgery Department


MRI

  • Main indication in rectal cancer T3 or not T3

  • Every patient with rectal CA should have pre-op MRI to decide whether or not neoadjuvant therapy is indicated

Colorectal Surgery Department


PET Scanning

Local recurrence at the splenic flexure

Colorectal Surgery Department


Current indications for PET Scanning

  • FDG PET is approved detection and localisation of recurrent colorectal cancer in patients with rising CEA levels and indeterminate findings on standard imaging studies

  • Indications may expand in the future but its final role is still to be determined

  • Radilogical imaging modalities in the diagnosis and management of colorectal cancer , Heamatology clinics of north america 202 16;90 875-95

Colorectal Surgery Department


Virtual Colonoscopy

Colorectal Surgery Department


Virtual colonoscopy – how does it work

  • Virtual Colonoscopy is a promising new method for detecting colorectal polyps and cancers. Air is insufflated into a cleansed colon, and high resolution, thinly-collimated spiral CT slices are acquired. The two dimensional slices, as well as the post-processed "fly-through" virtual colonoscopic images, are examined for polyps and tumors.

Colorectal Surgery Department


Virtual Colonoscopy- advantages

  • Advantages of Virtual Colonoscopy Virtual Colonoscopy is minimally invasive, and does not carry the low but real (1 in 1500) risk of perforation associated with Conventional Colonoscopy. It is well tolerated by patients and does not require sedation. It is capable of evaluating the colon upstream from obstructing lesions that prevent passage of an endoscope. Virtual Colonoscopy is significantly less expensive than Conventional Colonoscopy.

Colorectal Surgery Department


Virtual Colonoscopy-Disadvantages

  • The dose of ionizing radiation is less than that of a conventional abdominal CT, and is comparable to obtaining a supine and upright plain film exam of the abdomen.

  • Colonoscopy by CT does not provide the same information as Conventional Colonoscopy. Mucosal detail and color is not visible which limits the characterization of lesions. In addition, the detection of small polyps is inferior

Colorectal Surgery Department


Virtual colonoscopy-disadvantages

  • As with any procedure, including Conventional Colonoscopy, there are no guarantees that all clinically significant growths will be detected. It should be remembered than between 10 and 20% of all polyps, and up to 5% of colon cancers are missed, even on Conventional Colonoscopy.

  • Virtual Colonoscopy (like the Barium Enema) is a diagnostic not therapeutic technique. All patients in whom polyps are identified would need to undergo Conventional Colonoscopy for removal.

Colorectal Surgery Department


Virtual Colonoscopy Current indications

  • Frail elderly patients

  • Occlusive cancer for detection of other lesions

  • Previous incomplete colonoscopy

Colorectal Surgery Department


Surgical Advances

  • LOCAL RESECTION

  • TOTAL MESORECTAL EXCISION(TME)

  • COLOANAL POUCH ANASTOMOSIS

  • LAPAROSCOPIC SURGERY

Colorectal Surgery Department


Local Resection of low rectal tumours

Transanal resection or TEMS (Trans anal endoscopic microsurgery) allows anal sphincter preservation while avoiding the risks of abdominal surgery

- but its oncologic acceptability remains controversial.

  • No randomised trials exist

  • Safe application of this technique requires accurate preoperative staging, careful transanal resection, and meticulous histological examination. Factors that increase the risk of recurrence following local resection include T stage, poor histological grade, lymphovascular invasion, and positive excision margins

Colorectal Surgery Department


Local resection for low rectal tumours

  • Recent meta-analysis indicates that local recurrence occurs in

  • 9.7% of patients (range 0%-24%) of patients with T1 tumors

  • 25% (range 0%-67%) of those with T2 tumors

  • 38% (range 0%-100%) of those with T3 tumors

  • Sengupta S,Tjandra JJ. Local excision of rectal cancer: what is the evidence? Dis Colon Rectum. 2001;44:1345-1361.

Colorectal Surgery Department


Transanal Endoscopic Microsurgery

Colorectal Surgery Department


Total Mesorectal Excision

Colorectal Surgery Department


Total Mesorectal Excision

  • Definition; en bloc resection of the rectum and its enveloping mesentery to the level of the pelvic floor with a negative distal and radial resection margin.

  • reduces the incidence of local recurrence to less than 10% without the use of adjuvant treatment. Martling AL, Holm T, Rutqvist LE, et al.Stockholm Colorectal Cancer Study Group, Basingstoke Bowel Cancer Research Project. Lancet. 2000;356:93-96

Colorectal Surgery Department


Total Mesorectal Excision

Colorectal Surgery Department


Coloanal J pouch

Colorectal Surgery Department


Criteria necessary for successful sphincter preservation in rectal cancer

  • No pre-operative alteration of sphincter mechanism.

  • TME and nerve sparing surgery.

  • No damage to levator ani.

  • Preservation of at least half of the internal sphincter.

  • Low rate of anastomotic leakage.

  • Low rate of pelvic sepsis.

  • Low rate of anastomotic stricture.

  • Allow good bowel function.

Colorectal Surgery Department


How can we improve function?

  • Rectal cancer surgery may result in poor post-operative quality of life in survivors as a result of frequency, urgency and faecal soiling. McDonald et al BJS 1983

  • Postoperative function and continence after low anterior resection are significantly improved by a colonic pouch. Parc et al BJS 1986 Lazorthes et al BJS 1986 Mantyh et al DCR 2001

Colorectal Surgery Department


Coloanal J pouch vs. direct low anastomosis

  • Lower morbidity.

  • Better early function.

  • Improvement of function persists with time.

  • Lazorthes F. et al. Br J Surg 1997

  • Dehni N. et al. Dis Colon Rectum 1998

  • Harris G.J.C. et al. Br J Surg 2001

  • Age not a contra-indication.Dehni N. et al. Am J Surg 1998

Colorectal Surgery Department


Coloanal J pouch: functional results

  • Bowel movements 2.1 per 24 h

  • Continence

    • Perfect or good82%

    • Soiling14%

    • Frequent fecal incontinence 4%

  • Protecting PAD

    • Never71%

    • As a safety11%

    • Needed18%

Colorectal Surgery Department


Coloanal J pouch: functional results

  • Normal discrimination between 95%

  • flatus and stool

  • Urgency 4%

  • Fragmentation of stools21%

  • Suppository or enema20%

  • to elicit evacuation

Colorectal Surgery Department


Conclusion

  • Preoperative radiotherapy is followed by only minor deterioration in post-op anorectal function if colonic pouch anal anastomosis is performed.

  • Reconstructive technique of choice in preoperatively irradiated patients.

transanal

rectal

mucosectomy

exclusion of

anal sphincter

from field of

radiation

Colorectal Surgery Department


Laparoscopic Surgery

*78.9%

*27.2%

*Nair RG et al. British Journal of Surgery 1997;84:1369-98

Colorectal Surgery Department


Laparoscopic colectomy -Essential Questions

Is it safe?

  • Clinically

  • Technically

  • Economically

  • Oncologically

Colorectal Surgery Department


Laparoscopic Colorectal Surgery

  • Early mobilisation

  • Shorter ileus

  • Reduced opiate requirement

  • Lower cardiorespiratory morbidity

  • Reduced hospital stay

  • Cosmetically better

Potential advantages

Colorectal Surgery Department


Laparoscopic Colorectal Surgery

  • Technically demanding

  • Difficult orientation

  • Increased operative time

  • Increased tumour dissemination

  • Increased postoperative morbidity

Potential disadvantages

Colorectal Surgery Department


Patterns of Recurrence and Survival after Laparoscopic and Conventional Resections for Colorectal CarcinomaJohn E Hartley, et al

Annals of Surgery 2001;132:181-186

Colorectal Surgery Department


Methods 3 - Lap. Assisted

Operative Technique

  • “Laparoscopic principles are Open principles”

  • Laparoscopic Mobilisation

  • Intracoporeal vessel division

  • Intra /Extracorporeal bowel division

  • Extracorporeal stapled anastomosis

Colorectal Surgery Department


Results 1 - Demographics

Laparoscopic Open

n5853

Age 70 (51-87) 72 (36-90)

Sex M:F 38:20 42:11

Stage

Dukes A1210

Dukes B1915

Dukes C2221

Dukes D57

Colorectal Surgery Department


Results 2 - Operative

Laparoscopic Open

Operative Time185 (80-330)122 (70-285)*

*p<0.05 Mann Whitney

CONVERSIONS n=20 (34%)


Crude Survival - Kaplan-Meier

1

p=0.6264. Log Rank Test

.8

Probability of Survival

.6

.4

Open

.2

Laparoscopic

0

10

20

30

40

50

60

MONTHS

58

47

40

11

2

Number at risk

2

28

9

53

43


Recurrence

Open Lap. Assisted

Rectal Cancer

n 2728

Local + distant recurrence 21

Local recurrence in isolation 11

Total3 (11.1%) 2 (7.1%)

Wound recurrence(all patients)3 (5.6%) 1 (1.7%)

Colorectal Surgery Department


Recurrence

  • Rectal Cancer

    • Local recurrence 3 of 27 open11.1%

    • 2 of 28 lap. assisted7.1%

  • Wound recurrence

    • Open 3 of 535.6%

    • Lap. assisted1 of 581.7%

Colorectal Surgery Department


Conclusions

  • Oncological outcome at two years is not compromised by an “all-comers” laparoscopic assisted approach

  • Wound recurrence is a feature of both open and laparoscopic surgery for advanced disease

Colorectal Surgery Department


Conclusions - Current status

  • Laparoscopic surgery for cancer is still in the development phase

  • Convincing data that it is safe and new suggestions that survival may be improved

  • Very operator dependant

  • Needs strict control - ongoing audit and supervision.

Colorectal Surgery Department


“The Ongoing Randomized Trials”

COLOR

CLASICC

NIH

BARCELONA

SINGAPORE

? 2003 AD

Colorectal Surgery Department


Single Positive Randomised Trial

  • Laparoscopy-assisted colectomy versus open colectomy for treatment of non-metastatic colon cancer: a randomised trial.

  • Lacy AM et al

  • Lancet 2002 Jun 29;359(9325):2224-9

  • Multicentre trials not yet reported CLASICC etc

Colorectal Surgery Department


Lacy trial continued

  • 219 patients (111 laparoscopic)

  • Improved short term variables and

  • Improved survival in laparoscopic group particularly for Stage III (ie node +ve) cancers

  • Very significant data if can be replicated.

    • Single centre with enthusiast

    • Small numbers

Colorectal Surgery Department


Consensus Statements

  • “The use of laparoscopic surgery in the curative treatment of colorectal cancer remains controversial. However, assuming appropriate adherence to the principles of surgical oncology there appears to be no difference in the adequacy of tumour resection and adjacent lymph nodes. In addition, the short term outcome appears comparable to open surgery in respect of morbidity, mortality and cancer recurrence including wound deposits.”

ACPGBI & AESGBI

Colorectal Surgery Department


Laparoscopic Assisted Colectomy

  • Three port technique

  • Laparoscopic

    • identification of anatomy

    • division of vascular pedicle

    • mobilisation of colon, mesentery and relevant flexure

  • Extracorporeal

    • delivery of specimen

    • determination of margins

    • anastomosis

    • closure of mesenteric defect

  • Colorectal Surgery Department


    Colorectal Surgery Department


    Operating theatre

    Colorectal Surgery Department


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