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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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    1. Surgery for Inflammatory Bowel disease E .Condon Beaumont Hospital/ RCSI, Dublin. Colorectal Department Colorectal Surgery Department

    2. Overview Types • Diverticular disease • Ulcerative colitis • Crohns Disease • Ischemic colitis • Amoebiasis • Pseudomembranous colitis • Radiation enterocolitis Colorectal Surgery Department

    3. 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

    4. Presentations • Acute diverticulitis • Chronic diverticulitis Complications of diverticulitis • Obstruction • Abscess formation • Diffuse peritonitis • Fistula • Haemorrhage Colorectal Surgery Department

    5. Diagnosis • Bloods • CT • Barium • Colonoscopy Colorectal Surgery Department

    6. Indications for surgery • Acute diverticulitis- all complications except abscess • Chronic diverticulitis – Persistent Pain /anemia • 2 episodes of mild diveriticulitis Colorectal Surgery Department

    7. Surgical options • Laparoscopy • Sigmoid colectomy • Hartmans • Anterior resection • Transverse colostomy and peritoneal toilet Colorectal Surgery Department

    8. Operating theatre Colorectal Surgery Department

    9. Best operation to Do?? • Sigmoid colectomy • Anterior resection • Hartmans Colorectal Surgery Department

    10. 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

    11. 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

    12. Symptoms • Bloody diarrhoea • Abdominal discomfort • Diagnosis – colonoscopy barium enema • Treatment • Steroids local systemic • NSAIDS • Bowel rest Colorectal Surgery Department

    13. 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

    14. Operating theatre Colorectal Surgery Department

    15. 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

    16. Best Surgery • Pouch 3 stage • Proctocolectomy- permanent ileostomy Colorectal Surgery Department

    17. Pouchs • J Pouchs • Advantages no stoma / continence • Complications • Infertility • Pouchitis • Pouch failure 10 years 18 % • crohns Colorectal Surgery Department

    18. 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

    19. Crohns • Key histological differences • Granulomas • Fibrosis • Full thickness • Fistulas Colorectal Surgery Department

    20. Presentation • Usually regional ileitis • Like appendicitis • Mass RIF • Diarrhoea • Obstruction • Perforation • Fistula • Perianal Crohns • Anemia Colorectal Surgery Department

    21. Indication for Surgery • Surgery nearly always treatment of choice 80-90% of cases ultimately require surgery • Perianal disease and fistulas Colorectal Surgery Department

    22. Operating theatre Colorectal Surgery Department

    23. Surgical options • Regional ileitis • Ileal resection primary reanastomosis • Right Hemicolectomy • Colonic crohns • Panproctocolectomy and permanent ileostomy • Perianal crohns fistulotomy Colorectal Surgery Department

    24. Colorectal Surgery Department

    25. Colorectal Surgery Department

    26. Colorectal Surgery Department

    27. 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

    28. 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

    29. 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

    30. 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

    31. 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

    32. 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

    33. 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

    34. 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

    35. Questions? Good Luck!! Colorectal Surgery Department

    36. 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

    37. 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

    38. PET Scanning Local recurrence at the splenic flexure Colorectal Surgery Department

    39. 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

    40. Virtual Colonoscopy Colorectal Surgery Department

    41. 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

    42. 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

    43. 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

    44. 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

    45. Virtual Colonoscopy Current indications • Frail elderly patients • Occlusive cancer for detection of other lesions • Previous incomplete colonoscopy Colorectal Surgery Department


    47. 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

    48. 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

    49. Transanal Endoscopic Microsurgery Colorectal Surgery Department

    50. Total Mesorectal Excision Colorectal Surgery Department