1 / 25

M62 Course April 7-8 2005 SURGERY for COLONIC CROHN’S DISEASE

M62 Course April 7-8 2005 SURGERY for COLONIC CROHN’S DISEASE. RJ NICHOLLS. Crohn’s Disease Surgery. Indicated for Complications Recurrence Often Long term Relief Minimal Surgery No proven effect of Medical Treatment on Recurrence. CROHN’S DISEASE Indications for Surgery Elective.

indira-cote
Download Presentation

M62 Course April 7-8 2005 SURGERY for COLONIC CROHN’S DISEASE

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. M62 CourseApril 7-8 2005SURGERY forCOLONIC CROHN’S DISEASE RJ NICHOLLS

  2. Crohn’s DiseaseSurgery Indicated for Complications Recurrence Often Long term Relief Minimal Surgery No proven effect of Medical Treatment on Recurrence

  3. CROHN’S DISEASEIndications for SurgeryElective Obstruction Fistula/abscess Colitis Carcinoma Anal Disease

  4. Avoid Late Surgery Postoperative Complications Fasth Lindhagen Pocard 1980 1982 2000 Preoperative Sepsis NO 12 % 22% 5% YES 48% 45% 23% Hulten 2001

  5. CROHN’S DISEASEThe Cancer Risk n fu/y Dys Ca relative risk Swedish study 1655 30* - - SI 1 Il/col 3.2 LI 5.6 Gillen 1994 281 12-35 - 8 3.4+ Friedman 2001 259 -20 42(16) 5 *20.9 < 30y at onset +18.2 extensive colitis

  6. The Defunctioned Rectum 25 Patients Low Hartmann’s Procedure 3 Cases of Cancer Regular surveillance Ciccione 2000

  7. CROHN’S COLITISUrgent Surgery % Failed medical treatment 70 Toxic dilatation 20 Perforation < 10 Bleeding < 5

  8. ACUTE SEVERE COLITIS CROHN’S DISEASE 20-30% of cases 5 Studies 68 patients Medical Treatment Remission 65%(55-94%) Remission maintained 54-69% Kornbluth 1999

  9. ACUTE CROHN’S COLITISChoice of Operation 145 Patients Colectomy + IRA 47 Proctocolectomy 27 Colectomy + Ileostomy 13 Ileostomy alone 10 Keighley 1993

  10. ACUTE SEVERE COLONIC CROHN’S DISEASE Initial Colectomy + Ileostomy Operation Survivors 21 Rectal excision C + IRA 11 1 No surgery Ileal Colostomy 5 resection 1 3 Keighley 1993

  11. COLONIC CROHN’S DISEASE Main Indications for Elective Surgery Severe Local Symptoms Obstruction Fistulation Anorectal disease Systemic illness Chronic Proctocolitis

  12. Pouches and Crohn’s Disease Authors Year Mean F/U Total Crohn’s Pouch Cases Failure(%) Hyman 1991 38 25 32 Grobler 1993 - 20 30 Sagar 1996 - 37 46 Regimbeau 2001 113 41 7 Hartley 2003 - 60 25 Tulchinsky 2003 90 13 46 Total 227 31

  13. Restorative Proctocolectomy for Crohn’s Disease 3-5% in large surgical series Failure up to 50% (cf UC 10%) Failure increases with time

  14. COLONIC CROHN’S DISEASE Segmental v Total Colectomy + IRA Total Colitis 70% Segmental Colitis 30% Kornbluth 1999

  15. Segmental v Total Colectomy +IRA

  16. SEGMENTAL(SC) v TOTAL COLECTOMY + IRA 6 Studies 488 Pt 265 SC 223 IRA Meta-analysis Time to Recurrence Longer after IRA by 4.4 y Fewer Operations After IRA where two segments involved Tekkis et al 2005

  17. CROHN’S DISEASEColectomy with IRA N fu(y) Recurrence(%) Flint 1977 37 6 41 Buchman 1981 105 8 30 Ambrose 198463 10 48 Goligher1988 47 15 49 Allan 1989 63 15 53 Longo 1992 131 10 65

  18. Recurrence after Colectomy with IRA and Total Proctocolectomy

  19. CROHN’S DISEASECOLECTOMY + IRA 131 Patients Fu 9.5 y 13 Ileostomy never closed 118 Proctectomy Further ileal No resection 30 Diversion resection 48 16 24 Longo 1992

  20. Colectomy with IRA Rectal Sparing in 50% of Large Bowel Crohn’s Indicated where two or more segments are involved Recurrence in ~ 50% over 10 years May be possible to re-resect terminal ileal recurrence to avoid permanent stoma

  21. PROCTOCOLECTOMY Indications Severe Rectal Disease Cancer Severe Anal Disease (almost always rectal involvement present) Small Bowel Recurrence 20% at 10 y

  22. Perineal WoundDelayed Healing Incidence 30% or more of patients x3 in pre-existing anal sepsis Leave open in the presence of sepsis Medical management ?value Intensive Nursing

  23. RESTORATIVE PROCTOCOLECTOMY Close Rectal Dissection with Intersphincteric Anal Removal Avoids pelvic nerve damage Not with dysplasia Not with carcinoma

  24. SEVERE ANORECTAL CROHN’S DISEASE SPLIT ILEOSTOMY 29 Patients 36 mo Still defunctioned 15 Proctocolectomy 8 Restoration of Continuity 6 Late deaths 2 Harper 1982

More Related