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Colorectal Crohn’s

Colorectal Crohn’s. Dr Vidhyachandra Gandhi DNB (GI Surgery), DNB (Gen Surgery) MNAMS, FSGE Gastrointestinal & HPB Surgeon Pune WORLDCON ISCP 2018. Issues. CD vs ITB Peri operative care (optimization) Surgery – how much is too much ! Type of anastomotic technique / margins

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Colorectal Crohn’s

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  1. Colorectal Crohn’s Dr Vidhyachandra Gandhi DNB (GI Surgery), DNB (Gen Surgery) MNAMS, FSGE Gastrointestinal & HPB Surgeon Pune WORLDCON ISCP 2018

  2. Issues • CD vs ITB • Peri operative care (optimization) • Surgery – how much is too much ! • Type of anastomotic technique / margins • Role of pouches ! • Recurrence • Prevention of recurrence • Extra intestinal manifestations • Surveillance • Colorectal cancer in Crohn's • Perianal problems • Rectovaginal fistula

  3. Crohn's • Small bowel - 30% • Ileocolic – 40% • Colon – 10% Risk – environmental factors, genetic (NOD 2, CARD 15) Surgery – 40-45%

  4. Classification

  5. Ileocolonoscopy & Biopsy Minimum two biopsies from five sites

  6. Pathology – gross & microscopy Fissuring ulceration extending into submucosa Multiple sub mucosal granulomas Creeping of mesenteric fat Thickened messentry Luminal narrowing Skip lesions Apthous ulcers

  7. CD vs ITB Endoscopic features CT scan

  8. Mapping of disease– CT / MRI

  9. Extraintestinal • Ocular – uvietis, episcleritis • Musculoskeletal – arthritis, spondylitis, osteoporosis • Mucocutaneous – erythema nodusum, pyoderma gangrenosum, psoriasis

  10. Grading – Disease activity

  11. CDAI

  12. Definitions • Active disease • Remission • Response • Relapse • Steroid refractory • Steroid dependant • Recurrence • Localized CD • Extensive CD

  13. Competeting concept

  14. Active Crohn’s Disease Mild to Moderate Moderate to Severe Budesonide (9mg/d) 5-ASA Systemic Corticosteroid +/- AZA/6-MP Remission No Remission Remission No Remission Maintenance ASA/6-MP MTX 5-ASA Anti-TNF +/- AZA/6-MP Maintenance 5-ASA or Observation Relapse Relapse No Remission Remission Maintenance Anti-TNF +/- AZA/6-MP Surgery Other Biologics Relapse

  15. Predicting Response • CRP • Fecal calprotectin • Fecal lactoferrin

  16. Indications

  17. Optimization

  18. Optimization

  19. Surgery – Crohn's ColitisSegmental vs Sub total colectomy or TPC Colorectal Dis. 2017 Aug;19(8):e279-e287 A systematic review of segmental vs subtotal colectomy and subtotal colectomy vs total proctocolectomy for colonic Crohn's disease METHOD: The aim of the present study was to evaluate the differences in short-term and long-term outcomes of adult patients with colonic CD who underwent either subtotal colectomy and ileo rectal anastomosis (STC) or segmental colectomy (SC) or total proctocolectomy and end ileostomy (TPC). The study end-points were overall and surgical recurrence, postoperative morbidity and incidence of permanent stoma.

  20. Surgery – Crohn's ColitisSegmental vs Sub total colectomy or TPC Colorectal Dis. 2017 Aug;19(8):e279-e287 Results : 11 studies, 1436 patients (510 STC, 500 SC and 426 TPC) No significant difference between STC and SC in terms of overall and surgical recurrence STC showed a higher risk of overall and surgical recurrence of CD than TPC SC had a higher risk of postoperative complications compared to STC, and STC had a lower risk of complications than TPC . SC resulted in a lower risk of permanent stoma than STC Conclusion : All three procedures were equally effective as treatment options for colonic CD and the choice of operation remains intrinsically dependent on the extent of colonic disease. Lesser the better Avoid stricturoplasty

  21. Do we need to resect the mesentery ? JounralCrohnsColitis.2018 Jan 4. Inclusion of the mesentery in ileocolic resection for Crohn's disease is associated with reduced surgical recurrence RESULTS: Cumulative reoperation rates were 40% and 2.9% in cohorts A and B (p=0.003), respectively. Surgical technique was an independent determinant of outcome (p=0.007). Length of resected intestine was shorter in cohort B, whilst lymph node yield was higher (12.25 ± 13 vs. 2.4 ± 2.9, p=0.002). Advanced mesentericdiseasepredicted increased surgical recurrence (Hazard Ratio 4.7, 95% Confidence Interval: 1.71-13.01, p=0.003). The mesentericdiseaseactivity index correlated with the mucosaldiseaseactivity index (r=0.76, p<0.0001) and theCrohn'sdiseaseactivity index (r=0.70, p<0.0001). The mesentericdiseaseactivity index was significantly worse in smokers and correlated with increases in circulating fibrocytes. CONCLUSIONS: Inclusion of mesentery in ileocolic resection for Crohn's disease is associated with reduced recurrence requiring reoperation

  22. MarginsControversial • Resection of the gross disease • Wide margins / frozen section – not required

  23. Anastomotic technique Stappled side to side vs hand sewn end to end Dig Dis Sci. 2014 Jul;59(7):1544-51. Stapled side-to-side anastomosis might be better than hand sewn end-to-end  anastomosis in ileocolic resection for Crohn's disease: a meta-analysis. He X1 RESULTS: As compared with HEEA, SSSA was superior in terms of overall postoperative complications [odds ratio (OR), 0.54; 95 % confidence interval (CI) 0.32-0.93], anastomotic leak, recurrence and re-operation for recurrence. Postoperative hospital stay, mortality, and complications other than anastomotic leak were comparable. CONCLUSION: Based on the results of our meta-analysis, SSSA would appear to be the preferred procedure after ileocolic resection for CD, with reduced overall postoperative complications, especially anastomotic leak, and a decreased recurrence and re-operation rate.

  24. Stappled side to side vs hand sewn side to side Hepatogastroenterology. 2004 Jul-Aug;51(58):1053-7. Role of stapled and hand-sewn anastomoses in recurrence of Crohn's disease. Scarpa M RESULTS: No statistically significant difference between the three groups was observed in early postoperative follow up. The stapled side-to-side anastomosis group obtained a better symptom-free survival than the stapled end-to-side group . In the stapled and hand-sewn side-to-side groups reoperation rates were significantly lower than in the stapled end-to-side group CONCLUSIONS: A longer follow-up showed a significantly lower incidence of reoperation recurrence in the stapled and hand-sewn side-to-side anastomosis compared to the stapled end-to-side anastomosis group. This result may suggest the configuration of the anastomosis as the key point in the recurrence of anastomotic Crohn's disease.

  25. Open Quarter Colectomy 52 yrs male, smoker, recurrent abdominal pain/ vomiting (1/3/18) Colonoscopy – stricture in the ascending colon/ caecum

  26. Pouches • Very selective / Avoid • High failure rate – 56% • No small bowel / perianal disease

  27. Laparoscopy • A laparoscopic approach is to be preferred for ileocolic resections in Crohn’s disease where appropriate expertise is available. • In more complex cases or recurrent resection, there is insufficient evidence to recommended laparoscopic surgery as the technique of first choice

  28. Laparoscopic Right Hemicolectomy 60 yrs male , K/C/O Crohn's , obstruction (28/2/18)

  29. Surveillance

  30. Colorectal Cancer in Crohn's • Risk – 1-4 % Increased Risk • Dysplasia • Earlier age of diagnosis • Extensive colitis or ileitis • Duration > 10 years • Pseudo polyps • Presence of anal fistula or other penetrating disease • Primary sclerosing cholangitis

  31. Colorectal Cancer in Crohn'sSurgery • Segmental colectomy • Subtotal colectomy • Total Proctocolectomy Recommendations unclear

  32. Recurrence

  33. Predict - recurrence • Smoking • Prior intestinal surgery • Absence of prophylactic treatment • Penetrating disease at index surgery • Perianal location • Granulomas in resection specimen Ileocolonoscopy isgold standard to diagnose recurrence

  34. Risk factors - recurrence

  35. Endoscopic scoring

  36. Set of Rules

  37. Perianal Fistulas

  38. Diagnostic Algorithm Perianal Crohn's

  39. MRI

  40. Rectovaginal Fistulas

  41. Crohn’s with symptomatic Rectovaginal Fistula Active infection and/or Crohn’s No Infection and controlled Crohn’s Consider Seton for 4-6 wks Non cutting seton insertion, antibiotic therapy and Anti-Crohn’s medication Seton >/= 6 wks Transperineal Repair Martius Flap Advancement Flap Well controlled perianal disease & good operative candidate Minimally symptomatic & poor operative candidate Ongoing perianal sepsis or fecal incontinence Definitive Surgical treatment Continue with seton and consider collagen plug Fecal Diversion +/- Proctectomy

  42. Take home … • Aggressive medical therapy, conservative surgery drgandhivv@gmail.com

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