Transcript Colorectal cancer screening in high risk groups

Crohn’s Colitis
SR Brown
Colorectal Surgeon
Sheffield Teaching Hospitals
BSG guidelines
Gut 2004;53(suppl V):v1-v16
European Consensus Statement
(ECCO)
Gut 2006;55(suppl 1):i16-i35
Objectives
• Discussion of
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Primary surgery in localised Ileocaecal disease
Method of anastomosis
Segmental resections
Stricturoplasty
IPAA
Primary surgery for localised
ileocolic disease
• ECCO recommendations
‘ Localised ileocaecal
Crohn’s disease with
obstructive symptoms
can be treated by
primary surgery’
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’
Long term outcomes after
ileocaecal resection
Study
Graadel
Year Number Follow up Reoperation
(median) (%)
1994 58
18 years 54
Nordgren 1994 136
17 years
45
Weston
1996 10
14 years
50
Kim
1997 181
14 years
31
Landsend 2006 53
24 years
64
Total
17 years
43%
438
Evidence against early surgery
• Minimal long term data on medical therapy
• ?surgical studies out of date
– No AZA or Infliximab
Long term outcome of medical
management
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Bemelman 2001
Consecutive severe ileocaecal Crohn’s
1985-1994
Follow up 8 years
76 patients
62% surgery
Quality of life
NA Scott, LE Hughes Gut 1994
• 80 patients who had ileocolic resections
questioned
• ¾ wanted op sooner
• Reasons
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Severe symptoms –97%
Ability to eat properly –86%
Feeling well – 62%
No need for drugs –43%
Quality of life
Tillinger et al. Dig Dis Sci 1999
• 16 patients surveyed prospectively
• HRQOL improved up to 24 months after op.
Scenario
• Young male
• Presumed appendicitis
• Found to have
terminal ileitis
Options
• Do nothing
• Appendicectomy
• Right hemicolectomy
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
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
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’
Method of Anastomosis
• Functional end-to-end
or conventional endto-end
• Stapled or hand-sewn
Factors affecting recurrence
• Host related factors
– Smoking etc
• Type of Crohn’s
– Fistulating
– Obstructing
• Type of anastomosis
What influences recurrence at the
anastomosis?
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Faecal content
Ischaemia
Size
Tissue reaction to suture/staples
Functional end-to-end versus
end-to-end
Stapled functional end-to-end
versus handsewn end-to-end
Problems with meta-analysis
• Retrospective
• Follow-up
• Needs RCT
ECCO recommendations
‘ There is some evidence that a wide lumen
functional end to end anastomosis is the
preferred technique’
Segmental resections
• Proctocolectomy versus sphincter
preserving surgery
• Segmental resection versus colectomy and
ileorectal anastomosis
Proctocolectomy versus sphincter
preserving surgery
• Advantages
proctocolectomy
– Reduced recurrence
• Advantages segmental
resection
– Less morbidity
– No stoma
QuickTime™ and a
TIFF (Uncompressed) decompressor
are needed to see this picture.
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.
Segmental or total colectomy
• Advantages segmental
resection
– Preservation bowel and
function
• Advantages total
colectomy
– Reduced recurrence
Segmental versus total colectomy
Segmental versus total colectomy
Limitations to meta-analysis
• Retrospective
– Selection bias
• Publication bias
ECCO recommendations
‘If surgery is necessary for localised colonic
disease then resection only of the affected
part is preferable’
Stricturoplasty
• Endoscopic
• Surgical
Advantages over resection
• Preservation of bowel and function
• ?Improved QOL
• Avoidance of surgery (endoscopy group)
Disadvantages
• ?Safe
• Recurrence
• Adenocarcinoma risk
Endoscopic balloon dilatation
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8 studies
Technical success >90%
Often repeat dilations necessary
Avoidance surgery in 41-72%
Complication rate 10% (perforations 8/230)
Surgical stricturoplasty
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Retrospective
Plasty vs resection
58 patients (29 vs 35)
Surgical recurrence
– 36% vs 24%
• Complications
– 16% vs 22%
• QOL same
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.’
IPAA for colonic Crohn’s
QuickTime™ and a
TIFF (Uncompressed) decompressor
are needed to see this picture.
Initial data on IPAA for Crohn’s
• 3 papers (UK,US)
• Misdiagnosis UC
• 44 patients
– Pouch excision in 33%
– Good function in 26
(59%)
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
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
Meta-analysis of the literature
• 10 studies
• 3,103 IPAA
• 225 IPAA for Crohn’s
IPAA for Crohn’s
• Crohn’s IPAA
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More strictures (OR 2.12)
More pouch failure (32 vs 4.8%)
More Urgency (19 vs 11%)
More incontinence (19 vs 10%)
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
ECCO statement
‘ At present an IPAA is not recommended in a
patient with Crohn’s colitis’