Transcript RESTORATIVE PROCTOCOLECTOMY

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
Obstruction
Fistula/abscess
Colitis
Carcinoma
Anal Disease
Avoid Late Surgery
Postoperative Complications
Fasth
1980
Preoperative
Sepsis
NO
YES
12 %
48%
Lindhagen
1982
22%
45%
Pocard
2000
5%
23%
Hulten 2001
CROHN’S DISEASE
The Cancer Risk
n
fu/y Dys Ca
Swedish study
1655 30*
Gillen 1994
Friedman 2001
281
259
•*20.9 < 30y at onset
•+18.2 extensive colitis
12-35
-20
42(16)
8
5
relative risk
SI
Il/col
LI
1
3.2
5.6
3.4+
The Defunctioned Rectum
25 Patients
Low Hartmann’s Procedure
3 Cases of Cancer
Regular surveillance
Ciccione 2000
CROHN’S COLITIS
Urgent Surgery
Failed medical treatment
Toxic dilatation
Perforation
Bleeding
%
70
20
< 10
< 5
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
ACUTE CROHN’S COLITIS
Choice of Operation
145 Patients
Colectomy + IRA
Proctocolectomy
Colectomy + Ileostomy
Ileostomy alone
47
27
13
10
Keighley 1993
ACUTE SEVERE COLONIC
CROHN’S DISEASE
Initial Colectomy + Ileostomy
Operation Survivors
21
Rectal excision
C + IRA
11
1
No surgery
5
Ileal
resection
3
Colostomy
1
Keighley 1993
COLONIC CROHN’S DISEASE
Main Indications for Elective
Surgery
Severe Local Symptoms
Obstruction
Fistulation
Anorectal disease
Systemic illness
Chronic Proctocolitis
Pouches and Crohn’s Disease
Total Crohn’s Pouch
Cases
Failure(%)
Authors
Year
Mean F/U
Hyman
1991
38
25
32
Grobler
1993
-
20
30
Sagar
1996
-
37
46
Regimbeau 2001
Hartley
2003
Tulchinsky 2003
Total
113
41
7
-
60
25
90
13
46
227
31
Restorative Proctocolectomy
for
Crohn’s Disease
3-5% in large surgical series
Failure up to 50% (cf UC 10%)
Failure increases with time
COLONIC CROHN’S DISEASE
Segmental v Total Colectomy + IRA
Total Colitis
Segmental Colitis
70%
30%
Kornbluth 1999
Segmental v Total Colectomy +IRA
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
CROHN’S DISEASE
Colectomy with IRA
Flint 1977
Buchman 1981
N
37
105
fu(y)
6
8
Ambrose 1984
Goligher1988
Allan 1989
Longo 1992
63
47
63
131
10
15
15
10
Recurrence(%)
41
30
48
49
53
65
Recurrence after Colectomy with IRA
and Total Proctocolectomy
CROHN’S DISEASE
COLECTOMY + IRA
131 Patients
Fu 9.5 y
13 Ileostomy never closed
118
Proctectomy
Further ileal
30
Diversion resection
16
24
No resection
48
Longo 1992
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
PROCTOCOLECTOMY
Indications
Severe Rectal Disease
Cancer
Severe Anal Disease (almost always rectal
involvement present)
Small Bowel Recurrence 20% at 10 y
Perineal Wound
Delayed 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
RESTORATIVE
PROCTOCOLECTOMY
Close Rectal Dissection
with Intersphincteric Anal Removal
Avoids pelvic nerve damage
Not with dysplasia
Not with carcinoma
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