IBD SURGERY OR NOT?
Educational Objectives
| The goal of this program is to improve the management of inflammatory bowel disease. After hearing and assimilating
this program, the clinician will be better able to:
|
 | 1. Prescribe the appropriate drug therapy for ulcerative colitis (UC).
|
| 2. Review the indications for endoscopically managing strictures in Crohn’s disease (CD).
|
| 3. Distinguish indeterminate colitis from CD and UC.
|
| 4. Recognize the independent predictors for developing CD.
|
| 5. Discuss ways to optimize operative outcomes in reoperative surgery for CD.
|
Faculty Disclosure
In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the
planning committee to disclose relevant financial relationships within the past 12 months that might create any personal
conflicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes
quality in health care and not a proprietary business or commercial interest. For this program, the faculty and planning
committee reported nothing to disclose.
Acknowledgements
Dr. Mahmoud was recorded at the Kaiser Permanente 4th Annual National Surgical Symposium, held April 2-4,
2008, in Ojai, CA, and sponsored by Kaiser Permanente. Drs. Koltun and Strong were recorded at the 19th Annual International
Colorectal Disease Symposium, held February 14-16, 2008, in Fort Lauderdale, FL, and sponsored by
Cleveland Clinic Florida. Dr. Pemberton was recorded at the 70th Colon and Rectal Surgery: Current Principles and
Practice 2007, held October 24-27, 2007, in Minneapolis, MN, and sponsored by the Division of Colon and Rectal
Surgery at the University of Minnesota Medical School, Colon and Rectal Surgery Associates, Ltd, and the Minnesota
Colon and Rectal Foundation. The Audio-Digest Foundation thanks the speakers and the sponsors for their cooperation
in the production of this program.
| ULCERATIVE COLITIS: IS SURGERY NECESSARY IN THE ERA OF MODERN IMMUNOSUPPRESSION ?—
Najjia Mahmoud, MD, Assistant Professor of Surgery, University of Pennsylvania School of Medicine, Philadelphia
|
| Ulcerative colitis (UC): common (annual incidence 100-250 per 100,000); no sex preference; seen more in younger individuals,
with small second spike in those in their 60s and 70s; total proctocolectomy with J-pouch—standard for
moderate to severe medically unresponsive UC; several variations; total proctocolectomy with ileostomy—viable option
for patients with fecal incontinence, elderly, and very sick patients
|
| Drug therapies: include aminosalicylates, corticosteroids, and immunomodulators (6-mercaptopurine [6-MP]/azathioprine
[AZA], cyclosporine [CsA], and infliximab [Remicade]); most patients have mild disease; aminosalicylates—eg, mesalamine
(eg, Pentasa); ideal for mild disease; corticosteroids—used for moderate to severe disease, particularly flares; not
for long-term inflammation unresponsive to aminosalicylates and lower-rung medical therapy; immunomodulators—6MP/
AZA for long-term maintenance therapy; biologics—eg, infliximab (anti-tumor necrosis factor [TNF] antibody); CsA—not
used in speaker’s institution for short-term stabilization of acute inflammation; first-line drugs for long-term therapy for moderate
and severe UC include 6MP/AZA (usually combined with aminosalicylates) and, increasingly, infliximab or adalimumab
(Humira); corticosteroids not appropriate for long-term maintenance of UC
|
| Relapse rates after diagnosis with UC and Crohn’s disease (CD): within first year, rates similar (≈50% of patients
experience relapse requiring treatment), whether UC or CD; overall cumulative lifetime need for surgery higher in
CD than in UC (≈25%); for most patients, mild colitis maintained for years with relatively few flares or predominantly
proctitis or left-sided colitis; colectomy rates influenced by severity and distribution of disease; patients with pancolitis
more likely (40%) to undergo total proctocolectomy; colectomy rates for severe colitis 64% at 10 yr and nearly linearly
track severity rates; at 3 mo, average colectomy rate 20% in patients with moderate colitis and 46% in those with severe
colitis; looking at 20-yr data, 52% of patients with UC require colectomy if treated with steroids alone (increases with severity
of disease); 60% of patients treated with steroids alone, over lifetime, require total proctocolectomy
|
| Use of 6MP/AZA: immunomodulator; works through complicated pathway involving tissue inhibitors of metalloproteinases
on immune cells; most commonly used in moderate to severe UC for long-term maintenance; effects not seen
until 6 to 8 wk after treatment started; induction therapy or use of medications for salvaging patients with acute colitis in
hospital of no benefit; often used with CsA (for induction therapy), steroids, or infliximab; studies looking at maintenance
unable to show long long-term response rates; no significant difference from placebo; with CsA induction and
AZA maintenance therapy, ≈60% of patients avoid colectomy; study looking at influence of AZA on colectomy rates and
CsA-induced remission at 1, 3, and 7 yr found that patients on AZA consistently able to avoid colectomy; no controlled
trials of oral CsA in UC; side effects include decrease in renal function (independent of creatinine)
|
| ENDOSCOPIC MANAGEMENT OF STRICTURES IN CROHN’S DISEASE: IS IT SUPERIOR TO SURGERY ?—
Walter A. Koltun, MD, Professor of Surgery, Carlino Professor of Inflammatory Bowel Disease, Pennsylvania State University
Medical College, Hershey Medical Center, Hershey, PA
|
| Strictures: complication of CD; due to scarification; inflammatory vs fibrotic strictures (eg, inflammatory strictures best
treated with anti-inflammatory agents, fibrotic strictures unresponsive); symptoms—subtotal bowel obstruction, cramping,
food intolerance (worse with foods with high fiber content), bloating, and borborygmi; ≈20% of CD patients with
small bowel disease develop strictures, and 10% of patients with Crohn’s colitis develop colonic strictures
|
| Management of strictures: surgical resection effective; need for recurrent surgery studied for many years and only
minimal change seen (≈50% at 10 yr; widely variable between patients); potential risk of developing short gut, due to recurrent
and waxing-and-waning nature of CD (therefore, recurrent stricture formation) and need for repeat surgery; endoscopic
balloon strictureplasty—as standard, some studies determine whether colonoscope able to pass through
stricture; for difficult strictures, Seldinger technique used; length of balloon 8 cm (most strictures 2-4 cm in length); multiple
sessions usually required; strictures treated endoscopically—short (<4 cm); straight (defined by pretreatment x-
rays); noncomplex (no associated fistula, no sinus tracking or concern for abscess formation in vicinity); no mass effect
(no concern for possibility of cancer)
|
| Other issues: cancer in stricture—if any concern, perform biopsy and/or resection (instead of strictureplasty); higher
rate in colonic than small bowel strictures; reluctance to perform biopsy on strictures because of fear of perforation; critical
that preoperative enema or contrast study performed; stricture in inlet of pouch—seen in some patients who develop
CD after pouch procedure; effectively managed with balloon dilation; ideal circumstances for balloon dilation—short
stricture; easily reachable by scope; minimal inflammation; noncomplex; no fistula; minimum angulation; no evidence of
cancer; single dominant lesion that presumably relieves patient’s symptoms if dilated; technical failures average 10% to
20%; when technically completed, 5-yr symptom-free success rate ≈50%; complication rate 7% to 15% when calculated
on per-patient basis; multiple separate sessions required for effective long-term management
|
| Alternatives to surgery: in patient with symptomatic discrete ileocolic or other stricture 2 to 4 cm in length, options include
laparoscopic ileocolectomy, laparoscopic stricture resection, or strictureplasty; operative recurrence rate at 10 yr
≈50% (twice as good as that for balloon strictureplasty); major complication (eg, anastomotic leakage, bleeding) rate
≈5%; patient at risk for short gut has diffuse disease involving long segments of bowel and clearly not candidate for balloon
strictureplasty; balloon strictureplasty—indicated in appropriate stricture (2-4 cm in length, noncomplex, nonangulated,
with no sign or suggestion of cancer); patients with multiple previous resections already at risk for short gut and
who subsequently develop short stricture good candidates (surgery relatively contraindicated); appropriate in high-risk
patients with comorbidities that prohibit general anesthesia or major surgery; poor abdominal anatomy (eg, dense adhesions);
patients reluctant to undergo surgery; also appropriate in patients who present acutely with near-total obstruction
temporized with balloon strictureplasty (relieves obstruction acutely and prepares them for more definitive surgery under
elective circumstances); also in ileal pouch-anal anastomosis (IPAA) inlet stricture, in which risk for pouch loss if surgery
performed 40% to 50%
|
| INDETERMINATE COLITIS —Dr. Koltun
|
| Definition: relatively poorly defined; typically, pathognomonic features of CD or UC absent; features—deep ulcerations,
rake-like ulcerations, pseudopolyp formation, and rectal sparing; in some cases, colectomy specimen shows variability
in disease grossly seen extending from rectum to cecum, suggesting unclear diagnosis; when pouch procedure
performed for UC, success rate ≈95%; however, pouch loss (when CD diagnosis and ileal pouch procedure made) 40% to
50%; conservative wisdom that IPAA performed for UC but not for CD; pseudopolyp formation more suggestive of CD
than UC, but distribution of disease suggests UC
|
| Diagnosis: aids—presence of granulomata in specimen (<50%) makes diagnosis of CD; sensitivity and specificity relatively
low with immunohistochemical analysis and nuclear magnetic resonance (NMR) spectroscopy; antineutrophil cytoplasmic
antibodies (ANCA) and anti-Saccharomyces cerevisiae antibodies (ASCA) testing looks at positivity; more
recently, genetic testing considered; ANCA seen in 60% to 70% of patients with UC and in minority of patients with CD;
ASCA seen in 60% to 90% of patients with CD and not seen typically in UC; sensitivity and specificity of ANCA and
ASCA in patients with indeterminate colitis (IC) much less; CARD15 gene—one of ≈20 genes associated with IBD; definitively
associated with CD; plays role in host immunologic response to enteric bacteria; small study found 50% positive
mutation rate in patients with pouchitis vs 10% in patients without pouchitis
|
| IPAA and indeterminate colitis: study from Lahey clinic showed significant increase in stoma and perineal complications
in patients with IC, compared to patients with UC (IC patients incorporated into study before ileal pouch); subsequent
studies show pouch fistulization, pelvic sepsis, and pouch failure higher in patients with IC before undergoing IPAA; despite
complications, patients with functioning pouch still had good quality of life (QOL); overall, IC (when patients with
undiagnosed CD included) has worse prognosis; patients with IC but not CD experience similar function and pouch survival
as patients with UC, but as pouch matures, increasing complications seen (diagnosis of CD critically important); review
of specimen by gastrointestinal pathologist helpful; use all clinical criteria, including patient’s original presentation,
radiologic studies, subsequent biopsies, serum antibody studies, and even genetic testing; cautious counseling for patients
with IC; small increased risk for pouch loss and perineal complications (may require reinstitution of immunosuppressive
therapy); if evidence of CD present, risk for pouch loss relatively high
|
| CROHN’S COLITIS —Scott A. Strong, MD, Staff Colorectal Surgeon, Department of Colorectal Surgery, Division of Surgery,
Cleveland Clinic, Cleveland, OH
|
| Pelvic pouch surgery for CD: apprehension due to higher-than-acceptable incidence of perioperative morbidity, poor
function, and significant increase in pouch loss; ensure that there are no clues or hints of CD to prevent worry about performing
pouch operation on patient with IBD in presence of unsuspected CD
|
| Speaker’s recommendations: obtain thorough history of previous anal and perineal disease and family history of CD
and UC; thorough physical examination in office setting of anal canal, with digital examination and anoscopy; perineum
also examined for signs of undiagnosed CD; review endoscopy reports and obtain outside pathology slides for review by
in-house pathologist for any suggestion of CD; in selected cases, review previous small bowel studies or repeat if necessary;
possible role for serologic testing for IBD; consider examination under anesthesia (EUA) if any suspicion of CD;
Cedars-Sinai study— found 2 independent predictors (family history and ASCA-positivity) for development of CD; if
neither factor present, likelihood 4% (if one factor present, 16%; if both factors present, likelihood ≈66%)
|
| Ileal pouch–anal anastomosis: study—in speaker’s institution, looked at 49 patients with IPAA who were subsequently
diagnosed with CD based on specimen; with median follow-up of almost 4 yr, 20% of patients developed symptoms
of CD (average time ≈3 yr after IPAA); pouch failure in 8%
|
| Pouch–rectal anastomosis: in speaker’s experience, disease recurs in two-thirds of patients (minority of whom have
pouch as location of recurrence); after almost 8 yr, pouch failure seen in 9% of patients; no difference in functional outcome
(ie, number of stools per 24 hr, urgency, and incontinence) between those who had pouch-rectal anastomosis and
those who had conventional ileorectal anastomosis for CD; however, those with pouch-rectal anastomosis more likely to
suffer from nocturnal seepage and pad usage, compared to those with conventional ileoproctostomy with anastomosis at
upper rectum; no difference between 2 procedures in perceived QOL
|
| REOPERATIVE SURGERY FOR CROHN’S DISEASE —John H. Pemberton, MD, Professor of Surgery, Mayo Clinic
College of Medicine, Rochester, MN
|
| Surgery for CD: not curative but relieves symptoms and mitigates complications; maximum medical therapy primary
treatment; study showed >60% cumulative incidence of risk for any operation in patient with CD; good likelihood of reoperation
|
| Characteristics of recurrent disease: in studies, 73% of patients with ileotransverse colostomies had anastomotic
recurrence, 20% to 40% (varied by study) required reoperation; risk for reoperation by site of disease—terminal ileal
or colonic disease (risk 1.5%-2%/yr); disease in small bowel and colon (risk 4%-5%/yr); stapled ileocolostomies have
lower rates of recurrence and fewer reoperations; meta-analysis found significantly fewer leaks and shorter hospital stays
with double-stapled ileocolostomies; microscopic involvement at margin does not increase risk for recurrence; after strictureplasty,
disease “quiets”; rationale for strictureplasty that removal of all disease not necessary, and if only stenotic
complications present, relief possible without removing bowel; in study of 700 strictureplasties in 160 patients, no septic
complications and zero mortality; reoperation in patients with CD after strictureplasty almost never due to strictureplasty;
role of AZA, 6-MP, and infliximab in mitigating recurrence unclear; fistulas—speaker’s approach to drain collections
and aggressively attempt to quiet disease; with bowel rest, total parenteral nutrition, immunosuppressants, and infliximab,
70% closure of fistulas achieved; although closures not permanent, disease mitigated; ileoanal anastomosis in
CD—immunosuppressive and biologic agents able to manage patients with CD, supervening in pouch years after ileoanal
anastomosis performed for UC; speaker’s opinion that ileoanal anastomosis should not be performed in patients with
CD diagnosed previously
|
| Optimizing operative outcomes: visualize site of disease in GI tract via computed tomography (CT) enterography
and fistulography to determine complex nature of intra-abdominal abscesses; in first operation for CD, important to measure
exact amount of small bowel remaining; speaker has had good experience with bioresorbable hyaluronate-carboxymethylcellulose
membrane (Seprafilm); he recommends use of laparoscopic techniques to minimize adhesive
problems postoperatively, and for resultant shorter length of stay, decreased morbidity, better appearance of abdomen,
and decreased rate of small bowel obstruction; pearls for reoperation—use ureteral stents liberally; staple ileal colostomy
side to side
|
| Anal CD: minimal surgery, with maximal medical management; 50% of patients with CD experience perineal component;
fistulas difficult to manage and tracts complex because of previous surgeries; therefore, determination of anatomy
important (best method combination of intra-anal ultrasonography [US] and EUA; magnetic resonance imaging also increasingly
used); from Mayo Clinic data, US and EUA able to delineate tracts in perineum with greatest accuracy; setons
used to control sepsis and keep tracts drained; infliximab (Remicade) used; with treatment, perineal component of disease
resolves in ≈50% of patients, and all improve symptomatically; rectal component of CD controlled medically; use of diversion
and AZA and infliximab possibly new treatment for severe (preproctectomy) involvement of anus in CD;
fistulas—if superficial and simple, open fistula and give short course of antibiotics, then observe; almost all fistulas
complex, with many having active rectal disease; noncutting setons placed and patients aggressively managed with first-
line therapy (antibiotics, AZA, and 6-MP, with or without infliximab); drugs maintained if quiescence obtained; if not,
substitute CsA for infliximab; if medical therapy fails, disease not controllable, and patient incontinent, proctectomy indicated;
if extensive fistulas and abscesses present, risk for proctectomy 26%, compared to 6% if problem simple; risk
higher if severe proctitis present (if both present, risk almost 50%)
|
Suggested Reading
Albert JG et al: Diagnosis of small bowel Crohn's disease: prospective comparison of capsule endoscopy with magnetic resonance
imaging and fluoroscopic enteroclysis. Gut 54:1721, 2005; Crawford NP et al: CARD15 genotype-phenotype relationships
in a small inflammatory bowel disease population with severe disease affection status. Dig Dis Sci 52:2716, 2007;
Ferrante M et al: New serological markers in inflammatory bowel disease are associated with complicated disease behaviour.
Gut 56:1394, 2007; Hahnloser D et al: Results at up to 20 years after ileal pouch-anal anastomosis for chronic ulcerative colitis.
Br J Surg 94:333, 2007; Lawes DA et al: Avoidance of laparotomy for recurrent disease is a long-term benefit of laparoscopic
resection for Crohn's disease. Br J Surg 93:607, 2006; Meyer AM et al: Relapse of inflammatory bowel disease
associated with use of nonsteroidal anti-inflammatory drugs. Dig Dis Sci 51:168, 2006; Moorthy K et al: Factors that predict
conversion in patients undergoing laparoscopic surgery for Crohn's disease. Am J Surg 187:47, 2004; Parente F et al: Oral
contrast enhanced bowel ultrasonography in the assessment of small intestine Crohn's disease. A prospective comparison with conventional
ultrasound, x ray studies, and ileocolonoscopy. Gut 53:1652, 2004; Polle SW et al: Recurrence after segmental resection
for colonic Crohn's disease. Br J Surg 92:1143, 2005; Sandborn WJ et al: Adalimumab for maintenance treatment of
Crohn's disease: results of the CLASSIC II trial. Gut 56:1232, 2007; Sands BE et al: Infliximab maintenance therapy for fistulizing
Crohn's disease. N Engl J Med 350:876, 2004; Scarpa M et al: Quality of life after restorative proctocolectomy for ulcerative
colitis: different questionnaires lead to different interpretations. Arch Surg 142:158, 2007; Shapiro M et al: Surgical
management and outcomes of patients with duodenal Crohn's disease. J Am Coll Surg 207:36, 2008; Sprung D: The risk of colorectal
cancer in ulcerative colitis in a population-based setting. Gastroenterology 131:684; author reply 684, 2006.
|
