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3. surgery

Inflammatory Bowel Disease (IBD):
Evolution of Surgical Methods
Charles A. Ternent, MD
Associate Clinical Professor of Surgery and
Director Colorectal Surgery Research,
Creighton University School of Medicine,
Omaha Nebraska
IBD: Surgical Treatment
• Indications for Surgery
– Elective
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Intractability
Risk of malignant change
Growth retardation
Local anorectal complications (fissures, abscesses and
fistulas)
• Remote or systemic complications (arthritis, skin
lesions – pyoderma and erythema nodosum, eye
lesions (uveitis, iritis)
IBD: Surgical Treatment
• Indications for Surgery
– Urgent / Emergent
• Deterioration patient’s condition (Fulminant colitis)
• Local abdominal signs suggestive of perforation
• Acute colonic dilatation (Toxic megacolon)
– Surgical approach variable over the decades
• Ileostomy/cecostomy alone 50% mortality (Crile and
Thomas 1951)
• Colectomy and ileostomy (Gardner and Miller 1951)
– Subtotal colectomy and ileostomy recommended
Ulcerative Colitis: Early Surgical
Treatment
– Operations on the Nervous System (Historical
perspective only)
• Schlitt 1951: operative division of the pelvic
autonomic nerves (permanent sexual and bladder
dysfunction)
• Levy 1956: prefrontal lobotomy report in 5 patients
– “Some” improved
Ulcerative Colitis: Early Surgical
Treatment
• Appendicostomy (Keetly 1895)
– Simple procedure intended for very ill colitis
patients
– Appendix brought up through abdominal wall
and catheter passed into cecum and used to
irrigate colon
– Lockhart-Mummery 1934 reported on 79 cases
• 12 deaths, rest “very satisfactory “results but ? cyclical
disease factors
• Use abandoned circa 1940 in favor of ileostomy
Ulcerative Colitis: Early Surgical
Treatment
• Diverting Ileostomy or Cecostomy with
Subsequent Excision of the Large Intestine
(Brown 1913)
– Adopted in US 1920s-1940s (Strauss 1924, Cattell
1935, Lahey 1941). UK 1940s (Ogilvie 1940)
– Rationale: Resting colon to allow quiescence and
possible reversal of stoma
– Cattell 1948 reported ileostomy invariably
permanent and colectomy required due to failure
of recovery or because of cancer risk
Ulcerative Colitis: Early Surgical
Treatment
• Diverting Ileostomy with Excision of the Large
Intestine (Proctocolectomy) in Stages
– Gabriel 1952 reported three-stage procedure in
3-month intervals
• Ileostomy (initially affected bowel left in place)
• Subtotal colectomy with exteriorization sigmoid colon
• Abdominoperineal resection rectosigmoid colon
– Additive morbidity and mortality from serial
operations (not an efficient approach with
present day anesthesia)
Ulcerative Colitis: Early Surgical
Treatment
• Ileostomy with Immediate Subtotal Colectomy
or Proctocolectomy (Miller 1949 and Crile and
Thompson 1951)
– Rationale: Minimize toxicity of septic colon left in
place especially in more toxic cases
– Concern: Increased mortality in toxic patients and
increased morbidity from proctectomy in patients on
high dose steroids and biologic agents
• Toxic/compromised physiology – subtotal colectomy with
ileostomy
• Elective refractory – proctocolectomy with ileostomy
Ulcerative Colitis Early Surgical
Treatment: Colectomy with Ileostomy
Early Studies of
Urgent/Emergent
Colectomy for UC
Mortality
Urgent /
Emergent
Mortality
Elective
N Urgent /
Emergent
Lennard-Jones 1960
31%
4.4%
32
Brooke and Sampson
1964
16%
6%
62
Goligher 1970
14%
3%
184
Ulcerative Colitis: Early Surgical
Treatment
• Techniques of Ileostomy
• Initially ileostomy brought out 5 cm or so
straight and allowed serosal surface to
granulate (no eversion)
• Commonly resulted in fibrosis, stenosis and partial
obstruction or ileostomy dysfunction (Counsell and
Goligher 1952)
• Dragsted 1941 skin grafted serosal surface ileostomy
above skin level – contraction and stenosis still a
problem
Ulcerative Colitis: Early Surgical
Treatment
• Techniques of Stoma Creation
– Patey 1951 advocated immediate suture of stoma
bowel to skin (flat stoma a problem with ileostomy)
– Brooke 1952 adopted immediate mucocutaneous
suture in constructing ileostomies with evertion of
the last 1-2 cm of ileal wall to create projection
(standard of care today)
– Turnball 1953 would strip the terminal ileal portion
of serosa and muscularis before eversion (technically
difficult and without significant advantage)
Ileostomy Appliances
• Incontinent stomas require constant wearing of
an appliance (early on a bag or box)
• Koenig 1944 patient of Strauss in Chicago
developed the adherent ileostomy bag along
with Rutzen
– Water tight and leak resistant arrangement
• Turnbull 1975 introduced karaya gum powder to
minimize leakage
– Paste or wafer has soothing and efficient adhesive
• Stomahesive paste further enhanced stoma care
Ulcerative Colitis: Early Surgical
Treatment
• Continent – Reservoir Ileostomy (Koch 1969
Goteburg, Sweden)
• Internal pouch created out of 45-50 cm of ileum
immediately above stoma
• Continent valve requires intubation through
abdominal wall to evacuate
• No stoma appliance required. Cover with gauze
• Valve can slip and leak and complication and
revision rates high
Ulcerative Colitis: Early Surgical
Treatment
• Diverting Transverse or Left Sided Colostomy
after distal proctocolectomy
– Possible in very distal disease
– High incidence of extending disease to involve
proximal colon
– Staghlgren and Ferguson 1959 reported on 18
patients with this procedure. 11 required
completion colectomy and ileostomy
Ulcerative Colitis: Early Surgical
Treatment
• Colectomy with Ileosigmoid (Lilienthal 1903,
Devine 1943,1948)
– Extraperitoneal technique
– Gabriel 1952 reported that 4/5 required
separation of anastomosis and ileostomy
• Ileorectal Anastomosis (Aylett 1953-1963)
– End to end ileorectal anastomosis with
protecting loop ileostomy for 3 weeks
• FU 1963 N=123, 5% mortality, 13% conversion to
ileostomy
Ulcerative Colitis Early Surgical
Treatment Ileorectal Anastomosis
• Jagelman 1953 Postal inquiry of 200 of Aylett’s patients
• 25% had 6 or more stools per day
• 90% considered surgery successful
• Literature 1954-1977 (Goligher, Wangensteen…)
– 20-50% failure rate requiring ileostomy
– 7/350 patients followed 10-15 years developed carcinoma
– Goligher: reserve for patients with lesser degrees of rectal
involvement who are not interested in rectal excision or stoma
– Currently mainly considered in mild rectal disease,
indeterminate colitis, high risk or older patients not good
candidates for IPAA
Ulcerative Colitis: Early Surgical
Treatment
• Colectomy and Partial Rectal Excision with
Ileoanal Pull-Through (Ravitch 1948)
– Anal mucosectomy and straight ileoanal
anastomosis
– Others found great frequency of defecation and
incontinence (Goligher 1951, Wangenstein 1948)
– 7-8+ BMs per day
– Goligher 1980: More promising proposition
would be an ileoanal reservoir…
Ulcerative Colitis: Modern Surgical
Treatment
• Proctocolectomy with Ileoanal Pouch Anal
Anastomosis (IPAA)
– IPAA and protecting ileostomy
• Ferrari and Fonkalsrud 1978 report of successful
operation
• Parks and Nichols 1978 report of 5 patients with colitis
treated with IPAA with encouraging results
Ulcerative Colitis: Modern Surgical
Treatment
• Quality of life / functional issues: Proctocolectomy
with permanent ileostomy vs IPAA
– IPAA was associated with a significantly better perception
of body image than a permanent stoma
– Quality of life in general was similar in both groups
– Patients with a pouch had more long-term complications
than patients with an ileostomy within the same period
of time (52.6% vs. 26.3%)
– The median number of stages for pouch construction was
two, compared to a median of one stage for an ileostomy
(P<0.0001).
– Counsel thoroughly preoperatively
J Clin Gastroenterol. 2006 Sep;40(8):669-77.
Quality of life after proctocolectomy with ileoanal anastomosis for patients with
ulcerative colitis.Lichtenstein GR1, Cohen R, Yamashita B, Diamond RH
Ulcerative Colitis: Modern Surgical
Treatment
• Restorative Proctocolectomy and IPAA
• One, two or three stages?
– High dose steroids / biologics, urgent/emergent
surgery increase risk of infection (3 stage)
– No high risk of infection (2 stage)
– No steroids or biologics and elective (possible 1
stage in some centers but potential
drawbacks/risks)
Ulcerative Colitis: Modern Surgical
Treatment
• Laparoscopic approaches to Proctocolectomy
with permanent ileostomy and IPAA
• Is there a benefit to minimally invasive
techniques?
– Less blood loss
– Diminished postop pain
– Reduced narcotic requirement
– Shorter hospital stays
Ulcerative Colitis: Modern
Postoperative Issues
• Pouchitis after IPAA for UC
– Most common long-term complication (25%)
– Usually responds to PO antibiotics (Cipro/Flagyl)
– 60% second episode
– 20% chronic pouchitis (chronic maintenance
therapy – combination therapy and Rifaximin)
– Budesonide and Biologics (Infliximab), VSL-3
(probiotic)
– May need pouch revision or excision
Ulcerative Colitis: Modern
Postoperative Issues
• Crohn’s disease (CD) and IPAA: Outcomes
– One of most common long-term inflammatory complications
– Leading cause of pouch failure (10% if CD known preop and
carefully selected / 50% if CD develops postop)
– Treatment
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Topical / oral mesalamine or steroids
Antibiotics
Immunomodulators
Biologics may be considered in refractory disease of IPAA
particularly if extra-intestinal symptoms
• Consider pouch excision - revision
Crohn’s Disease: Early Reports
• Non-specific enteritis descriptions
– Moynahan 1907, Mayo-Robson 1908, Leeds and
Dalziel 1913
– Burrill Crohn NY 1932 established the clinical and
pathologic entity of regional or granulomatous
enteritis
• Anywhere in GI tract
• Skip lesions
Crohn’s Landmark Paper
Crohn’s Disease: Evolution of Surgical
Treatment
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Diverting stoma
Bypass with or without exclusion
Resection with stoma
Resection with anastomosis +/- stoma
Stricturoplasty +/- resection
Radical vs conservative resection of bowel
and mesentery (resect to grossly not
microscopically normal tissue)
Crohn’s Disease: Early Surgical
Treatment
• Bypass with exclusion advocated in mid
1930s (Mount Sinai Hospital, NY)
• President Eisenhower had successful bypass
without exclusion for Crohn’s (Heaton et al
1964)
• Surgical resection popularized with increasing
safety of surgery (Glotzer and Siren 1971)
• Clear indication for bypass operation alone is
duodenal Crohn’s (Fielding et al 1970)
Crohn’s Disease and Fistula-in-Ano
• Fistula Definition
– Abnormal communication/tract between any
two epithelium lined surfaces
– Presence of a rectal or anal internal opening
• Etiology
– Most common result of cryptoglandular
infections
– IBD/Crohn’s, Infectious, Cancer, HIV and other
immunocompromised states
MRI Complex Anterior Fistula-in -Ano
Classification of Anal Fistulas
Anal Fistula in Ancient Greece
Hippocrates (ca. 460-370 BC)
• Aware of anorectal fistulas and tried to interpret
mechanism of origin (first description)
• Attempted to treat them conservatively using
laxatives and purgative medications or surgically
via anoscope
• Understood importance of the surgical option
but lacked appropriate tools
• Numerous operations exist
• Aim to decrease recurrence and incontinence
rates
Louis 14th
17th Century
France
• Had anal fistula in 1686
at age 47 after
developing an abscess
in the “Foundation”
from riding horses
• Recurrent abscesses
made it impossible for
the King to walk
• Surgery as we know it
today did not exist
• Difficult for the King to
adopt majestic airs
Francois Felix: A Great BarberSurgeon and The Royal Anus
• Born in Avignon c 1635
• Developed technique to perform an
operation on the monarch after practicing
with peasants/prisoners at King’s request
• Found that addressing the internal fistula
opening was key to the operation while
preserving life and anal sphincter continence
Francois Felix: A Great BarberSurgeon and The Royal Anus
• SETON
One or more threads or horsehairs or a strip of
linen introduced beneath the skin by a knife or
needle to provide drainage or to produce or
prolong inflammation
Francois Felix: A Great BarberSurgeon and The Royal Anus
• The King required 4 operations for healing of fistula
(staged fistulotomies with setons)
• Back to riding horses by 3 months
• Felix was knighted, bought a town (Tassy) and asked
that the barber trade be separated from surgery
• Became the surgeon of the Sun King
• Had PTSD from ordeal and apparently was not able to
touch a scalpel thereafter
• Helped to establish the French Royal Academy of
Surgery in 1731 under King Louis XV
Crohn’s Disease: Anorectal Fistula
Modern Surgical/Medical Treatment
• Drain abscess if present
• Drain fistulas with setons to minimize
festering and abscess recurrence as
immunomodulator and biologic agents
started
• As fistula tracts dry up and therapy effective
can remove setons (may have to replace and
re-drain depending on CD activity
Crohn’s Disease: Modern Surgical
Treatment
• Fissure
– Pain and bleeding can be excruciating and may
be main complaints of CD
– May be atypical, lateral or associated with
edematous skin tags (CD)
– Maximize medical management when active
disease related fissures and symptoms usually
improve
– Surgery only if not CD related and no active CD
and anal sphincter hypertonic
IBD: Modern Surgical Treatment
• Timing of Surgery: Immunomodulator
Biologic and Steroid Therapy
– Ulcerative Colitis: high dose steroids and
biologics increase infection risk – stage
colectomies
– Crohn’s Disease: literature on biologics
controversial – time surgery around biologic dose
to maintain optimized medical management.
Steroids and biologic combinations increase risk
of infection
IBD Surgery Conclusions
• Extensive progress over last 100+ years
• Future: Genotype-phenotype correlations
may help guide surgery and medical therapy
• Continued improved medical management
will continue to compliment evolving surgical
techniques and capabilities
• The Cure…