Surgical Management of Crohn's Disease - cme

PhenotypesInflammatory Stricturing PenetratingPainTendernessDiarrheaWeight LossCrampsDistensionVomitingDiarrheaPainFeces and air in urineEnterocutaneousEnteroentericEnterovesical/vaginalRetroperitoneal

Indications for surgery• PerforationAbsolute• Intractable Hemorrhage• Persistent Obstruction• Dysplasia or cancer• Unresponsive fulminantdiseaseRelative• Refractory disease• Side effects of medication(steroid dependence)• Chronic or recurrent obstruction• Fistula• Abscess not amenable topercutaneous drainage

Goals of surgical management• Palliative• Early surgical consultation• Good communication with GI and patient essential• Establish goals and inform patient of expectations• Optimize nutritional status• Obtain “roadmap”– CT, colonoscopy, SBS

Surgical decision making• Timing of surgery• Preoperative infection control• Resection margins• Anastomotic technique• Strictureplasty versus resection• Laparoscopic versus open surgery• Segmental versus total colectomy• Perioperative CD medications

Surgical decision making• Timing of surgery• Preoperative infection control• Resection margins• Anastomotic technique• Strictureplasty versus resection• Laparoscopic versus open surgery• Segmental versus total colectomy• Perioperative CD medications

Surgery in the biologics era

Perforating Crohn's ileitis: delay of surgery isassociated with inferior postoperative outcome197 patients underwent 231 bowel resections for perforating ileitis(1992 – 2009). Duration of clinical deterioration prior to surgerydetermined.• If the patient was sick for >5 months:• Greater number of structures in the inflammatory mass (3.3 vs 2.8)• Higher probability of taking immunosuppressive drugs (26% vs 14%),budesonide (29% vs 14%), and a multiple-drug combination (31% vs 16%)at the time of surgery• Higher incidence of post-op septic complications (31% vs 13%)Retrospective study – but, the suggestion is that earlier operationmay mean better outcomesIesalnieks et al Inflamm Bowel Dis 2010

Timing of surgery• Timing is critical– For some patients, waiting leads to worseoutcome.– On the other hand, delaying surgery isbeneficial for many patients and in somecases may avoid surgery altogether.

Surgical decision making• Timing of surgery• Preoperative infection control• Resection margins• Anastomotic technique• Strictureplasty versus resection• Laparoscopic versus open surgery• Segmental versus total colectomy• Perioperative CD medications

Preoperative control of sepsis• For a contained,CD-related intraabdominalabscess,percutaneousdrainage issuccessful in 96% ofcases.• 50% of thesepatients willeventually requiresurgery.

Intraabdominal abscessInfluence of percutaneous abscess drainage on severepostoperative septic complications in patients withCrohn’s disease25 patients with CD and spontaneous intra-abd abscess whounderwent intestinal resection. Preop IR drainage performed in12/25 patients (avg of 37 days prior to surgery).Post op intra-abd complication (leak, abscess)– 3/12 (25%) with preop drainage– 9/13 (69%) without preop drainage– p=0.04

Surgical decision making• Indications for and timing of surgery• Preoperative infection control• Resection margins• Strictureplasty versus resection• Segmental versus total colectomy• Anastomotic technique• Laparoscopic versus open surgery• Nutritional status• Perioperative CD medications

Effect of resection margins on the recurrence ofCrohn’s disease in the small bowel• 131 patients randomized to 2cm vs 12 cm margin fromgrossly involved bowel.• Median f/u = 55.7 monthsRecurrence = operation for preanastomoticdisease• Recurrence rates– Limited resection = 25%– Extended resection = 18%– p=NS• Results – no differences in earlypost-op complications

Surgical decision making• Timing of surgery• Preoperative infection control• Resection margins• Anastomotic technique• Strictureplasty versus resection• Laparoscopic versus open surgery• Segmental versus total colectomy• Perioperative CD medications

Anastomotic technique• Stapled versus handsewn• 7 trials, 1125 patients (441 stapled,684 handsewn)• Stapled anastomoses associated withsignificantly fewer leaks than handsewn• No difference in other outcomes(stricture, time, bleeding, reoperation,mortality, LOS, abscess, woundinfection)• Side to side versus end to end• Multicenter, RCT• 139 patients per group, 1 yr followup• No difference in endoscopic (40%) orsymptomatic (20%) recurrence rate

Surgical decision making• Timing of surgery• Preoperative infection control• Resection margins• Anastomotic technique• Strictureplasty versus resection• Laparoscopic versus open surgery• Segmental versus total colectomy• Perioperative CD medications

Strictureplasty• First described in 1979• Adopted from treatmentof tuberculous strictures• Multiple series havedocumented thatperioperativecomplications are samefor strictureplasty andresection

Strictureplasty• Indications– Diffuse involvementof bowel withmultiple, remotestrictures– Patients who haveundergone majorprevious intestinalresection– Short, fibroticstrictures• Contraindications– Index operation– Multiple strictureswithin a shortsegment or close toa site of resection– Local sepsis(phlegmon,perforation)– Hypoalbuminemia– Suspicion of cancer

Surgery for Crohn’s Disease: StrictureplastyAn alternative to resection in “stenosing”disease• 698 strictureplasties in 162patients• Cumulative 5 year reoperativerecurrence = 28%• Re-stricture at previousstrictureplasty site = 5%• Most re-operationsperformed for new sites ofdisease

• Finding intestinal strictures at surgery

Surgical decision making• Timing of surgery• Preoperative infection control• Resection margins• Anastomotic technique• Strictureplasty versus resection• Laparoscopic versus open surgery• Segmental versus total colectomy• Perioperative CD medications

Laparoscopic surgery• Clearly improves– Body image– Cosmesis– Self-confidence• Meta-analysis– Longer OR times– Significant short termbenefits:• Return of bowel function• Resuming oral intake• Length of stay• Morbidity• Hospital cost– No difference in recurrence

Laparoscopic surgery• Cochrane DatabaseReview 2011– Included 2 RCTs on lapvs. open surgery forsmall bowel CD– No significant differencein perioperativeoutcomes or long-termreoperation rates fordisease or non-diseaserelated complications ofCD

Surgical decision making• Timing of surgery• Preoperative infection control• Resection margins• Anastomotic technique• Strictureplasty versus resection• Laparoscopic versus open surgery• Segmental versus total colectomy• Perioperative CD medications

Crohn’s colitis• Disease patterns dictate resection– Pancolitis with proctitis TPC w ileostomy– Pancolitis no proctitis TAC w IRA– Proctosigmoiditis or APR or TPCsevere perianal disease– Segmental colitis Segmentalcolectomy orTAC/IRA

Crohn’s colitis• Meta-analysis ofsegmental vs.subtotal colectomy– No difference insurgical recurrence,overall recurrence,postop complicationsor incidence ofstoma formation– Faster time tosurgical recurrencein segmental group• Conclusions– Segmentalcolectomy isappropriate in ahighly select group ofpatients• Truly segmental• Rectal sparing• No TI disease• No Perianal disease• Good sphincter tone• Distensible rectum

Surgical decision making• Timing of surgery• Preoperative infection control• Resection margins• Anastomotic technique• Strictureplasty versus resection• Laparoscopic versus open surgery• Segmental versus total colectomy• Perioperative CD medications

The surgeon’s viewpoint• If it goes well: I am a brilliant surgeon…• If it goes wrong: It’s because of thosedamned drugs that were prescribed bythe gastroenterologists…

SteroidsTotal complicationsSeptic complicationsOR 1.41, 95% CI 1.07-1.87 OR 1.68, 95% CI 1.24-2.28

Steroids – Dose matters

Biologics

Perioperative treatment with infliximab in patientswith Crohn's disease and ulcerative colitis is notassociated with an increased rate of postoperativecomplications413 consecutive IBD patients, 188 (45.5%) with CD.24.5% had received preoperative IFX < or = 12 weeks beforesurgery.• Results: No differences in anastomotic leak (3.0% vs. 2.9%),infections (5.97% vs. 10.1%), thrombotic events (3.6% vs.3.0%), prolonged ileus/SBO (3.9% vs. 2.8%), cardiac (1% vs.0.6%), and hepatic/renal complications (1.0 vs. 0.6%).• CONCLUSIONS: Preoperative IFX was not associated with anincreased rate of cumulative postop complications.

Summary• Surgery for CD is palliative.• Optimize nutritional status.• Set clear goals of therapy and communicate withpatient and gastroenterologist.• Conservative intestinal resection is important.• Laparoscopic approach is preferred.• Steroids but not biologics influence postoperativeoutcomes.