Convegno Annuale Fondazione Rosa Gallo. Risultati chirurgici a lungo termine nelle IBD John Nicholls

Transcription

1 Convegno Annuale Fondazione Rosa Gallo Verona novembre 2010 Risultati chirurgici a lungo termine nelle IBD John Nicholls

2 MORTALITY IN IBD Roberts et al BMJ 2007 Record Linkage Study Oxford Region England patients admitted with IBD LOS >3 days 5480 Colectomy Three year mortality Roberts et al 2007

3 IN HOSPITAL MORTALITY 7108 Discharges Colectomy for UC Nationwide IP Sample Reference OR =1.00 Odds Ratio 95% CI High Volume >/= 12 p a Low volume </= 3 p a Elective Emergency Age <40 y Age y Private Insurance Medicaid Kaplan et al 2008

4 Odds ratios of mortality (logistic regression) three years after elective colectomy, emergency colectomy, and no colectomy among patients admitted for ulcerative colitis and for Crohn's disease in Scotland (April March 2000) Adjusted for Age Sex Age Sex Age Sex Comorbidity Comorbidity LOS Elective Colectomy Emergency Colectomy No Colectomy Nicholls et al 2009

5 The ACPGBI National Ileal Pouch Registry Data submission to Dec ,491 patients 1977 to Dec centres 5,066 follow up events follow-up to 28.9 years

6 UK POUCH REGISTER FUNCTION OVER 20 Y Overall Year of follow up 20% 16% 12% 8% 4% 0% Overall Year of follow up Overall Year of follow up 16% 14% 12% 10% 8% 6% 4% 2% 0% Overall Year of follow up

7 Failure over 25 Years St Mark s Hospital Lovegrove et al 2008

8 Failure and function up to 20 years Hahnloser 2007 Lovegrove 2010

9 CAUSES of FAILURE SEPSIS 50% POOR FUNCTION 30% POUCHITIS 10% Tulchinsky et al 2003

10 Pouch Failure in Patients with Early Sepsis Heuschen et al 2002

11 QUALITY of LIFE 4013 patients St Marks Cleveland Clinic Cleveland Global QoL Score Lovegrove 2010 Year Score %

12 EFFECT of FUNCTION ON QUALITY of LIFE Lovegrove QoL 0.75 QoL QoL > hr stool frequency Never Rarely Sometimes Mostly Always QoL Nocturnal stool frequency No Yes Follow Up Year

13 Surgeon activity England 499 consultant surgeons Over eight years performed between 1 and 134 procedures Median Institution volume 17 procedures (IQR 8-31 procedures). 91% of surgeons carried out 20 cases Median Surgeon 4 operations over 8 years

14 Burns Kaplan Meier curve showing the adjusted pouch failure rate and volume for individual institutions Burns et al 2010

15 Cumulative risk for allforms of pouchitis in Heidelberg prospective longterm follow up programme Heuschen et al 2001

16 ileal pouch survival by diagnostic group St Mark s Hospital IC Cumulative ileal pouch survival Pathology CD IndC 10 CD p=0.05 Follow up (years)

17 Primary Sclerosing Cholangitis Penna 1996 Pouchitis after RPC

18 POUCH VAGINAL FISTRULA REPAIR Heriot et al 2004 Abdominal v Transvaginal UC/FAP v CD 1.0 Survival Functions 1.0 Survival Functions.8.8 Cum Survival st OP Local repair Local repair -censored Abdominal revision Abdominal revision -censored 10 ival Cumulative PVF-free survi Final Pathology UC/FAP UC/FAP-censored CD/IndC CD/IndC-censored 10 time to 1st recurrence Follow-up since last repair

19 UC POUCH DYSPLASIA n Fu yr D Ca Verress Sarigol Ettorre Heuschen Thompson 106 > Fawcett 2001 Tarroni Herline > Hulten*

20 UC UC IAA Original Specimen Site of Cancer Stern 1990 M 28 3 Ca Caecum Rectal mucosa Puthu 1992 M 17 6 D Rectal mucosa Rodrigues 1995 M 18 4 D Rectal mucosa Sequens 1997 S 16 2 Ca Rectum Rectal mucosa Vieth 1998 Ns 20 2 Ca Transverse Pouch Iwama 2000 M 21 2 D Pouch Heuschen 2001 M 26 4 Ca Descending Pouch Rotholtz 2001 S 13 7 D Rectal mucosa Laurenti 2002 M 20 2 Ca Sigmoid Rectal mucosa Baratsis 2002 S 24 2 Ca Caecum Rectal mucosa Hyman 2002 S 13 6 Ca Rectum Rectal mucosa Benthem 2003 M 30 3 Ca Ascending Pouch Hassan 2003 M 10 2 D Pouch Bell 2003 S D Rectal mucosa Negi 2003 M 10 5 D Rectal mucosa Das 2006 M No Ca or D Rectal mucosa

21 DYSPLASIA RISK FACTORS SURVEILLANCE Dysplasia Rare <2%0ver 15 y Cancer or Dysplasia in original specimen 10 years from onset of disease Type C mucosal morphology Primary Sclerosing Cholangitis

22 RESTORATIVE PROCTOCOLECTOMY Optimisng Results Indications Avoid Crohn s disease Adequate size pouch Leave no rectal stump Probably do ileostomy Early action with sepsis Identify patients at risk of cancer THE IBD SPECIALIST UNIT

23 INFLAMMATORY BOWEL DISEASE THE UNIT Gastroenterologist Surgeon Histopathologist Specialist Nurse Stoma therapist Dietitian Psychologist Multidisciplinary Care Decision taking Long term management

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25 PREDICTING FAILURE CC-IPF score diagnosis FAP 0 UC or IndC 1 CD 1.5 comorbid conditions nil 0 one 0.5 two or more 1 prior anal pathology no 0 yes 1 anal manometry normal 0 abnormal 1 anastomotic separation no 0 yes 1 anastomotic stricture no 0 yes 1 pelvic sepsis no 0 yes 1 fistula formation no 0 pouch-perineal 1 pouch-vaginal 2

26 survival curves for IPAA failure by CCF-IPF score % Cumulative IPAA A survival % CCF-IPF score (n=17) (n=34) (n=146) (n=469) (n=1299) Time (years)

27 Crohn s disease & RPC Authors Year Mean F/U Total Crohn s Pouch Cases Failure Hyman % Grobler % Sagar % Regimbeau % Hartley % Tulchinsky % Total %

28 Failure. Function, Qol St Mark s 382 Patients > 10 y Lovegrove 2008 Year Failure% 10.2 Freq/24 6(4-8) 6(4-10) Urgency% Seepage % day 7 13 night 11 8 Pad% night QoL % 80 90

29 Pouch Survival after Revision by Indication 1.0 eal pouch survival Cumulative il Sepsis Other Non-septic 5-year pouch survival sepsis = 56.8.% non-septic = 87.8% other = 61.9% Follow-up (years) Tekkis et al 2006 Log-rank = 4.76, p=0.083

30 FUNCTION OVER 20 YEARS Conclusion Frequency stable or slight rise Seepage increase Pad Usage increase QoL maintained

31 Interval in mo onths Pouch Cancer Interval from onset of UC and from RPC 550 Interval from UC 500 Interval from RPC Interval from UC Interval from RPC

32 SHORT SEGMENT TERMINAL ILEAL CROHN S DISEASE SEVERITY OF DISEASE QUALITY OF LIFE THE KEY General Local Little known Social dysfunction PATIENT S WISHES DOCTOR S PREJUDICE

33 Quality of Life PC v RPC Overall No Difference Specific Performance Status RPC > PC RPC v Active Disease (med) RPC > med General Satisfaction RPC=PC References: Pemberton 1989; McLeod 1991,1998; Kohler 1991; Martin 1998; Jimmo 1998.

34 Patients Assessment of QoL according to Severity of IBD against UK-norms SF36

35 100 Crohn s disease controlled or not with medication (patient perception) SF disease controlled not controlled PF-SF36 RP-SF36 BP-SF36 GH-SF36 VT-SF36 SF-SF36 RE-SF36 MH-SF36 HTI-SF36

36 St Mark s Social Questionnaire Survey of members of NACC with CD. 459 Patients 45 (12-84) years n/denom(%) notes Severe disease 230/459(50.1) Steroids 63/459(13.7) 329 not currently on, 67 never Education Full time at diagnosis 107/458 1 missing value Failed to complete 84/107(78.5) 281 not applicable, Employment Lost job due to disease 90/404 Rest not completed Reduced earning 256/ n/a, 5 missing Personal relationships Affected due to disease 220/459 Relationship break up Divorce/separation 108/ /108 2 missing values Life insurance Refused 177/ n/a, 1 missing Special conditions Paid more 279/ /842 Benefit Disability 53/ n/a 75 n/a Incapacity 59/458 1 missing

37 ELECTIVE SURGERY Mortality < 1% Morbidity 5-20% Recurrence Early surgery does not reduce the chance of recurrence Nor does it increase it Most patients will require two or three resections in a lifetime Short Bowel Rare

38 RECURRENT RESECTIONS (%) n Fu years No resection Higgens Shivananda [35] 21[6] Andrews

39 CUMULATIVE RATE OF RE-RESECTION Year 5 Year 10 Year 20 Hulten Shavananda Michaelassi

40 LOSS of SMALL INTESTINE Following First Terminal Ileal Resection for CD Hulten 1988 RESECTION CUMULATIVE LOSS OF SMALL BOWEL cm % OF TOTAL GUT LENGTH CHANCE OF RE-RESECTION AT 20 Y%

41 MEDICAL TREATMENT Asymptomatic patients in long term 10% Disease tends to progress Side Effects of drug treatment No Evidence that they reduce the chance of surgery Most patients require surgery in the end Considerable social pathology in IBD treated medically Evidence for increased mortality in intermediate term

42 DISEASE PROGRESSION 297 PATIENTS 125(42%) L1 10 years L1 125 YEAR 1 % YEAR 10 % B B B Louis et al 2001

43 CHANGES IN IMMUNOPRESSANT TREATMENT AND INCIDENCE OF SURGERY FOR CROHN S DISEASE Immunosuppressants % Surgery % 1978/ / / / / Cosnes et al 2005

44 POST OPERATIVE COMPLICATIONS ACCORDING TO PRESENCE OF PREOPERATIVE SEPSIS NO YES Fasth Lindhagen Pocard DON T LET A COMPLICATION BECOME A COMPLICATION

45 TREATMENT POLICY Some patients asymptomatic Some will respond to medical treatment Some symptomatic from outset will need surgery sooner or later Early surgery in these results in a better quality of life. Better to be well in the long term with 2-3 resections than to be chronically ill on medication

46 SURGERY GIVES RAPID RELIEF DOES NOT AFFECT RECURRENCE RATE LOW MORBIDITY AND MORTALITY SHORT BOWEL CONFINED TO A FEW PATIENTS ONLY EXCELLENT TREATMENT WHEN INDICATED DO NOT HOLD BACK WHEN POOR RESPONSE TO MEDICAL TREATMENT FACE THE INEVITABLE EARLY FOR THE PATIENT S SAKE

47 Failure and function up to 20 years Hahnloser 2007 Lovegrove 2008