Surgical Approach to Crohn s Colitis Segmental or Total Colectomy? Can We Avoid the Stoma?

Transcription

1 17 th Panhellenic IBD Congress Thessaloniki May 2018 Surgical Approach to Crohn s Colitis Segmental or Total Colectomy? Can We Avoid the Stoma? Janindra Warusavitarne Consultant Colorectal Surgeon, St Mark s Hospital, London, UK.

2 Decision making in Colonic Crohn s Colonic Crohn s needing Surgery

3 Typical Scenarios and Questions Single segment disease colon -? Segmental or total More than one segment -? Seperateresection or total Proctitis? Pouch or colostomy What is the malignant risk in strictures? is there a role for dilatation in strictures

4 Factors to consider in decision making The role of the colon Is it only water absorption and a sick colon that does not function is of no use Phenotype of Crohn s Small bowel involvement Perineal involvement medications

5 Restoration of Bowel Continuity Effect on PN volume Adaba et al. Ann Surg 2015; 262:

6 Restoration of Bowel Continuity Effect on PN energy Adaba et al. Ann Surg 2015; 262:

7 Is the colon is different to small bowel? Fluids / electrolytes? Minimal contribution to nutrients absorption Role in adaptation The role of the ileocaecal valve Digestion Absorption of nutrients Immunological fx Yes but it has more of a role in maintaining nutrition than previously thought

8 A clinical case Anna, dob : left-sided Crohn s colitis diagnosis treated w 5ASA AZA 2000: stricture localized at descending colon, very mild luminal left colonic disease

9 Questions to discuss with Anna? Functional outcomes Risk of recurrence and need for further surgery What is the risk of dysplasia or cancer

10 Functional results SR vs TC+IRA Retrospective comparison SR 31 TC 26 Fx results slightly better for Segmental resection Andersson DCR 2002 SR=segmental resection

11 Functional results SR vs TAC+IRA Superior functional results? almost 40% of SR were right hemis and were missing preop fx assessment! Andersson DCR 2002

12 QoL (SC vs TAC) 49 segmental (SR) vs 59 total (TAC) ( , retrosp.) Cleveland Global Quality of Life (CGQL) SC: 7.29 (median 7.7, IQR 6 8.7) TAC: 7.32 (median 7.7, ) (P = 0.88) Short Form Inflammatory Bowel Disease (SF-IBD) Questionnaire SC 5.39 (median 5.6, IQR ) TAC 5.31 (median 5.5, IQR 5 6) (P = 0.92) Kiran Ann Surg 2011

13 Recurrence after Segmental Resection Lightner 2018 The Influence of biologics?

14 Recurrence after ileorectal Probably post operative treatment dependent

15 Patients after TPC are more likely to be weaned off all medications Retrospective, , 179 pts primary colonic CD. Fichera DCR 2005

16 Small bowel recurrence after TPC

17 Small bowel recurrence at stoma Can make stoma care very difficult and can be very painful

18 Risk of permanent stoma Retrospective, , 179 pts primary colonic CD Risk of stoma does not differ for SR and TC But disease phenotype has an influence Fichera A, DCR 2005

19 Early recurrence of SC vs IRA Recurrence rate: TPC: 9% (4/75) TAC: 22% (8/49) SC: 38% (19/55) Fichera DCR 2005

20 Early recurrence of SC vs IRA Meta-analysis on 488 patients (223 IRA vs 265 SC) years earlier recurrence after segmental colectomy compared with IRA (p <0.001) - no difference in incidence of postoperative complications - no difference in the need for a permanent stoma Tekkis CD 2006

21 Surgical recurrence pats, SC for Crohn s Colitis Right sided is different phenotype, more like terminal ileitis Everyone talks about early recurrence for SR but is this really true? More related to disease location than surgical procedure Polle BJS 2005

22 Comparable complication rate Postoperative complication rate (overall 7,8) (P = 0.84): 5/55 SC (9.3 %) 3/49 TAC (6.1 %) 6/55 TPC patients (7.9 %) Tekkis CD 2006 Fichera DCR 2005 But what is the cumulative complication rate of repeated SC?

23 Risk factors for earlier recurrence: perianal disease and female gender pats, SC for Crohn s Colitis Polle BJS 2005

24 Are the colon and the rectum separate entities? Can we treat proctitis with proctectomy in the absence of colitis?

25 -Refractory distal and perianal CD (proximal colon normal at endoscopy) -Early symptomatic recurrence in 9/10 patients after a median follow-up of 9.5 months -6/10 pts luminal relapse in the proximal colon with disabling peristomal lesion - 5/10 pts completion colectomies, 1 pt segmental colectomy with terminal transversostomy (subsequent recurrence requiring re-surgery)

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27 The problem with the data is the selection In most studies patient selection does not follow a set protocol- most are retrospective so decision to treat is different Hence interpretation of results difficult How do we define rectal sparing

28 Is colonic Crohn s truly segmental or pan colonic Recurrences tend to occur in colon

29 But having a total colectomy and IRA is not the panacea University of Toronto 30% of patients needed reoperation for recurrent symptoms Either rectum or the small bowel Smoking increases risk of proctectomy HR= 3.93 Israel Tel-Aviv More patients who had total colectomy needed post operative treatment Recurrence rates for segmental colectomy ~ 35%

30 Odds ratio for re operation Ileocolic resection as index case Small bowel resection 2.95 ( ) Segmental colonic resection 6.20 ( ) Colectomy with ileorectal anastomosis ( ) End stoma 4.62 ( )

31 What is the risk of malignancy for Anna In the presence of a stricture the risk of undiagnosed cancer is about 3% Multifocal dysplasia seen in 44% remote from the site of cancer Subtotal colectomy should be considered for risk of multifocal dysplasia But 97% will have no dysplasia

32 How do patients make decisions

33 The thought of a stoma can polarise individuals

34 Psychosocial health following stoma Psychosocial impact around feeling of loss of control in relationship to body function and personal control as an adult Physical aspects that affect psychological function and quality of life Process of acceptance, adaptation and adjustment Feeling of loss of control in relationship Brown F (2017) Psychosocial health following stoma formation: Vol 15, N03, pg 43-49

35 Findings Pre-operative concerns and expectations Decisionmaking Surgery And recovery Towards long-term outcomes Dibley et al (2018) Decision-making about stoma surgery for IBD: a qualitative exploration and Academic of patient Institute and clinician perspectives, Inflamm Bowel Dis Volume 24, Number 2, February 2018

36 Summary Decision-making is complex Pre-operative contact with a carefully matched stoma buddy is the single most effective technique for dispelling anxieties For the majority, outcomes are very much better than expected

37 Defunctioning for perianal or colonic disease Only 10% of those defuntioned will ever be reversed

38 But try convincing Anna at age 17 that she needs a stoma

39 What was actually done 2000: left colon stricture--> left segmental colectomy 2001: perianal disease onset (ano-vaginal fistula) local repair attempt failure seton

40 2002: Anastomotic recurrence Transverse-descending colon resection and colostomy (closing of the rectal stump for perianal disease) Over the subsequent 7 years, despite fecal diversion, perianal disease evolves multiple perianal procedures (n=4)

41 2009: Second recurrence on colostomy site abscess and fistula Third segmental resection and second more proximal colostomy

42 2014: ascending-rectum anastomosis leak... loop ileostomy...progression of rectal disease...additional 2 procedures to control perianal sepsis

43 2015: functional exams before closing stoma reveal the patient is incontinent completion colectomy + intersphincteric proctectomy, end-ileostomy Was less really more for Anna? Consider the phenotype

44 What about IPAA for Crohn s Colitis Traditionally viewed as relative contraindication Higher failure rate ~ 35% and poor function Is there a paradigm shift Similar functional and failure rates to UC can be achieved Patient selection is the key here No perianal disease and no small bowel disease = good outcomes

45 If all else fails proctectomy needed But that may not solve the problem either unhealed perineum

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48 My pragmatic approach Single segment disease No dysplasia dysplasia Segmental resection- patient discussion Total colectomy if rectal sparing

49 Mutifocal disease No proctitis proctitis IPAA in selected patients Total colectomy and IRA Total colectomy and end ileostomy Proctocolectomy and end stoma

50 Conclusions Have an open mind Talk to the patient- risk of multiple operations vs single operation Consider cancer risk There is no right answer except the carefully thought of solution with the patient involved Can we avoid the stoma? - Sometimes!!