The role of Surgery and Stomas in IBD When do I need it? Can I avoid it? How do I live with it? Kyle G. Cologne, MD Assistant Professor of Surgery USC Division of Colorectal Surgery Topics Surgical Differences between UC / Crohn s Crohn s Disease: Surgical Indications / Disease Types Surgical Procedures Ulcerative Colitis Surgical Indications / Disease Types Surgical Procedures Outcomes after Surgery Living with an Ostomy Therapeutic Goals in IBD Induction of Remission Clinical Disease Activity Score Endoscopic severity score Reduced need for Surgery Maintenance of Remission Improvement in Quality of Life By Any Means Necessary Tools available to achieve this: The Surgeon s World View (in brief) Crohn s Disease Cannot remove all disease with surgery Disease pattern matters Isolated segment fibrostenotic Higher pouch failure rate Risk for Short Bowel (rare) Ulcerative Colitis Disease removed by surgery Good results with pouch Leave no colon behind No risk for Short Bowel Risk of Cancer after 8-12 years (with poorly controlled disease) Cancer Risk: Crohn s Disease Ulcerative Colitis Risk increases with time 1, 2 2% at 10 years 8% at 20 years 18% at 30 years 40% at 40 years 3-10x higher with PSC 16-33% right sided CA 2 1. Eden JA et al. The risk of colorectal cancer in ulcerative colitis: a meta-analysis. Gut 2001:48:526-35. 2. Collins PD et al. Cochrane database: strategies for detecting colon cancer. In patients with IBD, 2008 CCFA Patient & Family Education Conference 1
Why do I need to get scoped?? Allows differentiation between UC/Crohns Changes surgical management Allows description of extent/loc of disease Changes surgical management Allows screening for cancer May be an indication for surgery Safe Why do I need to get scoped AGAIN?? Confirm the Diagnosis Evaluate extent of disease Assess activity of disease Evaluate disease unresponsive to therapy (degree mucosal healing vs no response) Assess complications like stricture, dysplasia, cancer Vucelic B. Inflammatory Bowel Diseases: Controversies in the use of diagnostic procedures. Dig Dis 2009;27:269-77. Tools available to achieve this: Crohns Disease Majority of patients need surgery at some point 1 : 70-80% eventually require surgery (vs. 30% for UC) Crohns: Location, Location, Location Ileocecal involvement = 90% require surgery Left colon = 60% require surgery Rectal = 30% require surgery (higher rates of stoma creation) <10% eventually require permanent stoma 1. Cosnes J et al. Epidemiology and natural history of inflammatory bowel diseases. Gastroenterology 2011;140:1785-94 CCFA Patient & Family Education Conference 2
Crohns: When do we operate? Crohns: we try NOT to operate Perforation / Abscess / Fistula Percutaneous drainage effective, 15% surgery at 1 year Free perforation in 1.8-2.4% Bleeding 1.3-1.9%, 20-57% require surgery Megacolon / Fulminant Colitis 30% as initial presentation Short Bowel Syndrome Crohns: What operation do I need? It Depends! Disease location: <20% with colitis will develop small bowel disease <20% with ileal disease develop colitis 1. Cosnes J et al. Epidemiology and natural history of inflammatory bowel diseases. Gastroenterology 2011;140:1785-94 2. Froslie KF et al. Mucosal healing in inflammatory bowel disease: results from a Norwegian population-based cohort. Gastroenterology 2007;133:412-22 Small bowel/colon resection Small bowel stricturoplasty CCFA Patient & Family Education Conference 3
Total Colectomy (rectal sparing) Total Colectomy (rectal sparing) 1) Attach small bowel to rectum 1) Attach small bowel to rectum 2) end ileostomy 82% eventually able to get #1 with <50% risk of permanent stoma Hartmann s procedure: Partial colon resection and end colostomy Crohns: Will I need another surgery? 30% require second surgery by 10 years after first Mean of one surgery every 15-20 years 1 Recurrence rates differ by disease location Least with ileal disease; highest with jejunoileitis Mucosal healing associated with sustained clinical remission, less steriods, reduced hospitalization and surgery 2 1. Cosnes J et al. Epidemiology and natural history of inflammatory bowel diseases. Gastroenterology 2011;140:1785-94 2. Froslie KF et al. Mucosal healing in inflammatory bowel disease: results from a Norwegian population-based cohort. Gastroenterology 2007;133:412-22 UC: Who gets surgery? Emergent Fulminant colitis Urgent Hospitalized patients with ongoing symptoms after 7 days of maximal medical therapy (10%) 25-30% will fail medical therapy Elective CCFA Patient & Family Education Conference 4
UC: Who gets surgery? Elective 20-30% require colectomy after 25 years Highest risk if pancolitis (25%) Left sided colitis (10%) Minimally invasive approaches Complete removal of the colon and rectum Complete removal of the colon and rectum 1) j-pouch (usually with temporary stoma) 2) Complete removal of the colon and rectum 1) j-pouch (usually with temporary stoma) 2) end ileostomy Outcomes after Surgery: 3,707 pouch patients Complication Rate: 29% Pouch failure: 5.3% Pouch removal: 3.2% Pouchitis: 33%, Chronic pouchitis: 15% Quality of Life Good or Excellent in 95% Vazio VF et al. Ann Surg 2013 CCFA Patient & Family Education Conference 5
Quality of Life with a stoma? Quality of life with stoma is often BETTER Especially if alternative is: Poorly controlled disease Unable to work Ongoing pain Does not decrease ability to be intimate Body image level before surgery predicts response after stoma, improves with time Symms MR et al. Clin Nurse Spec 2008 Kasparek MS et al. Dis Colon Rectum 2007 Bullen TL et al. J Psychosom Res 2012 Da Silva GM et al. Ann Surg 2008 FAQ: Can I wear the same clothes? YES, even form fitting clothes work with most appliances stretch undergarments can smooth out bulges Some belts can be restrictive. Higher or looser waistbands on trousers and skirts are better Cotton knit or stretch underpants help support the pouch FAQ regarding stomas? Can I be active / go swimming? FAQ regarding stomas? Can I be intimate with a stoma? YES! Many organizations (undercoverostomy.org, UOAA ostomy.org), ccfa.org can help ¾ of a million people with stomas and over 350 local support groups nationally Ostomyoutdoors.com Summary: Crohns: Operate only for complications UC: Low percentage require surgery Surgery: safe, minimally invasive, good outcomes Stoma: does not have to control your life, is much better than out of control disease CCFA Patient & Family Education Conference 6