SURGERY FOR COLITIS THE BOTTOM LINE

SURGERY FOR COLITIS THE BOTTOM LINE

Speaker Declarations This presenter has the following declarations of relationship with industry None [Nov 2017]

Surgeons just like to cut..

ABSOLUTE INDICATIONS Toxic dilatation www.survivingsepsis.org Perforation Torrential bleeding

Travis et al BSG Guidelines 2004 Severe UC should be managed jointly by a Gastroenterologist in conjunction with a colorectal Surgeon Patients should be kept informed of treatment and prognosis, including a 25 30% chance of needing colectomy

Objective re-evaluation on the third day of intensive treatment. A stool frequency of >8/day or CRP>45 mg/l at 3 days appears to predict the need for surgery in 85% of cases. Surgical review is appropriate at this stage. (Grade B) Consideration of colectomy or iv ciclosporin if there is no improvement during the first 3 days (Grade A)

PLAN? Aza? Involve surgs Start cyclo 30 yr old female Previously treated for proctitis ( 3 years) 2 week history of bloody diarrhoea x 20/24 hrs 40 mg Pred for 8 days prior to admission Couldn t hold pentasa supps CRP = 77 on admission DAY 5 C Diff neg Abdo tender BO x 19 CRP 63

ABDOMINAL PAIN IN COLITIS Very little in the books Prognostic significance unknown Difficult to assess Voluntary guarding Rebound PCA

Day 6 Starting Cyclo R/V surgs Day 7 Surg Reg Severe UC perhaps beginning to get better? Get the colorectal Surgeons CRP 93 BO 15 (Previously 19)

Day 8 s/b cons Still profuse diarrhoea + no improvement Day 10 BO 15 begin polymeric diet Day 11 BO 5 better Day 12 BO 14.. Sb Cons Refer to CR surgs Pt desperate to avoid surgery want 2 nd opinion from another gastroenterologist Surgery recommended (infliximab considered) Day 13 Transfer to CR Day 14 Subtotal colectomy

ISSUES Guidelines.. Not adhered to. Slow to start ciclosporin Slow to refer to surgeon (wishful thinking on the part of the Gen Surg reg) (straw grasping) Surgery not explored with patient until late in the illness

49 acute colectomy patients Half felt that surgery wished they had earlier surgery 10% felt surgery was too soon 40% Didn t feel strongly or didn t like to say Fitzgerald E et al 2008

SHORTCOMINGS IN THE CARE PHYSICIAN SURGEON PATIENT AND FAMILY SYSTEMATIC PROBLEMS WITH THE GUIDELINES

Only had the operation at my request Get rid of it or you ll be dead Knowing what I know now I would have had the operation much earlier Not told about possible surgery. Would have had it straight away I wanted to try everything before op I was slightly dubious about surgery but should have had it when diagnosed Would have preferred not to have to try all the medicines

INDICATIONS FOR SURGERY FAILURE OF MEDICAL TREATMENT FAILURE OF PHYSICIANS TO CONTROL THE DISEASE ACUTELY CHRONICALLY SYMPTOMATICALLY NEOPLASTICALLY FAILURE FAILURE FAILURE FAILURE FAILURE FAILURE

INDICATIONS FOR SURGERY DISEASE THAT IS DRUG RESISTANT ACUTELY CHRONICALLY SYMPTOMATICALLY NEOPLASTICALLY BAD DISEASE BAD DISEASE BAD DISEASE BAD DISEASE MOST DEFINITELY NOT FAILING PHYSICIANS

SURGEON RELATED PROBLEMS 70 % of patients don t need one Availability Straw clutching Like to cut? Fallibility

PATENT RELATED PROBLEMS Loss of control Dread of stoma Feeling rotten Family flying back from abroad

INSTITUTIONAL / ADMINISTRATIVE Management in series (should be parallel) Lack of urgency.. Days slipping away Specialism Difficulty getting to theatre

PROBLEMS WITH THE GUIDELINES Guideline: a line drawn, or a rope, etc fixed to act as a guide; an indication of a course that should be followed, or of what future policy will be. The Chambers Dictionary 1998 edition p 715

Rules for the management of..

AT ADMISSION Start treatment Spell out the plan Describe the place of surgery Stoma / IBD nurse If 2 nd line drug treatment is to be used then redefine targets and time limit them (including when the surgeon should come back) Severe or unusual pain.. Call a surgeon AT DAY 3 If targets not met (Stool >8 or CRP>45) A surgeon should be involved

WHEN THE PATIENT IS BETTER Is he/she likely to relapse? Consider calling the surgeon now that you have achieved remission Elective surgery is better than emergency

BSG rules should be observed (stool frequency + CRP) Introduce the concept of second line therapy (incl surgery) for bad disease on day 1 Set measurable targets and time constrain them

DEFINITIVE SURGERY Restorative proctocolectomy is the first choice elective surgical treatment for ulcerative colitis N. S. Williams 1989

PANPROCTOCOLECTOMY ILEO-ANAL POUCH (RESTORATIVE PROCTOCOLECTOMY) Please do not call this reversal

ABSOLUTE CONTRA-INDICATIONS Acute colitis Crohn s disease Anal sphincter damage / incontinence Anal fistula Shape Co-morbidities RELATIVE CONTRA-INDICATIONS Extra-intestinal manifestations Drugs Previous small bowel resection Family planning Age Minor anal ailments

SPHINCTER FUNCTION HISTORY EXAMINATION MANOMETRY

Age

IA pouch Long term results Perioperative complications 50-60% 5% pouch excision Failure 5 10% BO 6-7 Night 1 2 soiling Leakage Obstruction Pouchitis 10% on long term treatment Fistula 10-20%

Laparoscopic v Open surgery Meta-analyses Sofo et al World J Gastrointest Surg 2016: 27; 558-563 Singh et al Colorectal Dis 2014: 15: e340-351 Ahmed et al Cochrance review 2009 Very little difference in short term outcomes Complications, LOS, Readmission, Failure.

POUCH FAILURE 24 patients after excision of the pouch Markedly reduced quality of life Lepistö A Dis Colon Rectum. 2002 Oct;45(10):1289-94. 136 patients (31 left in situ) Q of L better in patients that had pouch excised Kiran RP Dis Colon Rectum. 2012 Jan;55(1):4-9

Failure 10% Q o L markedly worse Poorly functioning pouch 20-30% / chronic complications Occasional / minor problems 20 30% Pretty much normal 40-50% NB Morbidity or permanent stoma

GOLD STANDARD Doing the right operation for the patient at the right time. Carried out by a team that has sufficient expertise (volume effect) With known results

FERTILITY, PREGNANCY AND THE ILEO-ANAL POUCH

SEXUAL FUNCTION AFTER POUCH MALE FEMALE Evidence is conflicting

Studies often questionnaire based Response / participation rates 40 50% Based on Female sexual function index 73% preop dysfunction 21% post op Davies et al Dis Colon Rectum 2008 47% postop Ogilvie JW Br J Surg 2008 8% preop 15 % post op Meta-analysis Cornish JA et al Dis Colon Rectum 2007

INFERTILITY Inability to conceive after 12 months of trying (unprotected intercourse) FECUNDITY Ability to conceive

Olsen 2003

Several studies 1.5 3 x increase in infertility rate Consider having family before pouch surgery

DELIVERY Normal delivery Risk of sphincter injury 30% on US 10% incidence of incontinence (2% severe) Pudendal nerve injury

Higher elective caesarian rate BUT Extensive evidence showing that vaginal delivery +- episiotomy does not result in altered pouch function

CONCLUSION Management pathway of acute colitis is well established but often slips Ileoanal pouch surgery is not straightforward. Careful and prolonged counselling and discussion is mandatory Few.. If any UK centres are high volume