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RESTORATIVE PROCTOCOLECTOMY by 0YxjB6I8

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									       M62 Course
      April 7-8 2005

       SURGERY
          for
COLONIC CROHN’S DISEASE

       RJ NICHOLLS
     Crohn’s Disease
        Surgery
Indicated for Complications
Recurrence
Often Long term Relief
Minimal Surgery
No proven effect of Medical Treatment
on Recurrence
CROHN’S DISEASE
Indications for Surgery
        Elective

      Obstruction
     Fistula/abscess
         Colitis
       Carcinoma
      Anal Disease
               Avoid Late Surgery

               Postoperative Complications
                  Fasth      Lindhagen         Pocard
                  1980        1982             2000

Preoperative
Sepsis
     NO           12 %         22%                5%
     YES          48%          45%               23%
                                             Hulten 2001
                  CROHN’S DISEASE
                           The Cancer Risk

                           n    fu/y Dys Ca            relative risk

Swedish study              1655 30*     -       -   SI        1
                                                    Il/col    3.2
                                                    LI        5.6
Gillen 1994                281 12-35     -      8            3.4+
Friedman 2001              259   -20   42(16)   5

•*20.9 < 30y at onset
•+18.2 extensive colitis
The Defunctioned Rectum
        25 Patients
  Low Hartmann’s Procedure
        3 Cases of Cancer
     Regular surveillance

                            Ciccione 2000
  CROHN’S COLITIS
    Urgent Surgery
                             %
Failed medical treatment     70
Toxic dilatation             20
Perforation                < 10
Bleeding                   < 5
     ACUTE SEVERE COLITIS

                 CROHN’S DISEASE
                  20-30% of cases
                     5 Studies
                     68 patients
                  Medical Treatment
Remission                          65%(55-94%)
Remission maintained               54-69%

                                     Kornbluth 1999
     ACUTE CROHN’S COLITIS
        Choice of Operation
                   145 Patients

Colectomy + IRA                   47
Proctocolectomy                   27
Colectomy + Ileostomy             13
Ileostomy alone                   10

                                  Keighley 1993
     ACUTE SEVERE COLONIC
       CROHN’S DISEASE
            Initial Colectomy + Ileostomy
                  Operation Survivors
                           21
Rectal excision                     C + IRA
     11                                1

     No surgery       Ileal        Colostomy
        5          resection           1
                       3       Keighley 1993
      COLONIC CROHN’S DISEASE
         Main Indications for Elective
                Surgery


Severe Local Symptoms
                          Obstruction
                          Fistulation
                          Anorectal disease

Systemic illness          Chronic Proctocolitis
        Pouches and Crohn’s Disease
Authors    Year   Mean F/U   Total Crohn’s Pouch
                                Cases      Failure(%)

Hyman      1991      38            25       32
Grobler    1993      -            20        30
Sagar      1996      -            37        46
Regimbeau 2001      113      41         7
Hartley    2003       -           60        25
Tulchinsky 2003      90           13        46
Total                             227       31
    Restorative Proctocolectomy
                 for
          Crohn’s Disease

3-5% in large surgical series
Failure up to 50% (cf UC 10%)
Failure increases with time
COLONIC CROHN’S DISEASE

  Segmental v Total Colectomy + IRA

 Total Colitis            70%
 Segmental Colitis        30%

                       Kornbluth 1999
Segmental v Total Colectomy +IRA
      SEGMENTAL(SC)
             v
   TOTAL COLECTOMY + IRA
6 Studies 488 Pt 265 SC 223 IRA
Meta-analysis
Time to Recurrence Longer after IRA by 4.4 y
Fewer Operations After IRA where two
  segments involved
                               Tekkis et al 2005
          CROHN’S DISEASE
          Colectomy with IRA

                N    fu(y)   Recurrence(%)
Flint 1977      37     6         41
Buchman 1981   105     8         30
Ambrose 1984    63    10        48
Goligher1988    47    15        49
Allan 1989      63    15        53
Longo 1992     131    10        65
Recurrence after Colectomy with IRA
and Total Proctocolectomy
           CROHN’S DISEASE
           COLECTOMY + IRA
                    131 Patients
                      Fu 9.5 y
             13 Ileostomy never closed
                        118

Proctectomy         Further ileal   No resection
    30    Diversion resection           48
             16         24
                                         Longo 1992
              Colectomy with IRA

Rectal Sparing in 50% of Large Bowel Crohn’s

Indicated where two or more segments are involved

Recurrence in ~ 50% over 10 years

May be possible to re-resect terminal ileal recurrence
                                 to avoid permanent stoma
   PROCTOCOLECTOMY

              Indications
         Severe Rectal Disease
                Cancer
Severe Anal Disease (almost always rectal
         involvement present)

  Small Bowel Recurrence 20% at 10 y
               Perineal Wound
                Delayed Healing

Incidence    30% or more of patients
             x3 in pre-existing anal sepsis
Leave open in the presence of sepsis
Medical management ?value
Intensive Nursing
    RESTORATIVE
 PROCTOCOLECTOMY
      Close Rectal Dissection
with Intersphincteric Anal Removal

       Avoids pelvic nerve damage
       Not with dysplasia
       Not with carcinoma
         SEVERE ANORECTAL
          CROHN’S DISEASE
                 SPLIT ILEOSTOMY
                      29 Patients
                        36 mo
     Still defunctioned           15
     Proctocolectomy              8
     Restoration of Continuity    6

Late deaths 2                Harper 1982

								
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