Recent Advances in IBD Surgery

Homayoon Akbari, MD, PhD

Recent Advances in IBD Surgery Homayoon M. Akbari, Akbari, MD, PhD, FRCS(C), FACS Associate Professor of Surgery Virginia Commonwealth University

Crohn’s disease first described as a surgical condition condition,, with the belief that “regional enteritis” could be cured with surgery. Recognition of Crohn’s disease throughout the gastrointestinal tract led to more conservative management with gradual movement away from surgical therapy towards medical management.

ACG Regional Postgraduate Course - Williamsburg, VA Copyright 2013 American College of Gastroenterology

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However… Majority will need surgery: 78% over twenty years Surgery generally indicated for complications of disease 70 70--90% of patients with Crohn’s disease will require surgery. Who gets it depends on location – Probability of surgery within 5 years of disease onset 75% in patients with ileocecal disease and 90% at ten years. – 5050-60% of patients with perianal Crohn’s disease will develop an abscess: 60% will have recurrent abscesses. More recently, decreasing rates of surgery in IBD have been noted: 35% rate of surgery within one year of diagnosis between 1962 and 1987 vs vs. 12% between 2003 and 2005. (Vend et al., 2006) No differences in 5 and 10 year rates reported so far.

The question then b becomes nott “If?” but “When?” Is it better to salvage or treat?


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Indications for Surgery Intestinal Obstruction Intraabdominal Abscess Fistulas Perforation Toxic Colitis Anorectal Abscess/ Fistula in Ano Refractory Disease

Intestinal Obstruction


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Cut, cut, cut….


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Intestinal obstruction may be due to a single narrow stricture or series of strictures strictures. May present acutely (acute inflammation, food bolus obstruction) or with chronic symptoms. Surgery reserved for fibrotic strictures, acute obstruction which does not resolve, or with associated fistula fistula, abscess abscess, or malnutrition malnutrition.

Single stricture or stricture associated with fi t l or abscess b ttreated t d with ith resection. ti fistula Multiple strictures treated with stricturoplasty. Recurrence rates higher for short disease duration, age, number of duration younger age strictures/stricturoplasties, and short interval from prior resection/stricturoplasty.


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Stricturoplasty


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Laparoscopic Surgery Diagnostic laparoscopy Adhesiolysis Fecal diversion for perineal sepsis (stoma creation) Closure of stomas Segmental small bowel resections


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Ileocolectomy Strictureplasty Feeding jejunostomy Segmental or total abdominal colectomy with or without anastomosis TPC with IPAA

Laparoscopy for Crohn’s disease

Comparative Studies Author

Study

Lap/Ope n (n)

Oper.time

Conversio n (%)

Morbidit Morbidity y

(min)

(%)

Hospital stay (days)

Bemelman, 2000

Case Case-control

30/48

138/104

6.6

10/14.6

5.7/10.2

Alabaz, 2000

Case Case-control

26/48

150/90.5

11.5

15.4/16.7

7/9.6

Milsom, 2001

RCT

31/29

140/85

6

12.9/27.6

5/6

Young--Fadok, Young

Case Case--match

33/33

147/124

5.9

-

4/7

Msika, 2001

Prospective Case Case-control

20/26

302/244.7

0

9.5/18.5

8.3/13.2

Duepree, 2002

Case Case-control

21/24

75/98

4.8

14.3/16.7

3/5

Bergamaschi,

Case Case-control

39/53

185/105

0

10.2/9.4

5.6/11.2

5

0/5

4.25/8.2 5

2001

2003

Bold, statistically significant (p