Colorectal Surgery Department Surgery for Inflammatory Bowel disease E.Condon Beaumont Hospital/ RCSI, Dublin. Colorectal Department

Colorectal Surgery Department

Surgery for Inflammatory Bowel disease

E .Condon

Beaumont Hospital/ RCSI, Dublin.

Colorectal Department


OverviewTypes

1. Diverticular disease

2. Ulcerative colitis

3. Crohns Disease

4. Ischemic colitis

5. Amoebiasis

6. Pseudomembranous colitis

7. Radiation enterocolitis


Diverticular disease• Definition ; Herniation of bowel mucosa through the

bowel wall (Blood vessels)

• Sites sigmoid and descending colon

• Raised intraluminal pressure

• Segmental contraction

• 30% of all patients over 60 in the western world


Presentations• Acute diverticulitis

• Chronic diverticulitis

Complications of diverticulitis• Obstruction• Abscess formation• Diffuse peritonitis• Fistula• Haemorrhage


Diagnosis• Bloods

• CT

• Barium

• Colonoscopy


Indications for surgery• Acute diverticulitis- all complications except abscess

• Chronic diverticulitis – Persistent Pain /anemia

• 2 episodes of mild diveriticulitis


Surgical options• Laparoscopy

• Sigmoid colectomy

• Hartmans

• Anterior resection

• Transverse colostomy and peritoneal toilet


Operating theatre


Best operation to Do??

• Sigmoid colectomy

• Anterior resection

• Hartmans


Ulcerative colitis• Definition; disease of unknown cause charecterised by

non specific and diffuse inflammatory changes of the mucosa of the rectum and the large bowel

• Causes

• Infection

• Allergy

• Autoimmunity


UC• Disease is mucosal

• Serosa – no serositis

• Segment usually descending colon

• Mucosa reddened friable

• Pseudopolyps

• Microscopic – inflammatory cellular infiltration of mucosa and the submucosa crypt abscesses dysplasia transmural inflammation


Symptoms• Bloody diarrhoea

• Abdominal discomfort

• Diagnosis – colonoscopy barium enema

• Treatment

• Steroids local systemic

• NSAIDS

• Bowel rest


Indications for surgery• Relative indications

– Chronic invalidisim- severe colitis few years chronic ill health anemia

– Relapsing colitis 2 severe episodes in 3years– Persistent steroids – the complications of roids

• Absolute indications– Failure of medical therapy in acute severe attack– Perforation– Toxic megacolon


Operating theatre


Surgical Options• 1. ileostomy

• 2.Proctocolectomy- permanent ileosotmy

• 3.Total colectomy- later ileorectal anastomosis

• 4.Pouch 2 stage / 3 stage

• 5. Total colectomy with ileostomy


Best Surgery• Pouch 3 stage

• Proctocolectomy- permanent ileostomy


Pouchs• J Pouchs

• Advantages no stoma / continence

• Complications• Infertility• Pouchitis• Pouch failure 10 years 18 % • crohns


Crohns• Definition ; regional enteritis granulomatous

entercolitis

• Unknown cause ( toothpaste)

• Characterised by discontinuous full thickness inflammation anywhere in the GI tract

• Common sites ileocaecal skip lesions in the ileum and perianal suppuration


Crohns• Key histological differences

• Granulomas

• Fibrosis

• Full thickness

• Fistulas


Presentation• Usually regional ileitis• Like appendicitis• Mass RIF• Diarrhoea• Obstruction• Perforation• Fistula• Perianal Crohns• Anemia


Indication for Surgery• Surgery nearly always treatment of choice 80-90% of

cases ultimately require surgery

• Perianal disease and fistulas


Operating theatre


Surgical options• Regional ileitis

– Ileal resection primary reanastomosis– Right Hemicolectomy

• Colonic crohns– Panproctocolectomy and permanent ileostomy– Perianal crohns fistulotomy





Ischemic colitis• Inflammatory response in the colon following an

ischemic episodeowing to occlusion or narrowing of the inferior mesenteric artery

• Causes

atheroma

embolism

surgery/ trauma

Severity depends on the duration and the patency of the marginal artery


Presentations• 2 phases

– Mucosal gangrene– Secondary invasion with organisims which accelerate the

gangerenous process

• Ischemic colitis with gangerene

• Transient ischemic colitis

• Stricture


Surgical options• Transient ischemic colitis –mesenteric angiogram

stenting of affected segment – primary vascular repair

excision of the affected segment

Ischemic colitis with gangarene excision total colectomy with permanent ileosotomy 80% mortality


Amoebiasis• Entamoeba histolytica

• Cyst water /faecal oral /sexual

• Colitis

• Transmural colitis with perforation

• Infamatory mass

• Hepatic abscess

• Stool exam ct scan -flagyl

• Perforation -resection


Pseudomembranous colitis• C difficile – cephalosporins

• Diarrhea

• Bowel rest / flagyl/ vancomycin ORALLY

• Toxic dilatation > 6 cm impending perforation

• PFA CT

• Proctocoletomy end ielostomy


Radiation enteritis• Usually SB following therapeutic radiation less

common now

• Diarrhoea /obstruction

• Ileitis /proctitis

• Treatment NSAIDS steroid rarely resect except for strictures


General Advise

• Categorise youre answers

eg intestinal obstruction

in the lumen

outside the lumen

in the wall

in medical

Be logical and organised


Answer questions• Definition• Pathology • Classification• Causes • Differential diagnosis• Symptoms signs• Complications S&S of complications• Investigations bloods radiology surgical• Management medical/ surgical• prognosis


Questions?

Good Luck!!


Preoperative MRI

• Preop MRI scanning allows selection of patients who will benefit from a course of preoperative radiotherapy

• T3 or T4 primary tumour or node positive patients

lymph node


MRI

• Main indication in rectal cancer T3 or not T3

• Every patient with rectal CA should have pre-op MRI to decide whether or not neoadjuvant therapy is indicated


PET Scanning

Local recurrence at the splenic flexure


Current indications for PET Scanning• FDG PET is approved detection and localisation of

recurrent colorectal cancer in patients with rising CEA levels and indeterminate findings on standard imaging studies

• Indications may expand in the future but its final role is still to be determined

• Radilogical imaging modalities in the diagnosis and management of colorectal cancer , Heamatology clinics of north america 202 16;90 875-95


Virtual Colonoscopy


Virtual colonoscopy – how does it work

• Virtual Colonoscopy is a promising new method for detecting colorectal polyps and cancers. Air is insufflated into a cleansed colon, and high resolution, thinly-collimated spiral CT slices are acquired. The two dimensional slices, as well as the post-processed "fly-through" virtual colonoscopic images, are examined for polyps and tumors.


Virtual Colonoscopy- advantages• Advantages of Virtual Colonoscopy

Virtual Colonoscopy is minimally invasive, and does not carry the low but real (1 in 1500) risk of perforation associated with Conventional Colonoscopy. It is well tolerated by patients and does not require sedation. It is capable of evaluating the colon upstream from obstructing lesions that prevent passage of an endoscope. Virtual Colonoscopy is significantly less expensive than Conventional Colonoscopy.


Virtual Colonoscopy-Disadvantages• The dose of ionizing radiation is less than that of a

conventional abdominal CT, and is comparable to obtaining a supine and upright plain film exam of the abdomen.

• Colonoscopy by CT does not provide the same information as Conventional Colonoscopy. Mucosal detail and color is not visible which limits the characterization of lesions. In addition, the detection of small polyps is inferior


Virtual colonoscopy-disadvantages• As with any procedure, including Conventional

Colonoscopy, there are no guarantees that all clinically significant growths will be detected. It should be remembered than between 10 and 20% of all polyps, and up to 5% of colon cancers are missed, even on Conventional Colonoscopy.

• Virtual Colonoscopy (like the Barium Enema) is a diagnostic not therapeutic technique. All patients in whom polyps are identified would need to undergo Conventional Colonoscopy for removal.


Virtual Colonoscopy Current indications

• Frail elderly patients

• Occlusive cancer for detection of other lesions

• Previous incomplete colonoscopy


Surgical Advances• LOCAL RESECTION

• TOTAL MESORECTAL EXCISION(TME)

• COLOANAL POUCH ANASTOMOSIS

• LAPAROSCOPIC SURGERY


Local Resection of low rectal tumours

Transanal resection or TEMS (Trans anal endoscopic microsurgery) allows anal sphincter preservation while avoiding the risks of abdominal surgery

- but its oncologic acceptability remains controversial. - No randomised trials exist- Safe application of this technique requires accurate

preoperative staging, careful transanal resection, and meticulous histological examination. Factors that increase the risk of recurrence following local resection include T stage, poor histological grade, lymphovascular invasion, and positive excision margins


Local resection for low rectal tumours

• Recent meta-analysis indicates that local recurrence occurs in

• 9.7% of patients (range 0%-24%) of patients with T1 tumors

• 25% (range 0%-67%) of those with T2 tumors

• 38% (range 0%-100%) of those with T3 tumors • Sengupta S,Tjandra JJ. Local excision of rectal cancer: what is the

evidence? Dis Colon Rectum. 2001;44:1345-1361.


Transanal Endoscopic Microsurgery


Total Mesorectal Excision


Total Mesorectal Excision• Definition; en bloc resection of the rectum and its

enveloping mesentery to the level of the pelvic floor with a negative distal and radial resection margin.

• reduces the incidence of local recurrence to less than 10% without the use of adjuvant treatment. Martling AL,

Holm T, Rutqvist LE, et al. Stockholm Colorectal Cancer Study Group,

Basingstoke Bowel Cancer Research Project. Lancet. 2000;356:93-96


Total Mesorectal Excision


Coloanal J pouch


Criteria necessary for successful sphincter preservation in rectal cancer

• No pre-operative alteration of sphincter mechanism.• TME and nerve sparing surgery.• No damage to levator ani.• Preservation of at least half of the internal sphincter.• Low rate of anastomotic leakage.• Low rate of pelvic sepsis.• Low rate of anastomotic stricture.• Allow good bowel function.


How can we improve function?

• Rectal cancer surgery may result in poor post-operative quality of life in survivors as a result of frequency, urgency and faecal soiling.

McDonald et al BJS 1983

• Postoperative function and continence after low anterior resection are significantly improved by a colonic pouch. Parc et al BJS 1986 Lazorthes et al BJS 1986 Mantyh et al DCR 2001


Coloanal J pouch vs. direct low anastomosis

• Lower morbidity.

• Better early function.

• Improvement of function persists with time.Lazorthes F. et al. Br J Surg 1997

Dehni N. et al. Dis Colon Rectum 1998

Harris G.J.C. et al. Br J Surg 2001

• Age not a contra-indication.Dehni N. et al. Am J Surg 1998


Coloanal J pouch: functional results

• Bowel movements 2.1 per 24 h• Continence

– Perfect or good 82%– Soiling 14%– Frequent fecal incontinence 4%

• Protecting PAD– Never 71%– As a safety 11%– Needed 18%


Coloanal J pouch: functional results

• Normal discrimination between 95%

flatus and stool

• Urgency 4%

• Fragmentation of stools 21%

• Suppository or enema 20%

to elicit evacuation


Conclusion

• Preoperative radiotherapy is followed by only minor deterioration in post-op anorectal function if colonic pouch anal anastomosis is performed.

• Reconstructive technique of choice in preoperatively irradiated patients.

transanal rectal mucosectomy

exclusion of anal sphincter from field of radiation


Laparoscopic Surgery

0

50

100

88 89 90 91 92 93 94 95 96 97 98 99

% L

apar

osco

pic

Cholecystectomy

Colorectal CancerResection

*Nair RG et al. British Journal of Surgery 1997;84:1369-98

*78.9%

*27.2%


Laparoscopic colectomy -Essential Questions

Is it safe?

• Clinically

• Technically

• Economically

• Oncologically


Laparoscopic Colorectal Surgery

• Early mobilisation

• Shorter ileus

• Reduced opiate requirement

• Lower cardiorespiratory morbidity

• Reduced hospital stay

• Cosmetically better

Potential advantages


Laparoscopic Colorectal Surgery

• Technically demanding• Difficult orientation• Increased operative time• Increased tumour dissemination• Increased postoperative morbidity

Potential disadvantages


Patterns of Recurrence and Survival after Laparoscopic and Conventional Resections for Colorectal Carcinoma

John E Hartley, et al

Annals of Surgery 2001;132:181-186


Methods 3 - Lap. Assisted

• “Laparoscopic principles are Open principles”

• Laparoscopic Mobilisation

• Intracoporeal vessel division

• Intra /Extracorporeal bowel division

• Extracorporeal stapled anastomosis

Operative Technique


Results 1 - Demographics Laparoscopic Open

n 58 53

Age 70 (51-87) 72 (36-90)

Sex M:F 38:20 42:11

Stage

Dukes A 12 10

Dukes B 19 15

Dukes C 22 21

Dukes D 5 7

Results 2 - Operative

Laparoscopic Open

Operative Time 185 (80-330) 122 (70-285)*

10

3

2

2

111

Tumour Fixity

Obesity

Adhesions

Bowel perforation

Small bowel obstrucion

Ureter not identified

Equipment failure

CONVERSIONS n=20 (34%) *p<0.05 Mann Whitney

Crude Survival - Kaplan-Meier 1

0

.2

.4

.6

.8

4030 2010 50 60 MONTHS

58

53 43

47 40

28

Probability of

Survival

p=0.6264. Log Rank Test

Laparoscopic

Open

2

9

11

2

Number at risk


RecurrenceOpen Lap. Assisted

Rectal Cancer n 27 28

Local + distant recurrence 2 1

Local recurrence in isolation 1 1

Total 3 (11.1%) 2 (7.1%)

Wound recurrence (all patients)3 (5.6%) 1 (1.7%)


Recurrence• Rectal Cancer

Local recurrence 3 of 27 open 11.1% 2 of 28 lap. assisted 7.1%

• Wound recurrence Open 3 of 53 5.6% Lap. assisted 1 of 58 1.7%


Conclusions

• Oncological outcome at two years is not compromised by an “all-comers” laparoscopic assisted approach

• Wound recurrence is a feature of both open and laparoscopic surgery for advanced disease


Conclusions - Current status

• Laparoscopic surgery for cancer is still in the development phase

• Convincing data that it is safe and new suggestions that survival may be improved

• Very operator dependant

• Needs strict control - ongoing audit and supervision.


NIHCLASICC

“The Ongoing Randomized Trials”

? 2003 AD

COLOR

SINGAPORE

BARCELONA


Single Positive Randomised Trial Laparoscopy-assisted colectomy versus open

colectomy for treatment of non-metastatic colon cancer: a randomised trial.

Lacy AM et al

Lancet 2002 Jun 29;359(9325):2224-9

Multicentre trials not yet reported CLASICC etc


Lacy trial continued• 219 patients (111 laparoscopic)

• Improved short term variables and

• Improved survival in laparoscopic group particularly for Stage III (ie node +ve) cancers

• Very significant data if can be replicated.– Single centre with enthusiast– Small numbers


Consensus Statements• “The use of laparoscopic surgery in the curative

treatment of colorectal cancer remains controversial. However, assuming appropriate adherence to the principles of surgical oncology there appears to be no difference in the adequacy of tumour resection and adjacent lymph nodes. In addition, the short term outcome appears comparable to open surgery in respect of morbidity, mortality and cancer recurrence including wound deposits.”

ACPGBI & AESGBI


Laparoscopic Assisted Colectomy

• Three port technique• Laparoscopic

• identification of anatomy• division of vascular pedicle• mobilisation of colon, mesentery

and relevant flexure

• Extracorporeal • delivery of specimen• determination of margins• anastomosis • closure of mesenteric defect



Operating theatre

Documents

Colorectal Surgery Department Surgery for Inflammatory Bowel disease E.Condon Beaumont Hospital/ RCSI, Dublin. Colorectal Department