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Q & A

Q & A. Greetings from New Orleans & The Ochsner Clinic . Restorative Proctocolectomy “ T he Pelvic Pouch Procedure in 2004” The Royal I nfirmary Manchester U.K. April 1, 2004. Terry C. Hicks, M.D. GOALS:. I ndications Technique Complications Controversies. Know the Enemy!.

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Q & A

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  1. Q & A

  2. Greetings from New Orleans & The Ochsner Clinic

  3. Restorative Proctocolectomy“The Pelvic Pouch Procedure in 2004”The Royal Infirmary Manchester U.K.April 1, 2004 Terry C. Hicks, M.D.

  4. GOALS: • Indications • Technique • Complications • Controversies

  5. Know the Enemy!

  6. Restorative ProctocolectomyThe Disease of Concern • Ulcerative Colitis • Familial adenomatous polyposis • Crohn’s disease • Indeterminate Colitis

  7. Ulcerative Colitis • Ulcerative Colitis is an inflammatory disorder. It affects the rectum and extends proximally to affect a variable extent of the colon. • The cause of the disease, and the factors determining its chronic course are unknown.

  8. Etiology of Ulcerative Colitis • 150 years after the discovery of this disease by Samuel Wilkes, the etiology of ulcerative colitis remains unknown. • The major hypotheses in 2003 include: infection, allergy to dietary components, immune responses to bacterial or self-antigens, and the psychosomatic theory.

  9. Incidence of Ulcerative Colitis Period of INCIDENCE Study (Per 100,000) USA Minnesota 1935-64 7.2 Baltimore 1960-63 4.6 UK Oxford 1951-60 6.5 Wales 1968-77 7.2 Aberdeen 1967-76 11.3 Denmark Copenhagen 1962-78 8.1 1981-88 9.5 Holland Leiden 1979-83 6.8 Sweden Stockholm County 1975-79 4.3 Israel Tel-Aviv 1961-70 3.6

  10. Medical Management of Ulcerative Colitis Active disease Mild-moderate disease Distal colitis Sulfasalazine or 5-ASA preparation (oral or rectal) Topical corticosteroid Extensive colitis Sulfasalazine or oral 5-ASA preparation Moderate-severe disease Distal colitis Topical corticosteroid Prednisone Extensive colitis Prednisone Severe-fulminant disease Extensive colitis Parenteral corticosteroid Intravenous cyclosporine Infliximab (Remicade) reports of small bowl tumors • Inactive disease • Distal colitis Sulfasalazine or 5-ASA • preparation (oral or rectal) Azathioprine or 6-MP • Extensive colitis Sulfasalazine or oral 5-ASA • preparation Azathioprine or 6-MP

  11. “Familial Adenomatous PolyposisSyndrome”

  12. “Familial Adenomatous Polyposis Syndrome” • Gastrointestinal polyposis refers to the presence of numerous polyps throughout the GI tract. Most of these syndromes are inherited, and most are associated with an increased colon cancer risk. • FAP is the most common adenomatous polyposis syndrome. Patients develop hundreds to thousands of adenomas, and if the colon is not removed, colon cancer is inevitable. • This disease is autosomal dominant with 80% to 100% penetrance and a prevalence of 1:7500.

  13. “Familial Adenomatous Polyposis Syndrome” • In 1987, a gene for FAP was isolated, and genetic testing is now available to identify family members that are carriers. • The average age of detectable polyps is 15 years. • Average age of cancer is 10-15 years after the onset of the polyps. • Associated findings: • Gastric polyps – 30 to 100% • Duodenal polyps – 60 to 90% • Papilla Vater Adenomatous Changes – 50 to 85% • Duodenal Cancer Lifetime Risks – 4 to 12% • Desmoid Tumors – 4 to 32%

  14. Familial Adenomatous Polyposis

  15. Crohn’s

  16. The “Crohn’s Disease” Trio in 1932

  17. Crohn’s Morphology

  18. Endoscopic Features of Ulcerative Colitis and Crohn's Disease Characteristics Ulcerative Crohn's Colitis Disease Distribution Symmetric AsymmetricRectal involvement Always VariableSkip lesions No YesVascular pattern Blunted Frequently normalFriability Frequent InfrequentErythema Frequent Less frequentAphthous ulcers No YesLinear ulcers Rare FrequentSerpiginous ulcers Rare FrequentCobblestoning No YesPseudo-polyps Frequent Frequent

  19. The Case Against R.P. for Crohn’s Disease • High complication rate (vs UC) • High pouch failure rate (vs UC) • Pouch excision risky, complicated • Small bowel loss is failure • Salvage surgery…High failure rate • Literature reports…Where • presumptive diagnosis was UC or indeterminate

  20. Final Thoughts on Crohn’s • Rarely should restorative proctocolectomy be advised if a diagnosis of Crohn’s is known prior to surgery. • One stage restorative proctocolectomy should be resisted in nearly all emergency situations. • At all times, it is the duty of the surgeon to inspect the resected specimen before pouch construction. If there are questions as to the diagnosis (even after frozen sections) forego pouch formation. • If patients with a pouch later develop clear evidence of Crohn’s, judge each case on its merits (i.e. Function: Are complications amenable to further surgical treatment?)

  21. Forrest says, “Inflammatory Bowel Disease is like a box of choc-lits”

  22. “Indeterminate Colitis” • Those five to ten percent of inflammatory bowel disease patients that can not be clearly diagnosed as either Crohn’s or ulcerative colitis.

  23. IPAA for Indeterminate Colitis at CCF Stool frequency 6.0 6.0 0.99 Night frequency 2.0 1.0 0.001 Q. Of life 9 9 0.06 Q. Of health 8 9 0.07 L. Of energy 8 8 0.21 L. Of happiness 10 10 0.28 IPAA again? (%) 93.3 97.9 0.05 IPAA for others? (%) 97.9 98.2 0.99 Indeterminate Ulcerative p

  24. Surveillance for Colorectal Cancer in Ulcerative Colitis

  25. Surveillance for Colorectal Cancer in Ulcerative Colitis • Colorectal cancer occurs in approximately six percent of patients with extensive disease and will be the cause of death in about three percent. • The risk of developing colorectal cancer increases over time, is greater in patients with extensive disease, older age at the onset of symptoms, and in those with cholestatic liver disease and sclerosing cholangitis . • The frequency of surveillance colonoscopies is contentious. • Goal of surveillance is to detect dysplasia.

  26. Surveillance for Colorectal Cancer in Ulcerative Colitis (cont’) • Low-grade dysplasia progresses or is synchronous with cancer 18% to 30% of patients. • High-grade dysplasia is concurrent with cancer or progresses to cancer in 40% of patients. • It is suggested that four biopsies be taken at ten centimeter intervals throughout the colon.

  27. Colonoscopic View Normal UC

  28. Normal UC UC

  29. SURGICAL INDICATIONS FOR ULCERATIVE COLITIS UrgentNon-urgent Severe/fulminant colitis Medically refractory disease Toxic megacolon Unacceptable medication-related toxicity Perforation Dysplasia, DALM, or suspected cancer Massive hemorrhage Selected extraintestinal manifestations Acute colonic obstruction Growth failure in children Colon cancer DALM = dysplasia-associated lesion or mass Immediate surgery warranted Prompt but not immediate surgery warranted Refractory to medical therapy Refractory to 5-aminosalicylic acid, corticosteroids, and immunomodulators

  30. Contraindications to Restorative Proctocolectomy Ulcerative Colitis Absolute • Acute, fulminant colitis, especially with clinical toxicity, peritonitis, or perforation of the colon • Known Crohn’s disease at time of operation • Severe anal sphincter dysfunction • Carcinoma of the distal rectum Relative contraindications • Morbid obesity • Severe malnutrition or debility • Age > 65 years • Psychologically impaired or patients at high risk for non-compliance.

  31. Age and IPAA • Early restrictions • Safety as experience increases • Expansion of age limits • Patient assessment of quality of life vs. • function • Function Quality of Life • Under 60 years +++ +++ • 61–70 years ++ +++ • 70 years plus + ++

  32. The Presence of Cancer…..Does it Rule Out IPAA? • The presence of colon cancer does not preclude IPAA (adherence to traditional standards of oncologic resection need to be maintained). • If advanced mid or low rectal cancer is diagnosed, this may preclude IPAA.

  33. Ulcerative ColitisSurgical Options • Proctocolectomy and Ileostomy • Colectomy and Ileostomy • Colectomy and Ileorectostomy • Proctocolectomy and Continent Ileostomy • Restorative Proctocolectomy

  34. Continent Ileostomies - Kock pouch (1969-1972)

  35. Continent Ileostomies • Stoma • Smaller & Flush • Lower in Abdomen

  36. Late Complications • Valve Slippage: 3 - 25% • Fistula : 3% • Skin Level Stenosis : 8% • Prolapse : 3% • Pouchitis : 5 - 43%

  37. Restorative Proctocolectomy • Major Operation • Cures Disease • Evacuation vs Normal Route • Bowel Function • Technical Variations or Controversy

  38. Restorative Proctocolectomy Variations or Controversy • Pouch Design • J , S , W , H • Anastomosis • Double-Stapled • Mucosectomy • Diversion

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