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Surgery for inflammatory bowel disease

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Surgery for inflammatory bowel disease By Rajeev Suryavanshi Dept of General surgery Inflammatory bowel disease Definition- Group of conditions involving whole or ... – PowerPoint PPT presentation

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Title: Surgery for inflammatory bowel disease


1
Surgery for inflammatory bowel disease
  • By
  • Rajeev Suryavanshi
  • Dept of General surgery

2
Inflammatory bowel disease
  • Definition-
  • Group of conditions involving whole or part
    of the bowel in the inflammatory process.

3
Causes of inflammatory bowel disease.
  1. Infective bacterial, viral, parasites
  2. Ulcerative colitis
  3. Crohns disease
  4. Radiation enteritis
  5. Ischemic colitis
  6. Microscopic colitis
  7. Drug induced colitis

4
Inflammatory bowel disease
  • Ulcerative colitis
  • Prevalence 80/100,000 in Europe
  • Peak Age 20-35 year
  • Characteristic feature- acute mucosal
    inflammation with crypt abscesses.
  • Crohns disease
  • Prevalence 40/100,000 in Europe
  • Incidence is increasing
  • Characteristic feature- Patchy transmural
    inflammation with non-caeseating granuloma.

5
Pathophysiology-
  • Exact Pathophysiology still unclear, both
    diseases have some features in common.
  • Inappropriate activation of mucosal immune
    system.
  • May have defective barrier function.
  • Genetic factor-
  • - variable prevalence in different population
  • - higher incidence in 1degree relatives
  • - ? Concordance in monozygotic twins.
  • Environmental factors-
  • - Smoking
  • - NSAIDs.

6
Pathological features
  • Ulcerative colitis-
  • Lesion continuous superficial.
  • Rectum always involved
  • Granulated, ulcerated mucosa.
  • No fissuring
  • Normal serosa
  • Muscular shortening of colon
  • Malignant change

7
Ulcerative colitis
  • Bowel showing severe ulcerative colitis with
    Pseudo polyp formation

8
Pathological features
  • Crohns disease-
  • Lesion patchy, penetrating
  • 50 no rectal involvement.
  • Terminal ileum involved in 30
  • Discretely ulcerated mucosa
  • Cobblestone appearance and fissuring.
  • Serositis common
  • Enterocutaneous or intestinal fistulae
  • Anal lesions in 75
  • Possible malignant change.

9
Crohns disease
  • Opened specimen of Terminal ileal Crohns disease.

10
Crohns disease
  • Histological appearance of Crohn's disease
    showing transmural inflammation

11
Clinical features of Ulcerative colitis
  • 30 confined to rectum.
  • 15 develop more extensive disease over 10 years.
  • 20 whole colonic involvement at presentation.
  • Clinically classified -
  • Severe acute colitis
  • Intermittent relapsing colitis
  • Chronic persistent colitis.
  • Asymptomatic disease.

12
Disease Severity ulcerative colitis
Grade Number of stools per day Systemic features- (Tachycardia, Fever, Anemia, Hypoalbuminaemia.)
Mild lt 4 Systemically well
Moderate gt 4 Systemically well
Severe gt 6 Systemically unwell
13
Endoscopic grading of ulcerative colitis
Grade Features
0 Normal
1 Loss of vascular pattern, granularity
2 Granular mucosa with contact bleeding
3 Spontaneous bleeding
4 ulceration
14
Endoscopic view
  • Ulcerative colitis at endoscopy

15
Endoscopic view
  • Crohns disease at endoscopy

16
Clinical features Crohn's disease
  • Depend on site of involvement
  • 50 have ileocecal disease
  • 25 present with colitis.
  • Systemic features more common.
  • Picture showing Crohn's stricture

17
Extra intestinal manifestations of IBD.
  • Associated with disease activity-
  • Skin
  • Erythema nodosum, Pyoderma gangrenosum
  • Joints
  • asymmetrical non - deforming arthopathy.
  • Eyes
  • anterior uveitis, episcleritis,
    conjunctivitis.
  • Hepatobiliary
  • Acute fatty liver
  • Thromboembolic disease

18
Extra intestinal manifestations
  • Pyoderma gangrenosum.

19
Extra intestinal manifestations -
  • 2. Unrelated to disease activity -
  • Joints
  • Sacroilitis, Ankylosing spondylitis
  • Hepatobiliary
  • - Primary sclerosing cholangitis
  • - Cholangiocarcinoma
  • - Chronic active hepatitis
  • - Gall stones
  • Amyloid
  • Nephrolithisis

20
Surgery for IBD
  • Surgical indication differs in ulcerative colitis
    and Crohn's disease.
  • Permanent Cure possible in ulcerative colitis,
    with Panproctocolectomy.
  • No cure possible in Crohn's disease, due to
    relapsing nature and tendency to recur anywhere
    in the gut. Surgery limited in treating
    complications.

21
Indications for Surgery in Ulcerative Colitis.
  • 20 of patients with Ulcerative colitis require
    surgery at some time.
  • 30 of those with total colitis require colectomy
    in 5 years.

22
Surgery in ulcerative colitis
  • Emergency -
  • Toxic Megacolon
  • Perforation
  • Hemorrhage
  • Severe colitis not responding to medical
    treatment.
  • B. Elective -
  • Chronic symptoms despite medical therapy.
  • Carcinoma or high grade dysplasia.

23
Ulcerative colitis
  • Radiograph showing features of toxic dilatation
    of colon in ulcerative colitis.

24
Surgical Options
  • Emergency -
  • Total colectomy with ileostomy and mucus fistula.
  • B. Elective -
  • Panproctocolectomy and Brooke ileostomy.
  • Panproctocolectomy and Kock continent ileostomy.
  • Total Colectomy and ileorectal anastomosis.
  • Restorative Proctocolectomy with ileal pouch.

25
Continent reservoir (Kock pouch)
  • Kock 1969 designed a reservoir from terminal
    ileum.
  • Indication was narrowed significantly with
    ileoanal pouch surgery as standard in 1980s.
  • Indication today-
  • Failed ileoanal pouch with poor sphincter
    function
  • Past Proctocolectomy with sacrifice of anal
    sphincter and ileostomy but want a continent
    ileostomy.

26
Restorative Proctocolectomywith ileal pouch
  • Need adequate anal musculature
  • If over 60 years, suggested evaluation with anal
    manometric studies.
  • Any histological evidence of Crohn's on rectal
    biopsy is absolute contraindication for any pouch
    procedure.
  • Need for mucosectomy unclear.
  • May need defunctioning ileostomy.

27
Pouch design
  • ileoanal pouch designs

28
ileoanal pouch
  • ileoanal pouch during surgery.

29
Functional results of ileoanal pouch
  • Mean stool frequency is six per day.
  • Perfect continence
  • During day - 90
  • At night - 60
  • Gross incontinence 5.

30
Proctocolectomy with ileal pouch
  • Morbidity
  • 50 develop significant complications.
  • Small bowel obstruction 20
  • Pouchitis 15
  • Genitourinary dysfunction 6
  • Pelvic sepsis 5
  • Fistula 5
  • Pouch failure 6
  • Anal stenosis 5
  • Larger capacity pouches reduce stool frequency.

31
Surgical indications Crohn's disease.
  • Absolute-
  • Perforation with generalized peritonitis.
  • Massive hemorrhage
  • Carcinoma
  • Fulminant or unresponsive acute severe colitis.

32
Surgical indications Crohn's disease
  • B. Elective -
  • Chronic obstructive symptoms.
  • Chronic ill health or debilitating diarrhea.
  • Intra-abdominal abscess or fistula.
  • Complications of Perianal disease.

33
Surgical options in Crohn's disease
  • Limited resections.
  • 30 undergoing ileocecal resection require
    further surgery.
  • Stricturoplasty often successful.
  • Bypass procedure rarely required.
  • Few facts-
  • Be conservative as possible.
  • No evidence that increased resection margin
    reduces risk of recurrence.
  • If possible improve preoperative nutritional
    state.

34
Surgery in Crohn's disease
  • Small bowel or ileocecal disease-
  • Resection-
  • - appropriate for single ileocecal lesion
  • - if mesentery thickened , transfix vessels.
  • - wide anastomosis suggested.
  • Detecting distal stenosis-
  • - using balloon catheter to detect proximal
    stenosis.

35
Surgery in Crohn's disease
  • Skip lesions
  • - ileocecal lesion with skip lesion, need
    resection of ileocecal region with proximal
    stricturoplasties
  • - Stricturoplasty ideal for duodenal
    disease.
  • - if multiple stricturoplasties done inflate
    stomach via NG tube with 2L of Co2, saline in
    abdominal cavity and test for leak

36
Surgery in Crohns disease
  • Technique showing Stricturoplasty in Crohn's
    disease.

37
Surgery for Crohn's disease-
  • B. Colorectal Disease-
  • Evaluation with colonoscopy, Anorectal
    physiological studies.
  • Localized area local excision
  • Wide distribution with no rectal involvement
    total colectomy with ileo rectal anastomosis.
  • If rectum involved- Panproctocolectomy.

38
Anal disease Crohn's
  • Often painless, and managed conservatively.
  • If pain suspect pus pocket in Perianal region.
  • EUA deroofing without sphincter division is
    indicated.
  • More chances of incontinence with aggressive
    surgery, rather than progressive disease.

39
Fistula Crohn's
  • Enteroenteric fistula common from ileocecal
    disease (small bowel to sigmoid colon)
  • Flexible sigmoidoscopy is helpful.
  • Surgical - resection of diseased segment
    anastomosis of healthy segment, interrupted
    repair of fistulous site is indicated.
  • Ensure no distal stenosis.

40
conclusion
  • Disease is very old and nothing about it has
    changed. It is we who change as we learn to
    recognize what was formerly imperceptible.

41
Thank you
42
  • Add servellance for ulcerative colitis .
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