- I wanted to introduce Ann Lowry who's a professor of
colon and rectal surgery at the University of Minnesota.
She did her undergraduate training at Radcliffe College
and residency at New England Medical Center.
She did her colon and rectal surgery fellowship at
the University of Minnesota where she has advanced
to the level of Professor.
She has served as the program director for colon and
rectal surgery fellowship up there and as well,
been the president of the Association of Program Directors
for colon and rectal surgery and is the past president
of the American Society of Colon and Rectal Surgeons
and just to remind you, we do actually read these things
that you've put and one of the most frequent comments
last year was requesting someone to speak about
perianal and pelvic complications of IBD and how
to do medical and surgical combining therapies
so we are fortunate that Dr. Lowry's here the first day.
- [Dr. Lowry] Thank you for the invitation and I've
had a really nice time here the last couple days.
I've gotten to see some old friends and make some
new ones and I'm very impressed by the facility
and the program so I've learned things which
is always a two way street so I hope I can give
back a little bit.
As Peter said I'm gonna talk about surgical dilemmas
in inflammatory bowel disease.
Basically my views, a few philosophic comments.
My view about inflammatory bowel disease may be all
surgical care is that there's a team approach
and we want the best for our patients and for
inflammatory bowel disease what that means is
that we all recognize that there've been
significant advances recently in IBD therapy.
But the surgery is sometimes necessary.
There is always this tension and I think particularly
inflammatory bowel disease,
it may not be so present here but it certainly
is in many centers.
On the GI side, calling us means that you've failed,
and on the surgical side it may mean a little
over enthusiasm about a chance to cut is a chance
to cure and it's balancing that tension that's
really important for the patient.
Surgical decision making can in many ways be brought
down to some very simple questions as,
do they need an operation, if they do what operation
to do and what's the best way to do the operation?
I'm gonna pick some particular clinical scenarios
this morning, they're situations and mostly
focus on what operation to do and a little bit
on what is the best way to do the operation.
I'm sure you have lots of discussions in this
forum about whether patients need an operation or
what are the indications.
And I've picked these three situations,
one ulcerative colitis, Crohn's colitis and
then perianal Crohn's disease.
And again, just a brief philosophic statement
that oversees all of our care, surgical care
for our IBD patients is first, do they really
need an operation?
And then if they do, our goal is to preserve bowl
and particularly to preserve function.
There are a number of reasons patients with
ulcerative colitis come to surgery and the
comments I'm gonna make about the surgical
questions of ulcerative colitis really apply
the most to the first two indications.
Toxic colitis is a different set of decisions
and I'm not gonna focus on that this morning.
(instructor and students discussing if room
is light enough to see properly).
As everyone knows, patients who have surgery for
ulcerative colitis, most of them require a total
proctocolectomy and there are a number of options
about what to do with the end of the small intestine
and the first two are the most commonly chosen
choices in most centers and
there is an emerging consensus that because of the ease
of the procedure, patient preference and the results,
there's almost near universal adoption of a J-pouch.
But there's still some questions in the surgical world
that remain controversial or needing discussion and
one is, do we do that anastomosis as a hand sewn
anastomosis or as stapled?
The hand sewn involves doing a mucosectomy of the
distal rectum and then sewing the J-pouch
to the anal canal.
Stapled is that we staple off the distal rectum
but you can see we're leaving this short cuff
of the distal rectum and then the J-pouch is
stapled to that rectal cuff.
In general it's felt that there's better function
with stapling, there's less incontinence and
may be related to a better sampling reflex
and that there are more anal problems,
both functional problems like the control issues
but also complications like anastomosis and leak,
stenosis and leading to more pouch removal.
And there has been a meta analysis, published just
a few years ago, of a large number of patients
comparing these two techniques and that
meta analysis confirms what peoples clinical
impressions have been that in hand sewn pouches
there's more likelihood of pouch failure and
significantly more functional issues
that patients are more likely to seep at night,
they're more likely to need to wear a pad
and have even day time incontinence.
So the consensus that's emerging about that
is that the staple technique is almost always used.
One discussion point, at lease in surgical conferences
is what do we do about patients who have
dysplasia in the rectum and are they still patients
that should have a mucosectomy and a hand sewn anastomosis?
Another surgical questions is do all of those patients
need to be diverted?
The standard treatment is has been moving towards a
two stage procedure where patients get the total
proctocolectomy and formation of the J-pouch
with a temporary ileostomy then the
ileostomy is taken down.
When these first were being done they were done
in three stages where the abdominal colon was
taken out, an ileostomy and a Hartmann pouch,
then the J-pouch was made, then the ileostomy was made.
We've moved through that to the two stage procedure
and then now to the question, does everybody
need to be diverted?
And again, I'm only talking about the elective patients.
We know that diverting the way that ostomies have
been proven to be useful for emergency surgery,
the question is, are they necessary for this?
And the arguments in favor of diversion are,
that while it does not prevent leaks,
it decreases the mortality from leaks,
it minimizes those functional consequences of leaks.
In addition to sepsis there's less likely to be
strictures or pouch failure and closing a
loop ileostomy is a pretty simple procedure
with very low morbidity.
Fewer patients needed a re-exploration and
some argue that since a percentage of these patients
will go on to a permanent ileostomy that it
makes sense for them to experience an ileostomy
so that if they are in that group that needs to
eventually have a permanent ileostomy they're
not quite so fearful.
The arguments against it are, the patients would obviously
prefer it both to avoid the ileostomy and to just
have one operation.
In some patients, either, particularly overweight
patients, the ileostomy may be technically
difficult to fashion because we're limited
by how much stretch we want to put that
ileoanal anastomosis on.
There is clearly a shorter total hospital stay
and therefore less cost and, while ileostomy
closure is a fairly simple procedure,
it does have associated morbidity.
There's also been a recent meta analysis
about this issue and this looked at studies
from 1978 to 2005, about 1500 patients and
it covered, pretty evenly split into patients who
were diverted and patients who weren't.
In this table, if the odds ratio is greater than one
it favors having a stoma so you can see that clearly
having a stoma was good, in terms of avoiding a leak.
There's a trend toward reducing pelvic sepsis or
pouch related sepsis although that wasn't significant.
Not too surprisingly it goes the other way for
anastomotic stricture.
What is a little more surprising is that pouch
failure is less in the patients who were not diverted
compared to the patients who were diverted.
That probably is an issue of patient selection
but it was a pretty consistent finding.