>> Bashar: My name is Bashar Safar, I am the chief
of colorectal surgery at Hopkins
and I'm gonna speak a little bit about surgery for IBD.
I've broken my talk into separate,
rather than combine the diseases.
I'll speak about Crohn's a little bit
and then I'll speak about ulcerative colitis.
This is meant to be really more of general themes
rather than specific disease problems.
Surgery for Crohn's, again,
tends to be very much individualized,
so there's not one size that fits all,
but there is some general principles that we will follow.
The distribution of the disease, essentially, for Crohn's,
could be anywhere from the mouth to the anus.
It's primarily a GI disease,
but as we heard earlier,
it could be other extra intestinal manifestations.
The terminal ileum is the most commonly affected area
but you can also get Crohn's colitis.
And most patients present with a variety of issues,
but the most common
would be abdominal pain, weight loss, diarrhea.
Again, most patients start with inflammation,
and then as the inflammation goes on,
you either have a perforation or a narrowing.
So, if you have a narrowing, patients' will have cramping,
they'd get distended as they once after meals, or vomiting.
If it's a perforation,
then they'll have infections, abscesses
that need to be dealt with.
This is an old slide that's a GI, actually, slide,
but I think it really describes the disease very well.
Every patient comes in and they have inflammation
almost a hundred percent of the time,
that's the orange part of the slide.
And as you treat them, as their treatment gets underway,
with time, we hope that most of the inflammation settles,
but some go on to become stricturing disease,
some go on to become penetrating disease
which means they, penetrating is like,
either a fistula or an abcess.
It's a hole in the bowel in the GI tract
and that could be to anything.
You know, you can fistualize, or as I said,
just have an abcess inside the abdominal cavity
and that needs to be drained
because that is active infection.
Next three slides really talks about surgery over time,
in Crohn's disease,
and this was published a couple years ago.
And the risk of surgery after one year is about 15%.
Once you've had the disease for five years, it's 30%,
and this is both abdominal and rectal.
And once you've had the disease for 10 years,
it's about 50%.
So a lot of the patients, about half of the patients,
will end up having surgery in their lifetime, of some sort.
You really don't wanna see me,
unless you have to, as a Crohn's patient,
because there is no cure for the Crohn's,
for these patients, at this time.
Surgery is to deal with complication,
whether it's infectious or whether it's obstructing.
As I mentioned a little bit earlier,
that's what surgery does.
So, for lack of a better description, surgery is palliative,
it's not curative.
But what's important and what we do well, I think,
at Hopkins, is have an IBD team.
Doctor Leslie Brown and I used to share many patients
and we tend to sort of see patients early on.
So when patients come to me see,
that's not necessary, just because they need surgery.
Sometimes they just wanna talk about surgery,
what it means for them, what are the approaches,
what is the long-term outlook?
We need to get a really good understanding
of how much this bowel is involved
and make sort of a plan down the road.
Doctor Brown, again, talks on a lot of the other things,
you know, quit smoking, continue the medication,
should not really stop,
'cause all these things will increase the likelihood
of having surgery,
or emergency surgery, later on down the road
and that really is something that we want to avoid.
What are absolute indications
as patients who come in with a bad perforation,
they have bad infections or bad bleeding?
These are not very common, really.
I mean, in Crohn's disease, you're talking
about relative indications on those patients
who have slowly gotten worse over time,
with infections and/or an ability to maintain,
basically, thriving in pain, et cetera, et cetera.
What about surgery, when we go to surgery,
what are our options?
Really, I would say, resection
is our primary option in the GI tract.
And again, as I mentioned, the small bowel
is our primary target.
We keep removing the bowel to a minimum,
only what's diseased, what's obviously diseased comes out.
We do not really consider giving a patient a stoma,
i.e., a bag or an appliance to empty the waste through,
unless they're very sick.
Meaning they've lost a lot of weight
over a short period of time,
they have an active infection
that we cannot put a connection back
in the middle of a big abcess
or if we've lost a lot of blood in surgery,
which again, we don't typically run into.
And this last one is TNF-alpha inhibitors.
That's a relative one.
We feel, at Hopkins, or most of us surgeons at Hopkins,
feel like that's not an absolute indication
to have someone have an ostomy,
but it does increase the risk of anastomotic problems,
you know, when you put someone together.
Stricturoplasty is a way of not removing the bowel
but rearranging things.
So you have a narrowing, I'll show you some pictures,
so there's a narrowing in the bowel
as you see on the far right side of the screen.
We open a long side of the bowel wall
and then close it in the exact opposite direction
at 90 degrees.
So, essentially, effectively removing that narrowing.
And the other two, the Finney
and this other one, the isoperistaltic strictureplasty
is to address long strictures.
Now especially the last two
are really only applicable in patients with short bowel,
whereby, if you remove the segment,
they're gonna end up with a very short bowel
and, therefore, we try to avoid any resection.
The reality of the matter is the bowel that's strictured
its ability to absorb,
is probably significantly reduced.
We do not perform those extensive one's very often, at all.
In fact, we don't perform strictureplasties,
in general, much anymore
because essentially, if you have one area
that's diseased, we just remove that area
and put things together again.
It only is applicable if you have multiple areas
that are diseased
and they are separated by large segments of bowel,
then we would consider it.
This is how we do it, you know
there's a narrowing in the bowel.
We put a catheter with a balloon
and we try and drag it through.
And if it doesn't move past an area
then we feel that that area is significantly narrow,
then we need to do something about it.
This is interoperative pictures of the same thing.
We open it alongside the bowel.
If you see that sort of yellow stuff at the bottom,
that sort of mesentery,
where the fat coming into the bowel, the blood supply,
we open it alongside one side
and then we close it at the other.
And that, essentially, removes the obstruction.
And we do that in two layers.
There's a very, very small chance of having a cancer
in those strictures.
And we recommend, if you're gonna do a strictureplasty,
to take a biopsy of that area that's narrowed.
Laparoscopy, not really debatable much.
I think it's definitely to the preferred approach.
If you have complicated Crohn's disease, however,
with a lot of internal fistulae and/or the bowel
that's involving a large area that's perforated,
then I think the safety is questionable.
And I think what you really want is a safe operation.
But if it's possible to do it laparoscopically,
it's the way to go.
For straight-forward ileal resection,
laparoscopically, I think, has been shown
to cause less morbidity from the wounds
and no more complications from anastomosis or anything.
So it's definitely the preferred approach,
however, I would say for complex disease,
it might not be appropriate.
We take every case on a case-by-case basis.
We look at the CT, we look at the MRI,
we look at the patient themselves
and have a long discussion as to how we should do this.
There's no difference in the rate of recurrence
from resections if they've done laparoscopic or open.
So, if possible, do it open.
ECCO, I would encourage anybody
to sort of look at their guidelines
if they're about to go to surgery or have a treatment.
ECCO is the European Society for Crohn's and Colitis,
and they put out guidelines
and this is relayed as guidelines from 2017.
And they have actually guidelines, or recommendations,
for almost anything that you talk about,
whether what kind of therapy you should be on
and what kind of surgery you should have.
And they really say that laparoscopic approach is preferred.
Also, when you have a connection,
they recommend to staple side-to-side.
That's another discussion that surgeons sometimes have,
whether you should put them together end-to-end
or side-to-side
and it seems to have the least type of complications.
So, in summary, surgery for Crohn's,
it's not curative, it's palliative.
We would like to optimize nutrition as much as possible
and good communication between the gastroenterologist
and the surgeon, is key.
Because what we see sometimes patients
who we don't have in our system, they come from outside,
is they might have left things a little bit too late
and have gotten a little too sick
and that makes surgery a little bit more complicated
and might have to be staged.
Data on medications, such as Infliximab
and other TNF-alpha inhibitors, is conflicting.
I'm not sure it's clear
as to whether you should delay surgery
or do a different surgery
if you're on these medications for Crohn's.
And laparoscopy's approach is preferable, if possible.
So that settles that for Crohn's.
The next section, I'll spend some time speaking
about surgery for ulcerative colitis
which I feel is obviously a little bit different
to the first disease entity.
Ulcerative colitis is a disease confined to the GI,
to the colon, at least, and the rectum
and only affects only, not the entire wall,
but sometimes it's difficult to tell,
but not the entire wall of the colon.
It is sometimes difficult to tell
whether this patient have Crohn's or ulcerative colitis,
or indeterminate colitis,
'cause they have severe colitis.
But the bottom line is if you know it's ulcerative colitis,
the treatment, or at least the goals,
are a little bit clearer.
Once you take out the disease,
the surgery should be curative,
you know, they should not have ulcerative colitis anymore.
Now, they might have other problems
but they should not have ulcerative colitis anymore.
The indications today, for surgery,
are either cancer risk or failure of medical therapy.
And in the second one that I mentioned,
which is the first one, in my slide,
which is disease refractory to medical therapy,
I can tell you that patients are getting sicker and sicker
before they come to surgery today.
The surgery for ulcerative colitis
is decreasing in the country,
which is maybe a good thing, maybe a bad thing.
I think the fact that it's decreasing, it's a good thing,
but the coming sicker is not necessarily a good thing.
So if you need surgery,
you tend to have gone through
a couple of cycles of medications before you come,
and I'm not gonna go through the medications, at this point,
for ulcerative colitis.
The other one is complications
from the medical therapy
which means that you can't continue on the medical therapy,
therefore, surgery becomes your only option,.
Emergency, luckily, we run in to this very infrequently,
once or twice a year,
where patients come with something called toxic megacolon
where the bowel is very distended
and we feel like it's imminently going to rupture.
And that really has
a significant mortality associated with it;
that and perforation.
Bleeding, again, is uncommon, much like Crohn's disease.
What are the options when you come for emergency?
Really, there's only one option.
And whether it's toxic megacolon, or bleeding
or when you're sick in the hospital,
'cause we take out the entire colon
and give you an end ileostomy
where the waste comes out from your abdominal wall
from an end ileostomy.
This allows you to get better.
The rectum stays in place, you get better,
you come off all the medication, you gain weight,
you gain muscle mass and you get healthy.
After this, you take a break for about two or three months,
to get healthy, and then you discuss future options.
But this is the operation of choice for emergency surgery.
What about elective surgery?
I would say the most commonly approach to operation
or the most commonly performed operation today
for this disease is an ileal J-pouch,
which is a little J-pouch anastomosis,
or IPAA, as it's otherwise known.
The Brooke ileostomy is a regular ileostomy.
The Brook ileostomy is the same ileostomy
as I mentioned earlier.
It's an ileostomy that sits on the outside of the bowel,
on the skin, and then you just put a bag on it
and that collects waste.
If you wanna do it on the inside,
where you create a pouch inside, that's called a Kock pouch.
That's not done much anymore.
And the third option,
which is end up collecting with an ileorectal anastomosis,
that's a very, very unlikely scenario
because the disease tends to start in the rectum
and very rarely, do you ever
get the rectum to be disease-free,
where you connect the small bowel back to the rectum,
in ulcerative colitis.
There are potential benefits
to not doing the rectal dissection in young people,
and I think I'm gonna touch on them in a minute.
So, proctocolectomy with permanent ileostomy
is definitely an option.
I don't think that's taken by many patients.
The benefits of this is you remove all the disease,
there's no risk of cancer,
it's actually a very well-tolerated operations
and there is no functional problems, permanently.
Essentially, you know what you're getting.
Obviously, the disadvantage
is you have a permanent ileostomy
and that's not very attractive to many people.
What about we're leaving the rectum in place
and connecting that small bowel back to the rectum,
when the patient is healthier?
Well, the advantage is that you avoid the pelvic dissection.
And the pelvic dissection causes two things.
Reduces fertility and causes sexual disfunction in young men
and both are not insignificant problems,
but the disadvantage to leaving it
is the rectum that remains is at high-risk of cancer,
plus, it might never, ever be able to heal,
if it's diseased.
You cannot connect bowel back to diseased bowel.
So that scenario is not common
because the rectum stays diseased
and we cannot connect the ileum, which is the stoma bag.
So if patients are having family planning
or young women wanna get pregnant,
they might wanna just leave the ileostomy,
do that portion of it first
and then come back and have it pouched,
if the disease is still in the rectum.
And I've had many patients
who have sort of approached it this way.
They'd say, "Let's leave the stoma."
There is no time period
where it's a minimum of leaving the ileostomy.
So you do the operation the first time,
you take out the colon, give them an end ileostomy
and that can stay like this for years.
And then come back, and address the pouch
in a different time.
This is the operation I told you
that is not done very often, this is the continent pouch
where a pouch is formed on the inside.
And as you can see, in this portion E,
or at least in the slide, the diagram E,
we put a Foley catheter, or some kind of catheter,
you empty it a few times a day
and you don't actually have a bag on the outside
because it's continent,
it doesn't just sort of produce when it wants.
It's got so many problems
that it hasn't really taken off in the country
and nobody does it today.
Well, a few people still do it, we're not doing it.
This is the operation of choice
where the bowel is turned on itself
and connected to the anus.
So you do a proctectomy, which is removing the rectum
and you do an ileoanal J-pouch anastomosis.
The biggest advantage, is no permanent bag.
The disadvantage is you can get pouchitis,
which is very common; a recurrent inflammation
in the pouch or infections.
We don't understand it extremely well why it happens.
And you could have some complications
and essentially, you might have to have the pouch removed
at some time in the future.
This is one of seventh most important publications
that came out of the Cleveland Clinic
looking at early experience of doing these pouches.
This was done in the 90s,
they have done a thousand pouches at that time.
And what they found is when you do these pouches,
you have a high risk of complications after the surgery
and they recommended that you give the patients
a temporary ileostomy,
so a loop ileostomy when you do the pouch.
So the pouch, again,
both removing the rectum, turning the small bowel on itself,
connecting that to the anus,
but you break the circuit
by giving the patients a loop ileostomy
and hoping to reduce that 27% rate
of post-operative infectious complications.
Once they get past the post-op period,
what do you look forward to long-term?
Extremely low mortality from the operation,
however, I would say five to six bowel movements in the day,
one at night, is about average.
It can be up to 10, that's also within
what you might see.
There's about a one to 2% chance
of sexual disfunction in men, impotence, mainly.
The pouchitis is very common.
I would quote 40% to patients with pouchitis,
which is inflammation of the pouch.
Most of the time, it's easily treated with antibiotics.
Sometimes it requires more therapy.
A decreased fertility in females,
and then other complications.
And the diagnosis, late diagnosis,
which this is where this comes into pouch-vaginal fistula,
a diagnosis of Crohn's into pouches
where the diagnosis has always been ulcerative colitis
but after you've got the pouch done, it gets to Crohn's.
And that, five in a hundred pouches, I would say,
get removed for those indications.
So, it's not common, but it can happen.
What about as you get older?
When you're young, less than 45,
the number of bowel movements, I would say about six,
like I said, but the risk
of never incontinent, decreases with time.
And then, patients have complained of nighttime seepage
which they have to wear a pad,
and that increases with age and increases with time.
So as you've had the pouch for 10, 20 years,
that's what sort of you can expect.
There's also been a study from the Mayo Clinic.
They have looked at disease 20 years out
and patients maintain their job that they had,
and most of them keep their pouches; again, about 95%.
This is a very special situation.
I would not necessarily advocate it.
I just wanna say that there some data to show
that in Crohn's disease, if the small bowel is spared,
and the anus is spared,
there might be an option to do a pouch.
Most of the time, Crohn's patients, for some reason,
have TI disease and they have anal disease.
So, that's not a common scenario,
where you just have colitis from Crohn's,
and no ileal disease and no anal fistulas.
But, we would consider it an intensive.
So if you knew you had anal disease
and/or small bowel disease,
the likelihood of failure of a pouch from Crohn's,
would be about over 50, 60%.
But in this scenario that I just mentioned,
70% of them actually did okay.