crohn's disase
TRANSCRIPT
Toru KonoDivision of Gastroenterologic and General Surgery Department of Surgery, Asahikawa Medical College
(Scenery from the window of my office)Mt. Taisetu National Park, Asahikawa,
Asahikawa (1 hour 40 min flight from Tokyo)
Tokyo
A new antimesenteric functional end to end hand-sewn anastomosis Surgical prevention of anastomotic recurrence in Crohn’s disease.
Diseases of the Colon & Rectum 2010
Kyoto
First International Consensus Conference on Kono-S anastomosis, Kyoto 2011
Autumn in Kyoto, Kinkakuji temple
Anastomotic recurrence and surgical recurrence of CD
(1993 to 2003)
5-year postoperative cumulative recurrence-free survival(ulcerative changes)
below 10% in historical CD cases
0
0.2
0.4
0.6
0.8
1
0 20 40 60 80 100 120 140 (mo)N=84
Cumulative recurrence-free survival (Kaplan-Meier analysis)
25% 6.4
50% 12.3
75% 38.6
5 years
> 90% recurrence within 5 years
Mean time to recurrence (mo.)
POP 11 months
Postoperative (POP) stenosis at anastomotic sitesPOP 40 months POP 52 months
5-year postoperative cumulative surgical recurrence increased to 26% in historical CD cases
0
0.2
0.4
0.6
0.8
1
0 20 40 60 80 100 120 140 (mo)
N=84
25% 56.850% 104.0
Cumulative surgical recurrence (Kaplan-Meier analysis) Mean time to reoperation (mo.)
Dept. Surgery
Asahikawa Medical University hospital
The S anastomosis technique was developed in 2003 at The S anastomosis technique was developed in 2003 at the Asahikawa Medical University Hospitalthe Asahikawa Medical University Hospital
Concept Concept •• Anastomotic recurrence site, which usually start Anastomotic recurrence site, which usually start
at at mesenteric sidemesenteric side of the anastomosing the ends of the anastomosing the ends of the remnant intestine. However, conventional of the remnant intestine. However, conventional anastomoses do not pay attention to this, anastomoses do not pay attention to this, besides the size of the anastomosis site. We besides the size of the anastomosis site. We designed an anastomotic technique to avoid the designed an anastomotic technique to avoid the stenosis at the anastomosing the ends of the stenosis at the anastomosing the ends of the remnant bowel by creating a remnant bowel by creating a supporting columnsupporting column, , like a stent. like a stent.
•• It is also important that the It is also important that the blood flow and blood flow and nervous systemnervous system should be preserved when a should be preserved when a resected intestine and its mesentery is divided, resected intestine and its mesentery is divided, because both are important factors for ulcer because both are important factors for ulcer healing and are etiologically abnormal in CD healing and are etiologically abnormal in CD intestine. intestine.
Normal ileum Crohn’s disease ileum
Red : nervous fiber and cell, Blue: DAPI indicate cell nucleus
SubmucosalSubmucosal nervous system is damaged due to nervous system is damaged due to repeated inflammation and can not fully recover repeated inflammation and can not fully recover
in Crohnin Crohn’’s diseases disease
CGRP
0
20
40
60
80
100
Control
CG
RP
( ng
/ g ti
ssue
wei
ght )
ADM
0.0
0.3
0.6
0.9
1.2
1.5
CD Model
AD
M (
ng /
g tis
sue
wei
ght )
Control CD Model
**
Selective loss of neuropeptide CGRP, but not ADM, in Crohn’s disease model and human
It has been reported that blood flow is decreased by more than 50% in the terminal ileum and colon of Crohn’s disease patients
Gastroenterology. 1977;72:388-96. Gut. 1986;27:542-9.
Ann N Y Acad Sci. 1992;657:319-27. Dig Dis. 2008;26:149-55.
Kono T. et al J Gastroenterology 2011 (in press)
Blood flow is decreased in Crohn’s disease because of depletion of neuronal peptide (CGRP), a potent vasodilatator, in human and animal models.
0 15 30 45 60 75 900.00
0.02
0.04
0.06
0.08
0.10
0.12
0.14normal colonTNBS treated colon
min
CV
BloodFlow
Kono T. et al J Gastroenterology 2011 (in press)
CrohnCrohn’’s disease and intestinal s disease and intestinal blood flowblood flow
Slovenia
Blood flow is a very important factor in Blood flow is a very important factor in pathogenesis of Crohnpathogenesis of Crohn’’s diseases disease
IlealIleal ulcers tend to occur along the mesenteric margin of ulcers tend to occur along the mesenteric margin of the bowel wall in CD and experimental models of CDthe bowel wall in CD and experimental models of CD
J Clin Pathol. 1997;50:1013-7. Aliment Pharmacol Ther. 1999;13:531-5. Aliment Pharmacol Ther. 2000;14:241-5.
Florida Everglade
Mesenteric side
Crohn’s disease ileum
stenosis
Mesenteric sideMesenteric side
stenosis
Who can answer the prepotency of the Who can answer the prepotency of the CrohnCrohn’’s disease?s disease?Hypothesis: Hypothesis: Primary pathological abnormality in Primary pathological abnormality in CrohnCrohn’’s disease is in the mesenteric s disease is in the mesenteric blood supplyblood supply
Lancet. 1989;2:1057Lancet. 1989;2:1057--62.62.
long artery short artery
Schematic diagram of human small intestine in Crohn’s disease
Remission
Mesenteric margin
No connection between the submucosal plexuses derived from short artery and long artery
*
*
Blood flow CGRP
The association might well be explained in terms of granulomatous vasculitisaffecting small end-arteries that specifically supply the mesenteric margin
Mucosal barrier
bacteria
inflammation
granuloma
glanulomatousvasculitis
flora
Active
vessel
ulcer
Mesenteric margin
Normal
Lancet. 1989;2:1057Lancet. 1989;2:1057--62.62.
How to do KonoHow to do Kono--S anastomosisS anastomosis
Kyoto Darumaji
mesentery
ulcer stenosisTransectionof intestine
Intraoperative endoscopy
The whole bowel was inspected carefully for diseased segments using an endoscopic fiber via enterotomy at a nearby obvious stenosis site in all cases. Before resection of the diseased intestine, the surgeon and the gastroenterologist ensure by intraoperative endoscopy or direct observation there are no apparent mucosal lesions at the site of the intestine designated for anastomosis.
Intraoperative endoscopy
The nearby mesentery of the intestinal loop which is to be excised is divided using the LigaSure system (Valleylab) in order to avoid an unnecessary neurectomy as well as blood vessel dissection
diseased intestine
nerve fiberblood vessel
How to divide “mesentery”
diseased intestine
Nervefiber
blood vessel
diseased intestine
Nervefiber
blood vessel
diseased intestine
anastomosis
diseased intestine
anastomosisdiseased intestine
Resected area
Kono-S anastomosis: resection
Conventional anastomosis: resection
diseased intestineResected areaResected area
Diseasedintestine
Kono-S resection with LS Conventional resection with LS
腸間膜
Mesentericside
the intestine designated for anastomosis Diseased ileum
Diseased ileum
Multiple stenosis at ileum
specimen
the intestine designated for anastomosis
Linear stapler (LS)
How to make a “Supporting Column”
The reason : Both ends of the stump are reinforced with 3/0 Vicryl (Ethicon) , when a linear staple cutter is used.
End of the stump has a risk (leakage)for sealing with single stapling, therefore reinforcement is needed at the both ends.
3/0 Vicryl control-release
The reason : Both threads of the ends of stumps are firstly tied for adjusting some differences of the size of the stump, when a supporting column is made.
Both stumps are united with 3 or 4 threads.
Mesenteric side
relapsestarting pointat mesenteric side
Before anastomosis, both stumps are securely sutured in order to create a Supporting Column that can maintain the shape of the anastomosis The creation of a supporting column that maintains the shape of the anastomosis in order to prevent distortion due to relapse at the anastomotic site.
Supporting column“Supporting Column” avoids stenosis
Longitudinal enterotomy is performed in the antimesenteric side 1cm from the supporting column so as to obtain the optimal effect of the supporting column on the anastomosis, and the incision is opened across the intestinal longitudinal axis, resulting in a large anastomosis resembling the Heineke-Mikulicz type. The length of the opened incision across the longitudinal axis should be 7-8 cm, and it is closed to the length of the intestinal circumference.
Supporting column
Enterotomy
A side-to-side enteroenteric transverse anastomosis is performed by a handsewn, single-layer Gambee manner, using 3/0 Vicryl running sutures.
Resembles anastomosing the bottom ends of two flasks
Supporting column
Antimesenteric functional end to end hand-sewn anastomosis
Videotape on Kono-S anastomosis technique
34 years old. maleReoperation for anastomotic stenosis within 6 years of initial surgery
Ileocolic anastomosis + ileoileal anastomosis
Results of Kono-S anastomosis84 consecutive cases of intestinal resection for CD
from 2003 to 2010Asahikawa Medical University Hospital
S anastomosis at 107 sites
Ileal/jejunal: 44 Ileocolic: 57 Colonic: 6
Results of Kono-S anastomosis84 consecutive cases of intestinal resection for CD
from 2003 to 2010Asahikawa Medical University Hospital
S anastomosis at 107 sites
Ileal/jejunal: 44 Ileocolic: 57 Colonic: 6
Comparative analysis with 73 historical CD patients Comparative analysis with 73 historical CD patients who underwent conventional anastomoses who underwent conventional anastomoses
from 1993 to 2003from 1993 to 2003
a b
cd
A side-to-side S anastomosis A side-to-side conventional anastomosis
Functional end-to-end anastomosisAn end-to-end conventional anastomosis
Arrow and dotted line indicate the mesenteric side
Kono-S anastomosis and conventional anastomoses
Supporting column
Kono-S anastomosis (1 year)
Endoscopy
Endoscopic observation one year after Kono-S anastomosis
Analysis of endoscopic recurrence at the anastomosis after undergoing S anastomosis (Group S) or conventional anastomoses (Group C)
3.4
2.6
P=0.008
Comparison of surgical recurrence for anastomotic restenosis between S anastomoses and conventional anastomoses
0 12 24 36 48 60 72 84 96 108 120 1320
102030405060708090
100Group SGroup C
P = 0.0004
months
N = 84N = 73
Group C
Group S
0 12 24 36 48 60 72 84 96 10812013260
70
80
90
100
Time in Months
% p
atie
nts
rem
aini
ng fr
ee o
f sur
gica
l rec
urre
nce
Group S
Group C
n = 42Infliximab +
Infliximab +Infliximab -
Infliximab -
n = 42n = 12
n = 61
Logrank Test **p = 0.0006Logrank Test *p = 0.0041*, **
Surgical recurrence rates after undergoing an S anastomosis (Group S) or conventional anastomoses (Group C). With or without postoperative Infliximab
Group S combined with postoperative infliximab therapy (infliximab +), no infliximab (infliximab -), and Group C combined with postoperative infliximab therapy (infliximab +), no infliximab (infliximab -). Group S infliximab + vs. Group C infliximab -: P = 0.0041. Group S infliximab - vs. Group C infliximab -: P = 0.0006.
Comparison of anastomotic restenosis recurrence between S ansatomosis and conventional anastomoses
No postoperative administration of Infliximab/Adalimumab
0 12 24 36 48 60 72 84 96 108 120 13260
70
80
90
100
Group C
Group S
Logrank Test *p = 0.0045
n = 42
n = 61
Time in Months
Pisa
ConclusionConclusionKonoKono--S anastomosis, a new antimesenteric functional end to S anastomosis, a new antimesenteric functional end to end handend hand--sewn anastomosis, may be effective for preventing sewn anastomosis, may be effective for preventing postoperative anastomotic stenosis, even if infliximab postoperative anastomotic stenosis, even if infliximab postoperative therapy is not administered. postoperative therapy is not administered.