Managing the Post Managing the Post ColectomyColectomy Patient Patient

Ellen J. Ellen J. ScherlScherl MD, FACP, AGAFMD, FACP, AGAFDirector of Jill Roberts IBD Center Director of Jill Roberts IBD Center

Associate Clinical Professor of MedicineAssociate Clinical Professor of MedicineWeill Medical College Cornell UniversityWeill Medical College Cornell University

New York Presbyterian HospitalNew York Presbyterian Hospital

Do I Really Need a Colectomy?Do I Really Need a Colectomy?

Can I live Without a Colon?Can I live Without a Colon?

Do I need my entire colon out?• What is the function of the colon?• Will I need a bag? What is a pouch?• How long will I be in the hosp?• When may I return to work?

You can’t live with your colon. You can live without a colon.

What are my Surgical Options?What are my Surgical Options?

• Subtotal colectomy vs total proctocolectomy with incontinent Brooke ileostomy

• Evolution of continent Kock pouch• Evolution of IPAA

What is a Pouch? What is a Pouch?

• Evolution of continent Kock pouch• Evolution of IPAA

Can an IPAA be Created with One Can an IPAA be Created with One Operation, One Stage?Operation, One Stage?

How do Pouches Really do?How do Pouches Really do?

• Adapts colonic function: – 10-20 bm to 6-8

• Incontinence/nocturnal• Sexual/fertility• Pouchitis

LongLong--Term Adverse Outcomes of Ileal Term Adverse Outcomes of Ileal Pouch Anal AnastomosisPouch Anal Anastomosis

DaytimeDaytimeIncontinenceIncontinence

NocturnalNocturnalIncontinenceIncontinence

AntiAnti--diarrhealdiarrhealMedicationMedication

Inability toInability toDistinguishDistinguishGas from Gas from

StoolStool

SexualSexualDisfunctionDisfunction

Meagher AP et al. Brit J Surg 1998; 85:800

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N = 300 pts.N = 300 pts.

PouchitisPouchitis

Stahlberg D et al. Dis Colon Rectum 1996; 39:1012

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MonthsMonths

What is Pouchitis?What is Pouchitis?

• Inflammation of pouch..replacing UC with a different disease ulcerative pouchitis.

• Pouchitis is a unique phenotype of IBD• Total proctocolectomy cures UC vs IPAA may

replace UC with UP

Constellation Pouchitis SymptomsConstellation Pouchitis Symptoms

• Rectal Urgency• Fecal Incontinence• Rectal bleeding/diarrhea• Abdominal cramping• Fever and malaise

Classifying PouchitisClassifying Pouchitis

• Pouch Disease Activity Index– Clinical– Endoscopic– Histologic

How do you Diagnose Pouchitis?How do you Diagnose Pouchitis?

What is Cuffitis?What is Cuffitis?

Differential DiagnosisDifferential Diagnosis

• Fistula/abscess : – Early is postoperative complication– Late is Crohn’s disease

• Crohn’s of inflow tract• Stricture

– Irritable pouch

Can you Predict Pouchitis?Can you Predict Pouchitis?

• Role of preop serology…Pouchitis as a unique phenotype of IBD

• Primary Sclerosing Cholangitis• Extraintestinal Manifestations

Can you Prevent Pouchitis?Can you Prevent Pouchitis?

Can You Predict CrohnCan You Predict Crohn’’s of the Pouch?s of the Pouch?

• In the old days: Nothing like a pouch to bring out Crohn’s disease

• Controversy regarding serology

Cumulative Incidence of Cumulative Incidence of Pregnancy Within 5 YearsPregnancy Within 5 Years

Adapted from Gastroenterology, Vol 122, Olsen KØ, Juul S, Berndtsson I, Öresland T, Laurberg S, Ulcerative Colitis: Female Fecundity Before Diagnosis, During Disease, and After Surgery Compared with a Population Sample, pages 15-19, Copyright 2002 with permission from Elsevier.

Time to Pregnancy (months)60

0.0

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After surgery

Before diagnosisReferenceBefore surgery

Male FertilityMale Fertility

Surgical Approaches to Surgical Approaches to Minimize InfertilityMinimize Infertility

• Possibly delay pelvic surgery• Minimize septic complications• Decrease adhesion formation

– Ferric hyaluronate adhesion-prevention gel– “Pexing” ovaries

• Laparoscopic procedures

What is the Risk of What is the Risk of Malignancy in Pouch?Malignancy in Pouch?

• Rare• Recommend handsewn anastomosis or

end ileostomy in a patient with rectal dysplasia or CRC

• Lymphoma of pouch

How do you Treat Pouchitis ?How do you Treat Pouchitis ?

• Cipro Flagyl• Mesalamines• Budesonide po/pr• Peptobismol po• Peptobismol carbomers pr• Scfa/glutamine• VSL/rifaximin

How do you Treat How do you Treat Refractory Pouchitis?Refractory Pouchitis?

• Immunosuppression• Anti-TNF

• Entire colon must be removed• J-Pouch formation can be staged• Expect to have 15-20 BM/day after J-Pouch

formation, decreasing to 6-8 over the next 2-3 months

• 50% will have at least 1 episode of pouchitis in the first year post-operatively

• Antibiotics are the mainstay of pouchitis treatment

• Refractory pouchitis can be treated like IBD (including 6MP, anti-TNF)

• Early post-operative abscesses or fistulae is likely a surgical complication – not Crohn’s disease

• Persistent diarrhea after 6 months warrants further investigation including possible pouchoscopy

• Surveillance for dysplasia of the pouch• Close collaboration between

gastroenterologists and colorectal surgeons

Summary Summary

• Early complications Team approach• Persistent diarrhea pouchoscopy• Pouch surveillance• Vast majority improved quality of life