St Mark's Hospital

and Academic Institute

Surgical Approach to Crohn’s Colitis Segmental or

Total Colectomy? Can We Avoid the Stoma?

Janindra Warusavitarne

Consultant Colorectal Surgeon, St Mark’s Hospital, London, UK.

17th Panhellenic IBD Congress Thessaloniki May 2018

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and Academic Institute

Decision making in Colonic Crohn’s

Colonic Crohn’s needing

Surgery

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Typical Scenarios and Questions

• Single segment disease colon - ? Segmental or total

• More than one segment - ? Seperateresection or total

• Proctitis – ? Pouch or colostomy

• What is the malignant risk in strictures – ? is there a role

for dilatation in strictures

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Factors to consider in decision making

• The role of the colon

– Is it only water absorption and a sick colon that does not function

is of no use

• Phenotype of Crohn’s

– Small bowel involvement

– Perineal involvement

– medications

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Restoration of Bowel ContinuityEffect on PN volume

Adaba et al. Ann Surg 2015; 262:1059 -64

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Restoration of Bowel ContinuityEffect on PN energy

Adaba et al. Ann Surg 2015; 262:1059 -64

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Is the colon is different to small bowel?

Fluids / electrolytes

? Minimal contribution to

nutrients absorption

Role in adaptation

The role of the ileocaecal

valve

Digestion

Absorption of nutrients

Immunological fx

Yes but it has more of a role in maintaining nutrition than previously thought

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Anna, dob 1983

1997: left-sided Crohn’s colitis diagnosis treated

w 5ASAAZA

2000: stricture localized at descending colon, very

mild luminal left colonic disease

A clinical case

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Questions to discuss with Anna ?

• Functional outcomes

• Risk of recurrence and need for further surgery

• What is the risk of dysplasia or cancer

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Functional results SR vs TC+IRA

Andersson DCR 2002

SR=segmental resection

Retrospective comparison

1970-1997

SR 31

TC 26

Fx results slightly better

for Segmental resection

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Superior functional results? almost 40% of SR were right hemis and were missing preop fx assessment!

Andersson DCR 2002

Functional results SR vs TAC+IRA

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49 segmental (SR) vs 59 total (TAC) (1995-2009,

retrosp.)

Cleveland Global Quality of Life (CGQL)

SC: 7.29 (median 7.7, IQR 6–8.7)

TAC: 7.32 (median 7.7, 6.7–8.7) (P = 0.88)

Short Form Inflammatory Bowel Disease (SF-IBD)

Questionnaire

SC 5.39 (median 5.6, IQR 4.9–5.9)

TAC 5.31 (median 5.5, IQR 5–6) (P = 0.92)

Kiran Ann Surg 2011

QoL (SC vs TAC)

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Recurrence after Segmental Resection

Lightner 2018The Influence of biologics?

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Recurrence after ileorectal

Probably post operative treatment dependent

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Patients after TPC are more likely to be

weaned off all medications

Fichera DCR 2005

Retrospective,1985-2003, 179 pts primary colonic CD.

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Small bowel recurrence after TPC

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Small bowel recurrence at stoma

Can make stoma care very

difficult and can be very painful

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Risk of permanent stoma

Fichera A, DCR

2005

Retrospective,1985-2003, 179 pts primary colonic CD

Risk of stoma does not

differ for SR and TC

But disease phenotype

has an influence

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Early recurrence of SC vs IRA

Fichera DCR 2005

Recurrence

rate:

TPC: 9%

(4/75)

TAC: 22%

(8/49)

SC: 38%

(19/55)

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Meta-analysis on 488 patients (223 IRA vs 265 SC)

-4.43 years earlier recurrence after segmental

colectomy compared with IRA (p <0.001)

- no difference in incidence of postoperative

complications

- no difference in the need for a permanent stoma

Tekkis CD 2006

Early recurrence of SC vs IRA

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Surgical recurrence

Polle BJS

2005

1987-2000 91 pats,

SC for Crohn’s Colitis

More related to disease location than surgical procedure

Right sided is different

phenotype, more like terminal

ileitis

Everyone talks about early

recurrence for SR but is this

really true?

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Comparable complication rate

Postoperative complication rate (overall 7,8) (P = 0.84):

5/55 SC (9.3 %)

3/49 TAC (6.1 %)

6/55 TPC patients (7.9 %)

Tekkis CD 2006

Fichera DCR 2005

But what is the cumulative complication rate of repeated SC?

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Risk factors for earlier recurrence:

perianal disease and female gender

Polle BJS 2005

1987-2000 91 pats, SC for Crohn’s Colitis

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Are the colon and the rectum separate entities?

• Can we treat proctitis with proctectomy in the absence of

colitis?

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-Refractory distal and perianal CD (proximal colon normal

at endoscopy)

-Early symptomatic recurrence in 9/10 patients after a

median follow-up of 9.5 months

-6/10 pts luminal relapse in the proximal colon with

disabling peristomal lesion

- 5/10 pts completion colectomies, 1 pt segmental

colectomy with terminal transversostomy (subsequent

recurrence requiring re-surgery)

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and Academic Institute

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The problem with the data is the selection

• In most studies patient selection does not follow a set

protocol- most are retrospective so decision to treat is

different

• Hence interpretation of results difficult

• How do we define rectal sparing

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Is colonic Crohn’s truly segmental or pan colonic

Recurrences tend to

occur in colon

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But having a total colectomy and IRA is not the

panacea

• University of Toronto

– 30% of patients needed reoperation for recurrent symptoms

• Either rectum or the small bowel

• Smoking increases risk of proctectomy HR= 3.93

• Israel – Tel-Aviv

– More patients who had total colectomy needed post operative

treatment

– Recurrence rates for segmental colectomy ~ 35%

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Odds ratio for re operation

• Ileocolic resection as index case

– Small bowel resection 2.95 (1.01-8.66)

– Segmental colonic resection 6.20 (2.04-18.87)

– Colectomy with ileorectal anastomosis 26.57 (2.59-273.01)

– End stoma 4.62 (1.90-11.26)

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What is the risk of malignancy for Anna

• In the presence of a stricture the risk of undiagnosed

cancer is about 3%

• Multifocal dysplasia seen in 44% remote from the site of

cancer

• Subtotal colectomy should be considered for risk of

multifocal dysplasia

• But 97% will have no dysplasia

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How do patients make decisions

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The thought of a stoma can polarise individuals

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Psychosocial health following stoma

• Psychosocial impact around feeling of loss of control

in relationship to body function and personal control

as an adult

• Physical aspects that affect psychological function

and quality of life

• Process of acceptance, adaptation and adjustment

• Feeling of loss of control in relationship

Brown F (2017) Psychosocial health following stoma formation: Vol 15, N03, pg 43-

49

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Findings

Pre-operative

concerns and

expectations

Decision-

making

Surgery

And

recovery

Towards

long-term

outcomes

Dibley et al (2018) Decision-making about stoma surgery for IBD: a qualitative exploration of patient and

clinician perspectives, Inflamm Bowel Dis • Volume 24, Number 2, February 2018

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Summary

• Decision-making is complex

• Pre-operative contact with a carefully matched stoma

buddy is the single most effective technique for

dispelling anxieties

• For the majority, outcomes are very much better than

expected

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Defunctioning for perianal or colonic disease

• Only 10% of those defuntioned will ever be reversed

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But try convincing Anna at age 17 that

she needs a stoma

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What was actually done

• 2000: left colon stricture--> left segmental

colectomy

• 2001: perianal disease onset (ano-vaginal

fistula) local repair attempt failure

seton

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• 2002: Anastomotic recurrence Transverse-descending

colon resection and colostomy (closing of the rectal

stump for perianal disease)

• Over the subsequent 7 years, despite fecal diversion,

perianal disease evolves multiple perianal procedures

(n=4)

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2009: Second recurrence on colostomy site

abscess and fistula

Third segmental resection and second more

proximal colostomy

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2014: ascending-rectum anastomosis …

leak...loop ileostomy

...progression of rectal disease...additional 2

procedures to control perianal sepsis

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• 2015: functional exams before closing stoma reveal the

patient is incontinent completion colectomy +

intersphincteric proctectomy, end-ileostomy

• Was less really more for Anna?

• Consider the phenotype

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What about IPAA for Crohn’s Colitis

• Traditionally viewed as relative contraindication

– Higher failure rate ~ 35% and poor function

• Is there a paradigm shift

• Similar functional and failure rates to UC can be

achieved

– Patient selection is the key here

– No perianal disease and no small bowel disease = good

outcomes

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If all else fails proctectomy needed

But that may not solve the problem either – unhealed perineum

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and Academic Institute

St Mark's Hospital

and Academic Institute

St Mark's Hospital

and Academic Institute

My pragmatic approach

Single segment disease

No dysplasiaSegmental

resection- patient discussion

dysplasiaTotal colectomy if

rectal sparing

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Mutifocaldisease

No proctitisTotal colectomy

and IRA

proctitis

Total colectomy and end

ileostomy

Proctocolectomy and end stoma

IPAA in

selected

patients

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Conclusions

• Have an open mind

• Talk to the patient- risk of multiple operations vs single

operation

• Consider cancer risk

• There is no right answer except the carefully thought of

solution with the patient involved

• Can we avoid the stoma? - Sometimes !!