Inflammatory Bowel Disease (IBD): Evolution of Surgical Methods

Charles A. Ternent, MDAssociate Clinical Professor of Surgery and

Director Colorectal Surgery Research, Creighton University School of Medicine, Omaha Nebraska

IBD: Surgical Treatment

• Indications for Surgery– Elective• Intractability• Risk of malignant change• Growth retardation• Local anorectal complications (fissures, abscesses and

fistulas)• Remote or systemic complications (arthritis, skin

lesions – pyoderma and erythema nodosum, eye lesions (uveitis, iritis)

IBD: Surgical Treatment

• Indications for Surgery– Urgent / Emergent • Deterioration patient’s condition (Fulminant colitis)• Local abdominal signs suggestive of perforation• Acute colonic dilatation (Toxic megacolon)

– Surgical approach variable over the decades• Ileostomy/cecostomy alone 50% mortality (Crile and

Thomas 1951)• Colectomy and ileostomy (Gardner and Miller 1951)

– Subtotal colectomy and ileostomy recommended

Ulcerative Colitis: Early Surgical Treatment

– Operations on the Nervous System (Historical perspective only)

• Schlitt 1951: operative division of the pelvic autonomic nerves (permanent sexual and bladder dysfunction)

• Levy 1956: prefrontal lobotomy report in 5 patients– “Some” improved

Ulcerative Colitis: Early Surgical Treatment

• Appendicostomy (Keetly 1895)– Simple procedure intended for very ill colitis

patients– Appendix brought up through abdominal wall

and catheter passed into cecum and used to irrigate colon

– Lockhart-Mummery 1934 reported on 79 cases• 12 deaths, rest “very satisfactory “results but ? cyclical

disease factors• Use abandoned circa 1940 in favor of ileostomy

Ulcerative Colitis: Early Surgical Treatment

• Diverting Ileostomy or Cecostomy with Subsequent Excision of the Large Intestine (Brown 1913)– Adopted in US 1920s-1940s (Strauss 1924, Cattell

1935, Lahey 1941). UK 1940s (Ogilvie 1940)– Rationale: Resting colon to allow quiescence and

possible reversal of stoma– Cattell 1948 reported ileostomy invariably

permanent and colectomy required due to failure of recovery or because of cancer risk

Ulcerative Colitis: Early Surgical Treatment

• Diverting Ileostomy with Excision of the Large Intestine (Proctocolectomy) in Stages– Gabriel 1952 reported three-stage procedure in

3-month intervals• Ileostomy (initially affected bowel left in place)• Subtotal colectomy with exteriorization sigmoid colon• Abdominoperineal resection rectosigmoid colon

– Additive morbidity and mortality from serial operations (not an efficient approach with present day anesthesia)

Ulcerative Colitis: Early Surgical Treatment

• Ileostomy with Immediate Subtotal Colectomy or Proctocolectomy (Miller 1949 and Crile and Thompson 1951)– Rationale: Minimize toxicity of septic colon left in

place especially in more toxic cases– Concern: Increased mortality in toxic patients and

increased morbidity from proctectomy in patients on high dose steroids and biologic agents• Toxic/compromised physiology – subtotal colectomy with

ileostomy• Elective refractory – proctocolectomy with ileostomy

Ulcerative Colitis Early Surgical Treatment: Colectomy with Ileostomy

Early Studies of Urgent/Emergent Colectomy for UC

Mortality Urgent / Emergent

Mortality Elective

N Urgent / Emergent

Lennard-Jones 1960 31% 4.4% 32

Brooke and Sampson 1964

16% 6% 62

Goligher 1970 14% 3% 184

Ulcerative Colitis: Early Surgical Treatment

• Techniques of Ileostomy • Initially ileostomy brought out 5 cm or so

straight and allowed serosal surface to granulate (no eversion)

• Commonly resulted in fibrosis, stenosis and partial obstruction or ileostomy dysfunction (Counsell and Goligher 1952)• Dragsted 1941 skin grafted serosal surface ileostomy

above skin level – contraction and stenosis still a problem

Ulcerative Colitis: Early Surgical Treatment

• Techniques of Stoma Creation– Patey 1951 advocated immediate suture of stoma

bowel to skin (flat stoma a problem with ileostomy)– Brooke 1952 adopted immediate mucocutaneous

suture in constructing ileostomies with evertion of the last 1-2 cm of ileal wall to create projection (standard of care today)

– Turnball 1953 would strip the terminal ileal portion of serosa and muscularis before eversion (technically difficult and without significant advantage)

Ileostomy Appliances

• Incontinent stomas require constant wearing of an appliance (early on a bag or box)

• Koenig 1944 patient of Strauss in Chicago developed the adherent ileostomy bag along with Rutzen– Water tight and leak resistant arrangement

• Turnbull 1975 introduced karaya gum powder to minimize leakage– Paste or wafer has soothing and efficient adhesive

• Stomahesive paste further enhanced stoma care

Ulcerative Colitis: Early Surgical Treatment

• Continent – Reservoir Ileostomy (Koch 1969 Goteburg, Sweden)

• Internal pouch created out of 45-50 cm of ileum immediately above stoma

• Continent valve requires intubation through abdominal wall to evacuate

• No stoma appliance required. Cover with gauze• Valve can slip and leak and complication and

revision rates high

Ulcerative Colitis: Early Surgical Treatment

• Diverting Transverse or Left Sided Colostomyafter distal proctocolectomy– Possible in very distal disease– High incidence of extending disease to involve

proximal colon– Staghlgren and Ferguson 1959 reported on 18

patients with this procedure. 11 required completion colectomy and ileostomy

Ulcerative Colitis: Early Surgical Treatment

• Colectomy with Ileosigmoid (Lilienthal 1903, Devine 1943,1948)– Extraperitoneal technique– Gabriel 1952 reported that 4/5 required

separation of anastomosis and ileostomy• Ileorectal Anastomosis (Aylett 1953-1963)– End to end ileorectal anastomosis with protecting

loop ileostomy for 3 weeks• FU 1963 N=123, 5% mortality, 13% conversion to

ileostomy

Ulcerative Colitis Early Surgical Treatment Ileorectal Anastomosis

• Jagelman 1953 Postal inquiry of 200 of Aylett’s patients• 25% had 6 or more stools per day• 90% considered surgery successful

• Literature 1954-1977 (Goligher, Wangensteen…)– 20-50% failure rate requiring ileostomy– 7/350 patients followed 10-15 years developed carcinoma– Goligher: reserve for patients with lesser degrees of rectal

involvement who are not interested in rectal excision or stoma

– Currently mainly considered in mild rectal disease, indeterminate colitis, high risk or older patients not good candidates for IPAA

Ulcerative Colitis: Early Surgical Treatment

• Colectomy and Partial Rectal Excision with Ileoanal Pull-Through (Ravitch 1948)– Anal mucosectomy and straight ileoanal

anastomosis– Others found great frequency of defecation and

incontinence (Goligher 1951, Wangenstein 1948)– 7-8+ BMs per day– Goligher 1980: More promising proposition

would be an ileoanal reservoir…

Ulcerative Colitis: Modern Surgical Treatment

• Proctocolectomy with Ileoanal Pouch Anal Anastomosis (IPAA)– IPAA and protecting ileostomy • Ferrari and Fonkalsrud 1978 report of successful

operation• Parks and Nichols 1978 report of 5 patients with colitis

treated with IPAA with encouraging results

Ulcerative Colitis: Modern Surgical Treatment

• Quality of life / functional issues: Proctocolectomy with permanent ileostomy vs IPAA– IPAA was associated with a significantly better perception of

body image than a permanent stoma– Quality of life in general was similar in both groups– Patients with a pouch had more long-term complications

than patients with an ileostomy within the same period of time (52.6% vs. 26.3%)

– The median number of stages for pouch construction was two, compared to a median of one stage for an ileostomy (P<0.0001).

– Counsel thoroughly preoperativelyJ Clin Gastroenterol. 2006 Sep;40(8):669-77.Quality of life after proctocolectomy with ileoanal anastomosis for patients with ulcerative colitis.Lichtenstein GR1, Cohen R, Yamashita B, Diamond RH

Ulcerative Colitis: Modern Surgical Treatment

• Restorative Proctocolectomy and IPAA• One, two or three stages? – High dose steroids / biologics, urgent/emergent

surgery increase risk of infection (3 stage)– No high risk of infection (2 stage)– No steroids or biologics and elective (possible 1

stage in some centers but potential drawbacks/risks)

Ulcerative Colitis: Modern Surgical Treatment

• Laparoscopic approaches to Proctocolectomy with permanent ileostomy and IPAA

• Is there a benefit to minimally invasive techniques?– Less blood loss– Diminished postop pain– Reduced narcotic requirement– Shorter hospital stays

Ulcerative Colitis: Modern Postoperative Issues

• Pouchitis after IPAA for UC– Most common long-term complication (25%)– Usually responds to PO antibiotics (Cipro/Flagyl)– 60% second episode– 20% chronic pouchitis (chronic maintenance

therapy – combination therapy and Rifaximin)– Budesonide and Biologics (Infliximab), VSL-3

(probiotic)– May need pouch revision or excision

Ulcerative Colitis: Modern Postoperative Issues

• Crohn’s disease (CD) and IPAA: Outcomes– One of most common long-term inflammatory complications– Leading cause of pouch failure (10% if CD known preop and

carefully selected / 50% if CD develops postop)– Treatment

• Topical / oral mesalamine or steroids• Antibiotics • Immunomodulators• Biologics may be considered in refractory disease of IPAA particularly if

extra-intestinal symptoms• Consider pouch excision - revision

Crohn’s Disease: Early Reports

• Non-specific enteritis descriptions– Moynahan 1907, Mayo-Robson 1908, Leeds and

Dalziel 1913– Burrill Crohn NY 1932 established the clinical and

pathologic entity of regional or granulomatous enteritis • Anywhere in GI tract • Skip lesions

Crohn’s Landmark Paper

Crohn’s Disease: Evolution of Surgical Treatment

• Diverting stoma• Bypass with or without exclusion• Resection with stoma• Resection with anastomosis +/- stoma• Stricturoplasty +/- resection• Radical vs conservative resection of bowel

and mesentery (resect to grossly not microscopically normal tissue)

Crohn’s Disease: Early Surgical Treatment

• Bypass with exclusion advocated in mid 1930s (Mount Sinai Hospital, NY)

• President Eisenhower had successful bypass without exclusion for Crohn’s (Heaton et al 1964)

• Surgical resection popularized with increasing safety of surgery (Glotzer and Siren 1971)

• Clear indication for bypass operation alone is duodenal Crohn’s (Fielding et al 1970)

Crohn’s Disease and Fistula-in-Ano

• Fistula Definition– Abnormal communication/tract between any

two epithelium lined surfaces– Presence of a rectal or anal internal opening

• Etiology– Most common result of cryptoglandular

infections – IBD/Crohn’s, Infectious, Cancer, HIV and other

immunocompromised states

MRI Complex Anterior Fistula-in -Ano

Classification of Anal Fistulas

Anal Fistula in Ancient GreeceHippocrates (ca. 460-370 BC)

• Aware of anorectal fistulas and tried to interpret mechanism of origin (first description)• Attempted to treat them conservatively using

laxatives and purgative medications or surgically via anoscope

• Understood importance of the surgical option but lacked appropriate tools

• Numerous operations exist• Aim to decrease recurrence and incontinence rates

Louis 14th

17th Century France• Had anal fistula in 1686

at age 47 after developing an abscess in the “Foundation” from riding horses

• Recurrent abscesses made it impossible for the King to walk

• Surgery as we know it today did not exist

• Difficult for the King to adopt majestic airs

Francois Felix: A Great Barber-Surgeon and The Royal Anus

• Born in Avignon c 1635• Developed technique to perform an

operation on the monarch after practicing with peasants/prisoners at King’s request• Found that addressing the internal fistula

opening was key to the operation while preserving life and anal sphincter continence

Francois Felix: A Great Barber-Surgeon and The Royal Anus

• SETONOne or more threads or horsehairs or a strip of linen introduced beneath the skin by a knife or needle to provide drainage or to produce or prolong inflammation

?

Francois Felix: A Great Barber-Surgeon and The Royal Anus

• The King required 4 operations for healing of fistula (staged fistulotomies with setons)

• Back to riding horses by 3 months• Felix was knighted, bought a town (Tassy) and asked

that the barber trade be separated from surgery• Became the surgeon of the Sun King• Had PTSD from ordeal and apparently was not able to

touch a scalpel thereafter• Helped to establish the French Royal Academy of

Surgery in 1731 under King Louis XV

Crohn’s Disease: Anorectal Fistula Modern Surgical/Medical Treatment

• Drain abscess if present• Drain fistulas with setons to minimize

festering and abscess recurrence as immunomodulator and biologic agents started

• As fistula tracts dry up and therapy effective can remove setons (may have to replace and re-drain depending on CD activity

Crohn’s Disease: Modern Surgical Treatment

• Fissure– Pain and bleeding can be excruciating and may

be main complaints of CD– May be atypical, lateral or associated with

edematous skin tags (CD)– Maximize medical management when active

disease related fissures and symptoms usually improve

– Surgery only if not CD related and no active CD and anal sphincter hypertonic

IBD: Modern Surgical Treatment

• Timing of Surgery: Immunomodulator Biologic and Steroid Therapy– Ulcerative Colitis: high dose steroids and

biologics increase infection risk – stage colectomies

– Crohn’s Disease: literature on biologics controversial – time surgery around biologic dose to maintain optimized medical management. Steroids and biologic combinations increase risk of infection

IBD Surgery Conclusions

• Extensive progress over last 100+ years• Future: Genotype-phenotype correlations

may help guide surgery and medical therapy • Continued improved medical management

will continue to compliment evolving surgical techniques and capabilities

• The Cure…