For purposes of this talk on when to remove the colon?

Transcription

1 When Should I have My Colon Removed (for IBD)? Miguel D. Regueiro, MD, FACG Professor of Medicine Associate Chief, Education Medical Director, IBD Center Senior Medical Lead, Specialty Homes University of Pittsburgh Medical Center 1 For purposes of this talk on when to remove the colon? I will combine Crohn s colitis with Ulcerative colitis 2 Page 1 of 18

2 Outline Indications for Colectomy Types of Surgery 3 What do patients fear the most about surgery? And why is the discussion about colectomy so difficult? 4 Page 2 of 18

3 Surgery (colectomy): 1) should not be considered a failure rxent and 2) know when enough is enough with medications. Do you want to save the patient s life or their colon? -Wolfgang Schraut, M.D., PhD, UPMC IBD surgeon Page 3 of 18

4 When is it time for colectomy? (note, surgery for CD is usually small bowel) 1) Failure of medical therapy (difficult decision) 2) Complication of disease (easier decision) Crohn s ds (1/2 of pts need a resection) Obstructing stricture Penetrating ds (fistula, abscess, perforation) Ulcerative colitis (1/4 of pts have surgery) Dysplasia/Cancer Perforation/Hemorrhage (rare) When Should I have my Colon removed? 57 yo male with a 30 year history of panulcerative colitis. Symptomatically has done well with 5ASA only Now presents with bleeding, 10 lb weight loss and fatigue Last colonoscopy 10 yrs ago he has canceled several colonoscopies and is noncompliant with follow up 8 Page 4 of 18

5 Colonoscopy when the decision for colectomy is easy? Is there ever a role for subtotal colectomy? 9 When should I have my colon removed? 37 yo male with panuc x 5 years and recent C. diff C. diff treated and now negative but having active symptoms of UC 20 bloody BMs per day despite 40 mg of prednisone and 4.8 g/d mesalamine 6MP one year ago caused pancreatitis Hgb 9.0, CRP elevated, albumin low, and ill appearing in office Decision is made to admit to the hospital Un-prepped flex sig reveals: Page 5 of 18

6 Should I have it removed now? (harder decision) PROGNOSTIC FACTORS: Endoscopic Severity of Disease Correlates With Colectomy 100 Severe endoscopic colitis (N=46) 100 Moderate endoscopic colitis (N=39) Patients (%) 0 93% Deep/ extensive ulcers 30% Mucosal detachment 26% Large mucosal abrasions 17% Well-like ulcers 0 77% Superficial ulcers 8% Deep but nonextensive ulcers 93% underwent colectomy 23% underwent colectomy Carbonnel F et al. Dig Dis Sci. 1994;39:1550. Page 6 of 18

7 Our Patient s Risk Factors for Colectomy Page 7 of 18

8 Clinical Algorithm Severe, Ulcerative Colitis KUB if suspicion of toxic megacolon, unprepped flexible sigmoidoscopy to determine diagnosis and severity of disease Consult with surgeon!!! Exclude CMV Exclude Clostridium difficile IV steroids 1-2 days (move quickly to next step) No response or partial response OR OR IV Cyclosporine No or partial response IV Infliximab Ada/Go-limumab? Vedolizumab? Colectomy Courtesy of Hans Herfarth, MD, PhD Back to our case IV methylprednisolone 60 mg/day initiated On hospital day 2, Infliximab 10 mg/kg initiated with sq methotrexate 25 mg/wk On hospital day 3 his BM s and bleeding less. He is dc d home. Plan for IFX 10mg/kg at 1 week and 4 weeks from first dose (0,1, and 4) assuming he continues to improve, repeat colonoscopy 6 months later. What about 5 mg/kg IFX and checking levels? What about vedolizumab? Page 8 of 18

9 Should I have my colon out now? (easy decision for doctor, difficult for pt?) 49 yo male newly diagnosed panulcerative colitis is transferred to your hospital after failing IFX 10 mg/kg at 0, 2 weeks and 3 days of IV steroids. Pt: I don t want surgery!! His bloody diarrhea started shortly after quitting cigarette smoking. Question: would anyone consider allowing him to smoke again? Flex Sig C. diff and CMV 20 cm from anus 40 cm from anus Page 9 of 18

10 Abdominal X ray CT Scan Page 10 of 18

11 The pt had a colectomy The entire colon was severely inflamed with a small perforation in the right colon Remember Do you want to save the patient s life or their colon? -Wolfgang Schraut, M.D., PhD, UPMC IBD surgeon Page 11 of 18

12 Types of IBD Surgery Crohn s ds vs ulcerative colitis 23 Surgery for Crohn s disease Intestinal resection with primary anastomosis (most common type) Exam under anesthesia for perianal abscess and placement of seton Subtotal or Total colectomy with end ileostomy (colonic CD) Gastrojejunostomy Intestinal Transplantation 24 Page 12 of 18

13 Most common surgery for Crohn s ds: Ileocolonic Resection 25 Colonic Crohn s surgery - segmental resection 26 Page 13 of 18

14 Severe Perianal CD failing setons/meds Surgery for Anal CD Fistula or Stricture Page 14 of 18

15 Surgery for Ulcerative colitis Remove entire colon and rectum (proctocolectomy) Two options after proctocolectomy: Permament end ileostomy J pouch (ileal pouch anal anastomosis) Technically surgery is a cure for ulcerative colitis and prevents the chance of colon cancer 29 What we know: a proctocolectomy with an end ileostomy is a cure for UC, but Page 15 of 18

16 Miguel D. Regueiro, MD, FACG 31 most patients prefer an IPAA and. 12 cm Rectal tunica muscularis Sutured to dentate line Ext sphincter CP Page 16 of 18

17 Benefits and Risks of IBD Surgery What the patients want to know 33 Crohn s disease surgery Benefits Remove the diseased segment (subtotal colectomy or segmental resection) Significant improvement for most after surgery; symptoms, nutrition, quality of life May be done laparoscopically Risks Is NOT a cure if an anastomosis is created Note. If CD colitis and end ileostomy (10-15% recurrence in the small bowel) Short gut, diarrhea, pain, adhesions Possibility of a permament ostomy 34 Page 17 of 18

18 Benefit Ulcerative colitis Technically a cure for UC (with an ostomy) and eliminates colon cancer risk Restore to health quickly anemia, nutrition May be done laparoscopically Risks Major surgery increased risk when ill, eg infection, blood clots, dehydration With pouch 3-10 BM per day, pouchitis, and chance this is Crohn s disease 35 Summary when to recommend colectomy Colectomy is not a failure of rxent Absolute indications for surgery Cancer and unresectable high grade dysplasia Refractory bleeding or perforation Relative indications Medication refractory Know when enough is enough!! Risk factors for colectomy #1 Deep ulcers in colon Hospitalization, CMV/C. diff, Steroids, significant CRP elevation 36 Page 18 of 18