Chapters Transcript Video Acute Surgical Management Dr. Worsey emphasizes the importance of the collaboration with surgeon in severe acute colitis. for the next talk and fortunate to have dr Jonathan Marcy. He's a colorectal surgeon at Scripps Memorial one of the course organisers and he'll be talking about acute surgical management. Um In and out in patients with IBD Dr marcI please take over. So chronic disease, small bowel and rectal ulcerative colitis which will include of course chronic disease and in the to escalate this and then a few miscellaneous topics at the end. Crohn's can present acutely in a number of ways obstruction, perforation and suspicion of bleeding and within a rectal disease. This being an abscess or a structure. Mhm. With regard to obstruction it's a common presentation but rarely is acute surgical intervention needed which is good. Most cases will get better with hydration and g decompression and steroids. And can then be approached electively with the low risk of complications and the lower likelihood of needing a stormer free perforation is quoted in the english is being present. One or 2% of the times I have never seen it. I think dr Crane himself was quoted as saying it never occurs. The nature of the disease doesn't really cause this. Um If it does then basic principles apply operation remove disease segment and then anastomosis depending upon the condition of the patient and the condition of the abdomen itself. Abscess and fisher again quite common. Most don't need me to be involved smaller amps etc. Truth antibiotics and most larger ones now are quite good at drinking per cutaneous lee. Very occasionally absence can be sizable. That symptomatic but not accessible and does need a decision to be involved. And again the basic principles apply drain the abscess resected disease and then an Eskimos depending upon the condition of the patient and the condition of the admin with anastomosis would be. This is a common scenario. The abscess is quite superficial and easy to drain. You, drain the abscess, send the patient home, come back in a few weeks and then you can perform resection and primary anastomosis. And this was terminal arterial disease. With the perforation abscess we came back we took it out we put put things back together and did it in a minimally invasive manner as opposed to a big open operation that would start with. Okay on the other hand this is a patient again with terminally ill disease. But the abscess is quite large symptomatic and surrounded by loops of small bowel. You can't get to this uh We are forced to operate and to drain it took out a segment of disease which is quite quite diseased as you can see. And because the anastomosis would have been in the absence field I did not put this patient back together again and then Dalio's Tommy. We'll plan to go back and re operated on him in another month or so when he's he's got better. A further example a patient came with a big pelvic abscess paying signs of sepsis from perforating T. I. Disease that could not be accessed by I. R. A. With antibiotics. It was not getting better. We were forced to operate and there was a big abscess between the terminal ilium and indeed official to the sigmoid colon. Had to respect both. But because the anastomosis were not in the operative field were able to put the patient back together and he did well. Yeah acute hemorrhage very rare. I've seen it twice in about 20 years. It's usually terminal ilium that is affected. We do see more commonly after surgery with a stricture capacity or anastomosis. But those are usually self limiting as with all G. I. Bleeding localization is the key. If you always look it makes life much easier. Especially multifocal disease. And um esoteric angiography is diagnostic and can often be therapeutic. And if you think you have to operate as the radiologist to inject some methylene blue which will stay in the bowel so you can find it afterwards. Provocative methods have been described. I'm not sure we do that myself but they are described and if the patient has a big bleed and it does not stop. Well then surgery can can be kneaded with reception as before. There are a variety of miscellaneous things. Sometimes after balloon dilatation you can see perforation. I'm sure it happens to none of our attendees at the conference but has been reported. Um that would require operation with reception of course capsules could be retained and if they just don't pass and can't be reached. Endoscopic Lee they need to be taken out. Intussusception very rare seen one case in 20 years as the bowel dilates and can predispose. Intussusception presents as an acute obstruction and really finding unexpected Crohn's. That's a historical interest with imaging studies being as good as they are now. It's very unusual to see that not diagnosed pre operatively. This is a patient who had obstructive symptoms. Equivocal findings. Very logically. I was given a capsule and uh interestingly had a stricture above and below of metals and the capsule passed through the first structure became attracted the metals and we had to operate to take it out About three weeks later. Okay this is a patient who had a short segment of T. Disease which was rejected but because the dilatation he had a massive interception and ended up losing a good chunk of his small bowel and almost developed shaka as a result because it uh intercepted and infarct it. Um He had terrible pain, acute obstruction and lost a good chunk of about because of this very rare complication. Yes in a rectal disease very common. We see lots of this where the patient presents acutely often to the office as well as the uh hospital and er it can be complex or simple. But the basic principles are the same. Keep it simple. Just drain the sepsis and occasionally these structures. We see the classical rhetorical structure that needs to be done emergent lee in the operating room. This will be an example of a patient with quite complex in a rectal disease. Several abscesses, each draining multiple scars from prior abscesses. Principles very simple, define the anatomy, drain the sepsis and then just place some satan's, you can come back later treat this medically and sometimes they heal. Sometimes they don't but don't do anything drastic. These patients that poor healing and you'll do them more harm than good. Yeah. When it comes to colitis and this again, uh, includes both indeterminant and cronies. They're really 22 scenarios. When a patient comes in, there may be a clear need for surgery. If they have a perforation, be an actual or impending or acute hemorrhage. You know what to do. This occurs in a smaller group of people because most will present the informant or toxic colitis. And as Becky just mentioned, they'll start with medical therapy when it comes to what to do. It's pretty well decided. Most people who are that sick don't get fancy just take out the colon and give them an entirely else. To me. This can be life saving. It doesn't burn any bridges for subsequent surgery. There are known as thomas is at risk of these patients, you get one chance to get a pouch, right? It's very hard to catch up so staged operation and a three stage operation as we heard earlier. It's now becoming the routine for those reasons there are perhaps a few nuances to what to do or how to do it. You can do this minimum basically I'm not sure I would if the patient had a perforation and an abdomen full of stool and with toxic mega colon the colonies paper thin fragile. It's very hard to manipulate that with instruments laparoscopically and uh you tear the colon perforated and often you're better off just making decisions. The rectal stump was mentioned before. What do you do? The concern is of course that was diseased and its staple closed. It won't heal and it will blow out and cause problems. A couple of examples. This is a man who had a long history but became acutely worse than presented with a pan colitis toxic colitis. Got some fluid some steroids. But the next day he changed dramatically developed an acute abdomen peritonitis. No question here what to do when he gets an operation he gets a subtitle collector me and he has a washout of a leader of stool from his abdomen. These patients get very sick obviously and this poor chap spent about two weeks in the I. C. U. A week in the hospital after that. But then five months later we come back and we take on his ideas to me take on his rectum and give him a J. Pouch. And he he did well the more common scenario is where people don't need an operation right away. Um And has I'm glad to hear gets mentioned have the sturgeon can early try steroids and then about three days as we just mentioned it's it's decision time. There are a variety of prognostic factors that will guide you as to whether to pursue medical treatment operate. But the basic mindset should not be the patients too sick to operate upon. But the patients to signal to operate upon and if bad things happen they can die. So try and have that float in mind. Okay. This is another example of a patient who had a nuance I colitis in her seventies. Slowly progressive to start with. But then acutely worse she comes in she's weak, she's an anemic debilitated has a severe colitis. Endoscopic lee and ideologically and after 48 72 hours she was just not getting better. And we felt that given her frailty that the simplest and safest thing would be to operate upon her. She had an open operation which was quick. You can see here very dilated but an involved like um we talked about the rectal stump. This is the stapled off and the director of sigma here and we implant this not in the abdomen. We saw it to the Fashir and sub acute beneath the skin. If this day hisses it'll be his through the skin and they just give a wound infection as opposed to the hissing intra abdominal e and then the patient gets really sick. And again we came back and took out her rectum at a later date when she she improved. Yeah This is just a historical interest. A hand drawn picture in the days of the medical records are being electronically to this very much nowadays. But this is her colon. And just to show this this is like wet tissue paper. You can't handle this laproscopic of the small instrument. It rips, it tears. It's safer to do it open because the color is just so diseased and so fragile. These patients can be a difficult challenge. Preoperative and postoperative the week malnourished immuno suppressed. They can be septic their risk of from bipolar disease. These are very challenging patients and afterwards they get very sick too. If they perforate they get even sicker. So I think that early surgery decision is the key. And as I mentioned in terms of should treat less is more just get the call out, get them well and come back to fight and live another day with definitive surgery. Just a few miscellaneous things to wrap up with with an obvious to me that occasionally some acute issues papaya, duma can present acutely requiring to bribe into syria injection. But that's uh not too common following protocol. Ectomy and j pouch small bowel obstruction is actually quite common. About a third to a quarter of people may be somewhat less in the era of invasive surgery. Of those historical numbers. Most don't need operation. But those that do it's because of adhesions occasionally. Valueless of the inflow tracked. But you can sometimes operate upon these that have been invasive way and get away with that. And then we'll just finish up by talking about a cook pouch. Not done very much nowadays. I think I've done one of these last five years but I've operated on about half a dozen a year to revise and fix them. Most people don't see them very often and uh most uh little experience with them. The common scenario where you may be involved is that uh you get called from the er doctor who says I've got this patient. But it's funny pouch never heard of it. They say they can't get the tube in and they feel the pouch is about to burst. Come and help. And uh poor patient has already got many blank stares. So first thing is trying to appear calm and reassure them. First give them some pain medication, a bit of analytic and ask them to try again as they relax. They may be able to do it, but more importantly, watch what they do. So you can do it yourself. Take a new catheter which may be a bit stiffer and try and maneuver into the pouch along the outflow tract. If you fail, then you have to use endoscopy um I am quite comfortable using a rigid scope, a small scope. I suspect that most gastroenterologist would be far more comfortable using a flexible scope and a direct vision. It just gently past with installation on the outflow track and expected to be somewhat tortuous. The reasons the two bunk go in. Could be a hernia or a slip valve and in each case it ends up being very tortuous. But with care and gentle insulation you can usually get into the pouch. Sometimes there's a stricture the valve tip which you can often push through or just get a smaller scope. If you can then take out some of the contents and decompress the pouch, you may be able to then have them pass the tube. If you can't, if it's very thick, very thick stool, you may want to take a guide wire and pass it through the biography channel. Take up the scope and then use that as a stent to guide the calf along the gateway into the poach. When you put the tube in the pouch, stand back. It may come out and hit the ceiling it or don't point it at yourself because it's very full of stool. Usually when you empty the pouch it may then change position and you can ask the patient to put the tube in themselves, they can often do that and then have them incubate a few times to make sure they can do it. And to reassure themselves. If you can't get the catheter in and out several times, then just leave the catheter their place. The catheter have it taped to the skin and attach a leg bag and then send it back to the soup urgent, assuming he's not retired or worse and have them flush it on a regular basis. Yeah, so to conclude thankfully acute intervention. Small bowel Crohn's disease is quite rare and we try and avoid that. If we can in in a rectal disease, it's quite common but be conservative, drain the sepsis and don't do anything more with severe acute colitis. I think it's fairly well established. We we know what to do. There are a few nuances with technique. There's a subset of collective me do the least get better and come back to fight another day. Sometimes it's clear the operation right right away sometimes or more often rather we begin with medical treatment and uh here's where judgment and collaboration is crucial. And it was very gratifying to hear the private speakers say that surgery is not a failure because the surgery is not a failure and it can be lifesaving. So I'll stop there and thank you Published Created by Related Presenters M. Jonathan Worsey, MD Colon and Rectal SurgeryScripps Health Dr. Worsey received undergraduate degree from the University of Cambridge and his medical degree from St. Thomas’ Hospital, London, England in 1985. View full profile
