Chapters Transcript Video IBD Surgery for the Gastroenterologist Dr. Bradford Sklow discusses how location, phenotype, and severity of the disease contribute to the decision to perform surgery. uh So I'd like to welcome dr Bradford slow. Uh He is the director of the digestive disease and surgery center at Cleveland clinic. And he will be speaking on IBD surgery for the gastroenterologist because we are starting about 20 minutes early. We will have a little bit of time for Q. And A. For dr slow. Welcome. Thank you very much. Uh And I want to thank scripts institute for inviting me to speak. And also Dr Amy Lightner, my colleague at the Cleveland clinic for many of her pictures and several of her slides. I have no disclosures so outlined for my talk. Uh I'm going to talk about all sorts of colitis first and indications for surgery, choice of operation and technical aspects surgical considerations of immuno suppression. Uh And what's new in surgery for all sort of colitis and Crohn's uh disease, phenotype surgical principles. The choice of operation and what's new in Crohn's disease. There may be some overlap all sorts of colitis indications for surgery. Um Most of you know medically refractory refractory disease as an outpatient which we don't see that often anymore. And I'll get to more of that later in my top. And certainly as an inpatient patients who get admitted with refractory disease urgent or emergent operations and then neo pleasure. Either a dysplasia or cancer in the setting of ulcers colitis. The severity disease dictates the surgical options. I'm going to start with a case presentation. This is a 33 year old female who presented to the emergency room with a 10 year history of all sort of colitis on maintenance therapy with inflicts a mob vital signs, has a temperature of 40 heart rate of 100 and 30 blood pressure of 80. She has diffused tenderness with guarding. CT scan shows a dilated, seeking to 13 centimeters. Stranding around the corner with a thickened Kalanick wall. What would be the next steps I. V. Steroids evaluate with serial abdominal exams. Probably not the best idea. This clinical scenario, rescue and flicks a mob or go to the opera as you can see here based on the specimen on the table, patient went um urgently to the operating room. And when do you call the surgeon call a surgeon with the patients in the emergency room With that type of presentation. Uh She has an acute abdomen. She's got unstable vital signs. And colorectal surgeon should be involved early in the presentation. She underwent an emergent laproscopic total collecting me with an indie lee asked me in Hartmann's. Well, when do we consider a case of also colitis emerging? These are the most common indications that we see. Certainly colonic perforation, life threatening hemorrhage which isn't all that common toxic mega colon uh toxic colitis both of which this patient had. And then sort of a more of a grey zone more than 10 stools per day with continuous bleeding, abdominal pain. Distension fever and anorexia. Basically, somebody who is admitted who's not getting any better than having consistent symptoms. Well how do you optimize the outcomes in the emergent setting. There's really no preoperative optimization because you have to go to the operating room so you can optimize your fluid status with I. V. Fluids, antibiotics and have blood products already if necessary. And the last microscopic approach is certainly warranted when feasible. But what do you do with the rectal stump in this scenario? Uh, Cleveland clinic. Our preference tends to be to tack it to the fascia below a small fantasy steel or midline incision. Uh That way, if the rectal stump blows out, you open the wound and you have a wound infection rather than inter abdominal abscess. More conservative approach would be to construct a former mucus fish formal mucus fistula. Uh And then another option is to leave the rectal stump stapled off in the abdomen with a drain next to it and a transitional drain to decompress the rectum. But you do risk rectal stump blowout and there's not a lot of data either way that says one is better than the other. Although the mucus fischelis probably the more conservative route, what are the surgical options in the elective setting? Certainly in the emergence setting, as I mentioned, the total collecting me with an and Ellie asked him, he's really uh one of the few only options, but in the elective setting we can do a total producto collecting me with Andy lee asked me total prato collectively was continent. They asked me or so called cook pouch, which is only done in a few centers in the United States because of a high complication rate. Uh total collecting with alia rectal anastomosis, which is not that common and then probably the most common. Uh We see as a total practical collecting with a little pouch, anal anastomosis or I. P. A. Yeah. Well, what about so called pouch Back in the nineties we used to do w pouches or S pouches, which are certainly more complicated to construct and are done much anymore. Most common pouch we see today is the J pouch. It's simpler to construct with a stapler. Uh And the function is equivalent to both the W. And S. Pouch and some would argue have less complications compared to, say, an S pouch where you worry about outlet obstruction. Okay, there's a picture of a J pouch constructed in the operating room. I like to make a 15 to 18 centimeter J pouch. Uh This is about 15. What are the key preoperative factors. When we're looking at a patient who has all sort of colitis and surgical intervention. Certainly we want to know what the receipt of statuses because that can affect uh their clinical picture. CMB status. The current symptoms, current steroid use and current biologic use. When you talk about a J pouch, you can construct the pouch and a variety of stages, the single stage pouch, which is not done. That often would be take the entire colon out a product. Oh collected me including the rectum and construct the pouch without any fecal diversion. The two stage pouch would be proctor collectively pouch and diverting. We asked me with the second stage, being really asked me reversal 3 to 6 months later. They modified to stage, which is popular in some centers but not done that often. Certainly at the Cleveland clinic where we have a high patient acuity and co morbidity index where you do a sub total collectively and Elias to me and then go back and do the pouch without a diverting. And he asked me and then probably the most common scenario that we see today is a three stage pouch. We do some total collectively and Elias to me, we in the patient office steroids, get them healthy, then go back do the elemental pouch with a diverting loop. Elias to me and then reverse the Elias to me is the third stage. But what about two versus a three stage pouch? There's certainly no randomized controlled trials looking at this, There have been six studies in the literature to with equivocal results before the studies favor the three stage approach and high risk patients patients, which is what actually we're seeing mostly today. There's a lower overall morbidity, pelvic sepsis and alias rates with a three stage approach. And there certainly is a low rate of morbidity. Following a laparoscopic sub total collecting me as the first stage. Well, who do we consider high risk for a pouch, patients who are on high dose cortical steroids? Previous biologic exposure, poor nutritional status and patients who have acute severe colitis. And if you look at uh this is unpublished data from Stefan. Hello Bar. At the Cleveland clinic. If you look at the percentage of patients undergoing three stages versus two stages or other approaches, the amount of three stage pouches has increased significantly uh in the last 15 years in the graph going straight up. So most of the pouches done today are three stages. Now that may be a biased view based on a patient population that we see at the Cleveland clinic, what about steroids and pouch pouch sepsis? We do know a study out of leeds England 2000 and seven show that when the dose of steroids goes above 20 centimeters, excuse me, 20 mg, that the complication rate goes up significantly. And this was a consensus statement from the european Crohn's and colitis organisation that stated when the predniSONE dose of 20 mg or more for more than six weeks. It's a risk factor for surgical complications and therefore the cortical steroids should be weaned if possible. Or uh the pouch construction should be delayed to a second stage, meaning three stage approach. So basically, if the steroid doses higher than 20 mg? Probably shouldn't do a pouch in a two stage fashion. What about anti TNF therapy? A lot of our patients that we see with also colitis are on anti TNF. So uh and they have been mixed results with numerous studies looking at this. Several have showed an increased complication rate uh with pouches. Others have showed no difference. So as the data is mixed, the consensus statement from the european christians and colitis organisation in 2014 was that uh preoperative use of inflicts map does not appear to increase the risk of infectious complications, but there may be an increase in short term complications. We have data from the Cleveland clinic showing an increased risk of complications. So we don't do a two stage power from patients who are on anti TNF agents. We prefer three stage approach. What about vandalism ob patients. But also for this. This study was actually published by my colleague at the Cleveland clinic. Amy Lightner who looked at this and found that there was after a pouch patients who are on vandalism at the rate of perry pouch abscess significantly was higher, 31% versus 6%. But statistical significance was not reached. So there's a suggestion of higher infectious complications. Following the pallets on patients on metal is a math, although it wasn't significant. So we tend to take a conservative approach and again perform a sub total, collect me first, get them off of the metal. Is a mob and then perform their pouches as the next stage. Well, what about that age? Uh Sure people would like to know. Am I too old for a pouch. Well, there's really no age cut off specifically. But we do know with increasing age. There's associated higher surgical complication rates. Poor functional results after a patch of increasing age. Uh And patient co morbidity factors increase with age leading to a higher surgical complication rate. So surgical options to consider the elderly would be a total practical collecting and permanent Elias to me or depending on their comorbidities. A sub total collected me with the hartmans and a permanent Elias to me. What about a permanent Elias to me as an alternative compared to a pouch? Uh This was a meta analysis done looking at that with 1600 patients. And there was actually no difference in quality of life in patients who had an anjali asked me compared to an elevator pouch. Overall satisfaction was similar over 90% for both. And the ability to return to work was also uh the same. So, uh and then daily asked me is actually not a bad alternative to a pouch in. Uh certain patients today, a minimally invasive collect to me is the standard of care uh performing certainly the initial sub total collecting me this patient here actually, uh in the center underwent a single poor laproscopic uh sub total collect me through the Elias to me site. So the only incision you see is actually the Elias to me. Uh makes surgery more acceptable to patients that they don't have a large incision. Well, minimally invasive can either be laproscopic, pan assisted single port as I mentioned or robotic, robotic uh collectively is just basically a fancy laproscopic way to take the corner direct. Um This is a hand assistant approach. The middle picture shows a single port approach and then the picture on the right is the robotic port placement. What are the advantages of the laparoscopic approach? Uh decreased wound infections because the wounds are smaller, decreased intra abdominal abscesses, decreased overall morbidity, decreased hospital stay uh And pain improve cosmetic result. Certainly without a large incision there's a long term reduction in adhesions and increased fertility rates. Probably due to a reduction adhesions. Although that's not terribly well studied. Uh As far as performing a robotic pouch, the robot is a great platform for the pelvis with a fixed structure of the rectum gives you a great three D. View and you can actually see the N. S. Emphasis on the right being performed. A pouch, anal anastomosis very clearly down to the pelvic floor. So the robot gives you a great view to the pelvis. It allows you to actually operate on a more obese patients in the pelvis than the laparoscopic approach would. What about new surgical approach approaches and all sort of colitis? Uh We'll talk about the three that I have listed first the appendectomy. Some data that performing an appendectomy might be somewhat protective in patients with all sorts of colitis About the data is mixed. There's some epidemiological data that's conflicting. It was a british study that had 3800 patients and showed no difference in patients who had an appendectomy versus not uh in the outcome patients with all sort of colitis. However the Swedish study of over 2100 patients showed that an appendectomy was protective and all sort of colitis um If it occurred before the U. C. Diagnosis the less than 20 years of age. There's been one prospective study on this uh with 30 patients and that was out of the Netherlands and showed that one third of the patients who had an appendectomy had a decrease in their uh manoa score. Um endoscopic lee and that a pencil information was actually predictive of the endoscopic pathological response. So the jury is um not out yet. On appendectomy, parole serve colitis. There have been some centers that have done uh fecal diversion only as opposed to collect me. Uh In patients with severe ulcerative colitis and or Crohn's colitis. They had both disease processes in the study at U. C. L. A. And they showed that 90% of patients with just Lupoli asked me were able to avoid an emergent or urgent collecting me greater than 85% and a decrease steroid dependence and improvement in oral intake. Uh and also 80 grand 80% allowed elective laparoscopic procedure or colon salvage. So there may be something to this but certainly not mainstream as of yet. The newest can on the block for pouches is actually the trans anal pouch. Uh There's still probably an abdominal portion of this. But you actually do a bottom up approach. You put this specialized port in the anus and you actually operate through the anus, mobilizing the rectum from below and also from above. But it gives you better visualization of the distal one third of the rectum. You control the height of the transaction so you're not too high. So you know, you're low enough close to the transition zone. You only have a single staple line. There's no crossing state lines and there's some question, maybe there's a lower lee. Great, although that hasn't been definitively proven, there is a steep learning curve, at least 50 to 75 cases. So it's technically challenging operation to perform. Early studies suggest possibly a lower post op complication rate. Um It's comparable post office of outcomes to just plain abdominal approach, comparable leak rates and comparable long term functional outcomes. What about the elemental pouch and Crohn's disease? It's generally accepted that Crohn's is a relative contraindications to an elevator pouch anastomosis because of these kind of problems with multiple fistulas and Crohn's in the pouch, which can really ruin your day. However, uh patients who have isolated Crohn's colitis without any periodontal or illegal information. Uh Our pouch candidates in the Cleveland clinic has a whole series of these patients um that they've published on but generally a pouch and Crohn's disease is relatively kind country indicated. Well, we know that also of colitis. Certainly the drds on this panel know that also of colitis and Crohn's is sort of a continuum with indeterminant colitis in the middle. But I wear crayons, colored glasses and having taken out pouches for Crohn's over 20 years of my career, My view of all sort of colitis and Crohn's is more like this. Uh but that segues into my next segment of Crohn's disease. General principles of Crohn's, it can affect any segment of the Gi tract from the mouth to the anus control rather than cure is the current goal. Until we have different medications that will provide a cure treatment is generally medical insurgents operate for the complications or medical failure of Crohn's. There must be close cooperation and collaboration with gastroenterologist to minimize complications and recurrence of crowns. The objective of surgical treatment is to correct the complications, restoration of health and quality of life and prevention of carcinoma. The outcome is superior emergent situation can be transformed into an elective one. We do know that free perforation of small bowel. Crohn's occurs in about 1% of cases. So most cases of crimes can be sort of pseudo elective and not emerging considerations and Crohn's location. The disease. The phenotype the severity of the principles of surgery and the prevention of disease recurrence starts in the operating room and get to that more in a little bit jesus with terminal alien Crohn's disease, we know that there can be structuring disease, penetrating disease and certainly have an inflammatory component, which the mainstay of treatment is medical. Okay. It's not till you have structuring disease or a stricture in the terminal ilium. Uh that does not respond to biologic therapy with a fixed stricture. Uh These can be symptomatic, but predictors of surgery are upstream bio dilation and obstructive like symptoms. Surgical options. Uh For fiber stand out of Crohn's disease include resection stricture plasticky to preserve barrel length and bypass as far as reception. Uh Certainly for limited diseases, we don't want to take out a lot of small bowel. Uh Most commonly in the terminal ilium right before the alien super ball. There's limited disease. We perform an area colic resection or limited small bowel resection. If there's just a single stricture, uh there can be inflammatory component. And certainly you want to respect that area. If there is a concern for malignancy, stricture plasticity is important to preserve bow length. If you have patients who have multiple strictures throughout the small bowel, you can't respect all of that. So you can actually do what's called a stricture plastic. This depicts a tiny chemical structure plastic where you make a longitudinal incision in the wall of the small bowel and you close it trans firstly, that's the simplest structure, plastic that we do. Uh This is a Finnish stricture plastic where you take the loop about the stricture, you folded upon itself and then you saw the two ends together after opening up the bow. And certainly this allows for about preservation because this would have been a much larger reception. Yes. And here's a picture of a patient who had multiple strictures uh in their small bowel. And this is the kind of patient who you would not do a reception on as you'd be respecting a significant portion of their small bow. So after looking at all this and doing stricture plastic, this is kind of what it looks like. Multiple stricture plastics throughout the small bowel. These are all Heineken Nicollet and then the big one uh is a finny and they say the patient a large small bowel resection bypass. Generally reserved for proximal disease uh as uh giardino structuring. And certainly in patients who have extensive ballot involvement that cannot be LISZT uh and safely resected or stricture plastic perform. But bypass would be a last resort. We prefer to do stricture plastic or resection well for penetrating. Uh Crohn's disease. We know that in that case 10 to 30% have an associated abscess. 4% have a flagman management for this uh is multifactorial, including medical management with antibiotics, um per continuous drainage and surgery. Yeah, the algorithm for this. You want to drain the sepsis with per cutaneous drain with antibiotics. Close clinical observations. However, patients have ongoing fever, peritonitis or inability to tolerate oral intake and may have to go to search for section. But if not you can leave a drain in for six weeks and planned for elective surgical resection uh with uh with without antibiotics possibly or biologic after the drain is place. But certainly close collaboration with gastroenterology uh is warranted professionalizing disease. Uh Internal Fischler's occur in 5 to 10, 5 to 10% of patients with Crohn's you can have enter on Terek Fischelis, which is from small about a small bowel. Uh Intracellular officials, intravascular Fischler's or enter cutaneous fisherman's do all internal fish does need surgery, as many are often asymptomatic or found incidentally on M mari or ct angiography. Uh and most often between loops of ilium. If these fish oils are asymptomatic, they certainly do not need any surgical intervention, but which Fischler's need surgery. Certainly an enter a vesicular fistula where patients have fecal Yuria or new materia recurrent urinary tract infections. Almost all of those patients will come to surgical intervention and certainly patients who have developed intro cutaneous fischelis, of which 85% occur postoperative and 15 are spontaneous. Um This kind of a case patient would need an operation if they don't close spontaneously, but certainly you want to control the sepsis prior to going in the operating room. So if you have any per catania's, if you have any absences that can undergo prettiness drainage. You want to control the inter abdominal inflammation and substance with drainage and antibiotics. Uh let things cool off and then go to the operating room when it's safe because otherwise you'll end up with hostile abdomen and it still may be a difficult operation after doing all of that, a little bit about Crohn's colitis in the colon is affected. Uh in 30% of patients, it can be difficult to differentiate from all sort of colitis. As I mentioned with my uh sort of sarcastic view of sort of colitis indications for surgery, failure of medical therapy, similar also colitis, bloody diarrhea, abdominal pain and certainly dysplasia or cancer. And the risk today, we know approaches that of all sort of kindness. It used to be that uh we thought you had to take the whole colon out for Crohn's colitis. But this was a study at a Sweden uh that had 55 patients uh from 1970 to 1997. So a while ago that had 31 segmental receptions in 26 total abdominal collect amis with earlier rectal anastomosis. They had the same rate of re reception. This was, you know, prior to the era of all the anti TNF agents and other agents for Crohn's, the segue, mentally receptive patients had fewer symptoms through stools and better function. And the conclusion was that segmental resection should be considered in patients who have limited Crohn's colitis say, a limited segment and just like ulcerative colitis and Crohn's. We take a minimally invasive approach. Certainly three little three or four little laparoscopic incisions is better than a very large midline incision is in the center of picture. We want to minimize the amount of bowel removed. Uh So we don't create a short bowel syndrome. The conservative approach, crone's disease surgery and that you can do a combination of receptions and stricture plastics, but you don't want to remove all of the bowel that's involved. You prefer to preserve it into a stricture plastic. Uh And a lot of times and patients who have multiple strictures, you may do a limited reception and a combination with a combination of structure plastics. So preservation is the key. And then lastly, the prevention of the disease recurrence starts in the operating room. Um It could be the type of an ass the most as you perform. Uh Then people have looked at this extensively, looking at side to side staple versus sewn and N. And S. Nemesis. And these studies were also were also done in the nineties uh basically have shown no difference between a staple and asked moses and hand sewn. One study actually showed less recurrence with the staples and asked moses out of the Mayo clinic. The most recent uh newcomer to uh Crohn's is the co no sns nemesis. Uh This was by cano from japan. Looking at a new way to perform at an Eskimo sis where you divide the bowel. You bring the two ends together and you actually open the bow longitude Italy. And then sewed together trans firstly creating this column of support in the center and early data on that from japan and the United States showed the five year recurrence free rate was 98%. With a 10 year surgical recurrence free rate of 98%. So very promising. It's also very easy and estamos is to survey by gastroenterologists because it acts like an end to end, wide open and esteem. Asus lastly uh is the message very important the disease recurrence conclusion of the military during a section may be associated with reduced post op recurrence. This was a small study out of Ireland and the Cleveland clinic that looked at 30 patients who had a conventional reception elia colic resection versus 34 patients that included a wide resection of the Mezze military and the currents. The re operation rate was only 2.9% in the wide resection versus 40%. And the patients who had uh just a conventional section. So currently the Cleveland clinic is doing a randomized controlled trial. Looking at wider section of the military versus just a conventional reception to prove that this may be a factor. So to conclude in Crohn's multi distant approach is key to optimizing outcomes location phoenix type severity. Drive the decision to proceed to surgery. You want to drain any sepsis pre operatively surgery is not curative. You want to minimize the amount of bowel resection to prevent short bowel syndrome. And certainly an operative strategy can potentially prevent recurrences. Thank you. Terrific. Thank you dr slump for that. Really wonderful overview of IBD surgery. Um We do have some questions for you. The first question relates to stricture plasticky, Is there data to show that doing a stricture plasticity to preserve the length equates to functionality of that small ball segment? Um That's something that's very hard to study. Uh and I don't know if anyone can actually uh study that with small bowel manama tree. To my knowledge. No, I do know that uh the recurrence rarely occurs at the site of the stricture plastic. We know that much if you're going to get a recurrence. We also know that based on the ice of peristaltic structure plastic, the so called Nicholas. See where you would do 20 centimeter, 30 centimeter. Elaine stricture plastic that those patients still have function of the bow because that's a very large structure plastic. I've done two of those in my career. The patients didn't seem to have any the problem with functioning. And if you look at the series by Nicholas C um that uh it doesn't seem to be an issue. He has published the largest series and it's also named after him traffic. Um This also relates to nest Imo sees. The question is that says it's been hypothesized that end to end versus into side an estimate. Massie's may functionally have different outcomes for patients long term. What are your thoughts on this? Um That's I think that's a controversial topic. In fact those of us, the Cleveland clinic don't agree necessarily on that. Some of the old school surgeons there do and decide for that very reason. Uh They also do it because an end of side may be easier to survey by gastroenterologist than a side to side as you get to that you know, at the end of your colon or the ilium comes inside to side. It takes that acute angle. I can't say there's any data that says one remains open more than the other. My personal bias is that if you create an eight centimeter anastomosis it's certainly a lot larger than a 28 millimeter of E. A aside to an anastomosis, I think the U. N. O. S. Uh the data is very impressive on that. Uh And a lot of us at Cleveland have actually moved to doing the phone os which certainly takes longer. But I think more data is needed for that because it's only been a couple studies out showing improved recurrence rates. Okay great. Um let's move on to dysplasia and cancer. One of the questions from the audience is what your approaches to low grade dysplasia in asymptomatic patients with either crowns or ulcer colitis. Just I think that's a loaded question. Uh Probably more geared towards my guest neurology colleagues uh with low grade we used to be doing chroma endoscopy and I know that sort of fallen a little bit out of favor. But I would uh like to get some of the gastric are on just what their current strategies for low grade. Certainly high grade there's no question. I think they need an operation for low grade. Um Can you clear it with promo endoscopy? I'd have to defer to you guys. What's what's your approach? Yeah, I think in general we really try to assess whether the lesion is visible or invisible. So if this was identified on a random biopsy, I think it's helpful to go back and do cro mo endoscopy to really enhance mucosal visualization. Uh see if there's truly a lesion there. And I think that's where separating biopsies by segment is also really helpful. Um If the lesion is visible. You know, then I think we have to ask ourselves whether it's endoscopic lee receptacle and if it is then I think surveillance is reasonable. Um patients may even have more than one lesion with low grade dysplasia. But again, if you have complete reception of those lesions um it would be reasonable to pursue close surveillance. Um Probably the patients that I might send for surgery in this setting would be multi focal dysplasia. Especially invisible dysplasia or un respectable lesions. That might not be amenable to uh even EMR or E. S. D. But I agree it's definitely allergic question. Yeah. I think there's not a simple answer to that question. And certainly that's where you have to have a close discussion with gastroenterologist on what the lesion looks like and what they think get their opinion as well. Yeah. Uh For patients who have colorectal cancer leading to a total practical collect me. Do you have any preferences on the type of surgery they have where they end up with an and Elias? To me, A pouch depends on the location of the cancer. If it's uh in the colon or in the rectum. Uh Done several pouches for patients with colon cancer. Um because it's not as big an issue compared to rectal cancer where radiation comes in potentially comes into play. We're certainly not going to radiate a pouch uh post post op if you do a pouch and sending a rectal cancer. So it really depends on the location of the cancer in the stage and what Adjuvant therapy. Mayor may not be necessary, but a diagnosis of cancer certainly doesn't disqualify them from having an L. A. L. A little pouch really depends on location and stage. Okay. Um and for patients who do have an illegal anal pouch, an Eskimo sis, what is your typical discussion with them on life after having a pouch sort of short term and long term expectations. Um Certainly. Uh Well, I don't know if we really know what the long term uh longevity of a pouches. I have patients that pouches in 1985. Let's still have good function. Uh So I think it depends on a lot of things. Did they have any complications? You know, post up, um I tell them as far as bowel movement frequency, the average number of all moments is about six after about a year initially, they may have 8 to 10. But not everybody has as good a function for patients who have bad, all sort of colitis, you know, having 20 about moments today. Uh certainly I tell them their quality of life is going to improve significantly. I also tell them, you know, and I had this cynical view of Crohn's disease, but there is a risk down the road that their diagnosis, you know, may change to Crohn's or they get Crohn's and nobody really knows was it all Crohn's to begin with? Does it become Crohn's? So we know there's a risk of that. Um down the road, as far as christians, we used to think it was as low as 5%. But uh my personal bias, it's probably closer to 30% based on how many pouches I've taken out with crones, but that's sort of, you know, selection bias. And as far as uh again, when I said what to expect short term 8 to 10 bowel movements initially, but the pouch adapts over the first year and the frequency goes down to close to £6 moments. They may have pouch itis, we talk about that, which is certainly treatable and those kind of things. Terrific and actually along those lines for patients who do have really adrenaline estamos ease and develop a stricture. This is not uncommon. We find that we often might dilate digitally during their exam. Maybe even a balloon dilation. I find that colorectal is really helpful in these settings to help instruct patients on the use of dilator ziff, It's something they need to do themselves. Um But at what point would you consider surgical techniques for treatment of these neuronal structures? Well, you're limited depending on the location of how low it is, exactly what you said initially. Dilate balloon dilate and then um self dilate if they can. That's probably the best option. Patients can daily dilate themselves daily. But when it becomes certainly also you want to rule out Crohn's if they have a really bad stricture because I've seen that patients who have strictures um but if you have room, if it's not a hand sewn pouch and you have room to advance the pouch, you can actually redo the anastomosis by pouch. Advancement often requires freeing up the pouch from above and from below, cutting the stricture out and advancing the pouch and doing a hand sewn uh esteem. Asus with diversion. So that's an option. And when would I do that? I would do that when they can't, you know, the stricture keeps coming back and you're dilating them so often, or they can't self dilate, then I'd consider that I'd also discussed with them the possibility of an and Elias to me as an alternative. Okay. I mean since uh one of the questions from the audience is that the acuity of the U. C. Patient population perhaps hasn't really changed as much in the past 30 years. But the question specifically is why do you think that the rate of three stage surgeries has increased so dramatically? Um I think it's probably multifactorial but they're in the last 30 years we've had the development of anti TNF sauce. Uh And gastroenterologist have a lot of medical options now that they didn't have before. You know before it was steroids and five essay compounds. And now we have you know uh inflicts a mob and Humira and Cimzia and vandalism ab and there's a different map coming on the market you know every year. So with all of those options I think patients seem to get treated longer and end up sicker in the hospital when we do see them and when they're sick or in the hospital um we won't do a pouch initially take their colon out, get them off on the medications and then do the pouch electively. We also know we there's mixed data that anti TNF may increase complication rates. So conservative approach is not to do a pouch and patients who are on anti TNF agents I say. Yeah it seems like the three stage approach really does help to reduce the risk of postoperative complications. This isn't just the Cleveland clinic phenomenon. When I was at University of Minnesota before coming to the clinic, I would say 90% of our pouches were three stage pouches even in that community. So I don't think it's unique just to the clinic for women who are undergoing surgery and specifically collect me and want to have Children. Do you typically recommend a sub total with an and Julius Kenny or what's your approach to that? Um depends on the age of the patient and when they're going to have kids, certainly it doesn't preclude having Children. We have plenty of pouch patients who've had kids and certainly in the era of laparoscopy we think that fertility rates have improved that operation. So I I wouldn't disqualify them from having a pouch is because they want to have Children. But we have the discussion saying your fridge ability could be affected. Um But a lot of younger patients don't want an ingenious to me. Um And don't want to live with it for I don't know how many years that be childbearing and then have their pouch. So it's it's an option. You can have that discussion but it might be a tough sell to say well for the next 5 to 8 years when you're having your kids you can have an end Elias typically it's not a common discussion that I've had. Okay. Um Yeah I think in general, you know we do counsel patients to help try to minimize pelvic surgery when possible, but certainly a lot of our patients are really young at the time of a total collected me and may not want to live with the nand Elias to me for 10 2030 years. Um So even though public surgery may affect there was a fertility, we've certainly seen a lot of patients with pouches uh or subtitle collect amis with and Elias Commies go through successful pregnancies. Um There is a question on the management of recto vaginal fistula. What is your general approach to this? I sent it to Tracy Hall um kind of half jokingly dr hall of the Cleveland clinic is sort of uh one of the country's experts on that. Uh It depends on the reason for the fish to if it's from Crohn's um Medical management, possibly fecal diversion if they're really symptomatic uh and see if it gets small enough treat their Crohn's disease. And if their rectum is no longer inflamed and the tissue appears normal. And then depending on the size of the fish, they may be able to undergo directory coastal advancement flap uh Or potentially a sphincter plasticky if they have any sphincter defect, bring tissue in there. Uh bacillus or Mariusz flap sort of all of those attractions. Um But it depends on the reason for the fish to in the setting of IBD certainly if there's any disease in the rectum. Uh you're doomed to fail. There's inflammation in the rectum with any repair. So I think medical management control of the information of the rectum is the first step before you consider any surgical intervention, then if they need to be diverted initially for symptoms, then they can have a diverting stoma. I see. And it sounds like from what you're saying if we can achieve control of the rectal inflammation than some of these surgical procedures are more tenable even without diversion? That's right. Um Along the lines of fistula, what is the status of using stem cells for complex fistula and crone's disease? We have a very vigorous clinical trials by Dr Amy Lightner at the Cleveland clinic who's been actually injecting uh you know Fischelis and patients with Crohn's with stem cells with surprisingly good results. Obviously the trials are ongoing. Nothing is published yet but in talking to her. Uh It's been remarkable how good some of these patients have responded to this and that's currently ongoing. Yes. Yeah. So in the United States for the audience, it is currently available through clinical trials in europe in certain countries. It is approved for you. Um So we look forward to more data emerging here and really understanding which patients would be best to use them in uh and then the last question before we wrap up and this is sort of putting on those screens glasses again. But when you have a patient of convincing ulcer colitis who's undergone a total practical ectomy with the j pouch only to come back later with penetrating disease? Perino fistula may be pre pouch illegal disease? Do you think that these patients had Crohn's disease along? Do you think that there for genotype somehow changed? Um And I think I'll add to this, you know, one of the questions is when they've had a long standing couch, do you think aspects like um changing their body habit, tous blood flow, you know, that that could somehow affect the risk as well? You know, that is the million dollar question. And I've seen it. I've seen a patient with a pouch for 10 years, 15 years, come back with fish lens and now it's supposedly Crohn's disease. I've seen it and after five years. Um and I don't know the answer. Uh I think that we need better ways of determining. Ah I don't think there are two separate diseases as we like to put on one end and the other Crohn's and ulcerative colitis. I think it's more of a continuum. It's much grayer and I don't know if it's if it's that we can't tell that it's Crohn's initially it looks like ulcerative colitis. You know, we do everything. We're supposed to we take the corn out, we look at the pathology, it looks like, you see. Um So is it that we're just not really good at telling one from the other or something changes over time, does it then sort of transforming the crones and I think that's the problem we have to answer and we don't know and it's very frustrating because yeah, these patients you do these operations and it looks everything points also of colitis and how can it be after 10 or even 15 years now they have fistulas and it looks like Crohn's. I think that patients who have problems initially immediately post operatively more likely technical leaks, subclinical leaks that weren't indicated those kind of things from the anastomosis like within the first year, six months. But these other patients, I don't have a good answer. And that's the frustrating thing. You know, I've taken out many punches in my career where uh it all looks like ulcer colitis initially and now all of a sudden it's crones and that's why I view the world with crayons colored blasts because I don't know the right answer. And I wish, you know, we had better ways of determining it, you know, one from the other and the serum tests, you know, Prometheus seven, which I think is done in SAn Diego. Uh isn't perfect either determining one from the other. That's right. That's right. And any test may not necessarily change the management that's needed, which is a collect me. Um and certainly even having an and Elias cammy isn't a foolproof method either. Some patients can develop Crohn's disease in their eternal alien leading up to the Oscar me. So yes, I would agree. It's certainly on a continuum and really highlights the fact that there's a systemic process going on. You know whether five years later, 20 years later that can drive this and somehow they get triggered. Yes, agree. 100%. Well, I would like to thank you doctor Slow for your for your presentation and taking the time to answer our Panelist questions and audience questions. Published Created by Related Presenters Bradford Sklow, MD Department of Colorectal SurgeryDigestive Disease and Surgery InstituteCleveland Clinic Dr. Bradford Sklow is the Director of the Digestive Disease and Surgery Center at Cleveland Clinic, Florida Martin Health. View full profile
