Inflammatory Bowel Disease: Update Course 2015

Inflammatory bowel disease. Three main, uh, areas I want to touch on Crohn's disease, ulcerative colitis, and indeterminate, uh, colitis. So we'll start with a, uh, case scenario. You have a 12-year-old male with 7 day history of rectal pain, poor PO tolerance, vomiting, fevers, and diarrhea. Uh uh family history significant for Crohn's with 18 pound weight loss in 2 months. Um, the white count is 18,000. And uh sed rate is 20. A CT of the abdomen and pelvis shows right lower quadrant phlegmentous changes that are encasing the ureter and uh 8 centimeters stricture in the terminal ileum. That's what you see there. So in combination with medical therapy, the most appropriate approach for this patient would be what? Jason. Jason. I don't think you're going to get away without resecting, and so you just want to make sure you do it safe and so I just ensure I would put a, I do this laparoscopically and so I'd put a lighted stent in for protection of the ureter, or at least to try to help me identify the ureter and do. Uh, laparoscopic ileocystectomy. When do you do that? Great question. So if you, if the patient's OK and you could give them a couple weeks of antibiotics to try to cool it down, that sounds like a great idea. Is there any data to support when exactly? No, it's just a feeling if you could get them a couple of weeks of antibiotics, I think the bigger question, and I forgot if this patient was on a TNF inhibitor or not, but if they are, that's gonna be my next question, um, is when to operate with that. And so having recently reviewed this literature, which is small, you should probably wait somewhere between 2 and 4 weeks preoperatively. Um, to operate if you can, so I'd wait 2 weeks since their last infusion of whatever TNF inhibitor they're using, and then postoperatively you can. I'm aggressive if I see active disease in other parts of the bowel. I'd probably after about 2 weeks give restart the medication if it's not as aggressive of a disease, I might wait 4 weeks. And do you counsel the patients that they have increased risk of anastomotic complications while on TNF alpha or steroids? I'm not sure. The literature on anastomotic complications is sort of mixed. It's wound complications. That's the biggest, at least in the literature with the TNF inhibitors, but I counsel the heck out of them because they're probably on steroids and every other poor wound healing concoction they might have, so. I always discuss ostomy when I talk to these patients, whether in the background that there's the potential for an ostomy. You want a safe operation. Great, so yeah, that's uh pretty much what we're gonna talk about here, um. So we'll go to the next scenario. We have a 17 year old female with a 6 month history of bloody mucoid, diarrhea and weight loss. She's diagnosed with, uh, ulcerative colitis 3 years previously and managed with 5 ASA and prednisone, but recently she required several hospitalizations. She was given, uh, corticosteroids and infliximab, 8 blood transfusions over the last 6 months. Here's a white count and a sed rate. The most appropriate surgical management for this patient is. Anybody, yeah, we do, uh, I would do a, uh, colectomy with a J pouch reconstruction, laparoscopic. That's a great question. Uh, there's mixed literature on that. I think, uh, we, I've been much more aggressive lately, uh, with not diverting. Um. This patient, you said, is on steroids and infliximab, so, um, it certainly has risk factors for anastomotic complications. Um, I think some of that is based, that's a decision that happens intraoperatively, and that's what I counsel the parents and the patient that, uh, depending on how the case goes and how easy it is to get the pouch down and how healthy everything looks, then if it looks great, then I will do it as a single stage. If I'm not, if there's tension or any other concerns, then I will divert. So I kind of forced your hand to operate on this patient with saying that multiple blood transfusions, etc. but um let's say for argument's sake, uh, this patient's doing just fine, not requiring transfusions. When do you counsel them? I think that at some point it becomes a discussion and usually it's the family's concern over the long term side effects of, ah, that are either known or presumed or or ah suggested about things like the anti-TNF drugs, um, and the steroids. If there's growth failure and other things that are complications of the medical management, then that becomes the determinant for when you operate on the patient. And they're essentially failure of medical therapy. The, the disease may be controlled, but the complications of the therapy are such that the parent patients are unwilling to tolerate them. So there's recently um in, in, in the spirit of updates. Recently it's come into the adult literature, the big concern about infertility in females after a J pouch and uh in Sweden, a recent survey of their, their facilities, 50% of the facilities were doingileorectal anastomosis and not. Ilial pouch anal anastomosis, I guess my argument to that would be, does that, I mean, what is it that causes the infertility? Presumably it's pelvic scarring, and is it any better with an ileal rectal anastomosis than it is with a J pouch. The other thing is that, and that infertility rates are not trivial, as high as 60%, so there, so that is a huge issue and we always discuss that with the patients pre-op. Um, but I don't think most of those series, uh, report, uh, laparoscopic approaches which presumably reduce the amount of, uh, scarring in the pelvis. I've actually looked into this a lot because I don't know about other people in the audience, but I'm usually the first one to mention the infertility rate to the families, and they, the tissue boxes have to come out and have to restart the conversation a little later because, uh, usually our colleagues from the gastroenterology side don't mention some of these things, and it's important, so. There's recent literature coming out from laparoscopic approach J pouches that the infertility rate is less. So the infertility rate in the United States is around 10 or 11% just in general, and infertility rate in laparoscopic procedures go up to about 20 or 30%, whereas in the open procedures it's more about 50 or 60%. So The infertility rate is certainly improving. It's still double the national infertility rate, but lower. The fecundity rate, which is a new word for me that I learned recently, which is actually the ability to get pregnant, not the old fashioned way, but anyway, is the same. So these patients are able to carry a pregnancy and just might need some assistance. But it is interesting, I presented this, our approach at a European meeting and somebody stood up and said, if I ever did a pull through on a patient, uh, on a, um, patient before the end of their childbearing time, whatever that is, I would be sued or you know, that would be unacceptable. So. I think there are places where it is considered wrong to do this operation. Yeah, I think they wait until after they've delivered. Let me, so I was always taught that we had to take the colon out in these patients, and that's not necessarily true anymore. There's a lot of. Um, literature and practice, um, of people saying we can do surveillance colonoscopy, because you said you changed it to a kid who's doing OK, so I used to say at some point in your life, this colon will come out, but actually that's not necessarily true, so you can absolutely postpone this if you need to. It's only about 20% or so of patients with ulcerative colitis by 20 years from the time of original diagnosis that develop a colon cancer. So you, there are patients who. Live their entire life with their colons and have ulcerative colitis, so you need to be screened and usually it's a yearly surveillance colonoscopy, but there's no reason to have a colectomy without other reasons. It's not just a cancer scare scare. That's new. It used to, I mean, I think it used to be that you get your colon out, and I think now with surveillance colonoscopy is absolutely acceptable, at least I think it's new because it's new for me. All right. Keep going. So now you have a 17-year-old female with uh 6 months of bloody stained diarrhea, perianal purulent drainage. She's diagnosed with indeterminate colitis after endoscopic biopsy despite 6 months of medical treatment. She continues to have blood, bloody diarrhea and now reports, uh, significant weight loss. How would you address this patient? So what is she again? Go back, she's indeterminate indeterminate indeterminate. It's patchy through the colon. Well, I think there are, there are two choices here. I think the conservative way to treat this if it's really patchy throughout the colon is just to divert with the ileostomy and see what happens to the colon. If the colon is extensively diseased, one would consider doing a subtotal. ect om y and an ileostomy and then you have a very large specimen for the pathologist to try to determine where in the spectrum because I don't think it's always ulcerative colitis, Crohn's disease, there's a spectrum of disease, the patient lies and so there's certainly literature on doing a Total proctal colectomy and J pouch on indeterminate colitis, um, it's a little bit more of a risk, and that goes into the counseling of the families. That's the only, I mean, that's, I wouldn't do that. That's the only one I, I know it's people do it. That's the one choice that I wouldn't do. People do it for Crohn's disease, huh? People do it for Crohn's. I wouldn't do a J pouch, yeah, right. I, I think you have to be very careful. About doing a J pouch because if it turns out to be Crohn's, you just created way more challenges than you really could have imagined. I would argue not necessarily, and there are people who in selected Crohn's patients will do a total proctor colectomy with a J pouch reconstruction the last good results or something. Yes, it was presented to adults and it's also in the adult literature, but the Determinative colitis, you have to be, it's very difficult, especially sort of thin aesthetic females, and they do not do well. Would you go right away to a J pouch, or would you? No, I, I, I think I do with what you just you do stepwise, stepwise, yeah, absolutely stepwise, and that's the point, because between that time you might get more information, right? So it's almost like not doing something on a, on a, you know, a J pouch for a Crohn's patient that actually acts up is going to be misery, but everybody. Yeah, would you guys consider JPuch is one of those operations that's really a surgery institution volume quality kind of operation? How would you determine that? How many cases should your institution be doing to say we're reasonably competent? It's one of those procedures where I think there is definitely a learning curve in terms of the technical aspects of doing the operation, but I don't, can't give you a number of what is the number that's the right number. Do you do an EEA anastomosis, or do you do a hand song? I've switched actually to doing an EEA but not the same way the adults do an EEA because you can't get the staplers into the pelvis and the smaller kids. We actually, I divide the rectum laparoscopically, avert it, or staple across at the uh at the columns. So as our discussion before, um, and then, uh, endoscopically, or I actually make the J pouch externally just because it's faster and put the anvil in at that point and bring it down and EEA got it. OK, so, so let me just ask once again just for clarification for me. Who in here, given the literature from Europe about ileorectal anastomosis for ulcerative colitis, who here would start considering that down the line? Not me, not yet. OK, maybe something will change. I mean, the, the issue is, is what's the best operation for control of the bowel issues that the child has, and then. We, they can still get pregnant, you know, at the same rate, they may not get pregnant the way they would like to get pregnant or to be able to or, I mean, you know, again, the insurance covers it or whatever whatever is part of the process, but I want to do the best operation that I can that's going to give them the bowel results that I want, and then the pregnancy, I'm not, I'm not doing a hysterectomy, I'm not doing an oophorectomy. They still are able to carry babies. Yeah, that's that, I know, yeah, we'll go to pneumothorax and then we'll. Just a couple of questions and we're gonna do like uh maybe 2 or 3 minutes on pneumothorax and then we're gonna move on. Um, I hear your point. It shouldn't, we shouldn't get paralyzed.