cutting edge topics in ibd surgery - static.livemedia.gr · st mark's hospital and academic...

St Mark's Hospital

and Academic Institute

Cutting edge topics in IBD surgery

Janindra Warusavitarne

Consultant Colorectal Surgeon and Lead IBD Surgeon,

St Mark’s Hospital, London, UK.

17th Panhellenic IBD Congress Thessaloniki May 2018

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Perceptions of surgeons

• Cutting edge = Playing with toys

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But is that all that’s new in IBD surgery?

The Thinking Surgeon

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How is IBD surgery evolving

• The pastI think I have done

all I can now its your

turn to sort it out

boy!!

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What is cutting edge now

• Joint clinics

• IBD MDT

• Patient in the centre of decision making

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IBD Surgery

• IBD surgery is a sub speciality in its own right

• Requires an understanding of the disease process

• The aim is to restore quality of life

• An adjunct to optimise response to treatments

• Develop and maintain high quality standards in surgery

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Why are standards important in IBD

Surgery

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Why are IBD patients different

• Sepsis/abscess

• Albumin

• Medications

– Steroids anti TNF, vedolizumab,etc

• Fistula at the time of surgery

• Bowel anatomy

• Recurrent disease

• QUALITY OF LIFE !!!!!

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St Mark's Hospital


Low Surgeon

Volume

• Associated with

high re-

hospitalisations

• Poor outcomes

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St Mark's Hospital


Setting the standards can make a

difference

Involving patients can also make a

huge difference

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Defining Key Performance Indicators for the surgical

management of Inflammatory Bowel Disease

Aims

To achieve an expert consensus on the development of

KPIs that will be used to measure quality of service

provision in IBD surgery

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Outcome measure for Crohn’s

surgery

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Outcome measures specific to case adjusted Crohn's small bowel or ileocolonic

surgery include:-

Likert ratings

(median; interquartile

range)

Round 1 Round 2

➢ the proportion of patients who require re-operations within 30 days secondary to

intra-abdominal septic complications.5; 0.5 5, 0

➢ the proportion of patients who develop enterocutaneous fistulae within 90 days. 4; 1 5, 1

➢ the proportion of cases performed laparoscopically without conversion to open. 3; 0 3, 0

➢ the proportion of patients who are stoma free after 12 months. 4; 1 4, 2

➢ the proportion of patients who develop clinical recurrence within 12 months. 4; 1 4,1

➢ the proportion of patients who develop surgical recurrence within 36 months. 3; 1 3, 1

➢ the proportion of patients who receive preoperative nutritional optimization where

indicated.4; 1 4, 1

➢ the proportion of patients who develop subsequent short bowel. 5; 1 5, 1

➢ the proportion of patients who are started on prophylactic immunomodulatory

therapy within 6 months after surgery.4; 1 4, 1

➢ quality of life measures at 6 month postoperatively using the Crohn's Life Impact

Questionnaire (CLIQ).4; 2 4, 1

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Outcome measures specific to Crohn's perianal fistulae surgery:

Likert ratings

(median; interquartile range)

Round 1 Round 2

➢ the proportion of patients who develop recurrent perianal

abscesses within 12 months following surgery.4; 1 4; 1

➢ the proportion of patients who go on to require proctectomy. 4; 1 4; 1

➢ the proportion of patients who require perineal diversion with a

defunctioning stoma.4; 1 4; 1

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Outcome measure for UC

surgery

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Outcome measures specific to subtotal colectomy with end ileostomy:-

Likert ratings


Round 1 Round 2

➢ 30 day mortality rates in patients aged over 70. 5; 1 5; 0

➢ 90 day mortality rates in patients aged over 70. 5; 1 5; 0

➢ the proportion of cases performed laparoscopically without conversion to

open.3; 1 3; 1

➢ the proportion of patients who develop rectal stump blowouts. 4.5; 2 4; 1

➢ the proportion of patients who undergo re-operation within 30 days after

surgery.5; 1

St Mark's Hospital


Outcome measures specific to proctocolectomy include:-

Likert ratings


Round 1 Round 2

➢ the proportion of cases that are performed laparoscopically

without conversion to open.3; 1 3; 1

➢ the proportion that develop perineal sinus formation. 4; 2 4; 0

➢ the proportion of patients who have concomitant ileoanal

pouch formation out of the total number of

proctocolectomies.

4; 2 4; 1

➢ the proportion of patients who develop sexual dysfunction. 5; 1 5; 1

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Outcome measures specific to ileoanal pouch formation

include:-

Likert ratings


range)

Round 1 Round 2

➢ the proportion of patients who undergo re-operations within

30 days secondary to intra-abdominal septic complications.5; 1 5; 0

➢ the proportion of patients who develop pelvic septic

complications within 30 days following surgery.5; 1 5; 0

➢ the proportion of patients who require permanent faecal

diversion with an ileostomy for long term pouch-related

complications (including pouchitis, fistulae or pouch failure).

5; 1 5; 1

➢ the proportion of patients who require pouch salvage

surgery in the long term for pouch failure.4; 2 4; 1

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Outcome measure for overall

quality

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Outcome measures required in measuring the overall quality of an

IBD surgical service include:-

Likert ratings


range)

Round 1 Round 2

➢ the proportion of readmissions within the six month postoperative

period, relative to the length of initial postoperative inpatient stay.4; 1 4; 1

➢ the length of postoperative inpatient stay. 4; 2 4; 2

➢ the proportion of patients that return to work normal activities

within a six month postoperative period.4; 1 4; 1

➢ distribution of patient satisfaction surveys (through IBD specific

patient panels, departmental open days, or patient opinion

websites).

4; 2 4; 1

➢ overall case adjusted 30 day postoperative morbidity (as graded

by the Clavien-Dindo classification).4; 1 4; 1

➢ overall mortality rates within 90 days after surgery. 5; 1 5; 0

➢ quality of life measures 12 months postoperatively by use of the

Inflammatory Bowel Disease Questionnaire (IBDQ).4; 1 4; 1

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Structural necessities for an

IBD surgical service provision

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Quality assurance mechanisms for the delivery of a high quality IBD surgical

service should include:-

Likert ratings


Round 1 Round 2

➢ an IBD team meeting discussion for all IBD deaths within 12 months of surgery

with the outcome of the discussion recorded and submitted to national data

collection.

5;1 5; 0

➢ an IBD team meeting discussion in the event of significant postoperative

morbidity (Clavien-Dindo grade 3) and mortality with the outcome of the

discussion recorded and submitted to national data collection.

4; 1 5; 1

➢ an IBD team meeting discussion in the event of all IBD-related postoperative

readmissions.4; 2

4; 0➢ an IBD team meeting discussion considering the length of postoperative

inpatient stay is greater than 14 days. 4; 14; 1

➢ discussion in the surgical Morbidity & Mortality meeting in the event of surgical

deaths within 30 days of surgery.5; 0

5; 0➢ open publication or registry reporting for case adjusted morbidity and mortality. 4; 2 4; 0

➢ a process of credentialing from a national or international governing body for

the IBD unit to deliver surgical services. 4; 2 4; 1

➢ submission of surgical outcome data into national IBD audits or registries

(including the IBD audit, ileal pouch registry, IBD registry). 5; 1 5; 1

➢ a local registry of surgical IBD patients. 5; 1

St Mark's Hospital


An individual consultant colorectal surgeon should be performing the following number of IBD major

resections per year (including proctocolectomy, subtotal colectomy, ileoanal pouch formation &

ileocolonic/small bowel Crohn's surgery):

Round 1 Round 2

Consensus following round two: 85.7%

> 16

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An institution delivering a high quality surgical service should be performing the following minimum

number of IBD major resections per year (including proctocolectomy, subtotal colectomy, ileoanal pouch

formation and ileocolonic/small bowel Crohn's surgery):

Round 1 Round 2

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The IBD team members required to deliver a high quality IBD surgical service,

include:-

Likert ratings


range)

Round 1 Round 2

➢ a consultant colorectal surgeon trained and experienced in laparoscopic

surgery.

5; 1 5; 0

➢ a consultant colorectal surgeon who is a core member of the IBD

multidisciplinary team.

5; 0 5; 0

➢ a consultant colorectal surgeon who is on a dedicated IBD on-call rota

providing emergency IBD surgery when required.

4; 2 4; 2

➢ a consultant radiologist who is a core member of the IBD multidisciplinary

team.

5; 1 5; 1

➢ a consultant gastroenterologist who is a core member of the IBD

multidisciplinary team.

5; 0 5; 0

➢ a clinical nurse specialist with a special interest and competency in stoma

therapy and ileoanal pouch surgery.

5; 1 5; 1

➢ a consultant histopathologist who is a core member of the IBD multidisciplinary

team.

4; 1 4; 1

4; 2 4 ;1

St Mark's Hospital


Multidisciplinary team

• Essential to good working of a IBD

unit

• Joint clinics enhance the patient

experience and decision making

• For the surgeon – understanding the

medications and its impact pre and

post operatively

• For the gastroenterologist –

understanding the surgery and its

impact on patients

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The road map:

Radiologist who understands

IBD

• CT enterography

• Barium Follow through

• MR enterography

stricture

abscess

fistula

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Thinking outside the box

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How do we decide on the surgical approach?

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To Join or Not to Join

• Sepsis/abscess

• Albumin

• Medications

– Steroids ? Infliximab

• Fistula at the time of surgery

• Risk of anastomotic leak

– 50% with all 4 risk factors, 29% with 3 14% -16% with 2 or 1 risk

factor and 5% with none

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St Mark's Hospital


Hazards in Crohn’s surgery

The mesentery and risk of bleeding

Undetected fistula

State of small bowel- do not

miss a stricture

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St Mark's Hospital


Types of strictureplasty

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St Mark's Hospital


`

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strictureplasty is safe

• 1112 patients (1975-2005)

• 3259 strictureplasties– 81% Heineke-Mikulicz

– 10% Finney

– 5% Michelassi

• Surgical recurrence rate 23% – Site specific 3%

• 4 % septic complications (leak, abscess, fistula)

Yamamoto DCR 2007

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St Mark's Hospital


Michelassi strictureplasty

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Michellassi strictureplasty

-results

• Length of diseased bowel 20-68 cm

• Anastomotic haemorrhage 2%

• Anastomotic leak 1%

• Bowel obstruction 1%

• Enteric fistula from site of strictureplasty 20%

• 22% needed surgery for recurrent disease

– 7.7% of these for disease at site of previous

strictureplasty

• Average time to surgery after strictureplasty 35 months

• 5 year recurrence free survival 77%

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Courtesy Andree D’Hoore UZ Leuven

Michelassi strictureplasty over the IC

valve provides ultimate bowel preservation

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Isoperistaltic strictureplasty

extending over ilecaecal valve

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caecum

Opened terminal ileum

Proximal diseased segment

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Deep Ulcerations

IC valve

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The Kono-S anastomosis

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Kono-s Anastomosis

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The mesentery as an organ

What is its role in Crohn’s disease ?

Are we heading to more radical

surgery for Crohn’s?

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Crossroads in decision making

Medications Surgery

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Laparoscopic Ileocolic Resection

or !nfliximab treatment of distal

ileitis in Crohn’s disease

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No participation

Randomisation (N=130)

Laparoscopic ileocolic

resection (N=65)

Infliximab treatment

(N=65)

Follow-up for 12 months by trial nurse with

questionnaires

Analysis: quality of life, costs, morbidity

and mortality

Patients with Crohn´s disease

located in terminal ileum

Flow chart

LIR!C trial

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LIR!C Trial

• 143 patients – after exclusions

– 65 for Infliximab and 70 for surgery

• No difference in Quality of Life after 1 year –

laparoscopic surgery non inferior

• 21 (31%) had to stop infliximab and 13 went on to

surgery

• 4% started infliximab after surgery

• Cheaper to have surgery but is this true in the era of

biosimilars?

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• Is there a paradigm shift

• Move to reducing recurrence

• Role of medications and surgical complications

• Or are surgeons just losing touch with reality?

• Should we operate earlier?

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Ulcerative colitis

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Pouch procedures

and outcomes

• Only 26 surgeons in the UK

carried out more than 15

pouches in 5 years

• But 126 Surgeons perform

one pouch procedure in 5

years

• The concept of the occasional

pouch surgeon

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Laparoscopic pouch surgery

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Adhesions

• Significant reduction in adhesion related admission

attributed to laparoscopic surgery

Faiz et al 2011

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Fecundity

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fecundity

• Definite increase in time to first pregnancy after

laparoscopic pouch surgery

Bemelman et al 2010 Annals of Surgery

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TATME

• Established as an alternative approach to rectal excision

• Overcomes some of the issues associated with

laparoscopic excision

• There is a learning curve

• How can we adopt to benign disease

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St Mark's Hospital


What additional benefits can we achieve for benign

disease

• Low anastomosis

• No need for multiple firings

• Double purse string

• ? Reduced leak rate

• Single port technique for proctectomy

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Consequences of leak UC

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No Leak

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Anastomosis

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Ileoanal Pouch: 2014 April to 2017

• SILS & TATME IPAA Cases: 32

• Not defunctioned: 6

• Complications: 8 (29.6%)

• Anastomotic stricture

– Simple dilatation: 5 (18.5%)

– ileostomy not reversed: 2 (7.4%)

• Pouch leak: 2 (6.25%)

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Evolution of the Technique

• Males only to start

• Hand sewn anastomosis

• Stapled anastomosis with reinforcing

• Change of stapler and method of anastomosis

• No defunctioning

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Quality of Life

• 47 patients St Mark’s and Milan with 12 month follow up

• Significant improvement in the 24h bowel frequency and

nocturnal frequency

• 80% of patients having 6 to 8 bowel movements

• 80% of patients reporting absence of nocturnal

frequency. A positive trend was also found in relation to

social, work, dietary and sexual activity during the 12

month follow up.

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Quality of life assessment

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

0 2 4 6 8 10 12 14

CGQL

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Back to the future

• Is the appendix making a resurgence

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Will these hold the key?

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• IBD surgery is cutting edge

• Requires a different mind set with very much a

multidisciplinary approach

• Do not underestimate the value of the joint clinic

cutting edge topics in ibd surgery - static.livemedia.gr · st mark's hospital and academic...

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