general principles of medical and surgical management of inflammatory bowel disease jeraldine s....
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General Principles of Medical and Surgical
Management of Inflammatory Bowel Disease
Jeraldine S. Orlina
Colorectal Conference
December 22, 2005
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Medical Therapy of Ulcerative Colitis
5-Aminosalicyclic acid agents Corticosteroids Cyclosporine 6-Mercaptopurine Azathioprine
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5-Aminosalicylic Acid Agents
Sulfasalazine
- 5-ASA linked to sulfapyridine by an azo bond
- poorly absorbed in upper GI tract
- principle use to maintain remission
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Operative Indications
Failure of medical therapy Obstruction Fistula or abscess Hemorrhage Growth retardation (in pediatric population) Perforation of carcinoma Extraintestinal manifestations
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Preparation of the Patient
Endoscopic and Radiologic studies Correction of dehydration, electrolyte
deficiencies, coagulation deficits, and anemia
Optimization of comorbid conditions Nutritional optimization Pre-op marking for stoma (if needed) Bowel prep
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Preparation of patient
Withdrawal of immunosuppressives Perioperative antibiotics Stress dose steroids DVT prophylaxis
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Strategic Planning for Surgery
Midline incision to preserve potential stoma sites
Preservation of small bowel Resection margins—extended resection
margins are unnecessary Use of temporary stoma
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Management of Small Bowel Crohn’s Diesease
Chronic obstruction (35%) Internal fistulas (30%) Intractability (22%) Abscess formation (11%)
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Types of Operations
Small bowel resection Multiple small bowel resections (with
enteroenterorostomy, diversion, or both) Bypass Strictureplasty Balloon dilatation
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Resection
Most common surgical procedure Wide resection unnecessary Division of inflamed mesentery
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Indications for Strictureplasty
Diffuse involvement of small bowel with multiple strictures
Strictures in a pt who has undergone prev major resection of small bowel
Rapid recurrence of disease manifested as obstruction
Stricture in pt with short bowel syndrome Nonphlegmonous fibrotic stricture
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Relative Contraindications for Stictureplasty
Free or contained perforation of the small bowel Phlegmonous inflammation, internal fistula, or
external fistula involving the affected site Multiple strictures within a short segment Stricture in close proximity to a site chosen for
resection Colonic strictures Hypoalbuminemia
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Heineke-Mikulicz Strictureplasty
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Finney Strictureplasty
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Side-to-side isoperistaltic strictureplasty
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Stapled Strictureplasty
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Complications
Hemorrhage form suture line Restricture at strictureplasty site Fistula/Abscess/Leak Small bowel adenocarcinoma
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Take Home Points
Conservative Management Preservation of small bowel