Crohn’s Colitis

Question 1

CD

Answer 1

• Chronic inflammatory disorder
• Populations with Northern European and Jewish heritage exhibit the highest incidence of CD.
• Bimodal peaks around ages 20 and 50
• The environmental factors
• Genetic Factors
• Smoking

Question 2

Name some of the Factors

Answer 2

• Environmental factors :
  gastrointestinal infection
  chronic use of NSAID
  exposure to antibiotics
• Disruption in the integrity of the intestinal mucosa and natural gut flora
• Smoking > Active and passive smoking + previous history of smoking
• Genetic > MLH1, a DNA mismatch repair gene, and in CARD15, a nuclear factor-kappa B transcription factor.

Question 3

Notable characteristics pointing toward Crohns

Answer 3

• Skip lesions
• rectal sparing
• longitudinal ulcers
• intestinal and perianal fistulizing disease
• mucosal cobblestoning

Question 4

Lab Works

Answer 4

• C-reactive protein
• erythrocyte sedimentation rate
• fecal calprotectin
• albumin levels
• complete blood count
• basic metabolic panel.

Question 5

Imaging

Answer 5

• x-rays abdomen > initial > free perforation and evaluate severity of colonic dilation.
• Barium enema > longitudinal or transverse ulcers, deep fissuring of the bowel wall, coarse mucosa cobblestoning, or longitudinal intramural fistulas.
• Single or double contrast ( Rarely used )
• CTE > bowel wall thickness, stricturing, intraabdominal abscess, internal hernias, and/ or extraintestinal involvement and clarify the anatomy.
• Endoscopic examination with biopsy

Question 6

What Percentage of CD spares Rectum ?

Answer 6

40%

Question 7

If UC is suspected, In Colonoscopy what to do ?

Answer 7

• biopsy of the rectum, even if normal appearing on visual inspection, is helpful to rule out pathologic inflammatory changes.

Question 8

What is inflammatory bowel disease unclassified (IBDU) ‘‘indeterminate colitis’’

Answer 8

When differentiation between UC and CC not possible even under pathologic examination

Question 9

MEDICAL MANAGEMENT

Answer 9

• bowel rest
• intravenous hydration
• antibiotics
• Nasogastric tube > if the stomach and small bowel are dilated
• Intravenous glucocorticoids > initiated early
• Serial abdominal exam
• plain radiographic films
• serologic markers > monitor disease progression.
• If symptoms do not improve in 72 hours
  use of an anti-TNF antibody (infliximab) should be considered > response to anti-TNF should occur within 5 to 7 days.

Question 10

emergent exploration, When ?

Answer 10

Acute abdomen with diffuse peritonitis, severe bleeding, and hemodynamic instability

Question 11

Urgent exploration within the same hospitalization

Answer 11

• Toxic megacolon
• Acute large bowel obstruction unresponsive to medical management
• Intraabdominal abscess without successful control of sepsis by percutaneous drainage

Question 12

Elective surgery

Answer 12

• Disease continues to progress despite extensive medical therapy
• Partial obstruction with fecalization of the small bowel,
• Persistent intraabdominal abscess despite percutaneous drainage and antibiotics
• Presence of high-grade dysplasia or malignancy
• Failure to thrive in children

Question 13

Multidisciplinary management including

Answer 13

• gastroenterology
• infectious disease
• enterostomal nursing
• nutrition
• surgery
• interventional radiology

Question 14

Steroids Vs immunomodulators for operative morbidity

Answer 14

• Dose-dependent operative morbidity with steroid therapy is well documented.
• In contrast, no clear association has been established between use of immunomodulators such as azathioprine, 6-mercaptutopurine, and methotrexate and postoperative morbidity.

Question 15

what is associated with postoperative intraabdominal septic complication.

Answer 15

• weight loss > 10%

Question 16

Enteral Vs TPN

Answer 16

• EEA is preferred over TPN due to maintenance of the physiologic route of nutrient absorption and avoidance of complications associated with TPN and central line placement.
• Preoperative EEA supplementation, for 3 months when feasible, has been shown to reduce the rate of postoperative septic complications.

Question 17

What size of collection to Drain ?

Answer 17

• Any intraabdominal collection > 3 cm should be managed with percutaneous drainage with interventional radiology

Question 18

What is the primary goal of preoperative optimization.

Answer 18

The reduction of the surrounding secondary inflammatory response to an area of severe disease or local perforation

Question 19

Patients with CD are at increased risk of developing venous thromboembolism (VTE) , Why ?

Answer 19

• hypercoagulability in a proinflammatory state
• malnutrition
• anemia
• thrombocytosis
• prolonged hospital stay with limited mobility
• use of steroids.

Question 20

Prophylaxis for venous thromboembolism (VTE), when to start and how long ?

Answer 20

• initiated during the optimization period and carried through the operation unless significant bleeding risk is present.
• The risk of VTE continues to be elevated at least 30 days after an operation, and VTE prophylaxis should be continued postoperatively.
• Judicious use of postdischarge VTE prophylaxis should be considered, especially if other risk factors are involved such as smoking, obesity, prolonged pelvic surgery, immobilization, and malignancy.

Question 21

If < 20 cm colon is affected, especially in the proximal colon

Answer 21

• segmental resection with primary anastomosis should be considered.
• Leaving behind a segment of colon does put the patient at increased risk of recurrence
  up to 62% at 5.5 years.
• This risk should be clearly discussed with the patient before surgery.

Question 22

Segmental colectomy

Answer 22

• Previous multiple small bowel resections
• < 20 cm involved segment in the proximal colon, segmental resection with or without primary anastomosis should be considered

Question 23

Total abdominal colectomy (TAC)

Answer 23

• More than two segments of colon are involved with rectal sparing and anastomosis is deemed unsafe
• Patient is in extremis with pancolitis and a total proctocolectomy is not indicated
• Definitive diagnosis is not established, and indeterminate colitis is considered

Question 24

Total proctocolectomy (TPC)

Answer 24

• Involvement of two or more segments of colon especially with perianal fistulizing disease
• Visible dysplasia not amenable for complete endoscopic removal
• Multifocal dysplasia, dysplasia in the surrounding flat mucosa
• Carcinoma in the setting of pancolitis

Question 25

Ileal pouch-anal anastomosis (IPAA)

Answer 25

• Absence of small bowel or perianal involvement with a definitive preoperative diagnosis of CC

Question 26

The dissection for laparoscopic TAC begins with

Answer 26

• transection of the ileocolic pedicle
• mobilizing the cecum in a medial to lateral fashion
• continues in a clockwise rotation to the hepatic flexure
• gastrocolic ligament and any ligamentous attachments to the liver, spleen, and pancreas are divided to mobilize the transverse colon
• The lateral attachments of the right colon to the lateral abdominal sidewall are divided last to finally release the right colon to the midline.
• Divide the omentum distal to the gastroepiploic arcade and remove it with the specimen.

Question 27

Then Left Side ?

Answer 27

• The splenic flexure is mobilized in an antegrade fashion from the right to the left
• When severely inflamed or in obese patients, it may be necessary to return to the splenic flexure in the retrograde fashion after partial mobilization of the left colon
• Care must be taken to divide the base of the mesentery of the splenic flexure
• All ligamentous attachments of the splenic flexure should then be dissected close to the colon to avoid injury to the splenic capsule.
• The left colon is mobilized by dividing the lateral attachments and freeing it off of the retroperitoneum starting at the left pelvic brim and dissecting medially, taking care to avoid injury to the left ureter
• Ureteral stents placed at the induction of anesthesia can facilitate identification and protection of the ureters in a patient with severe inflammation in the descending colon and sigmoid regions.
• A medial approach to releasing the left colon and rectosigmoid junction allows avoidance of inflammatory attachments of the sigmoid and left colon to the critical structures at the pelvic brim.
• Working from soft normal dissection planes toward the diseased areas gives a better chance to complete the dissection and avoid injury to diseased and normal structures.

Question 28

Regarding Ligation of the Vascular Supply ?

Answer 28

• Unlike TAC for malignancy,
• ligation of the vascular supply to the colon does not need to occur close to its origin in CC, and the mesentery can be ligated closer to the colon.

Question 29

Then Retum

Answer 29

• The rectum is identified at the distal sigmoid colon where the tenia coli “splay” out onto the anterior surface of the rectum.
• The peritoneal reflection is incised around the pelvic sidewalls and the proximal rectum is mobilized using the areolar tissue plane posterior to the rectum at the sacral promontory
• The terminal ileum and the rectosigmoid junction are transected with a linear cutter stapler to control spillage after dividing the mesentery up to the bowel wall, either intracorporeally or through a small Pfannenstiel incision.
• The rectosigmoid junction is the preferred level of distal transection. This provides adequate rectal length for ileorectal anastomosis or creation of a mucus fistula and removes all colonic mucosa.
• Depending on the clinical scenario either an end ileostomy or ileorectal anastomosis is performed using either hand-sewn or stapled technique.

Question 30

“ileorectal syndrome” ??

Answer 30

• Patients with ileorectal anastomosis > period of rapid return of bowel function followed by a sudden decrease in bowel function, marked abdominal distension, and vomiting
• caused by exposure of the terminal ileum to a high back pressure from the rectal vault.
• Drainage of rectal contents and relief of build-up of pressure in the ileum using an in-dwelling large catheter (24– 34F) in the rectum can alleviate this ileal response

Question 31

certain factors that need to be considered when deciding between ileorectal anastomosis and end ileostomy

Answer 31

• The rectum and the perianal region must be examined
• free of stricturing or fistulizing disease before committing to ileorectal anastomosis.
• Adequate sphincter resting tone and maximal squeeze pressures are required to prevent incontinence of liquid stool.
• The presence of fistulotomy or episiotomy scars should raise concern for postoperative inadequate control of liquid stool.
• The patient’s general condition such as nutritional status, weight loss, usage and dosage of steroidal agents, and smoking status should be reviewed to determine the feasibility of anastomosis.

Question 32

Opting for an end ileostomy

Answer 32

• confers a lower rate of recurrence of CD
• especially in active smokers and patients with penetrating disease.

The ileostomy and Hartmann stump of the rectum allows the surgeon to appreciate the natural history of the patient’s disease to determine whether an ileorectal anastomosis is possible in the future.

Question 33

When to perform Brook ileostomy

Answer 33

• in the acute setting
• in cases of indeterminate colitis
• when the rectum is involved

Question 34

transected Hartmann rectal stump

Answer 34

• drain the stump with a rectal tube and leave a drain by the staple line for the duration of the hospital stay.
• The transected Hartmann rectal stump of an inflamed rectum is at risk for dehiscence of the upper staple line due to active disease and tissue friability.
• Other surgeons bring the stump to the incision and either suture it to the fascia or open it as a formal mucus fistula.
• These two options require a longer stump that may not be feasible with sigmoid involvement or in the obese patient.

Question 35

Total Proctocolectomy

Answer 35

• Pelvic dissection follows the total mesorectal excision (TME) plane
• loose avascular areolar tissue of the retrorectal space is dissected to mobilize the rectum with the mesorectum intact.
• Once the posterior dissection is complete to the levator ani
• the lateral attachments and the anterior Denonvilliers’ fascia/ rectovaginal septum are dissected to the levator ani to completely mobilize the mesorectum.
• Extra care must be taken not to mistake the pelvic parietal fascia for the fascia propria of the rectum because the loose avascular areolar tissue between presacral fascia and pelvic parietal fascia can look identical
• Mistake > transect the hypogastric nerve embedded within the pelvic parietal fascia.
• A helpful hint is that if median sacral vessels running on the sacral periosteum are visualized, the dissection plane is already in a posterior plane deep to the desired plane anterior to the pelvic parietal fascia.
• One technique to reduce potential pelvic nerve injuries is to perform close rectal dissection (CRD).
• dissection is performed close to the rectal muscle wall within the mesorectum.
• This minimizes the risk of injury to the hypogastric nerves, the pelvic splanchnic nerves, and the inferior hypogastric plexus.

Question 36

anal canal

Answer 36

• Once the rectum is completely mobilized
• IThe dissection is begun at the anal verge in the palpable intersphincteric groove with a circumferential incision into the space between the internal and external sphincters.
• The autonomic internal sphincter circular fibers do not twitch when touched with electrocautery.
• The somatic external sphincter fibers that encircle the internal sphincter fibers do twitch.
• The longitudinal rectal muscle fibers run at right angles to the circular fibers in the intersphincteric space and guide the dissection cephalad to the level of the puborectalis muscle.
• Preserving the well-vascularized external sphincter reduces the size of the perineal wound, allows better pelvic closure and healing, and reduces the risk of injury to the vagina/ prostate and neurovascular bundle.
• extra care must be taken during anterior dissection to avoid injury to the vagina or the prostatic capsule.
• Frequent palpation of the posterior vaginal wall or the bladder catheter in the perineal and prostatic urethra helps to maintain orientation in the correct dissection plane.
• The dissection progresses circumferentially in a cephalad direction, and the levator ani muscles are finally separated from the rectum at the puborectalis sling to join with the dissection plane from the intraabdominal portion of the procedure.
• The levator ani, the external sphincter, and the ischiorectal fat are approximated in layers across the midline, but the subcutaneous tissue and skin are left open.
• draining the wound as well as leaving an opening that cosmetically resembles an anal orifice. The drain is typically removed in two weeks if drainage is minimal.