Inflammatory Bowel Disease - Open Access...

Role of surgery for idiopathic inflammatory bowel disease with a focus on postoperative

events and their managementGunjan S Desai*; Prasad Pande; Aniruddha Phadke

Department of Gastrointestinal surgery, Lilavati hospital and research centre, Maharashtra, India.

*Correspondence to: Gunjan S Desai, Department of gastroenterology, Lilavati hospital and research centre,

Mumbai, Maharashtra, India 400050.

Email: [email protected]

Chapter 4

Inflammatory Bowel Disease

Keywords: Ileal pouch; Crohn’s disease; Ulcerative colitis; Surgery

1. Spectrum of Inflammatory Bowel Disorders [IBD]

Theinflammatorydisordersofbowelareverycommoningastrointestinalclinics.ThesearecharacterizedbyintermittentrelapsingandremittingcourseorchronicinflammatorycourseaffectingthegastrointestinaltractandcompriseofaspectrumofdisordersasshowninFigure 1[1].

Inthischapter,thefocusisonunderstandingidiopathicIBD,especiallyulcerativecoli-tis(UC)andcrohn’sdisease(CD)fromasurgeon’sperspectivewithspecificfocusonlifeaftersurgeryforthisIBD.

2. Natural History of the Disease and its Relevance to Clinical Practice

IdiopathicIBDis relapsingandremittingorchronicprogressivediseasewherein thediseasenaturalhistorycanbedividedinto4phasesbasedonthediseaseactivity.

PhaseI:Detection/diagnosisofdiseasebasedonclinicalpresentation:Activeorcomplicateddisease

PhaseII:Initiationoftreatmentandachievingthephaseofremission

PhaseIII:Phaseofmonitoringtomaintainremissionandearlydetectionofrelapse/complica-

InflammatoryBowelDisease

2

www.openaccessebooks.comDesaiGS

tions

PhaseIV:Treatmentof relapseandmonitoringforprogressionofdiseaseorcomplications[2].

Figure 1:Spectrumofinflammatoryboweldisorders

Crohn’sdiseaseisoftenmisdiagnosedinitially.Nearly25%ofthepatientsarelabeledasirritablebowelsyndromeandmeantimetodiagnoseCDoftenreachedupto2yearsfromthefirstsymptom.Itisprogressiveinupto75%patientsandaspertheViennaclassification,canbeinflammatory,stricturingorpenetrating.Itprogressesinthesegmentwhereitbeganandhence,disease location is an important consideration.Progression toneoplasia is nowknowntobeassignificantpartofnaturalhistoryasinUC[3]. Ulcerativecolitis,ontheotherhand,progressesasachronicinflammatorydiseasestateaffectingthelargeintestineandhasnoothersubtypes.StricturingdiseaseinUCismoresug-gestiveofmalignancy.RiskofmalignancyisawellknownphenomenoninUC.Thenaturalhistory,itsclinicalsignificanceandtheeffectonpostoperativecomplicationsisshowninFig-ure 2[4]. InboththeseIBDs,progressiontocolorectalmalignancyisknownandthenaturalpath-way of progression tomalignancy is different from the sporadic colorectal cancer [CRC].ThisisshowninFigure 3.Apartfromthis,Crohn’sdiseasealsohaschronicfistulaewhichcanresultintosquamouscellcarcinomasatthosesitesandalsohasanincreasedriskoflungcancerandsmallintestinaladenocarcinoma.Also,theautoimmune,geneticandenvironmentalfactorsthataffectthegastrointestinaltract,alsoaffecttheextra-intestinaltissuesandproducetheextra-intestinalmanifestationsofthedisease[5,6].


3

Figure 2:Naturalhistoryofdisease,pathophysiologicalbasisofclinicalpresentationsandcomplicationsaftersurgery

3. Disease Classification and Measurement of Severity Indices

ClassificationofCDisbasedontheMontrealclassificationortheParisclassification[7,8].Thediseasesubdivisionineitheroftheseisbasedonageatdiagnosis,diseaselocationandbehaviour[inflammatory/stricturing/penetrating]andwhetherthereisgrowthretardationornot.Also,attemptstogaugetheseverityofdiseasebyusingdifferentscoringsystemssuchasCrohn’sdiseaseactivityindex,HarveyBradshawindex,Oxfordindexetc.,havebeenmade[9].

Figure 3:DiseaseprogressiontocarcinomainIBD

UlcerativecolitisisclassifiedonthebasisofdiseaseextentandseveritybyMontrealclassification.SeveritygradinghasalsobeenattemptedusingTrueloveandWittsclassificationintomild,moderateandseverediseaseaswellasbySutherlandindex.However,theseveritygradingsaremoreacademicanddon’t actuallyguide the treatmentpathways.Clinical rel-evanceoftheseclassificationsandseverityscoringsisnotyetidentified[10].


4

4. A Surgeon’s Understanding of the Medical Options of Management

ThefirstepisodeofulcerativecolitisismildinmajorityofcasesandsevereUCisseenonfirstpresentationinonlyabout15-20%cases.Morethan50%ofallcasesachieveremis-sionwithfirstlinemanagementwithASAanalogues.Upto35%ofthepatientsrelapseinthefirstyearaftertreatment.Ifthepatientsdonotrelapseinfirstyear,itisamarkerofquiescentdiseasewhereinthechancesofrelapseinthenextyearisaround20%[1,11].

InCrohn’sdiseaseon theotherhand, relapsesare seen inupto20%patients infirstyear,40%within2yearsandaround80%within10yearsofdiseasediagnosis.InbothUCandCD,incidenceofcolorectalcancersis2-5%at10yearsofdiagnosis,5-10%at20yearsofdiagnosisand12-20%at30yearsfromdiagnosis.InCD,nearly28%patientsmaydevelopsmallbowelcarcinomaand1-2%patientsareatriskforlymphoma,lungcancerand/orcervi-caldysplasia.Somestudieshavealsoconfirmedriskofprostatecanceratahigherincidenceinthesepatients[12].

Themanagementofthesepatientsisbasedontheclinical,radiological,endoscopicandhistopathologicalnatureofthediseaseineachpatient.Theoptionsformanagingthesepatientsaremedical,endoscopicandsurgical.Completediscussionofmedicalandendoscopicmeansofmanagingthesepatientsisoutofscopeofthischapterandonlytheclinicallyandsurgicallyrelevantpointsarediscussedfurtherinthesetwooptions.

The goals of the management in these patients are

• AchievethecorrectdiagnosisasthemanagementofdifferentIBDsisdifferent

• Toinduceandmaintainremission–Remissioncanbedefinedclinicallyorintermsofmucosalhealing

• Assessfordiseaseprogression,complicationsandcarcinoma

• Ensureagoodqualityoflife[QOL]whiletreatingthesepatients[13].

SalientfeaturesofthevariousmedicaloptionsforIBDareasshownin Table 1.

5. Algorithm of Medical Management of IBD at Our Centre

Our algorithmic approach for themedicalmanagement of these patients is summarized inFigure 4[14,15,16,17,18].


5

AGENT SALIENT FEATURESROLE IN

MANAGEMENT

5- ASA analogues

(Sulfasalazine, mesalazine) 19,20

DoesnothelpinCDformaintainingremission•Hasadosedependentaction•Topical+oralismoreeffectivethaneitheralone.Oraland•topicalaloneareequallyeffective15%patientscannottolerateit•Doesnotalterthesurgicaloutcomes•Maleinfertilityisaconcernwithsulfasalazine•

InductionandmaintenancetherapyinUC.

InductiontherapyinCD.Notformaintenance.

Glucocorticoids 21

Doesnothelpinmaintenancetherapy

Steroidresistance*-20%

Steroiddependence**-40%

Theremaininghavealongtermresponseonsteroids

Affects surgical outcomes adversely

Induction therapy in UC

6-Mercaptopurine (6 MP)/ Azathioprine(AZA) 14,17

Takenearly6monthstoshowresponse–needcoverduring•thattimewithsteroids/methotrexate/cyclosporine.Steroidsparingforsteroiddependentpatients[better•outcomesincombinationwithinfliximab].Ifmorethan2coursesofsteroidsarerequiredinayearorif•parenteralsteroidsarerequiredtoachieveremission,theseareindicated.Reduce colectomy rates• inthesepatientswithsevere,refractorydisease.TPMT(Thiopurinemethyltransferaseenzyme)mutation•needstoberuledoutbeforestartingtreatment–Morechancesofcholestasis,bonemarrowsuppression,pancreatictoxicityandnodularregenerativehyperplasiainthesecases.Mildleucopeniaisagoodindicatorofresponseandis•desirable.Mantainancetherapyisusuallycontinuedupto3.5years.•10%patientscannottolerateit•Relapserateis8%•Does not affect surgical outcomes•

InductionandmaintenancetherapyinUCandCD

Infliximab 15,16

Mucosalhealingisbetterthananyotheragents

Effectiveoptionforsteroidrefractoryaswellas

immunomodulatorrefractorysevereUC/CDcasesforinductionaswellasmaintenanceScreeningrequiredfortuberculosis,HepatitisB/C,HIVas

wellasriskoflymphomaneedstobediscussedFormaintenancetherapy,itisusedwithsteroidor

immunomodulatorstopreventthedevelopmentofAnti-drugantibodiesPositive influence on surgical outcomes

InductionandmaintenancetherapyinCD>UC

In CD - Earlyaggressivemedicaltherapyistheparadigmshift

Other biological agents

22,23

Adalimumab•Natalizumab–Notusedduetoriskofprogressive•multifocalleukoencephalopathy[PML]Certolizumab/Vedolizumab•Ustekinumab–SubcutaneousdrugactiveagainstIl-12and•Il-23

Maybecomefrontlineinfuture

Table 1:SalientfeaturesandroleofdifferentmedicalagentsfortreatmentofIBD


6

Figure 4:OuralgorithmicapproachtomedicalmanagementofIBD

6. Surgical Management of IBD

Inulcerativecolitis,20%ofthepatientsneedsurgeryduringthefirst10yearsafterdis-easediagnosisandnearly1/3rdofthepatientsneedsurgeryduringthefirst25yearsofdiseasediagnosis.Relapseratesareminimalinulcerativecolitis.InCrohn’sdiseaseontheotherhand,nearly80%ofthepatientsneedsurgeryatsomepointintheirlifewhichissignificantlyhigherthanulcerativecolitis.Also,afterthefirstsurgery,1/3rdofthepatientsrelapsewithin3yearsand2/3rdoftheserequireatleastoneothersurgeryduringtheirlife.1/3rdofthepatientswithCrohn’sdiseaseneedmorethantwosurgeriesduringtheirlifetime.10%ofpatientshavedis-easethatdoesnotrespondtoanytherapyandisreferredtoasdisablingdisease.Indications for surgeryareasshowninTable 2[24,25,26].

*-Activediseasepersistsdespitegivingasteroiddoseof0.75mg/kg/dayprednisoloneequivalent,**-Inabilitytore-ducesteroiddoseto<10mg/dayprednisoloneequivalentwithin3monthsofstartingsteroidwithoutadiseaserelapsewithin3monthsofstoppingthetherapy.


7

Table 2:IndicationsofsurgeryinIBD

7. Options for Surgical Management and Surgical Techniques

BasicprinciplesofsurgeryforintestinesremainthesameforsurgeryeveninIBD–Toachievediseasefreemarginandestablishcontinuityofthegutbyatensionfree,vascularanas-tomosis.InCD,theprincipleisofbowelpreservationtoavoidshortbowelsyndromeduetotheneedforrepeatedsurgeries.Also,inCD,patientsundergoingsurgeryearlyafterdiagnosishaveanincreasedprobabilityofbeingre-operated[24,26].

Owingtothisobservationandalsoonseeingtheexcellentresponsetoimmunomodula-torsinCDforvariousindications,thenewerapproachescameinCDwhereinearlyandaggres-siveinitiationofimmunomodulator/infliximabtherapyledtoreductioninratesofsurgeries.However,forthepatientswhohavealreadyundergoneearlysurgery,theearlyinitiationofthisdrugtherapydoesnotseemtoprotectagainstthere-surgeryrates.Hence,itisrecommendedtoavoidearlysurgeryandbeginimmunomodulator/infliximabtherapyasearlyasfeasibleinCDwhichisabigparadigmshiftinthemanagementofCD[25].

There are various surgical optionstotakecareofthevariedclinicalpresentationsandvarieddiseaselocationinIBD.For CD,segmentalbowelresections,divertingloopileosto-myandsubtotalcolectomywithileostomyaretheemergencysurgeries.Forperianalfistulas/abscess, incisionanddrainageofabscess,fistulotomy/setonplacement/fistulectomy,divert-ingstomasandadvancementflapsareutilized.ForstricturesduetoCD,HeinekeMickuliczstricturoplasty and Finney stricturoplasty or side to side isoperistaltic stricturoplasty are the options[1,27].

ForUC,subtotalcolectomywithileostomyisthesurgicaloptionofchoiceinemergencywhereastotalproctocolectomywithBrooke’sorKock’sileostomyorsubtotalcolectomywithileorectalanastomosis[IRA]orrestorativeproctocolectomywithilealpouchanalanastomosis[RPAwithIPAA]arethetreatmentoptionsinelectivecases.Ofthese,thesurgeriesapartfrompouchareroutinelyperformedforotherindicationsalsoandarenotdiscussedatlengthinthis

Emergency Surgery Elective Surgery

GastrointestinalbleedingIntestinalobstructionIntestinalperforationSevere colitis/Toxicmegacolon not responding tomedicaltherapyin72hoursofstartingtreatment

Steroid dependenceSteroidrefractorydiseaseNon-compliancetomedicaltherapySuspected/confirmedmalignancyFinancialconstraintstomedicaltherapyNottoleratingadverseeffectsofmedicines

Indications specific to Crohn’s Disease

Intractablefistula[Enterocutaneous,entero-enteric,enterovesical,enterovaginal]•Complex/Simpleperianalfistula•Growthretardation•Intra-abdominal/Pelvicabscessnotrespondingtomedical/percutaneoustreatment•


8

chapter.AwordismentionedhereontechnicaldetailsofpouchsurgeriesforUC[28,29].

7.1. IPAA for IBD

TheIPAAcanbedonebyadoublestapledtechniquewhereinarectalmucosalcuffofupto2cmremainsabovetheanaltransitionzoneoritcanbedonebyhandsewnanastomosisafteramucosectomywhichtheoreticallyremovesall therectalmucosaandhence,protectsagainstfutureriskofmalignancy.Hence,thedoublestapledtechniqueiscontra-indicatedincaseswithdysplasiainlower2/3rdofrectum.Studieshowever,haveshownnodifferenceinoncologicoutcomeswhenthetwotechniquesarecompared[30].

Theproblemwithmucosectomyisthatitisnotalwayscompleteandislandsoftissuesareoftenleftbehindwhichmayleadtomalignancy.Thisrectalcuffisburiedbehindtheanas-tomosisandhence,isnotamenabletoendoscopicsurveillanceorbiopsyacquisition.Also,duetoextensiveretractionduringsurgery,thereisfoundtobehigherriskofsphincterdamageandalso,becauseoflossofcompleterectalmucosa,thereislossofdiscriminationbetweenflatusand stool and results in incontinence.Studieshave shownahigher rateofnocturnal seep-ageascomparedtothedoublestapledtechnique.Inadditiontotheseproblems,itisdifficultintraoperativelybecausecompletemucosectomyandhandsewnileo-analanastomosisneedadditional2-4cmofmobilizationofpouchtomakeitreachthelowerstumpwhichmaybedifficultinsomecases–Mayleadtotensionontheanastomosisandproblemswithitsbloodsupplywhichmaypredisposetopostoperativepouchrelatedcomplications[31,32].

TheshapeofthepouchconstructedcanbeS,WorJshaped.SandWshapedpouchesarecomplextoconstruct.Also,theyoftendilateexcessivelyovertimeandleadtofecalstasisandanastomoticstenosisattheileo-analend.TheSpouchhasalongoutflowlimbandthiscancauseproblemswiththeemptyingofthepouch.FailureratedofSandWpoucharehighatnearly50-60%.Jpouchiseasiertoconstruct,haslesscomplicationsthantheothertwobut,hasmorediarrheaepisodesinitially.TheanatomyoftheJpouchisasshownintheFigure 5 below[33].

7.2. Minimally invasive surgery for IBD

LaparoscopyhasevolvedslowlyforIBDwhencomparedtotheotherindications.Thisisbecauseofseveralfactors.Thediseaseischaracterizedbyinflamedtissues,multipleop-erationsandbadplanesdue to inflammationandprevious surgery.Also,patientsareoftenmalnourishedwith low albumin, are anemic,may be on chronic steroids andmay have astronghistoryofsmoking,allofwhicharedetrimentaltosurgicaloutcomes.Incurrenttimes,laparoscopyisconsideredfeasibleandsafeforfirstelectivesurgeryaswellasforemergencysurgeries for idiopathic IBD in expert handswith equivalent surgical outcomes.However,nostudieshavebeenabletodemonstrateconclusivelythataddedbenefitsoflaparoscopyon


9

postoperativescoresandpainscorestranslateintopracticeandthesebenefitshavenotreachedstatisticallysignificantlevelsacrossstudies[34].

Laparoscopyisassociatedwithhigheroperativetimes,but,lowerbloodloss.Penetrat-ingtypeofIBDhasbeenshowntobeassociatedwithhigherconversionratesandhigherratesofstomacompared to laparoscopyforother indications inIBD.Technologicaladvances inlaparoscopyandtheadventofroboticsurgeryhaveencouragedsurgeonstousethesemodali-tiesinpatientsofIBDalso[35].

Both hand assisted laparoscopy (HALS) and Single incision laparoscopy (SILS) aswellasnaturalorificespecimenextraction(NOSE)andtransanalminimallyinvasivesurgery(TAMIS)haveallbeenattemptedforIBDsurgeryandallhaveclearedthesafetyandfeasibil-itystage.HALSrestorativeproctocolectomyisassociatedwithshorteroperativetimeswithnoothersignificantdifferencecomparedtocompletelaparoscopicsurgery.SILShasnotgainedfamesofarandstudiesarescantyforthisindication.Whetheritisbeneficialstatisticallyisnotyetestablished.TAMIShasbeenusedfortotalmesorectalexcisiontoachievetherightplanefromperinealsideincombinationwithabdominalsurgeryinrectalcancer.FeasibilityinIBDforrectaldiseaseandcomplexfistulashasbeenestablishedwhereaslongtermresultsonout-comesareawaited[34,35].

Roboticsurgeryhasalreadydemonstratedbenefitforrectalsurgeriesowingtothedex-teroushandofrobottoworkinthenarrowpelvis.Nervepreservationratesarehigherwithrobotic pelvic dissections for rectum.Hence, robotic completion proctectomy is a feasibleandgoodoption.Ontheotherhand,forothersurgeriesofIBD,roboticinstrumentswillberequiredinmorethanoneabdominalquadrantandthecostandtimerequiredforthesestepsmaynotbeasbeneficial[36].

8. Life after first Surgery

Thisistheperiodwherethepatienthasachievedcontrolofthediseaseandisonmain-tenanceprotocols.Theissueshereincludemonitoringforprogressionofdisease,relapse,dys-plasiaandcancerorextra-intestinalmanifestationsaswellasthecomplicationsofthesurgery.Focusalsoneedstobeonassessmentforlifestylechangesandqualityoflifeissues.Thesepointsarenowdiscussedintheremainingchapterandthemanagementofassociatedproblemsarepresented.

Alotofparametershavebeenevaluatedforuseasmarkersofdiseaserelapseorpro-gressionaswellastoevaluatetheresponsetotherapysuchasc-reactiveprotein,erythrocytesedimentationrate,fecallactoferrin,fecalneopterinetc.Onlyfecalcalprotectinlevelshavebeenshowntobehelpfulinthisregard.Thiscalciumandzincbindingproteinisproducedbyneutrophils, remains stable inunprepared samples forupto7days,helps indifferentia-


10

tionbetweenIBDandirritablebowelsyndromeandismoreaccuratethanCRPandESRformonitoringfordiseaserelapse.Elevationabovenormalvaluefor2consecutivevaluespredictarelapsewithinthenext3monthswithasensitivityof95%andspecificityof91%.Regimesfortestinghavebeenmonthlyto3monthlyacrossdifferentstudies[2].

Response isusuallymonitoredbyclinicalparameters.Endoscopicdocumentationofmucosalhealingisnotmandatory.However,incaseofdoubt,colonoscopicevaluationinCDorlimitedsigmoidoscopicevaluationafterpouchforUCtoevaluatemucosalhealingisap-propriate[1,28].

Figure 5:PartsofJpouchandrelatedpostoperativeeventsatspecificpoints

Studieshaveshownthatifapatientachievesaclinicalremission,thetypeofsur-geryi.e.stomaversuspouchdoesnotmakeamajordifferenceinthequalityoflifeandmorethan95%ofthesepatientsdorecommendsurgerytootherpatientswhenaskedafter5yearsoftheirfirstsurgery.Onevaluationofdailyactivitiesthough,theJpouchperformedbetterintermsofsocialinteraction,recreationalactivities,sexuallife,participationinsportsandalliedactivitiesetc.However,thedifferencewasnotsignificantoverall[37].

Physiologically,thesepatientshavealimitedphysiologicalreservetofightsituationswithfluid losses.This isbecausecoloncan increase its absorptivecapacity from1-1.5 lit/daytoupto5lit/dayincaseofneedforwater.Similarly,coloncancausesaltreabsorptiontoexcretelessthan2meq/dayincaseofneed.Withileostomyorpouchdiarrheainabsenceofcolon,thesepatientshaveanobligatoryfluidlossof500-800ml/dayandsodiumlossof30-40meq/daywhichisnotmodifiable.Also,thepatientsdevelopvitaminB12,folateandsecond-


11

arybileaciddeficiencyduetolossofterminalileumandcolonandtheseneedtobereplaced.[37,38].

Numberofdaytimeandnighttimedefecationepisodesrangefrom6/dayand1-2/night.Incontinenceusuallyincreaseswithtimeandmaydoubleoverthenext15-20yearsaftersur-gery.However,theoverallsuccessrateofpouchisstillupto90%.SexualdysfunctionafterIPAAoccursintheformofdyspareuniain5-7%womenandretrogradeejaculationandimpo-tencein4%and2%malesrespectively.Overalllifeexpectancyhowever,isnotchangedafterthesurgeryinthelongtermprovidedtherearenoothercomplications[39].

9. Complications and their Management

Theoverallmorbidityrateshavecomedownduetoadvancesinsurgicaltechnology,equipmentsaswellasimprovedperioperativecareofthepatient.However,themorbidityrateisstillreportedaround30-60%andthemortalityrateisreportedanywhereintherangeof2-17%acrossthevariousstudiesonIPAA.Thecomplications/adverseevents/morbiditiesthatcanoc-curafterthefirstsurgeryforidiopathicIBDareasshowninthe Figure 6[28,31,32,40].

9.1.1. Pouch related septic complications

Nearly20%ofthepatientshavesepticcomplicationsofwhichuptohalfhaveabscesswhichcanbepelvicabscess,intra-abdominalabscessoranastomoticcuffabscess.Theprocessusuallystartsasananastomoticleakin1/3rdofthesepatientswhichcanbefrompouchanalanastomosis>reservoirstapleline>endoftheappendage.

Anastomotic leakismorecommoninobesepatients,patientsoperatedatanage>50yearsandthoseonlongtermsteroiduse.Surgeoninexperienceisalsoassociatedwiththiscomplication.ClinicalpresentationissimilartocasesofGIleakusuallywithpatientdevel-opingfeaturesofsepsistowardstheendofthefirstpostoperativeweekormaypresentwithaltereddrainoutputorwounddischarge.Someanastomoticleakspresentlaterasapersistentsmallenterocutaneousfistula.Diagnosiscanbeachievedbyusingcomputedtomography[CT]scanwithrectalcontrast{maydemonstratealeak/mesentericstranding/extravasationofcon-trast/extraluminalair}.Gentlepouchoscopycanvisualizetheleakincaseofdoubt.Antibiot-ics,bowelrestandpercutaneousdrainageincaseofneedaretheintialmanagementoptions.However,morethanhalfthecasesmayneedsurgerywherein,ifthedefectiseasilyvisibleandsmallwithgoodbleedingedges,aprimaryrepairwithdiversionloopileostomycanbedone.Inallothercases,optionsincludelavageanddiversionorpouchexcisionwithpermanentileo-stomyasalastresort[28,41].


12

Figure 6:ComplicationsinthepostoperativelifeafterfirstsurgeryforidiopathicIBD

Abscessescanbeintra-abdominal,pelvicoranastomoticcuffabscess.Anastomoticcuffabscessisuniquetohandsewnpouchanalanastomosiswithmucosectomywhereinbleedingaftermucosectomyandresultanthematomaandanastomoticdehisencewithsecondaryinfec-tion fromabovevia thepelvicspaceorascending infectionfromtheanastomotic leaksitemayleadtothisabscess.Anastomoticleaksandvascularcompromiseofthepouchresultinanabscesssoonaftersurgery.DelayedpresentationshouldraiseaflagtoevaluateforCD.CTscanwithrectalcontrast,magneticresonanceimaging[MRI]ofpelvisforperianalsepsisand/orfistula,examinationunderanesthesiaand/orpouchogramareusefulinvestigationsheretoachieveadiagnosis.Thesearepreferablydrainedtransanallyiffeasibletoavoidfistulacre-ationwhichisapossibilityaftertrans-perinealortrans-vaginaldrainage.Ifitdoesnotresolveorincasesofabdominalabscess,laparotomymayberequiredtodraintheabscesswith/outdivertingstomaordelayofthestomareversalincaseofapre-existingstoma,incaseofaleak.Itisamajorcauseofpouchfailureinupto30-40%cases[42].

Pouch fistulas can arise from appendage, afferent or efferent limb, reservoir suturelineorfromthepouch-analanastomosis.Theotherendofthefistulousopeningcanbeskin,vagina,urinarybladderorotherintestinalloop.Mostcommonoftheseispouch-vaginalfis-tula.Overallincidenceisaround3.5%acrossstudies.Fistularesultingfromanastomoticleakfollowedbyabscessisthemostcommonevent.OtherfactorsresultingintoafistulaincludeimproperapplicationofstaplerduringpouchcreationorCDof thepouch.On thebasisofcause,presentationcanbeanastomotic site fistulaincasesofsurgicalerrororanastomoticleak,perianal fistulaincaseofCDandfistulaatandaroundthedentate lineincasesofcryp-toglandularorigin[43,44].


13

Clinicalpresentationissoonaftersurgeryincaseoftechnicalerrors.However,delayedpresentationnearlyafteroneyearofsurgeryismorecommon.Examinationunderanesthesiawithpervaginalandperrectalexamination,pouchoscopyandcontrastenemaorCTwithrec-talcontrastaretheusefulinvestigations.MRIisveryusefulincasesofcomplexfistulasorincasesofdiagnosticconfusion.BiopsyisrequiredincasesofsuspectedCD[40].

Managementofafistulafollowsthesameprotocolsasforanyothercauseoffistulaviz.fluidandelectrolytebalance,sepsiscontrol,woundmanagement,nutrition,evaluationandplan-ningfordefinitivesurgeryandfinallypost-surgerycare.SpecificallyinIBD,local(transvaginalorperineal)approachispreferredforlowlyingfistulasatthepouch-analanastomosiswith/outlocaladvancementflaps.Abdominalapproachtorepairisutilizedinhighfistulas(abovethepouch-analanastomosissite)whereinthepatientsmayalsorequiredivertingloopileostomyforsepsiscontrol.Collagenplugswith/outbuttonstoplugthefistulas,excisionoffistulaandprimaryrepairwithmeshpartitionofthetwoorgansareotheroptions[40,43,44].

Nearly20-25%patientsendupwithpouchfailureleadingtopermanentileostomybe-causeofrecurrentorrefractoryfistulas.Medicalmanagementwithinfliximabhasbeenshowntobenefitthesepatients.Surgicaltimingwithinfliximabdosingisessential.Initialdosingisat0,2and6weeksfollowedby8weeklydoseswhereinsurgeryisplanned4weeksafterthedoseandthenextdoseisgiven4weeksafterthesurgery[44,45].

9.1.2. Non-septic pouch related complications

Pouchitisisanidiopathic,nonspecificinflammationoftheilealpouch.Itisthemostcom-monofthepouchrelatedcomplicationsseeninupto40%ofthecasesforulcerativecolitisandonlyaround8-10%casesafterpouchconstructionforfamilialadenomatouspolyposis(FAP).Itsincidenceincreaseswiththedurationaftersurgeryandupto75%ofthepatientssufferfrompouchitisatleastoncewithin20yearsofthesurgeryforitscreation.Themostcommontimeperiodisthepostoperative6monthperiodafterdivertingstomaclosureifitwascreated.Etiol-ogyisnotknown.Riskfactorsincludedurationofulcerativecolitispriortosurgery,durationofstomapriortoclosureandnumberofsurgeriesrequiredbeforepouchcreationorforpouchcreation.Itisoftwotypes–AcuteandChronicasshowninTable 3.Itmustberememberedthatacuteandchronicarebasedonsymptomduration[46,47].


14

Table 3:Differencesbetweenacuteandchronicpouchitis

Clinically, these patients have intermittent or persistentsymptomsrelatedtopouchaswellassystemicsymptomsrelatedtotheinflammatoryprocessanditssystemiceffects.Local symptomsincludeabdominalcramps,fecalurgency,bleedingperrectumandtenesmus.Sys-temic symptomsincludefever,anemia,electrolytedisturbancesandgeneralizeddiscomfortandmalaise[47,48].

DiagnosisisaidedbythescoringsystemssuchasPouchitisdiseaseactivityindex(PDAI)wherebyclinical,endoscopicandhistologicfeaturesareclubbedtogetherandascore≥7isdiagnosticforpouchitis.Endoscopically,themucosaisedematous,friablewithlossofvascu-larpatternduetoedema.Also,theremaybemucosalgranularity,mucoidexudatescoveringthemucosaormucosalulcers.Biopsyfeaturesshowvillousatrophyordistortionofcryptar-chitechtureormucosalpolymorphonuclearinfiltrationandulceration.ManagementalgorithmisasshowninFigure 7[28,48,49].

Cuffitisischronic,nonspecificinflammationoftheretainedcuffofrectalmucosajustabovetheanaltransitionzoneindoublestapledtechniqueofpouchreconstruction.Incidenceislowerthanpouchitisandisaround15%.Clinicalpresentationissimilartopouchitisanditsmedicalmanagementisonthesamelinesasforpouchitisexceptthattheantibioticsarenotusefulforcuffitisandhencethemanagementprotocolstartswithtopicalsteroidsandmesacolenemas.Refractorycuffitis ismanagedsurgicallybycombinedabdominalandperinealap-proachtoperformcompletemucosectomyandpouchadvancementwithre-anastomosisandalmostalwaysadivertingloopileostomytobeclosedatalaterdate[28,46].

Small bowel obstructionisseeninupto20%cases.Intestinalobstructioninthesecasescanbe because of structural reasons or non-adhesive obstruction and adhesive obstructionwhichcanpresentwithin90days(early)orafter90days(late).Usually,structuralcausesleadtoearly intestinalobstructionwhereasadhesiveobstructionpresents late.Themanagementofadhesiveobstructionfollowsthesameprinciplesasforanyadhesiveintestinalobstruction[50].Structuralcausesneedspecificmanagementandthisisasfollows:

Acute pouchitis Chronic pouchitis

Symptomduration<4weeks Symptomduration>4weeks

Presentationisdelayedafterstomaclosure Presentationisearlyafterstomaclosure

Incidence–7-8% Incidence–10-12%

PatientshavelowlevelofpANCAactivity PatientshavehighlevelofpANCAactivity

Extra-intestinalmanifestations–Primarysclerosingcholangitis,historyoflongtermsteroiduseandsmokingpredispose

Postoperativecomplicationsafterpouchsurgerypredispose.

Smokingisprotective

Antibioticresponsive Antibioticdependentorrefractory


15

Anastomoticstenosisatpouch-analanastomosis–RepeatedanaldilatationswithHe-gar’s dilators

Redundantandlongdilatedappendage(>2cm)–Revisionpouchsurgerywithexcisionoftheexcessappendage

Floppypouchreservoir–Laparotomywithpouchpexytosacrumandinseverecases,revisionpouchsurgerywithcreationofajejunapouchorpouchexcisionwithpermanentileo-stomy

Pouchvolvulus–Untwistingofpouchandpouchpexyorpouchexcision

Pouchprolapse–Mucosalprolapsedcanbemanagedwith stoolbulkingagentsandbiofeedbacktherapyandifitdoesnotresolveonthat,trans-analmucosalexcisioncanbeper-formed.Fullthicknessprolapsedrequireslaparotomywithpouchpexyorpouchexcisionandpermanentileostomy[28].

Figure 7:Treatmentalgorithmforpouchitis


16

Postoperative stricturesoccuratanincidenceof10-15%afterthesesurgeries.Patientfactors(obesity, smoking),surgeonfactors (handsewnanastomosis,anastomosisunder ten-sion,poorbloodsupplyofpouch)andpresenceofdiverting ileostomyare the risk factorsforpostoperativestrictures.Stapledanastomosisusuallyresultinshort,non-fibroticstrictureswhicharemanageablewithendoscopicdilatationwhereashandsewnanastomosiswithmuco-sectomyresultsinlongandfibroticstrictureswhicharedifficulttomanageendoscopicallyandaremanagedwithtransanaladvancementflapanoplasty.Ifthestrictureisproximaltoafferentlimb,strongsuspicionshouldbemadeforCDandifidentified,itismanagedasforCDstric-turesbystrictureplasty/bypassandmedicalmanagement.The last resort ispouchexcision.[51].

Dysplasia and carcinomaarealso reportedafter IPAA.Squamouscellcancerat theperianalregion,adenocarcinomaofthepouchortheafferentlimbareallpossibilities.Hence,surveillanceisrecommendedforpatientsathighrisksfortheseeventsviz.patientswithhis-toryofprimarysclerosingcholangitis,orcancerintheresectedcolonicspecimenorhistoryofulcerativecolitismorethan10yearsduration.Surveillancescopyinthesepatientsisrecom-mendedeveryyear.Allotherpatientscanbefollowedupwithendoscopy5yearly[52,53].

Crohn’s disease of the pouchisoneofthemostcommonreasonsforpouchfailureanditsincidenceisaround10%.AsdiscussedinnaturalhistoryofCD,inpouchalso,thediseaseissuspectedwheninflammatory,fibroticorpenetratingdiseaseoccursinpouchoritsvicinity.Thus,CDofpouchissuspectedwhenpatienthasinflammatorydiseasecharacterizedbyrecur-rent(>4)episodesofpouchitisfor2consecutiveyearswhichmaybeantibioticresistantorhaspenetratingdiseaseinformofperianalorsmallbowelfistulasorhasfibroticdiseasewithafferentlimbstricturesoranysmallbowellongsegmentstricture[54].

Riskfactorsincludeapouchsurgeryforindeterminatecolitispreoperativelyandapa-tientwithfamilyhistoryofCDorhavinghistoryofperianalfistulasorintestinalstricturesorinactivesmokers.Thediseaseusuallymanifestsitselfafterthedivertingstomaisreversedandcanbeearlyonset(withinmonths)orlateonset(withinyears)afterthestomaclosure.

TreatmentissameasforCD.Patientswithrefractorydiseasetoconventionaltreatment,youngage,historyofsteroiduse,fistulizingdiseaseespeciallythepouch-vaginalfistulahaveapoorprognosisforpouchpreservation.Nearly30-80%willeventuallyrequirepouchexcision.6MP/AZAhasachievedgoodresponseratesforfibroticCDwhereasinfliximabhasachievedagoodresponserateforallthetypesofCDnotrespondingtoconventionaltreatment.Thewidespreadtrendtowardsearlyaggressivemedical therapyinCDmaytranslate into lowerratesofpouchfailureinfuture[54,55].


17

9.2. Stoma related complications

General complicationsrelatedtosmallbowelstomasuchasstomadiarrhea,peristomalexcoriations,stomaproplapse,mucocutaneousseparation,parastomalherniaandstomalob-structionareallpossibleafterthissurgeryandthemanagementisthesameasforothercases.SpecificissuesrelatedtoIBDpatientswithstomaarediscussedbelow.

Prestomal ileitiscanoccursecondarytoIBDrecurrenceorduetobowelobstructionandcanpresentwithsystemicsignsofsepsis,anemiaandendoscopywillshowmultipleulcersinthepre-stomalileum.ItismorecommoninCDthaninUCandthemanagementwilldependonthecause.

Pyoderma gangrenosumisasevere,debilitatingdermatologicmanifestationmorecom-monwithUCthanwithCDthatpresentswithsterilepustulareruptionswith/outulcerationswhichmaygetsecondarilyinfected.Medicalmanagementispreferredwithsteroidsinitiallyandimmunomodulatorsandinfliximabarereservedforrefractorycases.Relocationofstomadoesnothelpinmostcasesbecausethediseasecanrecuratthenewsite[28,50].

9.3. Events related to the natural history of the disease

Thepresentationandmanagementofextra-intestinalmanifestationsissimilarinpre-surgeryandpost-surgeryperiodandisnotdiscussedatlengthhere.Instead,thefocusisonintestinaldiseaseprogressionandassociatedmanifestationsandtheirmanagement.

9.3.1. Recurrent strictures

RecurrentstricturesisthemostcommondiseaserelatedeventinpatientsaftersurgeryforCD.Theratesgoupto35-80%inthesepatients.Riskfactorsincludehistoryofsmoking,multiplepreviousintestinalresectionsandanastomosis,presenceofilealdiseaseandpresenceof>50cmdiseasedbowel(extensivedisease).CTscanwithcontrasthelpsindifferentiatinginflammatoryfromfibroticstrictures.Endoscopy,withitsadvancedtechniquessuchasdoubleballoonorsingleballoonendoscopyandpushenteroscopy,helpinachievingdiagnosisaswellastreatment.Also,endoscopycanbeperformedintraoperativelyincasesofneed[56].

Medicalmanagementworkswellforinflammatorystrictures.Gentleendoscopicdila-tationwith/out self expandingmetal or bioprosthetic stents for 4weeks followed by stentremovalisalsoafeasibleoptionforendoscopicmanagementofthesecases.Foranastomoticstrictures, endoscopic dilatation and intralesional steroid injection followed by endoscopicneedleknifeelectro-incisionunderultrasoundguidancearethetreatmentoptions.Surgeryisindicatedincaseswithfibroticstricturesorinstricturesassociatedwithfistulas/abscess/ma-lignancyaswellasstrictureslongerthan5cmorstricturesclosetoileocecaljunctionwhereendoscopicmanagementwillnotbepossible[57].


18

Surgicaloptionsincludestrictureplastyorresectionandanastomosis.HeinekeMicku-liczstrictureplastyisusedforstrictures<10cmlength,Finney’sstrictureplastyisusedforstricturesbetween10-20cmlengthandsidetosideisoperistalticstrictureplastyispreferredforlongerstrictures.Asmentionedbefore,strictureratesarehighandthesepatientsarepronetoshortbowelsyndrome.Hence,principlesofbowelconservationareofutmostimportanceinthesepatients[56,57,58].

9.3.2. Fistulas

Fistulasinthesepatientscanbeperianalorabdominal–entero-enteric,entero-cuta-neous,entero-vesicalorenterovaginal.Forallthefistulasapartfromtheperianalfistulas,themanagement is the sameas forother cases.Perianalfistulas arediscussednext.These aredebilitating,recurrenteventsinCD.Theycanbesimpleorcomplexsameasinotherfistulas.Thediseasecanbeassociatedwithabscess,stricture,fissureorulcerintheperianalregion.PerianaldiseaseisassociatedmostcommonlywithcolorectalCD(40-45%),smallbowelin-volvement(25%)andisolatedperianaldiseaseintheremainingpatients[59].

Examinationunderanesthesiaisthebesttodiagnosethepresenceandextentoffistula.MRIpelvisisthebestmodalityfordiagnosisandnatureofthefistula.Endoscopicultrasound(EUS)isthebestinvestigationfortheassessmentofinvolvementoflowerpelvicmusculature.Managementbeginswithsepsiscontrolandantibiotics.1/3rdto½ofthepatientsneedsurgeryforsepsiscontrolinspiteofantibiotics.Thealgorithmicapproachthatweusetomanageperia-nalfistulasinthesepatientsisshowninFigure 8[60].

9.3.3. Short bowel syndrome

Short bowel syndromehas the samemanifestations,diagnosticcriteriaandmanage-mentoptionsasforanyothercaseandhence,isnotdiscussedindetailhere.Thesepatientsarealsoatriskforgall stones and renal stonesandthemanagementoutlineissimilartoothercasesduetodifferentetiologies.

9.3.4. Dysplasia and cancer

Dysplasiaandcancerareknownevents in thenaturalhistoryofIBD.Longstandingcolitis(>10years),extensivecolitis(>50%coloninvolvement),pancolitis(diseaseuptoorproximaltohepaticflexure),youngmales(<45yearsage),colitisassociatedwithdysplasiaonbiopsyandhistoryofprimarysclerosingcholangitisareknownriskfactorsformalignanttransformation.UCandCDhavethesameriskofcarcinogenesis[61,62,63].

Thediseaseisimportanttorecognizebecausethemeanageofcancerdiagnosisinthesepatientsisless(10-20yearsearlier),diseaseismorecommonlymulticentric(nearlydoubleincidenceofsynchronousdisease),associateddysplasiacanbepresentawayfromcancersites


19

inIBD,p53mutationsaremorecommonandRasmutationsarelesscommonandlateandthetumorsareoftenpoorlydifferentiated,anaplasticandmucinouswhencomparedtosporadiccancers.

DiagnosisandmanagementisbasedontherecentSCENICrecommendations.Surveil-lanceisbeganafter8yearsofdiagnosisofpancolitisandafter15yearsofdiagnosisofleftsidedcolitisastheriskofmalignancyislowinleftsidedcolitis.Foralltheabovementionedriskfactors,thesurveillanceendoscopyisdoneyearly.Inallothers,thetestisperformed5yearly.Also,thepatientswithfirstdegreerelativewithcolorectalcanceratage<50areathighriskandthesurveillanceintheseisalsocarriedoutyearly.Chromoendoscopyandtargetedbiopsyisnowthepreferredendoscopicmethodofsurveillanceifavailableasithasshowntoincreasethedysplasiadetectionrateby7%.Thepreviouslyused4quadrantbiopsyevery10cmrecommendationisnolongeranabsoluterequirementforsurveillancenow[64].

Figure 8:AlgorithmicapproachtomanagementofperianalfistulasassociatedwithCD


20

Ifalesionisidentifiedonendoscopy,theParisclassificationisfollowedforthelesionsidentificationandtheirmanagementwhichisasfollows:

IporIs(Polypoidlesionpedunculatedorsessile)–Endoscopicmucosalresection•

Non-polypoidlesion–flatbutelevatedwith/outmildcentraldepression(IIa,IIb)–•Endoscopicmucosalresection

Non-polypoid lesionbut IIc (flatandnonelevated,mucosaldepressionand raised•edge)–Endoscopicsubmucosaldissection

Margins not distinct, high grade dysplasia, carcinoma – Total proctocolectomy•anddependingonthelowertwo-thirdsofrectum,pouchifnocancerorhighgradedysplasia there, ileostomy if cancer is present there and handsewn pouch withmucosectomyifhighgradedysplasiaispresentthere[64,65,66].

10. Conclusion

TherearealotofissuestotakecareofinpatientswithIBDevenaftertheirfirstattemptatmedicalandsurgicalmanagementisoverandremissionisachieved.Theseeventsneedtobeunderstoodandstandardizedmanagementguidelinesneedtobeunderstoodtotreatthesecomplexsituationsandprovidethesepatientswithadiseasefreegoodqualityoflife.

11. References

1.FeldmanM,FriedmanL,BrandtL.SleisengerandFordtran'sgastrointestinalandliverdisease.Philadelphia,PA:Saunders/Elsevier;2016.

2.HeidaA,ParkK,vanRheenenP.ClinicalUtilityofFecalCalprotectinMonitoringinAsymptomaticPatientswithInflammatoryBowelDisease.InflammatoryBowelDiseases.2017;23(6):894-902.

3.FreemanH.Naturalhistoryandlong-termclinicalcourseofCrohn’sdisease.WorldJournalofGastroenterology.2014;20(1):31.

4.WanderasM,MoumB,HoivikM,HovdeO.Predictivefactorsforasevereclinicalcourseinulcerativecolitis:Resultsfrompopulation-basedstudies.WorldJournalofGastrointestinalPharmacologyandTherapeutics.2016;7(2):235.

5.AlthumairiA.Inflammatoryboweldiseaseassociatedneoplasia:Asurgeon’sperspective.WorldJournalofGastroen-terology.2016;22(3):961.

6.WeizmanA,HuangB,BerelD,TarganS,DubinskyM,FleshnerPetal.Clinical,Serologic,andGeneticFactorsAs-sociatedwithPyodermaGangrenosumandErythemaNodosuminInflammatoryBowelDiseasePatients.InflammatoryBowelDiseases.2014;20(3):525-533.

7.SatsangiJ.TheMontrealclassificationofinflammatoryboweldisease:controversies,consensus,andimplications.Gut.2006;55(6):749-753.

8.LevineA,GriffithsA,MarkowitzJ,WilsonD,TurnerD,RussellRetal.PediatricmodificationoftheMontrealclas-sificationforinflammatoryboweldisease.InflammatoryBowelDiseases.2011;17(6):1314-1321.

9.Peyrin-BirouletL,PanésJ,SandbornW,VermeireS,DaneseS,FeaganBetal.DefiningDiseaseSeverityinInflam-


21

matoryBowelDiseases:CurrentandFutureDirections.ClinicalGastroenterologyandHepatology.2016;14(3):348-354.e17.

10.KediaS.Managementofacutesevereulcerativecolitis.WorldJournalofGastrointestinalPathophysiology.2014;5(4):579.

11.KaneS,MarchioniBeeryR.Currentapproachestothemanagementofnew-onsetulcerativecolitis.ClinicalandExperimentalGastroenterology.2014;111.

12.GolovicsP.InflammatoryboweldiseasecourseinCrohn’sdisease:Isthenaturalhistorychanging?.WorldJournalofGastroenterology.2014;20(12):3198.

13.CarterM.Guidelinesforthemanagementofinflammatoryboweldiseaseinadults.Gut.2004;53(suppl_5):v1-v16.

14.DassopoulosT,SultanS,Falck-YtterYT, Inadomi JM,HanauerSB.AmericanGastroenterologicalAssociationInstitutetechnicalreviewontheuseofthiopurines,methotrexate,andanti-TNF-αbiologicdrugsfortheinductionandmaintenanceofremissionininflammatoryCrohn’sdisease.Gastroenterology.2013;145:1464–1478.e1–5.

15.DaneseS,FiorinoG,Peyrin-BirouletL,LucenteforteE,VirgiliG,MojaL,etal.Biologicalagentsformoderatelytoseverelyactiveulcerativecolitis:asystematicreviewandnetworkmetaanalysis.AnnInternMed.2014;160:704–711

16.CostaJ,MagroF,CaldeiraD,AlarcãoJ,SousaR,Vaz-CarneiroA.Infliximabreduceshospitalizationsandsurgeryinterventionsinpatientswithinflammatoryboweldisease:asystematicreviewandmeta-analysis.InflammBowelDis.2013;19:2098–2110.

17.ChatuS,SubramanianV,SaxenaS,PollokRCG.TheroleofthiopurinesinreducingtheneedforsurgicalresectioninCrohn’sdisease:asystematicreviewandmeta-analysis.AmJGastroenterol.2014;109:23–34;quiz35.

18.KornbluthA,SacharDB.Ulcerativecolitispracticeguidelinesinadults:AmericanCollegeOfGastroenterology,PracticeParametersCommittee.AmericanJGastroenterol.2010;105(3):501–523;quiz24.

19.WangY,ParkerCE,BhanjiTetal.Oral5-aminosalicylicacidforinductionofremissioninulcerativecolitis.TheCochraneDatabaseSystRev.2016(4):CD000543.

20.LimWC,WangY,MacDonaldJKetal.AminosalicylatesforinductionofremissionorresponseinCrohn’sdis-ease.CochraneDatabaseSystRev2016;7:CD008870.21.FordAC,BernsteinCN,KhanKJetal.Glucocorticosteroidtherapyininflammatoryboweldisease:systematicreviewandmeta-analysis.AmericanJGastroenterol.2011;106(4):590–599;quiz600.

22.BlonskiW,BuchnerAM,LichtensteinGR.Inflammatoryboweldiseasetherapy:currentstate-of-the-art.CurrOpinGastroenterol.2011;27(4):346–357.

23.StrikAS,BotsSJ,D’HaensGetal.optimisationofanti-TNFtherapyinpatientswithInflammatoryBowelDisease.ExpertRevClinPharmacol.2016;9(3):429–439.

24.HwangJ.Surgeryforinflammatoryboweldisease.WorldJournalofGastroenterology.2008;14(17):2678.

25.FerrariL,KraneM,FicheraA.Inflammatoryboweldiseasesurgeryinthebiologicera.WorldJournalofGastroin-testinalSurgery.2016;8(5):363.

26.BottiF,CaprioliF,PettinariD,CarraraA,MagarottoA,ContessiniAvesaniE.SurgeryanddiagnosticimaginginabdominalCrohn’sdisease.JournalofUltrasound.2013;18(1):3-17.

27.SeifarthC,KreisM,GruneJ.IndicationsandSpecificSurgicalTechniquesinCrohn'sDisease.Viszeralmedizin.2015;31(4):273-279.

28.YeoC.Shackelford'ssurgeryofthealimentarytract.Philadelphia,PA:Elsevier/Saunders;2013.


22

29.KuhnF,KlarE.SurgicalPrinciplesintheTreatmentofUlcerativeColitis.Viszeralmedizin.2015;31(4):246-250.

30.CarneP,PembertonJ.TechnicalAspectsofIleoanalPouchSurgery.ClinicsinColonandRectalSurgery.2004;17(01):35-41.

31.M’KomaA,MosesH,AdunyahS.Inflammatoryboweldisease-associatedcolorectalcancer:proctocolectomyandmucosectomydonotnecessarilyeliminatepouch-relatedcancerincidences.InternationalJournalofColorectalDisease.2011;26(5):533-552.

32.BachSP,MortensenNJ.Ilealpouchsurgeryforulcerativecolitis.WorldJGastroenterol.2007;13(24):3288–3300.

33.TriguiA,FrikhaF,RejabH,BenAmeurH,TrikiH,BenAmarMetal.Ilealpouch-analanastomosis:Pointsofcon-troversy.JournalofVisceralSurgery.2014;151(4):281-288.

34.ShresthaB.Minimallyinvasivesurgeryfor inflammatoryboweldisease:Currentperspectives.WorldJournalofGastrointestinalPharmacologyandTherapeutics.2016;7(2):214.

35.Holder-MurrayJ,MarsicovetereP,HolubarSD.Minimallyinvasivesurgeryforinflammatoryboweldisease.In-flammBowelDis.2015;21:1443–1458

36.ByrnJC,HrabeJE,CharltonME.Aninitialexperiencewith85consecutiverobotic-assistedrectaldissections:im-provedoperatingtimesandlowercostswithexperience.SurgEndosc.2014;28:3101–3107

37.LightnerA,MathisK,DozoisE,HahnsloserD,LoftusE,RaffalsLetal.ResultsatUpto30YearsAfterIlealPouch–AnalAnastomosisforChronicUlcerativeColitis.InflammatoryBowelDiseases.2017;23(5):781-790.

38.WeinrybRM,LiljeqvistL,PoppenB,etal.Alongitudinalstudyoflongtermqualityoflifeafterilealpouch-analanastomosis.AmJSurg.2003;185:333–338

39.KuruvillaK,OslerT,HymanNH.AcomparisonofthequalityoflifeofulcerativecolitispatientsafterIPAAvsileostomy.DisColonRectum.2012;55:1131–1137.

40.ShermanJ,GreensteinA,GreensteinA.IlealJPouchComplicationsandSurgicalSolutions.InflammatoryBowelDiseases.2014;20(9):1678-1685.

41.HeuschenUA,HinzU,AllemeyerEH,etal.RiskfactorsforileoanalJpouchrelatedsepticcomplicationsinulcer-ativecolitisandfamilialadenomatouspolyposis.AnnSurg.2002;235:207–216

42.FaroukR,DozoisRR,PembertonJH,etal.Incidenceandsubsequentimpactofpelvicabscessafterilealpouch-analanastomosisforchroniculcerativecolitis.DisColonRectum.1998;41:1239–1243.

43.JohnsonPM,O’ConnorBI,CohenZ,etal.Pouch-vaginalfistulaafterilealpouch-analanastomosis:treatmentandoutcomes.DisColonRectum.2005;48:1249–1253

44.HeriotAG,TekkisPP,SmithJJ,etal.Managementandoutcomeofpouchvaginalfistulasfollowingrestorativeproc-tocolectomy.DisColonRectum.2005;48:451–458.

45.MacLean,AR,O’Connor,B,Parkes,R,Cohen,Z,McLeod,RS2002Reconstructivesurgeryforfailedilealpouch-analanastomosis.AviablesurgicaloptionwithacceptableresultsDisColonRectum458806

46.SteinhartA,Ben-BassatO.Pouchitis:apracticalguide.FrontlineGastroenterology.2012;4(3):198-204.

47.HeuschenUA,AllemeyerEH,HinzU,etal.Diagnosingpouchitis:comparativevalidationoftwoscoringsystemsinroutinefollow-up.DisColonRectum.2002;.45:.776–788.

48.SandbornWJ,TremaineWJ,BattsKP,etal.Pouchitisafterilealpouch–analanastomosis:apouchitisdiseaseactiv-ityindex.MayoClinProc.1994;69:409–415.


23

49.PardiDS,D’HaensG,ShenB,etal.Clinicalguidelinesforthemanagementofpouchitis.InflammBowelDis.2009;9:1424–1431.

50.FranconeTD,ChampagneB.Considerationsandcomplicationsinpatientsundergoingilealpouchanalanastomosis.SurgClinNorthAM.2013;93:107–143.

51.PrudhommeM,DozoisRR,GodlewskiG,etal.Analcanalstricturesafterilealpouch-analanastomosis.DisColonRectum.2003;46:20–23.

52.DasP,JohnsonMW,TekkisPP,etal.Riskofdysplasiaandadenocarcinomafollowingrestorativeproctocolectomyforulcerativecolitis.ColorectalDis.2007;9:15–27.

53.NegiSS,ChaudharyA,GondalR.Carcinomaofpelvicpouchfollowingrestorativeproctocolectomy:Reportofacaseandreviewoftheliterature.DigSurg.2003;20(1):63–65

54.LightnerA,PembertonJ,LoftusE.CrohnʼsDiseaseoftheIleoanalPouch.InflammatoryBowelDiseases.2016;22(6):1502-1508.

55.HaveranLA,SehgalR,PoritzLS,etal.Infliximaband/orazathioprineinthetreatmentofCrohn’sdisease-likecom-plicationsafterIPAA.DisColonRectum.2011;54:15–20.

56.RiederF,ZimmermannE,RemziF,SandbornW.Crohn'sdiseasecomplicatedbystrictures:asystematicreview.Gut.2013;62(7):1072-1084.

57.TharianB,GeorgeN,NavaneethanU.EndoscopyintheDiagnosisandManagementofComplicationsofInflamma-toryBowelDisease.InflammatoryBowelDiseases.2016;22(5):1184-1197.

58.AmbeR,CampbellL,CagirB.Acomprehensivereviewofstrictureplasty techniques inCrohn’sdisease: types,indications,comparisons,andsafety.JGastrointestSurg.2012;16:209–217

59.SandbornWJ,FazioVW,FeaganBG,etal.AmericangastroenterologicalassociationclinicalpracticeCommittee.AGAtechnicalreviewonperianalCrohn’sdisease.Gastroenterology.2003;125:1508–1530.

60.WisePE,SchwartzDA.TheevaluationandtreatmentofCrohnperianalfistulae:EUA,EUS,MRI,andotherimag-ingmodalities.GastroenterolClinNorthAm.2012;41:379–391.

61.BrackmannS,AndersenSN,AamodtG,etal.Twodistinctgroupsofcolorectalcancerininflammatoryboweldis-ease.InflammBowelDis.2009;15:9–16.

62.FarrayeFA,OdzeRD,EadenJ,ItzkowitzSH.AGAtechnicalreviewonthediagnosisandmanagementofcolorectalneoplasiaininflammatoryboweldisease.Gastroenterology.2010;138:746–74,774.e1-4;quize12-13.

63.CollinsPD.Strategiesfordetectingcoloncanceranddysplasiainpatientswithinflammatoryboweldisease.In-flammBowelDis.2013;19:860–863

64.LaineL,KaltenbachT,BarkunA,McQuaidK,SubramanianV,SoetiknoRetal.SCENICinternationalconsensusstatementonsurveillanceandmanagementofdysplasia in inflammatoryboweldisease.GastrointestinalEndoscopy.2015;81(3):489-501.e26.

65.TheParisclassificationofsuperficialneoplasticlesions:esophagus,stomach,andcolon.GastrointestEndosc2003;58(suppl):S3-43.

66.UpdateontheParisClassificationofSuperficialNeoplasticLesionsintheDigestiveTract.Endoscopy.2005;37(6):570-578.

Inflammatory Bowel Disease - Open Access...

Documents

Transcript of Inflammatory Bowel Disease - Open Access...