SAGES

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Inflammatory Bowel Disease

First submitted by:
Shawn Tsuda
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Presentation and Differentiation: Ulcerative Colitis and Crohn’s Disease

From the perspective of the laparoscopic colorectal surgeon there are some aspects of the management inflammatory bowel disease that do not require differentiation between the two main disease processes – Ulcerative Colitis and Crohn’s disease. For example patients with toxic megacolon require the same surgical input initially allowing for subsequent differentiation between the two conditions at a later date. Other scenarios however require more careful thought before elective surgical procedures however for the most part these are not particularly influenced by the laparoscopic approach. This presentation will detail the main clinical presentations within the two conditions and how they relate to the laparoscopic colorectal surgeon.

Ulcerative Colitis

For the most part patients with ulcerative colitis (UC) undergoing surgery are highly suitable candidates for laparoscopic surgery. Minimally invasive surgery has not resulted in any fundamental changes in the surgical approach to these patients but the level of trauma involved has been substantially reduced in several scenarios. In the early experiences of laparoscopic surgery it was frequently considered that the main operations performed for UC were not suitable for a laparoscopic approach but in the last decade a minimally invasive approach has become the first choice option for the vast majority of patients in several categories.

For UC patients there are three clinical presentations that represent the majority of patients:

 

  • Urgent/emergency surgery for toxic megacolon/fulminant colitis
  • Elective surgery for medically resistant UC not deemed suitable for definitive
  • surgery
  • Elective definitive surgery for long standing UC

For patients requiring a total colectomy in the emergent or semi-emergent setting – leaving the rectum in place for future management – the differentiation between UC and CD is not truly an issue. A proctocolectomy with end ileostomy (and excision of the anal canal) is not a suitable option in the vast majority of patients with semiacute disease whether the surgery is to be performed laparoscopically or via an open technique. On the other hand delivering the entire colon to the pathologist remains the gold standard for differentiation between UC and CD. In the 21st century there is extensive data demonstrating that a laparoscopic approach to total colectomy is eminently feasible as well as safe. In addition it is generally agreed that the reduction incision size and intra-abdominal adhesions is very beneficial for patients undergoing subsequent surgery. Either a completion proctectomy or reconstructive surgery by way of a completion proctectomy and ileo-anal pouch anastomosis is made much easier than would be the case after an open colectomy.

Current surgical practice allows the initial colectomy be performed either using a pure laparoscopic approach or by using a hand-assisted technique. Both approaches have their advocates but there is very little evidence to sway the decision either way. What is perhaps more controversial is perhaps the use of such techniques in patients with truly fulminant colitis. Some surgeons believe that the longer operative times required by laparoscopic surgery are not in the patients best interest especially when septic. In addition, in true emergencies where the colon is perforated there is still little consensus as to surgical approach.

Crohn’s Disease

Crohn’s Disease remains as big a clinical challenge in the laparoscopic era as it ever did in earlier years. The variability of clinical presentations as well as uncertainty of diagnosis can pose real problems in some instances – mainly in patients with colonic disease. In essence, once again with CD there are three main patient groups that present to the laparoscopic surgeon:

 

  • Patients with colonic disease – colitis – whether acute or chronic
  • Patients with small bowel disease
  • Patients with peri-anal disease

For the purpose of this article those patients with small bowel CD do not represent a diagnostic dilemma. Once the diagnosis has been made there is little doubt that they have CD rather than UC. For the laparoscopic surgeon the main question is whether the operation being proposed can be reasonably achieved using a laparoscopic approach.

There is now an extensive literature demonstrating clearly that for patients with primary ileo-cecal disease a laparoscopic resection is probably the first choice option in 2010. Morbidity and recurrence rates are similar to open surgery although operative times are somewhat longer. However, for many patients with CD the cosmetic benefits are real as is the speedier recovery fowling the laparoscopic resection. For patients with peri-anal disease the challenges are greater for the clinician. The usual question being pondered is whether or not the patient should be de-

functioned by way of a loop ileostomy – something that lends itself greatly to a laparoscopic approach. However, once again these patients are not likely to represent a diagnostic dilemma in relation to US. As with UC patients, those with Crohn’s colitis are highly suitable for a laparoscopic colectomy using techniques that are identical. Either a pure laparoscopic or handassisted approach is appropriate. These patients are the ones where diagnostic confusion may be a problem – as they always have been. Surgeons remain correctly vary of undertaking a definitive restorative procto-colecomy in patients where any suspicion of CD may be present. Current evidence suggests that pouch surgery in CD patients is not the inevitable catastrophe once thought. Pouch failure rates in UC patients remain in the region of 10% in most series. For CD patients the equivalent figure is higher – about 30%. What this means is that many patients who undergo a pouch when thought to have UC and on final pathology are deemed to have CD may in fact do well with no major problems. This knowledge has led some authorities to recommend at least considering elective pouch surgery in selected patients with CD. Those with low granuloma counts or “the occasional” granuloma have been proposed as suitable candidates for this type of surgery.

In summary therefore the commonest scenario that causes diagnostic confusion between UC and CD will be in those patients with colitis. Classically those patients with non-confluent (patchy) colitis and rectal sparing must raise clinical suspicion of CD rather than CD even when biopsies do not distinguish one way or the other. Certainly any evidence of structuring disease will increase clinical suspicion and of course if there is any evidence of ulcerating or structuring small bowel disease then the diagnosis must be considered to be CD regardless of biopsy findings. Most authorities would recommend a CT scan in newly diagnosed colitics as a relatively sensitive method of identifying small bowel disease. In addition a small bowel series should also be considered as a reasonable baseline investigation for the same reason.

For practical reasons it is always worthwhile considering a careful review of pathology specimens – perhaps by a second specialist GI pathologist – before any patient is considered for primary pouch surgery. Although some clinical patterns of endoscopic findings on colonoscopy may guide the astute clinician there is little doubt that some patients who have a pattern typical of UC may ultimately prove to have UC. The opposite is also true but the consequences of that finding may be less troublesome in most cases.

Recognizing these issues still results in many surgeons recommending a stage approach to pouch surgery accepting that even after such a cautious policy no firm answer may be obtained. However, if the colectomy specimen yields clear evidence of CD this means a different discussion may be held with the patient prior to the next stage of surgery – including of course the option of an ileo-rectal anastomosis in some cases.  Distinguishing between Crohn’s disease and ulcerative colitis remains problematic in selected cases. Small bowel disease usually resolves the issue in favor of CD but colitis patients can still be a problem in this respect. Surgical options for the laparoscopic surgeon cover the full spectrum from simple diversion to restorative proctocolecomy. In 2010 the astute clinician remains sensitive to the issues of diagnosis and will seeks appropriate confirmation whenever possible and appropriate.

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