Crohn’s Disease and Ulcerative Colitis: Surgical Management PDF
Preview Crohn’s Disease and Ulcerative Colitis: Surgical Management
Devinder I(umar and John Alexander-Williams Crohn's Disease and Ulcerative Colitis Surgical Management With 141 figures Springer-Verlag London Berlin Heidelberg New York Paris Tokyo Hong I(ong Barcelona Budapest Devinder Kumar, PhD, FRCS Senior Lecturer, Department of Surgery, Queen Elizabeth Hospital, Birmingham B15 2TH, UK John Alexander-Williams, MD, FRCS Professor of Gastrointestinal Surgery, The General Hospital, Birmingham B4 6NH, UK With contributions from: R.N. Allan, MD, FRCP Consultant Physician, The Queen Elizabeth Hospital, Edgbaston, Birmingham B15 2TH, UK Cover illustration: Ch. 12, Fig. 12. A long strictureplasty in Crohn's disease. The incised gut is bent over in a loop and the posterior wall is sutured with a continuous seromuscular stitch. Ch. 23, Fig. 16. The steps in pouch construction. The beginning of the suture line for the anterior layer of a pouch; a small hole is made in the proximal limb of the pouch; completed pouch-anal stapled anastomosis. ISBN-13: 978-1-4471-3298-1 e-ISBN-13: 978-1-4471-3296-7 DOl: 10.1007/978-1-4471-3296-7 British Library Cataloguing in Publication Data Kumar, Devinder Surgical Management of Crohn's Disease and Ulcerative Colitis I. Title II. Alexander-Williams, John 617.5 ISBN-13: 978-1-4471-3298-1 Library of Congress Cataloging-in-Publication Data Kumar, Devinder. The Surgical management of Crohn's disease and ulcerative colitis 1 Devinder Kumar and John Alexander-Williams; [with contributions fron R.N. Allan]. p. cm. Includes bibliographical references and index. ISBN-13: 978-1-4471-3298-1 1. Enteritis, Regional - Surgery. 2. Ulcerative colitis - Surgery. I. Alexander-Williams, John. II. Allan, R.N. (Robert Norman) III. Title. [DNLM: 1. Crohn Disease - surgery. 2. Colitis, Ulcerative surgery. WI 512 K96s 1993] RD541.K85 1993 617.5'541059-dc20 DNLM/DLC 93-4186 for Library of Congress CIP Apart from any fair dealing for the purposes of research or private study, or criticism or review, as permitted under the Copyright, Designs and Patents Act 1988, this publication may only be reproduced, stored or transmitted, in any form or by any means, with the prior permission in writing of the publishers, or in the case of reprographic reproduction in accordance with the terms of licences issued by the Copyright Licensing Agency. Enquiries concerning reproduction outside those terms should be sent to the publishers. © Springer-Verlag London Limited 1993 Softcover reprint of the hardcover 1s t edition 1993 The use of registered names, trademarks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant laws and regulations and therefore free for general use. Product liability: The publisher can give no guarantee for information about drug dosage and application thereof contained in this book. In every individual case the respective user must check its accuracy by consulting other pharmaceutical literature. Typeset by Expo Holdings Sdn. Bhd. 12/3830-543210 Printed on acid-free paper Foreword As with most chronic diseases having a low mortality but high morbidity, the inflammatory bowel diseases (IBD) are distressing for patients and for their physicians. The frustrations and fears of our patients should be readily understood, though they are perhaps not as well appreciated by doctors as they should be. My own training in IBD was with W.E. King and "Bill" Hughes in Melbourne, Avery Jones in London and in the Mayo model of J. Arnold Bargen; these teachers impressed upon me that patients with ulcerative colitis and Crohn's disease deserve and require special education as to the nature of their illnesses, and that the expectations, options and uncertainties of their diseases must be addressed. Though lay organizations have done much to address these concerns, my experience in consultative practice has been disappointing. Too often, patients have been given little or no appreciation of the relative roles of medical as against surgical management or they have unrealistic expectations of one form of therapy versus the other. As doctors, we all share the responsibility. Medical gastroenterologists appear at times to regard the surgical options of IBD as impugning their therapeutic skills, and to interpret these as indicating their failure as "medicine men". One has seen many errors of judgement based on this false tenet; in the right patient, at the right time, surgery for ulcerative colitis and Crohn's disease is imperative! Certainly, ill judged or excessive surgery has also created many intestinal cripples. A useful philosophy might be that those with IBD should have an aggressive and secure gastroenterologist and a thoughtful and conservative surgeon! Concepts of the IBDs are currently undergoing much change. Crohn's disease, which was once considered almost as a malignant equivalent - "let us remove all the disease, even by radical excision" - is now accepted as a pathological condition that can involve the gut from mouth to anus. We now accept the inevitability of its expression and, thanks in large measure to John Alexander-Williams, the medico surgical philosophy has changed. Surgery will never be curative, and operative philosophies need to be focused on specific indications and expectations. To move to ulcerative colitis: it is thanks largely to Nils Kock, Alan Parks and others, that the less attractive consequences of proctocolectomy have been addressed and, in part, corrected. Surgical treatment of stubborn colitis is much better accepted by patients and doctors; the sphincter-saving operations have altered our thinking dramatically. We may even be seeing a swing of the pendulum to the other extreme - perhaps the ileo-anal anastomosis offers too easy a "fix" for colitis. Patients are now often referred too soon for colectomy; patients, that is, with maximal symptoms and minimal disease. These are individuals unable to deal with the symptoms of the disease and sometimes unwilling to deal with the consequences vi Foreword of colectomy, even after successful pouch procedures. Thus, even though better medical options may be offered by 5-ASA and cortico-steroids without major systemic side effects and even though the more rational surgical options engender optimism, we all know that the IBDs still represent major dilemmas. This monograph therefore is timely, and both authors are well placed to evaluate the current and future practice of surgery in IBD. John Alexander-Williams brought continued fame to the chair he inherited from his mentor, Bryan Brooke. He has been acclaimed for three decades as a teacher, by gastroenterologists and fellow surgeons alike. Devinder Kumar is also a physician's surgeon, his extensive training and record in gastrointestinal physiology is well suited to a surgical discipline that alters so dramatically the overall functions of the gut. Until major etiological breakthroughs enable us to prevent or cure the (probable) multiple forms of inflammatory bowel disease, surgical intervention will be needed. In the interim, we must apply the surgical arts rationally, conservatively and wisely. This text examines the options and provides much for further thought. We should read and think seriously about all that is written here. Gastroenterology Unit Sidney F. Phillips, MD Mayo Clinic Rochester, MN, USA Preface Since the 1940s the Birmingham School, where medical/surgical collaboration has always been strong, has been in the forefront of the treatment of inflammatory bowel disease. We have been privileged to practise in a tertiary referral centre to which many complex intestinal problems have been referred. We decided to collaborate to produce this book for a variety of reasons. We came to work together as colleagues in Birmingham when one of us was coming to the end of his surgical career and the other was just beginning. The senior author was completing over 30 years' experience in the surgical management of Crohn's disease and the other was on the threshold of a specialist career in colorectal surgery having had a background of clinical and research experience in colorectal physiology. We were each impressed by what the other had to offer from the opposite ends of their surgical careers. We also had in common our research training in Minnesota, USA. We have aimed the presentation at a wide audience. We feel that this book will interest specialist colorectal surgeons who will wish to compare our technique and results with their own. In addition, surgical trainees will find a comprehensive description of the rationale for, as well as technique and results of, an operative approach based on a sound pathophysiological basis. Furthermore, the book has important messages for our medical gastroenterologist colleagues, who should understand the rationale behind the essential surgical approaches to these diseases and also learn from us what they can reasonably expect from their surgical collaborators. Medico-surgical collaboration is the very essence of these diseases whose cause is still elusive and whose natural history is still little influenced by medical manipulation. Both Crohn's disease and ulcerative colitis are conditions in which surgical intervention does nothing to alter the natural history, but simply alleviates the discomfort and distress of the inevitable complications. The section on ulcerative colitis bases its approach firmly on the study of the physiology of the large bowel, particularly the physiology of defaecation. It is based also on the careful assessment of the patient with a view to predicting the outcome of surgical intervention. There is particular emphasis on predicting the likelihood of malignant change and the chances of a successful outcome after sphincter-saving surgery. It appropriately concludes with precise details of our techniques for performing the different surgical options of panproctocolectomy, ileo-rectal anastomosis and the continent ileo-anal pouch. The section on Crohn's disease is based on an understanding of the pathophysiological progression of the disease with a natural history that is relentless, although often intermittent. The role of surgical intervention is simply viii Preface to overcome the consequences of the fibrotic stenoses that follow chronic gut ulceration. We stress the detection and management of these stenoses, preferably before they lead to complications such as abscess and fistula. The essential theme throughout the management of Crohn's disease of the small bowel, large bowel and ano-rectum is one of timely intervention and a conservative operative approach. As we anticipate that many of the chapters will be referred to in isolation when advice is sought about a problem case, we have deliberately repeated some of the technical advice and even some of the illustrations. We feel a compelling need to record what we have learned about these fascinating diseases. At the same time, we are conscious that the details of the various management options are constantly changing, yet feel that, until the underlying cause is found and can be eradicated, the present principles of management will prevail. Birmingham 1993 D. Kumar J. Alexander-Williams Acknowledgement Permission to reproduce MRI pictures Department of Surgery, Tuebingen Contents SECTION I I History J. Alexander-Williams 3 The History of Crohn's Disease. 3 The History of Ulcerative Colitis 7 2 Aetiopathology and Natural History R.N. Allan. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 3 Nutrition in Inflammatory Bowel Disease D. Kumar . . . . . . . . . . . . . . . . . . . . . . 23 Specific Nutritional Problems in IBD . . . . . 23 Nutritional Support in the Treatment for IBD 25 4 Psychosis, Psychology, Stress and Counselling J. Alexander-Williams ................. . 27 Relationship of Psychiatric and Psychological Disorders. 27 Stress .............................. . 27 The Effect of Diagnosis ................... . 28 Psychological Counselling of Patients with Crohn's Disease 28 The Role of Patient Societies and Clubs. . . . . . . 32 Assessment of the Quality of Life . . . . . . . . . . 32 Longitudinal Surveillance (a Surgical Perspective) 33 SECTION II 5 Crohn's Disease: A Remaining Medical Enigma and Surgical Challenge J. Alexander-Williams 37 Introduction . . . . 37 Demography . . . . . 38 6 Surgical Management J. Alexander-Williams 41 The General Principles ............... . 41 Overcoming the Complications of Crohn's Disease 41 7 Indications for Surgical Intervention J. Alexander-Williams 45 Emergency Indications 45 Elective Indications .. 48 x Contents 8 Reducing the Risks of Operation J. Alexander-Williams . . 51 Principles .............. . 51 Minimise Blood Loss . . . . . . . . . 51 Preventing Damage to Adjacent Tissues and Organs. 53 Minimise Infection . . . . . . . . . . 55 Avoid Unnecessary Sacrifice of Gut . . . . . . . 56 Avoiding Anastomotic Leakage ........ . 58 Risk of Recrudescence and How to Minimise It 63 9 Assessment and Preparation J. Alexander-Williams . . 67 Principles ........ . 67 General and Nutrition . . 67 Psychological Preparation 67 Bowel Preparation . . . . 68 10 Resection of the Ileum or Ileocaecum J. Alexander-Williams . . . . . . . 71 Operative Position . . . . . . . 71 Skin Preparation and Draping 71 The Incision . . . . . . . 71 Peritoneal Access . . . . 73 Technique of Dissection 75 Haemostasis . . . . . . . 76 Extent of Excision ... 79 Opening and Occluding the Gut 79 Suturing ........... . 80 When to Avoid Anastomosis 82 Creation of a Stoma. . . . . . 83 Abdominal Wall Closure .. 83 Management of Contaminated Wounds ...................... 84 11 Bypass, Diversion and Dilatation J. Alexander-Williams . . . . . . . . . . 85 Indications and Principles of Bypass ... 85 Ileo-transverse and Entera-enteric Bypass 85 Dilatation with Balloon or Dilator 86 Indications . . . . . . . . . . . . . 86 Technique ............ . 86 Complications and Precautions . 87 Results .............. . 87 12 Strictureplasty J. Alexander-Williams . 89 Why Strictures Cause Problems . 89 Towards Conservative Operations 89 The Concept of Strictureplasty 89 Indications . 90 Technique .. 91 Results .... 97 Complications 97 Strictureplasty Now and in the Future 98 Contents xi 13 The Management of Fistula J. Alexander-Williams . . . . . . . 103 Principles . . . . . . . . . . . . . 103 Defence Mechanisms and Repair 103 The Natural History of an Intestinal Fistula. 104 Classification of Fistulas . . . . . . . . . . . . 104 Causes of Fistula. . . . . . . . . . . . . . . . . 104 Peculiarities of Fistulas in Crohn's Disease . 105 Assessment . . . . . . 105 Nutrition ...... . 107 Surgical Intervention 109 14 Colonic Crohn's Disease (Including Rectal Disease) J. Alexander-Williams . . . III Indications for Surgery . III Surgical Options 113 15 Technique of Total Colectomy and Ileo-rectal Anastomosis J. Alexander-Williams . 117 Pre-operative Check .......... . 117 Bowel Preparation. . . . . . . . . . . . . 117 Patient Position and Skin Preparation . 117 Position of the Surgical Team 118 Incision .............. . 118 The Laparotomy . . . . . . . . . . 118 Dissection of the Upper Rectum 119 Colectomy ....... . 120 The Anastomosis ... . 121 Closure of the Abdomen 122 16 Technique of Panproctocolectomy J. Alexander-Williams . . . . . . . . . . . 123 Preparation and Position of the Patient 123 Rectal Dissection from Above .. 123 Perineal Dissection. . . . . . . . . 124 Management of the Pelvic Space 125 Creation of the Stoma 126 Abdominal Closure . . . . 129 Eversion of the Ileostomy 129 17 Post-operative Complication J. Alexander-Williams . 131 Early Complications 131 Intermediate . . . . . 133 18 Perianal Crohn's Disease J. Alexander-Williams 135 Introduction . 135 Definition. . . 135 Classification. 135 Pathology ... 138 Symptoms and Signs 140
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