J Gastrointest Surg DOI 10.1007/s11605-014-2503-7
SSAT/ASCRS JOINT SYMPOSIUM
SSAT/ASCRS Joint Symposium: Controversies in Surgery for Ulcerative Colitis Emina Huang & Steven Wexner
Received: 7 October 2013 / Accepted: 10 March 2014 # 2014 The Society for Surgery of the Alimentary Tract
Abstract The following is a summary of Session 2: Inflammatory and Infectious Bowel Disease within the Maintenance of Certification (MOC) course directed by Jeffrey B. Matthews, MD, President of the Society of Surgery of the Alimentary Tract. This MOC course was held in Orlando, FL, USA on Saturday, May 18, 2013 during Digestive Diseases Week. Multiple disciplines, including gastroenterology, with general and colon and rectal surgery, were represented at the session Keywords Colitis . Novel treatments . Management Topic: endoscopic evaluation and treatment of dysplasia Presented by: Dr. Jeffrey Marks The progression of colitis to cancer remains unclear. While the gold standard remains endoscopic surveillance for those patients with longstanding disease, interventions in surveillance may be more sensitive or specific in defining those features which most correlate with the need for resection. Dr. Marks initiated the session and presented multiple key concepts. He defined surveillance in the context of clinical implications. He summarized the data correlating the incidence of cancer with increasing severity of dysplasia: low-grade dysplasia has a 20 % risk, while high-grade dysplasia is associated with a 40 % risk of cancer. Current strategies for surveillance include four random colonoscopic biopsies taken every 5 cm. The differentiation between a dysplasia-associated lesion or mass (DALM) vs. a polyp may be critical as the former may require further surgical intervention. The pathogenesis of colitis-associated cancer involves certain principles including cellular and genomic instability, which may be identified as an aberrant crypt focus (ACF). E. Huang (*) Departments of Colorectal Surgery, Stem Cell Biology and Regenerative Medicine, Lerner Research Institute, 9500 Euclid Avenue, Cleveland, OH 44195, USA e-mail: [email protected] S. Wexner Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd, Weston, FL 33331, USA
Dr. Marks gave details regarding enhanced endoscopic techniques. These techniques have a significant learning curve, and may require more time in the endoscopy suite. Specifically, he discussed the use of methylene blue to improve visual detection. Confocal laser endomicroscopy (CLE) requires advanced equipment but improves detection. Narrow band imaging (NBI) in conjunction with regular light colonoscopy also enhances abnormal mucosal patterns. Topic: the role of the pathologist in treatment decision for inflammatory bowel disease Presenter: Mariana Berho Since the histopathology remains the gold standard for selecting colectomy in those patients with colitis-associated cancer, Dr. Berho not only presented the classic findings and pathology for colitis-associated cancer, but also presented some original research. First, she outlined the known risk factors in the development of CRC, including the duration of disease and the degree of inflammation. Secondly, she discussed some of the molecules which might be involved in the pathogenesis, including Cox-2. As known from the literature on the most common polyposis syndrome, familial adenomatous polyposis, administration of Cox-2 inhibitors may mitigate a low-level polyp burden. Dr. Berho discussed the potential for Cox-2 to correlate with the potential of cancer. For these studies, archived tissue blocks from patients having chronic ulcerative colitis (UC), UC and dysplasia, or colitisassociated cancer were retrieved. Immunocytochemistry for Cox-2 was completed and then analyzed by blinded pathologists. Both interobserver and intraobserver agreements were
J Gastrointest Surg
excellent. Within the groups of patients, expression of Cox-2 increased with increasing dysplasia from inflammation to dysplasia to cancer. Topic: laparoscopic pouch surgery: results after 20 years Presenter: Dr. Jonathan E. Efron Dr. Efron shares with us that this procedure continues to be technically challenging and that we, as surgeons, introduce selection bias as patients selected for this procedure may have anatomic features which improve the results. Most of the initial series are small and therefore have limited generalizability. However, one series compared 100 laparoscopic vs. 200 open procedures.1 In this series, there were benefits in the short-term outcomes, including duration of ileus, and length of stay. The next level of intervention includes single-incision laparoscopic surgery. Here, there are even fewer data. However, there are enough reports to suggest feasibility. In all laparoscopic series, complications as analyzed via NSQIP, are reduced.2 Topic: reoperative pouch surgery: avoiding the pitfalls Presenter: David W. Larson Dr. Larson summarized pouch failures by categories: 50 % are due to infections, 30 % are mechanical, and 10 % are due to Crohn’s disease. Regarding infectious risks, these are mostly associated with recurrent anastomotic sepsis. Clearly, due to anatomy, reoperation risks injury to nerves, vessels, ureters, fertility, and incontinence. Technically, the ileal pouch anastomosis may be completed using either a pursestring from below or if handsewn; a Lone Star retractor may facilitate the anastomosis. Overall, there is a salvage rate of 70–90 % at 5 years. For fistulas Dr. Larson had several approaches.3 If the fistula is low and involves the ileal-pouch anal anastomosis, he suggests a seton for 6–8 weeks, followed by a secondary procedure. For pouch-vaginal fistulas, a secondary repair may involve inclusion of the perineal body with a sphincter repair using a Martius or gracilis flap. For these cases, there are poor results in 50 % of the cases. Topic: the J pouch for patients with Crohn’s disease and indeterminate colitis: (when) is it an option? Presenter: Feza H. Remzi Restorative proctocolectomy for Crohn’s disease remains controversial, with an increased rate of intervention and failure compared to performing the procedure for either ulcerative
colitis or polyposis syndromes. Dr. Remzi discussed the literature regarding this topic. For those patients with known Crohn’s disease, he expressed his opinion that the ileal pouch-anal anastomosis (IPAA) should be offered “rarely, selectively, with a multidisciplinary approach in a motivated patient.” Baseline selection criteria include the absence of perianal or small bowel disease. He suggested ileal pouch rectal anastomosis as a potential alternative.4 He felt that most of the cases of Crohn’s disease he has had experience with are those that were initially diagnosed as ulcerative colitis or as indeterminate colitis, and only after the TPCIPAA was completed was a clinical diagnosis of Crohn’s substantiated. Clearly, the overlap of these diseases in a spectrum of presentation may represent challenges in diagnosis and therefore management. A larger series based on the Cleveland Clinic, Cleveland experience was also reviewed.5 Within this series of 204 patients, 10 % of the patients were known to have Crohn’s disease, 47 % of patients were diagnosed perioperatively, while 43 % of the patients had a delayed diagnosis. For those with Crohn’s disease, the overall pouch retention rate was 55 % at long-term follow-up or a 10-year retention rate of 71 %. The patients with higher failure rates include those with a delayed diagnosis, a pouch-vaginal fistula, or post-operative sepsis. Overall, this study supports that with careful patient selection, the restorative proctocolectomy may be considered in patients with Crohn’s disease.
References 1. Larson DW, Cima RR, Dozois EJ, et al. Safety, feasibility, and shortterm outcomes of laparoscopic ileal-pouch-anal anastomosis: a single institutional case-matched experience. Ann Surg. 2006;243(5):667– 670; discussion 670–662. 2. Fleming FJ, Francone TD, Kim MJ, Gunzler D, Messing S, Monson JR. A laparoscopic approach does reduce short-term complications in patients undergoing ileal pouch-anal anastomosis. Dis Colon Rectum. 2011;54(2):176–182. 3. Nisar PJ, Kiran RP, Shen B, Remzi FH, Fazio VW. Factors associated with ileoanal pouch failure in patients developing early or late pouch-related fistula. Dis Colon Rectum. 2011;54(4): 446–453. 4. Kariv Y, Remzi FH, Strong SA, Hammel JP, Preen M, Fazio VW. Ileal pouch rectal anastomosis: a viable alternative to permanent ileostomy in Crohn’s proctocolitis patients. J Am Coll Surg. 2009;208(3): 390–399. 5. Melton GB, Fazio VW, Kiran RP, et al. Long-term outcomes with ileal pouch-anal anastomosis and Crohn’s disease: pouch retention and implications of delayed diagnosis. Ann Surg. 2008;248(4): 608–616.
SSAT/ASCRS JOINT SYMPOSIUM
SSAT/ASCRS Joint Symposium: Controversies in Surgery for Ulcerative Colitis Emina Huang & Steven Wexner
Received: 7 October 2013 / Accepted: 10 March 2014 # 2014 The Society for Surgery of the Alimentary Tract
Abstract The following is a summary of Session 2: Inflammatory and Infectious Bowel Disease within the Maintenance of Certification (MOC) course directed by Jeffrey B. Matthews, MD, President of the Society of Surgery of the Alimentary Tract. This MOC course was held in Orlando, FL, USA on Saturday, May 18, 2013 during Digestive Diseases Week. Multiple disciplines, including gastroenterology, with general and colon and rectal surgery, were represented at the session Keywords Colitis . Novel treatments . Management Topic: endoscopic evaluation and treatment of dysplasia Presented by: Dr. Jeffrey Marks The progression of colitis to cancer remains unclear. While the gold standard remains endoscopic surveillance for those patients with longstanding disease, interventions in surveillance may be more sensitive or specific in defining those features which most correlate with the need for resection. Dr. Marks initiated the session and presented multiple key concepts. He defined surveillance in the context of clinical implications. He summarized the data correlating the incidence of cancer with increasing severity of dysplasia: low-grade dysplasia has a 20 % risk, while high-grade dysplasia is associated with a 40 % risk of cancer. Current strategies for surveillance include four random colonoscopic biopsies taken every 5 cm. The differentiation between a dysplasia-associated lesion or mass (DALM) vs. a polyp may be critical as the former may require further surgical intervention. The pathogenesis of colitis-associated cancer involves certain principles including cellular and genomic instability, which may be identified as an aberrant crypt focus (ACF). E. Huang (*) Departments of Colorectal Surgery, Stem Cell Biology and Regenerative Medicine, Lerner Research Institute, 9500 Euclid Avenue, Cleveland, OH 44195, USA e-mail: [email protected] S. Wexner Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd, Weston, FL 33331, USA
Dr. Marks gave details regarding enhanced endoscopic techniques. These techniques have a significant learning curve, and may require more time in the endoscopy suite. Specifically, he discussed the use of methylene blue to improve visual detection. Confocal laser endomicroscopy (CLE) requires advanced equipment but improves detection. Narrow band imaging (NBI) in conjunction with regular light colonoscopy also enhances abnormal mucosal patterns. Topic: the role of the pathologist in treatment decision for inflammatory bowel disease Presenter: Mariana Berho Since the histopathology remains the gold standard for selecting colectomy in those patients with colitis-associated cancer, Dr. Berho not only presented the classic findings and pathology for colitis-associated cancer, but also presented some original research. First, she outlined the known risk factors in the development of CRC, including the duration of disease and the degree of inflammation. Secondly, she discussed some of the molecules which might be involved in the pathogenesis, including Cox-2. As known from the literature on the most common polyposis syndrome, familial adenomatous polyposis, administration of Cox-2 inhibitors may mitigate a low-level polyp burden. Dr. Berho discussed the potential for Cox-2 to correlate with the potential of cancer. For these studies, archived tissue blocks from patients having chronic ulcerative colitis (UC), UC and dysplasia, or colitisassociated cancer were retrieved. Immunocytochemistry for Cox-2 was completed and then analyzed by blinded pathologists. Both interobserver and intraobserver agreements were
J Gastrointest Surg
excellent. Within the groups of patients, expression of Cox-2 increased with increasing dysplasia from inflammation to dysplasia to cancer. Topic: laparoscopic pouch surgery: results after 20 years Presenter: Dr. Jonathan E. Efron Dr. Efron shares with us that this procedure continues to be technically challenging and that we, as surgeons, introduce selection bias as patients selected for this procedure may have anatomic features which improve the results. Most of the initial series are small and therefore have limited generalizability. However, one series compared 100 laparoscopic vs. 200 open procedures.1 In this series, there were benefits in the short-term outcomes, including duration of ileus, and length of stay. The next level of intervention includes single-incision laparoscopic surgery. Here, there are even fewer data. However, there are enough reports to suggest feasibility. In all laparoscopic series, complications as analyzed via NSQIP, are reduced.2 Topic: reoperative pouch surgery: avoiding the pitfalls Presenter: David W. Larson Dr. Larson summarized pouch failures by categories: 50 % are due to infections, 30 % are mechanical, and 10 % are due to Crohn’s disease. Regarding infectious risks, these are mostly associated with recurrent anastomotic sepsis. Clearly, due to anatomy, reoperation risks injury to nerves, vessels, ureters, fertility, and incontinence. Technically, the ileal pouch anastomosis may be completed using either a pursestring from below or if handsewn; a Lone Star retractor may facilitate the anastomosis. Overall, there is a salvage rate of 70–90 % at 5 years. For fistulas Dr. Larson had several approaches.3 If the fistula is low and involves the ileal-pouch anal anastomosis, he suggests a seton for 6–8 weeks, followed by a secondary procedure. For pouch-vaginal fistulas, a secondary repair may involve inclusion of the perineal body with a sphincter repair using a Martius or gracilis flap. For these cases, there are poor results in 50 % of the cases. Topic: the J pouch for patients with Crohn’s disease and indeterminate colitis: (when) is it an option? Presenter: Feza H. Remzi Restorative proctocolectomy for Crohn’s disease remains controversial, with an increased rate of intervention and failure compared to performing the procedure for either ulcerative
colitis or polyposis syndromes. Dr. Remzi discussed the literature regarding this topic. For those patients with known Crohn’s disease, he expressed his opinion that the ileal pouch-anal anastomosis (IPAA) should be offered “rarely, selectively, with a multidisciplinary approach in a motivated patient.” Baseline selection criteria include the absence of perianal or small bowel disease. He suggested ileal pouch rectal anastomosis as a potential alternative.4 He felt that most of the cases of Crohn’s disease he has had experience with are those that were initially diagnosed as ulcerative colitis or as indeterminate colitis, and only after the TPCIPAA was completed was a clinical diagnosis of Crohn’s substantiated. Clearly, the overlap of these diseases in a spectrum of presentation may represent challenges in diagnosis and therefore management. A larger series based on the Cleveland Clinic, Cleveland experience was also reviewed.5 Within this series of 204 patients, 10 % of the patients were known to have Crohn’s disease, 47 % of patients were diagnosed perioperatively, while 43 % of the patients had a delayed diagnosis. For those with Crohn’s disease, the overall pouch retention rate was 55 % at long-term follow-up or a 10-year retention rate of 71 %. The patients with higher failure rates include those with a delayed diagnosis, a pouch-vaginal fistula, or post-operative sepsis. Overall, this study supports that with careful patient selection, the restorative proctocolectomy may be considered in patients with Crohn’s disease.
References 1. Larson DW, Cima RR, Dozois EJ, et al. Safety, feasibility, and shortterm outcomes of laparoscopic ileal-pouch-anal anastomosis: a single institutional case-matched experience. Ann Surg. 2006;243(5):667– 670; discussion 670–662. 2. Fleming FJ, Francone TD, Kim MJ, Gunzler D, Messing S, Monson JR. A laparoscopic approach does reduce short-term complications in patients undergoing ileal pouch-anal anastomosis. Dis Colon Rectum. 2011;54(2):176–182. 3. Nisar PJ, Kiran RP, Shen B, Remzi FH, Fazio VW. Factors associated with ileoanal pouch failure in patients developing early or late pouch-related fistula. Dis Colon Rectum. 2011;54(4): 446–453. 4. Kariv Y, Remzi FH, Strong SA, Hammel JP, Preen M, Fazio VW. Ileal pouch rectal anastomosis: a viable alternative to permanent ileostomy in Crohn’s proctocolitis patients. J Am Coll Surg. 2009;208(3): 390–399. 5. Melton GB, Fazio VW, Kiran RP, et al. Long-term outcomes with ileal pouch-anal anastomosis and Crohn’s disease: pouch retention and implications of delayed diagnosis. Ann Surg. 2008;248(4): 608–616.
