phillip fleshner, md shierley , jesslyne , and emmeline widjaja chair in colorectal surgery

Phillip Fleshner, MD

Shierley, Jesslyne, and Emmeline Widjaja Chair in Colorectal Surgery

Program Director, Colorectal Surgery ResidencyClinical Professor of Surgery

UCLA School of Medicine

Cedars-Sinai Medical CenterLos Angeles, California

C S

Clinical DebateA patient with severe Crohn's disease, an ileal

stricture and proximal dilation on CTE should have an ileocolonic resection first

Therapeutic Alternatives to Treat CD Strictures

• Additional medical therapy

• Endoscopic dilation

• Surgery

Why Medical Therapy Not Useful• Expensive• When do you stop, ? lifetime exposure• QOL issues in partial responders• IV steroids frequently used to assess response

Steroids associated with development of stenosisSteroids associated with postoperative morbidity

• Aggressive medical therapy ↑ surgical morbidity• Prestenotic dilation is a negative prognostic factor

Disease assessment scores Clinical studies

Lehman Score• Score measuring the progressive nature or

cumulative structural bowel damage, independent of the current and fluctuating disease activity

• A longitudinal tool currently being developed and validated prospectively

Pariente B, et al., IBD 2011

Prestenotic Dilation and Clinical Response in CD

No stenosis

Stenosis

; no dila

tion

Stenosis

; yes d

ilation

0

50

100 7561

28

%

“Patients with intestinal narrowing and prestenotic dilatation … were less likely to respond to medical therapy”

(OR = 7.85, 95% CI 1.73-35.6,p= 0.008)

Lawrance IC, et al., WJG 2009

Why Medical Rx Is Not UsefulExpert Consensus Opinion

Why Medical Rx Is Not UsefulExpert Consensus Opinion

Laparoscopic Ileocolic Resection• Short term outcomes

Minimal scarringEnhanced cosmesisFast surgical recoveryFast restoration of QOL Complications are low (<10%)Medication can be stopped or limited in prevention modeSmall bowel loss is generally small (usually 20–25 cm)

• Long term outcomesLower incisional herniaLess adhesions, possibly less SBO

Endoscopic Dilation vs Laparoscopic Surgery

Criterion EndoscopicDilatation

LaparoscopicSurgery

Average Procedure Length Can be long with deep SB strictures using DBE

120 min

Overall complications � 10% <10%

Complications requiring surgery

� 5% <1%

Peritonitis/perforation 2% 2%

Potential for leaving CA Present; Biopsy critical None

Endoscopic Dilation vs Laparoscopic Surgery

Criterion EndoscopicDilatation

LaparoscopicSurgery

Technical success rate 90% 100%

Clinical success rate � 50% >95%

Patients requiring only 1 procedure � 30% 99

Mean # of procedures needed � 4 1

QOL after procedure Unknown Very high

Severe CD, Ileal Stricture and Proximal Dilation

Is Endoscopic Dilation Ever Preferable to Surgery?

• Multicentric disease• Multiple prior resections

AdhesionsLoss of bowel → short bowel syndrome

• Poor surgical risk • Initial presentation of the disease• Stricture location

GastroduodenalRectosigmoid