anastomosis in ibd barry salky, md facs professor of surgery chief (emeritus), division of...
DESCRIPTION
Anastomosis in IBD Ulcerative Colitis Mucosectomy versus Double-stapleTRANSCRIPT
Anastomosis in IBD
Barry Salky, MD FACSProfessor of Surgery
Chief (Emeritus), Division of Laparoscopic Surgery
The Mount Sinai HospitalNew York
Anastomosis in IBD
Ulcerative Colitis
Mucosectomy versus Double-staple
Anastomosis in IBD
Mucosectomy Vs. Double-Stapled M DSTechnical ease N YPreserves ATZ N YImproved function N YDecrease septic event ? ?Decrease dysplasia Y NDecrease cancer risk N N Larson, Pemberton; Gastroenter, 2004
Anastomosis in IBD
ATZ• Portion of the anal canal between squamous epithelium below and the columnar epithelium above.• Nocturnal fecal incontinence less with DS as the ATZ is preserved. (multiple RCTs, a few RCTs don’t agree)
Anastomosis in IBD
Leaks and sepsis• Several series demonstrated a better prognosis from leaks and sepsis in DS compared to mucosectomy. ( non RCT)
MacRae et al Ziv et all
DCR 1997 Am J Surg 1996
Anastomosis in IBD
Cancer risk• Dysplasia in ATZ at 10 years 5%. *• Multiple reports of development of cancer in both DS and mucosectomy patients ( that means residual rectal mucosa can be left behind)• Most experts agree that if dysplasia is present in the rectum-mucosectomy is procedure of choice. Remzi et al DCR 2003 (*) O’Connell et al DCR 1987
Anastomosis in IBD
Crohn’s Disease
Does type of anastomosis make a difference in recurrence, leak or function?
Anastomosis in IBDCrohn’s Disease
Whether the actual anastomotic technique impacts rate of recurrence or the need for a second surgery is completely unknown.
Larson, Pemberton Gastroenterology 2004
Anastomosis in IBDCrohn’s Disease
Several non-randomized papers have suggested that the recurrence free time is lengthened by using a stapled anastomosis at the original surgery.
Hashemi et al Yamamoto et al Munoz-Juarez et al DCR 1998 World J Surg 1999 DCR 2001
Anastomosis in IBDCrohn’s Disease
“Stapled vs handsewn methods for ileocolic anastomoses”Cochrane analysis5 large RCT including 1125 ileocolic pts441 stapled, 684 hand sewn• Stapled anastomosis (functional end to end) had significantly fewer anastomotic leaks p=0.03(CONT)
Anastomosis in IBDCrohn’s Disease
“Stapled vs handsewn methods for ileocolic anastomoses”All other outcomes: stricture, hemorrhage, time, re-operation, mortality, abscess, wound infection, LOS showed not significant difference. Choy et al Cochrane Library 2011
Patient Demographics Intracorporeal ( n=54)
Extracorporeal (n=51)
P value
45 50 0.181 19(35) 28(23) 0.042
BMI (kg/m2) 23.8 23.4 0.705ASA class* 2.1 2.2 0.242Prior operation 21 23 0.519IBD 33 30 0.167Neoplasm 19 16Other 2 5*Mean
Operative DataIntracorporeal n = 54
Extracorporeal n = 51
p value
Operation performed
Ileocolic 33 33 0.583 R hemi 14 15 L hemi 6 3Subtotal 1 0Fistula take down 14 16 0.537OR time (minutes) 190 156 0.001EBL (ml) 85.4 164 0.014Intraop narcotics (mg)*Morphine equivalents
49 48 0.826Intraop complications 0 0
Post-op DataIntracorporeal Extracorporeal P value
Narcotic use (mg)* 16 49 0.001
Time to flatus(days)* 2.0 2.4 0.017
Time to BM (days)* 2.2 2.5 0.167
Length of stay (days)* 3.2 3.8 0.019
Periop morbidity (n) 6 15 0.019
Anastomotic leak 0 1
Enterotomy 1 0
GI bleed 0 2
Obstruction 1 4
Intra-abd abscess 0 2
Wound infection 0 2
Cardiac 2 0
Blood transfusion 1 3
Urinary retention 0 1
Hematuria 0 2
Other 0 2
Mortality 0 0
QuickTime™ and aDV/DVCPRO - NTSC decompressor
are needed to see this picture.
Anastomosis in IBD
Conclusions (UC)1. DS is comparable to mucosectomy, and it is technically easier to perform.2. Use mucosectomy for rectal dysplasia3. No difference between laparoscopic
and open cases (so far)
Anastomosis in IBD
Conclusions (Crohn’s Disease)
1. Stapled techniques are appropriate in the surgery for CD.
2. Intracorporeal anastomosis appears to decrease morbidity and LOS.