Download - Phillip Fleshner, MD Shierley , Jesslyne , and Emmeline Widjaja Chair in Colorectal Surgery
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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
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Therapeutic Alternatives to Treat CD Strictures
• Additional medical therapy
• Endoscopic dilation
• Surgery
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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
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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
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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
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Why Medical Rx Is Not UsefulExpert Consensus Opinion
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Why Medical Rx Is Not UsefulExpert Consensus Opinion
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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
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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
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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
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Severe CD, Ileal Stricture and Proximal Dilation
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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