panel discussion surgery for crohns disease. ad 24 female crohns disease since 2001 on penatasa,...
TRANSCRIPT
PANEL DISCUSSION
SURGERY FOR CROHNS DISEASE
AD 24 female
• Crohns disease since 2001
• on penatasa, budesonide, prednisolone
• needle phobia resolved by psychologist onto azathioprine
• October 2004 – wt loss, colicky abdominal pain on eating
• barium meal and follow through
AD 24 female
Barium Meal and F/T - Featureless terminal ileum over 15cm with a very tight stricture at the ileocaecal valve over a very short distance
• no previous surgery
• BMI 18
WHAT NEXT ?
AD 24 female
LAPAROSCOPIC RESECTION
• laparoscopic resection – ileocaecetomy 25cm specimen
• stapled anatomosis
• postoperative ileus
• home on day 10
AD 24 female
KH 38 female nurse
• Crohns disease for 17 years involving the terminal ileum managed with azathioprine and steroids
•August 2003 – IP subacute obstruction
KH 38 female nurse
• BM & F/T “long segment of strictured terminal ileum - ? Early filling of sigmoid and rectum ?? Fistula
KH 38 female nurse
• September 2003 OPD – poor appetite, weight loss, urinary frequency but no pneumaturia.
•O/E mass in lower abdomen
•Hb111, Plts 645, Albumin 28g/l, CRP 122
•CT Scan – mass of small bowel with local perforation and fistulation into bladder and sigmoid
WHAT NEXT ?
KH 38 female nurse
• Medical therapy - ? Infliximab
• Resection
• Laparoscopic / Laparotomy
• Defunction or not ?
OPTIONS
KH 38 female nurse
• 20cm mass of fistulating small bowel Crohns
• fistulation into dome of the bladder
• multiple complex openings into sigmoid over 8cm
LAPAROTOMY 7.11.03
WHAT NEXT ?
KH 38 female nurse
LAPAROTOMY 7.11.03
WHAT NEXT ?
• ileocaecectomy
• broken off dome of the bladder – catheter 10 days
• sigmoid cannot be repaired, extensive indurated defect
KH 38 female nurse
LAPAROTOMY 7.11.03
• sigmoid resection, on table lavage and left colo-colonic anastomosis in two layers maxon
• end ileostomy and ascending colon mucous fistula
KH 38 female nurse
POSTOP.
• developed heparin induced thrombocytopenia
• LOS 25 days
• HISTOLOGY
KH 38 female nurse
KH 38 female nurse
Crohns disease – small bowel adenocarcinoma arising from dysplastic epithelium
KH 38 female nurse
JH 38 female
• 9.3.00 perianal Crohns fistula – seton inserted
• 13.9.01inflamed stricture upper rectum
• 28.1.02 – white cell scan shows uptake in descending colon and sigmoid
• 28.11.02 – acute gynae admission with pelvic pain, ultrasound shows complex solid/cystic mass arising from the right ovary
JH 38 female
• 12.11.02 – Gynae Laparotomy
• inflammed mass involving the sigmoid and the uterus and adenexae. Small amount of pus – colon normal to proximal descending then very abrnormal and thickened.
JH 38 female
• sigmoid separated from the uterus and pelvis washed out.
• not clear if PID or Crohns so no resection - proximal loop ileostomy brought out.
• home pod 17
JH 38 female
• gradually improved little in the way of symptoms – attended OPD to reassess pelvis and explore options for re-anastomosis
• 24.9.03 – CT showed bilateral adnexal fluid collections
• 27.10.03 – Colonoscopy halted at ulcerated mid-rectal stricture
• 19.2.04 contrast enema
JH 38 female
JH 38 female
JH 38 female
WHAT NEXT ?
JH 38 female
• TAH and BSO
• Left Hemicolectomy – small abscess around very abnormal proximal rectum, so rectum divided at the pelvic floor.
• TV colon to distal rectum cross stapled anstomosis
• loop ileostomy maintained
LAPAROTOMY 10.3.05
JH 38 female
• initially good recovery
• then unwell, low grade pyrexia, superficial wound breakdown
• CT presacral fluid collection – small amount of contrast in a 2cm cavity adjacent to anstomosis.
POSTOP