UNLOCKING THE SECRETS OF INFLAMMATORY BOWEL DISEASE
Selections from the Cleveland Clinic Florida’s 17th Annual International Colorectal Disease Symposium, presented
February 16-18, 2006
| LAPAROSCOPIC TREATMENT OF CROHN’S DISEASE: IS IT THE STANDARD APPROACH? —Steven D. Wexner,
MD, Chair, Department of Colorectal Surgery, and Chief of Staff, Cleveland Clinic Florida, Weston, FL
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| Crohn’s disease of terminal ileum
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 | Alabaz et al (2000): 74 patients received laparoscopy or laparotomy; patients well matched for age, sex, and duration of
disease; operative times longer but hospital stay significantly shorter (7 vs 9.6 days) in laparoscopic group; use of postoperative
narcotics reduced two thirds, more favorable cosmesis, and more rapid return to social and sexual function,
normal activity, and work in laparoscopic group; rate of symptomatic bowel obstruction significantly less in laparoscopic
group at long-term follow-up
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| Duepree et al (2002): 45 patients received laparoscopy or laparotomy; hospital stay significantly shorter in laparoscopic
group (3 vs 5 days)
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| Milsom et al (2001): 60 patients with ileal and, in some cases, cecal disease received laparoscopic or conventional surgery;
operative time significantly longer but incisions shorter (5 vs 12.5 cm) in laparoscopic group; no significant reduction
in postoperative pain or hospital stay (5 vs 6 days); time to return of bowel movement and flatus same for both
groups
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| Recent study: 60 patients with ileocecal Crohn’s disease prospectively randomized to laparoscopy or laparotomy; patients
excluded if laparoscopy contraindicated, eg, patients with fixed palpable large mass; operative times not dramatically
longer and hospital stay reduced from 7 to 5 days in laparoscopic group; modern techniques and skilled surgeons
have led to significant reduction in morbidity from 33% to 10%; no difference in use of pain medication; cost—overall
cost less for laparoscopy due to shorter hospital stay and less resource utilization; quality of life—in both groups,
quality of life scores declined in first week after surgery, returned to baseline, and improved at 3 mo
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| Recurrent Crohn’s disease: Hasegawa et al—laparoscopic surgery for primary disease vs recurrent disease; mean
body mass index (BMI; weight (kg)/[height (m)]2 ) <20 in both groups; higher rate of fistulae in primary disease group
(50% vs 33%); similar conversion rates; operative time slightly longer in recurrent group, but no difference in hospital
stay
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| Complicated Crohn’s disease: data—73 laparoscopic resections performed in series of patients, 90% of whom had
Crohn’s fistulae (one third had multiple fistulae, 40% had previous surgery); overall complication rate 11%
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| Long-term outcomes of laparoscopic surgery: Alabaz et al—suggested fewer adhesions with laparoscopy (8%
vs 31%); Bergamaschi et al—adhesions reduced from 35% to 11%
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| Cosmesis: Dutch study—34 patients, mean age 32 yr, received open ileocolic resection, laparoscopic ileocolic resection,
or medical management; patients shown photographs and asked questions about body image, cosmesis, and self-confidence;
of patients who underwent no resection, 2 selected laparotomy as surgery of choice and 10 selected laparoscopy;
of patients who underwent laparotomy, 1 still selected laparotomy as surgery of choice and 10 selected laparoscopy; of
patients who underwent laparoscopy, none expressed preference for laparotomy; when patients told that laparoscopy carries
5% chance of ureteral injury, majority still expressed preference for laparoscopy; when patients told they also would
have to pay for laparoscopic procedure, majority (70%-80%) still expressed preference for laparoscopy
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| Recurrence: retrospective study—fewer recurrences associated with laparoscopic resection, compared to open ileocolic
resection (9.5% and 24%, respectively)
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| Cost: Young-Fadok et al—total hospital costs for laparoscopy $9900, compared to $13000 for laparotomy; Duepree et
al—reduced costs and hospital charges for laparoscopy
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| Summary: laparoscopy continues to have longer operative time than conventional procedure but clearly has significant
benefits and represents preferred approach for patients with terminal ileal Crohn’s disease
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| LAPAROSCOPIC TREATMENT OF MUCOSAL ULCERATIVE COLITIS: READY FOR ROUTINE USE? —Elisa H.
Birnbaum, MD, Associate Professor, Division of General Surgery, Washington University School of Medicine, St. Louis,
MO
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| Laparoscopic surgery: advantages—few incisions required; fewer adhesions; incisions tend to be smaller; shorter
time between finishing total colectomy and beginning pouch surgery (due to diminished inflammatory response);
disadvantages—greater learning curve; advanced procedure; operative time often >4 hr; potential for damage to other
areas (eg, ureter, spleen); laparoscopic procedures contraindicated if perforations present
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| Surgical strategies: strictly laparoscopic approach—disconnect colon and rectum and take out through ileostomy;
hand-assisted approach—helps to mobilize transverse colon; 3-stage operation—laparoscopic total colectomy,
followed by laparoscopic completion proctectomy and pouch surgery 6 to 8 wk later, then closure of ileostomy; removal
of specimen—patients frequently have fluid-filled bowel, and removal of colon through small ileostomy incision
can lead to discharge of fluid into abdomen, causing serious complications; extending incision allows removal of
specimen without discharge of fluid
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| Pouch surgery: advantages—few adhesions; less small bowel obstruction; better cosmesis; earlier return to routine activities
(most patients ready to begin work at 2 wk); improved fertility due to less pelvic scarring; disadvantages—
advanced technical procedure; devices—hand-assist devices help when working on transverse colon, shortening operative
time; hemostatic devices help in cases of bleeding along omentum (speaker prefers devices to clips);
contraindications—perforated or acute fulminant colitis
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| Functional outcomes: study—case-matched series; 33 patients underwent laparoscopy, and 33 patients underwent
open surgery; morbidity less in laparoscopic group; functional outcomes and quality of life equivalent for both groups
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| Hand-assisted vs open pouches: study—patients randomized to hand-assisted or open pouches (30 patients in each
group); no difference in quality of life at 3 mo; operative times longer and morbidity slightly higher in hand-assisted
group; length of hospital stay about same
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| 3-stage procedures: study—26 patients in laparoscopic and 36 in open group; stage 1 (total colectomy)—length of
stay significantly shorter in laparoscopic group; return to bowel function shorter, better food tolerance, and fewer complications
in laparoscopic group; most laparoscopic complications relate to ileus; incisions, especially with hand port or extraction
site, associated with more wound infections; stage 2 (completion proctectomy)—length of hospital stay (6-7
days), return of bowel function (4-5 days), and complications (40%; most related to wounds and ileus) same for both
groups; decreased blood loss in laparoscopic group; significantly fewer adhesions and subsequent dissections associated
with laparoscopic technique; stage 3 (closure of loop ileostomy)—no difference between groups; total
complications—no significant difference between groups
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| Summary: 3-stage restorative proctocolectomy for acute colitis associated with significant morbidity; benefits include
decreased length of hospital stay, faster return to bowel function, less blood loss, and lower risk for overall complications;
procedure feasible and safe, but potentially aggravating; hand-assisted approach recommended
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| REOPERATIVE POUCH SURGERY —Ian Lavery, MD, Vice Chair, Department of Colorectal Surgery, Cleveland Clinic
Foundation, Cleveland, OH
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| Indications: rarely performed in patients with Crohn’s disease; usually related to mechanical problems, eg, twist in
pouch, kinking in afferent limb; sepsis that will not resolve with less intervention; pouch-vaginal fistulas require frequent
multiple operations; obstructed defecation sometimes seen, particularly in patients who have had pouch with S-configuration
or mucosectomy leaving 6 to 8 cm of muscular cuff of rectum; dysplasia in remnant of colon in anal canal occasionally
an indication
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| Types of leak: (1) leak from middle of back of pouch causing long presacral tract; extravasated contrast material seen;
requires operation because problem does not resolve with antibiotics or drainage; (2) leak from short end of J-pouch,
extending up into pelvis or down posterior to pouch in presacral space; (3) leaks from pouch itself into presacral space;
(4) large number come from ileal pouch-anal anastomosis itself, perforating posteriorly and causing chronic presacral
sinus; anteriorly, abscesses can form, which ultimately discharge spontaneously or drain into vagina, perianal skin, or
urethra
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| Complications requiring reoperation: persistent and heavy bleeding from anus; residual inflammation and pouchitis
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| Contraindications for reoperative surgery: incontinence; Crohn’s disease; rigid, hard scar tissue, eg, patients with
desmoid tumors associated with familial polyposis; difficulty getting pouch into pelvis
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| Surgical technique: use stirrups and put patients in modified Trendelenburg position; use of stents in ureters sometimes
beneficial; when removing pouch, speaker performs transanal disconnection of pouch and upward dissection in
good vision before entering abdomen to mobilize, as opposed to abdominal approach; curet any sepsis; trim pouch if
to be replaced; if patient had previous anal operation, use hand-sewn anastomosis rather than stapled anastomosis;
curet and clean granulation tissue from back of pouch before replacing pouch and performing anal anastomosis (many
patients require long-term antibiotics postoperatively to prevent recurrence); create new pouch if existing pouch damaged
during removal; Cleveland Clinic Florida study—32 patients, 10 with pouch excisions (4 had Crohn’s disease);
reconstruction success 20%; 8 patients had pouch advancements (success 60%); perianal operations more successful
than intra-abdominal operations
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| Pathologic diagnosis: study—89 of 100 patients had initial diagnosis of ulcerative colitis; before redo pelvic pouch
operation, 68 patients still considered to have ulcerative colitis; with time, many patients requiring redo operations shown
to have Crohn’s disease, not ulcerative colitis; in 65% of patients, indication for operation related to septic problems;
note—indication for operation does not influence outcome
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| STRICTUREPLASTY AND RECURRENT BOWEL DISEASE: BOWEL PREPARATION —Scott Strong, MD, Staff
Colorectal Surgeon, Department of Colorectal Surgery, Cleveland Clinic Foundation, Cleveland, OH
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Intestinal Bacterial Flora
| Small intestine: proximally, contains predominantly gram-positive bacteria (105 bacteria per mL of fluid), typically lactobacilli
and Enterococcus; distally, contains 108 bacteria per mL of fluid, consisting of gram-positive bacteria, coliforms, and
Bacteroides
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| Large intestine: contains 1011 bacteria per mL of fluid, predominantly anaerobes (eg, Bacteroides, Bifidobacterium)
but also methane-producing bacteria; in colon, typically find 1000 to 10,000 anaerobes per aerobe
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| Bacterial overgrowth: some disease entities associated with bacterial overgrowth in small intestine, involving increase in
number and change in type of bacteria, ie, colonization with anaerobes; symptoms—diarrhea or soft stools; abdominal pain
or cramping; bloating; diagnosis—lactulose breath test or glucose breath test (higher sensitivity); prevalence—20% of patients
with Crohn’s disease, 25% of patients with stricture, and 33% of patients who underwent previous operation (particularly
resection of ileocecal valve) have bacterial overgrowth of small intestine; treatment—usually responds to 10-day course
of metronidazole or ciprofloxacin; note—symptoms suggestive of recurrent disease but may just be bacterial overgrowth that
can be treated easily
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Role of Antibiotic Prophylaxis
| Indications: warranted in any high-risk procedure; necessary in patients at low risk for postoperative infection but at high
risk for infection sequelae if infection should occur
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| Administration: direct antibiotics against resident bacteria; be aware of susceptibility profile in institution; time delivery
to ensure optimal tissue concentrations at times of high risk for introducing bacterial inoculum
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| Single- vs multiple-dose therapy: literature review (1998)—of patients undergoing major surgery, no difference in
surgical site infection rate for single- or multiple-dose therapy; in 147 studies of patients undergoing colorectal surgery, no difference
in surgical wound infection rate for single- or multiple-dose therapy
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| Oral preparation: McGill University meta-analysis (2002)—surgical site infection rate reduced with combination of
oral (azithromycin, neomycin) and single- or multiple-dose parenteral therapy, compared to parenteral therapy alone;
Stanford University study (2005)—increased risk for Clostridium difficile infection in patients receiving combination
therapy, compared to parenteral therapy alone
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Role of Mechanical Bowel Preparation
| Preparation vs nonpreparation: meta-analysis—7 trials, 1500 patients; likelihood of anastomotic leakage greater
in patients undergoing bowel preparation, compared to those not undergoing preparation; no difference in wound infection
rate (true for polyethylene glycol and sodium phosphate preparations); no difference in overall morbidity and mortality
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| Spillage of enteric contents: Israeli study—prospective study of 300 patients undergoing colorectal surgery; likelihood
of anastomotic leakage, wound infection, and abdominal abscess tended to be greater in patients who had spillage;
17% of patients who had bowel preparation had spillage, compared to 12% of patients in whom preparation avoided
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| Minimizing risk for spillage during strictureplasty or resection for recurrent disease: decompress dilated
small bowel—can milk contents back into stomach using hand-over-hand technique and decompress using nasogastric
tube; some use linen ties to occlude bowel in 2 places and use nasogastric tube introduced at enterotomy at operative site
to decompress bowel; quarantine operative site—occlude proximally and, using sponges or towels, pack rest of bowel
away from site; in event of spillage, spillage captured by lap packs; elevate bowel—any pooling will occur away from open
bowel; minimize bowel manipulation—moving bowel unnecessarily increases risk for spillage
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Educational Objectives
| The goal of this program is to educate the listener on issues in inflammatory bowel disease. After hearing and assimilating
this program, the clinician will be better able to:
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| 1. Discuss laparoscopic treatment of Crohn’s disease.
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| 2. Treat mucosal ulcerative colitis laparoscopically.
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| 3. Review the indications for reoperative pouch surgery.
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| 4. Use antibiotic prophylaxis in the treatment of patients with inflammatory bowel disease.
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| 5. Minimize spillage of enteric contents during mechanical bowel preparation.
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Discussed on This Program
Azithromycin [Zithromax, Zmax]
Ciprofloxacin [Ciloxan, Cipro, Cipro I.V., Cipro XR, Proquin XR]
Metronidazole [Flagyl, Flagyl 375, Flagyl ER, Flagyl IV, Flagyl IV RTU, Metric 21, MetroCream, MetroGel, MetroGel-
Vaginal, MetroLotion, Noritate, Protostat]
Neomycin sulfate [Mycifradin, Neo-fradin, Neo-Tabs]
Suggested Reading
Alabaz O et al: Comparison of laparoscopically assisted and conventional ileocolic resection for Crohn's disease. Eur J
Surg 166:213, 2000; Baixauli J et al: Functional outcome and quality of life after repeat ileal pouch-anal anastomosis
for complications of ileoanal surgery. Dis Colon Rectum 47:2, 2004; Bergamaschi R et al: Comparison of conventional
and laparoscopic ileocolic resection for Crohn's disease. Dis Colon Rectum 46:1129, 2003; Bucher P et al: Morphologic
alterations associated with mechanical bowel preparation before elective colorectal surgery: a randomized trial.
Dis Colon Rectum 49:109, 2006; Duepree HJ et al: Advantages of laparoscopic resection for ileocecal Crohn's disease.
Dis Colon Rectum 45:605, 2002; Guenaga KF et al: Mechanical bowel preparation for elective colorectal surgery. Cochrane
Database Syst Rev CD001544, 2005; Hamel CT et al: Laparoscopic surgery for inflammatory bowel disease.
Surg Endosc 15:642, 2001; Hartley JE et al: Analysis of the outcome of ileal pouch-anal anastomosis in patients with
Crohn's disease. Dis Colon Rectum 47:1808, 2004; Hasegawa H et al: Laparoscopic surgery for recurrent Crohn's disease.
Br J Surg 90:970, 2003; Lowney JK et al: Is there any difference in recurrence rates in laparoscopic ileocolic resection
for Crohn's disease compared with conventional surgery? A long-term, follow-up study. Dis Colon Rectum 49:58,
2006; Moorthy K et al: Factors that predict conversion in patients undergoing laparoscopic surgery for Crohn's disease.
Am J Surg 187:47, 2004; Remzi FH et al: The outcome after restorative proctocolectomy with or without defunctioning
ileostomy. Dis Colon Rectum 49:470, 2006; Sklow B et al: Age and type of procedure influence the choice of patients
for laparoscopic colectomy. Surg Endosc 17:923, 2003; Tekkis PP et al: Evaluation of the learning curve in ileal pouch-
anal anastomosis surgery. Ann Surg 241:262, 2005; Thaler K et al: Assessment of long-term quality of life after laparoscopic
and open surgery for Crohn's disease. Colorectal Dis 7:375, 2005; Winslow ER et al: Wound complications of
laparoscopic vs open colectomy. Surg Endosc 16:1420, 2002; Wren SM et al: Preoperative oral antibiotics in colorectal
surgery increase the rate of Clostridium difficile colitis. Arch Surg 140:752, 2005.
Faculty Disclosure
In adherence to ACCME guidelines, the Audio-Digest Foundation requests all lecturers to disclose any significant financial relationship
with the manufacturer or provider of any commercial product or service discussed. For this issue, the speakers reported
no conflict.
Drs. Wexner, Birnbaum, Lavery, and Strong spoke at the 17th Annual International Colorectal Disease Symposium,
presented February 16-18, 2006, by the Cleveland Clinic Florida and held in Fort Lauderdale, FL. The Audio-Digest
Foundation thanks the speakers and the sponsor for their cooperation in the production of this program.
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