PREPRINT

  • 1. Introduction
  • 2. Surgical Approach
  • 3. Access
  • 4. Mobilize Colon
  • 5. Divide Distal Sigmoid Colon
  • 6. Pull Colon Through Infraumbilical Port Site
  • 7. Divide at Ileum and Make J-Pouch
  • 8. Secure Ileal End of EEA Stapler
  • 9. Regain Laparoscopic Access
  • 10. Insert EEA Stapler
  • 11. Anastomosis
  • 12. Test Anastomosis
  • 13. Reposition Omentum
  • 14. Examine Resected Colon
  • 15. Closure
  • 16. Post-op Remarks
cover-image
jkl keys enabled

Laparoscopic Total Abdominal Colectomy with Ileorectal Anastomosis for Crohn's Colitis and Multifocal Dysplasia

Richard Hodin, MD
Massachusetts General Hospital

General Surgery
Main TextProcedure OutlineTranscript

Main Text

Table of Contents

  1. Abstract
  2. Case Overview
    1. Background
    2. Focused History of the Patient
    3. Physical Exam
    4. Natural History
    5. Options for Treatment
    6. Rationale for Treatment
  3. Discussion
  4. Equipment
  5. Disclosures
  6. Statement of Consent
  7. Citations

Crohn's disease is a type of inflammatory bowel disease that can chronically affect the entire gastrointestinal tract, with a propensity for the distal ileum. It causes transmural inflammation of the intestines, where it can cause abdominal pain, severe diarrhea, fatigue, weight loss, and malnutrition. It occurs in about 200 patients per 100,000 and follows a bimodal distribution pattern with peaks in the 3rd and 6th decades of life. The exact cause of Crohn's disease is unknown; however, it is believed to be influenced by immune system disorders, genetics, and environmental factors. Diagnosis is usually made by endoscopy and clinical history. Endoscopic findings show characteristic skip lesions, and a cobblestone-like appearance is seen in approximately 40% of cases, representing areas of ulceration separated by narrow areas of healthy tissue. There is no cure for Crohn's disease; the goal of treatment is to palliate symptoms, accomplished with both medical and surgical options. Medications such as antibiotics, aminosalicylates, corticosteroids, immunomodulators, and a variety of biologic medications are used to reduce inflammation and prevent recurrence. Surgery is generally reserved for patients who are unresponsive to aggressive medical therapy or those who develop complications such as intestinal obstruction due to stricture, bleeding from ulcers, abscesses, and fistulas. Segmental intestinal resection of grossly evident disease followed by primary anastomosis is the usual procedure of choice. Here, we present the case of a 59-year-old male with chronic gastrointestinal problems thought to be Crohn's colitis. Colonoscopy with biopsy of multiple areas showed dysplasia, prompting surgical resection. In this case, the entire colon was affected with rectal sparing; therefore, a total abdominal colectomy with ileorectal anastomosis was performed. Laparoscopic access was gained, and the colon was mobilized and divided at the distal sigmoid colon. The colon was pulled through the infraumbilical port site and divided at the ileum, and a J-pouch was made. Anastomosis was achieved using an end-to-end anastomosis stapler and was tested using a scope; the port sites were then closed.

Inflammatory bowel disease (IBD) is a set of diseases affecting the alimentary tract. IBD is generally subdivided into ulcerative colitis and Crohn's disease (CD), each of which are characterized by distinct, although overlapping, symptoms and often similar pathologies. By 2015, approximately 3.1 million Americans suffered from some form of IBD.1 The incidence of IBD appears to be increasing worldwide.2 The etiology is unknown, although it appears to be multifactorial, involving both environmental and genetic factors.

Medical treatment of IBD is based on salicylates, steroids, immunomodulators, monoclonal antibodies against tumor necrosis factor-alpha (e.g., infliximab), and other newer biologic agents.3 Surgery is indicated when medical therapy fails to control symptoms, and particularly in the context of fulminant colitis, perforation, severe bleeding, and toxic megacolon. Relevant to the present case, surgery is also indicated in the setting of dysplasia or malignancy.4

The patient is a 59-year-old male with a past medical history of presumed irritable bowel syndrome. In retrospect, his symptoms were likely due to Crohn's colitis. Prior to surgery, he underwent colonoscopies that revealed multifocal dysplasia in at least two or even three areas of the colon. These areas could not be excised via the endoscope; therefore, surgery was recommended as the reasonable approach to managing his disease.

On the basis of colonoscopy and biopsies, it appears that patient’s rectum has always been spared. He has had neither inflammation nor dysplasia in this area. Therefore, after much discussion, we decided to proceed with a subtotal colectomy or total abdominal colectomy with an ileorectal anastomosis rather than an ileoanal J-pouch operation.

There are no specific signs of IBD on physical exam. Examination of the abdomen may reveal tenderness, distention, or masses. One-third of patients with IBD have fistulas, perirectal abscesses, or fissures during the course of their illness. Therefore, an anorectal exam should not be omitted.5

CD is characterized by episodes of exacerbation and remission. Following diagnosis, as many as one-third of patients will experience an exacerbation. One in five patients will have chronically active disease, and only one in ten will remain in remission for years at a time. Starting at about 20 years from diagnosis, most patients with CD will require surgery. The life expectancy of patients with CD is slightly less than that of the general population.3

In this patient, we created a small ileal J-pouch. It is not clear how much benefit derives from this approach; nevertheless, our anecdotal experience over many years and many patients suggests that patients seem to do better with a small ileal J-pouch (as an extra reservoir) than with a straight ileorectal anastomosis. Following surgery, many of these patients will have only two or three bowel movements a day. The standard ileoanal J-pouch generally requires two operations rather than one (we usually use a temporary diverting loop ileostomy). A major advantage to the ileorectal anastomosis is that the bowel function is much better than the ileoanal J-pouch. We would anticipate that this patient will enjoy a normal quality of life, eating a normal diet with perhaps more frequent bowel movements than average.

Chronic dysplasia places this patient at risk for the development of colon cancer. Indeed, some patients with dysplasia already have cancer discovered at the time of surgery. The rationale for the approach we took was that his rectum has been healthy and was unlikely to be a problem for him in the future. Again, this operation would provide a much better functional result than the J-pouch surgery.

We performed a laparoscopic total abdominal colectomy with ileal J-pouch rectal anastomosis. We generally do a small ileal J-pouch in this setting, which helps facilitate the anastomosis and often provides extra capacity and reservoir in terms of bowel function.

There are several unusual aspects to this case. First, the patient had chronic colitis, and the transverse colon in particular was thickened, making the dissection more of a challenge. We also had to make our incision at the enlarged infraumbilical port site a little bit larger than we normally create; this was done to obtain enough exposure in this obese patient to safely remove the bowel and also get the J-pouch in good position for the anastomosis.

On final pathology, his colon showed multifocal dysplasia, with no high-grade dysplasia, no cancer, and all the lymph nodes were negative.

The patient went home from the hospital after a couple of days. His bowel function was relatively normal; he was eating normally and having only three to four bowel movements a day. Going forward, the patient will need to undergo regular monitoring and surveillance of his remaining rectum, which will entail annual flexible sigmoidoscopy with extensive biopsies. This is to ensure that there is no evidence of dysplasia in the remaining sigmoid and rectum. Given that he has never had inflammation in the rectum, his risks of developing inflammation or malignancy in his rectum are extremely low.

  • LigaSure Device
  • EEA Stapler

None.

The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online.

Citations

  1. Dahlhamer JM. Prevalence of inflammatory bowel disease among adults aged≥ 18 years—United States, 2015. MMWR Morb Mortal Wkly Rep. 2016;65. doi:10.15585/mmwr.mm6542a3.
  2. Molodecky NA, Soon S, Rabi DM, et al. Increasing incidence and prevalence of the inflammatory bowel diseases with time, based on systematic review. Gastroenterology. 2012;142(1):46-54. doi:10.1053/j.gastro.2011.10.001.
  3. Baumgart DC, Sandborn WJ. Inflammatory bowel disease: clinical aspects and established and evolving therapies. Lancet. 2007369(9573):1641-57. doi:10.1016/S0140-6736(07)60751-X.
  4. Ferrari L, Krane MK, Fichera A. Inflammatory bowel disease surgery in the biologic era. World J Gastrointest Surg. 2016;8(5):363. doi:10.4240/wjgs.v8.i5.363.
  5. Wilkins T, Jarvis K, Patel J. Diagnosis and management of Crohn's disease. Am Fam Physician. 2011 Dec 15. Available from: http://hdl.handle.net/10675.2/316533.