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++++++++++++++++++++++++++++++++++++++++++++++++++++++++++ + + ++++++++++++++++++++++++++++++++++++++++++++++++++++++++++ SPECIAL SECTION: MINIMALLY INVASIVE PROCEDURES +++ +++ Invasive Surgery Minimally for IBD By Oliver Soldes, MD A DVANCED LAPAROSCOPIC INTESTINAL surgery has been embraced by the surgical com- munity for its many benefits. Although the more technically complex procedures require more time, this gap has narrowed as techniques improve. Minimally invasive procedures offer substantial benefits, including smaller incisions, reduced pain, quicker recovery time and return to normal activities. For patients with Inflammatory Bowel Disease (IBD) — a chronic and often extremely painful and debilitating condi- tion — laparoscopic surgical procedures have become more available during the last 15 years and are preferred for many patients. IBD is a broad term for a set of autoim- mune diseases affecting the gastrointestinal system when the body targets the intestine. Generally, medical therapy is the initial treatment. When surgery is indicated, appropriate procedures are determined by identifying the type of IBD — Crohn's disease or ulcerative colitis (UC) — with approximately 10 percent of colitis patients being initially diagnosed with an indeter- minate type of IBD. Although surgical procedures don't offer a cure for Crohn's disease, appropriate medical treatment combined with surgical treatment of disease complications can allow patients to achieve significant symptom control. UC patients can essentially be "cured" of their IBD symptoms by a colectomy, although lifelong follow-up is needed. Crohn's disease may affect any part of the gastrointestinal tract from the lips to the anus. In children, surgery is usually reserved for situations when symptoms become intractable to medical therapy, dependence on steroid medication to remain in remission develops, or to stop progression of disease. It may also be used to treat complications such as fistula, strictures, growth failure, severe bleeding and anemia. In UC, the inflammatory process is confined to the colon and rectum. In contrast to Crohn's disease, UC symptoms can be almost completely ameliorated with proctocolectomy — the surgical removal of the entire colon and the rectum or the rectal lining (mucosa). There are five primary surgical options for UC (see Table 1). The treatment preferred by most children and adolescents is a total abdominal colectomy with mucosal proctectomy and ileal pouch-anal anastomosis (IPAA). The IPAA procedure offers the advantage of almost completely removing the diseased mucosa without requiring a permanent ostomy, although a temporary ostomy is frequently employed for several months while healing occurs. Although IPAA is favored by most young patients, all of these procedures help quality of life, improve symptoms and reduce long-term malignancy risk. As minimally invasive surgical proce- dures continue to evolve with improved techniques and patient outcomes, IBD patients will see treatment options such as laparoscopic/laparoscopic- assisted IPAA become more routine corrective procedures. Dr. Oliver Soldes is a board-certified pediatric general surgeon with the Akron Children's Hospital Pediatric General Surgery Center. ■ TABLE 1 — SURGICAL OPTIONS FOR UC PROCTOCOLECTOMY WITH PERMANENT ILEOSTOMY (BROOKE ILEOSTOMY) Total removal of colon/rectum; permanent ileostomy. Patient has lifelong ostomy and wears bag to contain stool. PROCTOCOLECTOMY WITH CONTINENT ILEOSTOMY (KOCK POUCH) Total removal of colon/rectum; permanent internal reservoir w/ catheterizable ileostomy (no bag). Patient catheterizes pouch several times daily to drain stool. High failure rate and frequent re-operations. ABDOMINAL COLECTOMY WITH ILEORECTAL ANASTOMOSIS Total removal of colon, leaving behind significant diseased rectal mucosa. Technically less complex; ameliorates but does not "cure" rectal disease. Increased risk of persistence of symptoms and malignancy. 38 | Cleveland-Akron-Canton MD NEWS n MDNEWS.COM n MARCH-APRIL 2012 ABDOMINAL COLECTOMY AND STAPLED ILEAL POUCH-DISTAL RECTAL ANASTOMOSIS Total removal of colon and most of rectal mucosa, leaving behind a very short segment of rectal mucosa. No ileostomy long term. Technically simpler, potentially better sensation and continence, especially at night, than IPAA. TOTAL ABDOMINAL COLECTOMY WITH MUCOSAL PROCTECTOMY AND ILEAL POUCH-ANAL ANASTOMOSIS (IPAA) Total removal of colon and rectal mucosa. No ileostomy long term. More technically complex, small risk of urinary/sexual dys- function. Generally resolves UC symptoms; less malignancy risk. Preserves ability to pass stool per anus.