Ulcerative Colitis and Familial Adenomatous Polyposis: Update Course 2016
With Dr. Jason Frischer · hosted by Dr. Todd Ponsky · StayCurrentMD
Part of
Ulcerative Colitis 4 items
Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
In the last 50 J-pouch patients at Cincinnati Children's, none had an albumin level greater than 3.5 g/dL at the time of surgery.
Pediatric UC patients differ from adult populations because adults often undergo reconstructive surgery for dysplasia, which is extremely rare in pediatric patients.
The speaker's rule of thumb for pouch sizing is age of patient plus 1 cm (e.g., 6 cm pouch for a 5-year-old, 11 cm for a 10-year-old), with a maximum of 15 cm for post-pubertal patients.
The speaker limits maximum pouch size to 12 cm after having several 15 cm pouches become so dilated they required revision.
Taking the mesentery extracorporeally (after laparoscopic mobilization) took a solid hour off the procedure time, reducing cases from all-day to 2-2.5 hours.
The speaker converted from open stapling device to endoscopic stapling device for pouch creation because the limbs are smaller, making the common enterotomy smaller and the operation cleaner.
Leak rate after J-pouch is quoted as somewhere between 5 and 15%, which correlates with pelvic infections.
Pediatric gastroenterologists are so committed to medical management that they sometimes keep UC patients longer on therapy, resulting in sicker children (bleeding, on TPN, steroids, and Remicade) when surgery is finally consulted.
Three-stage operations (simple colectomy first) can dramatically change the course for very sick UC patients, allowing them to become immunocompetent before subsequent reconstructive procedures.
One surgeon made an agreement with a partner to specialize: taking thyroids and IBD patients while giving up lung lesions, allowing the team to develop expertise through repetition (10,000 hours concept) and reduce case times significantly.
Cincinnati Children's averages 10-18 J-pouches per year in recent years.
The compartment syndrome rate in patients with elevated legs for extended periods is surprisingly high, leading one surgeon to keep legs down in stirrups until anal work is required.
Cincinnati Children's data showed daytime soiling rate of about 5% in younger patients and nighttime soiling in about one-third of patients (18% in older patients), with no statistically significant difference between younger (mean age 7) and older (mean age 14) groups.
The rate of conversion from UC to Crohn disease was approximately 10-12% in both younger and older patient populations, with no difference between age groups.
A 12-year-old UC patient developed a golf ball-sized thrombus in the right atrium 3 hours after subtotal colectomy, despite compression boots for thromboprophylaxis.
In a study of contrast enemas before ileostomy closure, none demonstrated problems that weren't already known clinically; symptomatic patients had pouch problems, asymptomatic patients did not.
Indications for FAP surgery include: symptomatic presentation (bleeding, pain), colonoscopy showing >100 polyps with increasing burden, or dysplasia (extremely rare in pediatric population).
For FAP patients with family history, colonoscopy screening typically begins at least 10 years prior to the age when the affected parent was diagnosed with heavy polyp burden.
Cleveland Clinic data showed anastomotic leak rates were significantly different in hypoalbuminemic patients (albumin <3.5) compared to those with normal albumin levels after pouch surgery.
A consensus statement recommends that delay in surgical intervention to enhance nutrition is not recommended in acute UC flares.
Pre-operative steroid administration is associated with increased risk of anastomotic leak and infectious complications.
Low serum albumin is a marker associated with increased risk of post-operative infections.
The cumulative risk of cancer approximately 25 years after restorative proctocolectomy is about 3.5%.
Average-risk J-pouch patients should undergo pouchoscopy and biopsy every 3 years, starting 10 years following their diagnosis of ulcerative colitis.
Infertility rates after J-pouch are between 43% and 63% at two years, compared to North American baseline infertility rate of approximately 8%.
Infertility rates following open J-pouch operations went as high as 90+%, but more recent papers following laparoscopic approach show rates in the 20-30% range.
C-section rate in J-pouch patients is between 38 and 78% versus 22% in the general population.
There is no literature to support whether C-section versus vaginal delivery is safer in J-pouch patients, but when asked, colorectal surgeons unanimously suggest C-section.
Helsinki Group data showed daytime stooling frequency of about 5-6 bowel movements per day in J-pouch patients, with daytime incontinence in 22% and nighttime soiling in 56%.
All IBD patients are at higher risk for thromboembolism, which puts the surgical patient population at elevated baseline risk.
Thromboprophylaxis efficacy is much better if administered before induction of anesthesia rather than during or after.
Adult literature strongly supports using heparin or low molecular weight heparin in combination with compression boots for VTE prophylaxis, showing no increased bleeding risk or adverse outcomes.
PICC lines in IBD patients are a huge risk factor for thromboembolism, with much greater odds ratio for developing thromboembolic events.