Seminars in Colon and Rectal Surgery最新文献

Inflammatory bowel diseases are a group of chronic, relapsing disorders of the gastrointestinal tract. The initially limited therapy options were significantly expanded with the advent of biologics and small molecules. Biologics and small molecules can be divided into four categories based on their immunologic targets – anti-tumor necrosis factor, anti-interleukin, anti-integrin, and janus kinase pathway inhibitor. Each class of medication functions through a particular mechanism of action that dictates its indications for use, rate of efficacy, and safety profile.

Crohns disease (CD) is a chronic inflammatory condition that can affect any portion of the intestinal tract. The disease presents with myriad symptoms and signs and is best diagnosed and staged through a combination of laboratory tests, endoscopic procedures, and radiographic studies. Appropriate medical therapy is based upon the disease behavior, location, and severity and may require use of one or more classes of medications in an attempt to achieve endoscopic remission as well as histologic normalization. Several clinical scenarios require special consideration and it is important for the gastroenterologist to work with the patient, surgeon, and other healthcare providers to achieve optimal outcomes.

As biologics have become the cornerstone of medical management for ulcerative colitis, an increasing number of surgical candidates have been recently exposed to biologic therapy. Evidence regarding the impact of biologic therapy on postoperative outcomes remains controversial. Data comes largely from retrospective single-center databases which are limited by significant interstudy heterogeneity. Although some debate remains, it is imperative that surgeons have an understanding of how to best manage biologic therapy in the perioperative period, and potentially adjust their surgical approach in order to optimize postoperative outcomes.

The medical management of inflammatory bowel disease has shifted towards more frequent use of biologics in the current era. This has led to an increasing number of patients exposed to various classes of biologics in the perioperative period. Evidence regarding the impact of preoperative exposure to this therapy on surgical outcomes remains controversial and difficult to completely assess given different confounding factors associated with the disease process. Regardless, it is imperative that surgeons have an improved understanding of the perioperative optimization of biologics in order to more closely work with both their patients and gastroenterologists to achieve optimal outcomes.

Despite dramatic advances in medical treatment of inflammatory colitis, a substantial proportion of patients with ulcerative colitis (UC) and isolated Crohn's disease (CD) colitis will acutely develop severe disease requiring hospitalization and surgery. It is imperative that surgeons understand the multidisciplinary nuances at the intersection between medical and surgical management. It is important that the surgeon be able to evaluate and stratify the severity of inflammatory bowel disease (IBD) colitis, understand medical treatment options, monitor responses to medical therapy, and ultimately execute timely and appropriate surgery for these often-ill patients.

Ulcerative colitis is a chronic inflammatory condition characterized by abdominal pain and diarrhea usually with hematochezia. Optimal medical management of ulcerative colitis is aimed at resolving clinical symptoms as well as achieving mucosal healing. Treatments are selected based on several variables including severity of symptoms, overall inflammatory burden, and whether risk factors for poor prognosis are present. Various medications currently approved for use in ulcerative colitis include 5-aminosalicylates, corticosteroids, thiopurines, anti-tumor necrosis factor antagonists, ustekinumab, vedolizumab, and tofacitinib. While the appropriate use of these as solitary drugs or in combination is often straightforward, therapy for particularly complex patients such as those requiring a rapid onset of action, those who are elderly or have significant medical co-morbidities, those with history of or active malignancy, those who are pregnant or breastfeeding, as well as those with extra-intestinal manifestations requires special consideration.

Multidisciplinary management of Crohn's disease is mandated by the complexity of the clinical scenarios and interfaces between medical treatment, nutritional support, and surgical interventions. Surgery is a critical component of the treatment algorithm intended to improve patient symptoms and quality of life, resolve disease-associated complications, and maximize efficacy of medical therapy.

The most common procedure performed for intestinal Crohn's disease is resection of the affected segment of bowel with primary anastomosis when feasible and indicated. Different surgical techniques have been proposed with the goals of limiting postoperative complications and preventing surgical recurrences. Selected patients affected by intestinal Crohn's disease are at especially increased risk for repeated surgical intervention and bowel sparing techniques have been developed to reduce the risk of short bowel syndrome in this population.

The clinical scenarios of intestinal Crohn's disease vary as to when surgery is indicated and what techniques should be employed. Multiple surgical options might be used in a single patient with multifocal disease with an intent to provide a longer remission time. The important role of preoperative optimization and postoperative treatment reinforces the notion that timing and coordination of medical and surgical treatments is crucial in this debilitating and complex disease.

Low anterior resection syndrome (LARS) is a constellation of symptoms that includes incontinence to flatus and/or feces, urgency, and frequency. LARS affects up to 80% of patients after low anterior resection. The pathophysiology of LARS is complex, and a variety of mechanisms have been proposed. These mechanisms include disruption of autonomic innervation and the rectoanal inhibitory reflex, internal anal sphincter dysfunction, decreased anal canal sensation, and decreased capacity and compliance of the neorectum. As the management of colorectal diseases such as rectal cancer continues to improve, there is a concomitant increase in organ preservation, survivorship, and attention to quality of life. Therefore, recognition and understanding of LARS is key to the diagnosis and treatment of this debilitating disease process.

There has been a recent increase in patient reported outcomes, specifically quality of life (QoL), following recovery from a restorative proctectomy. The constellation of post-operative bowel dysfunction symptoms has been collectively termed the Low Anterior Resection Syndrome (LARS). Research efforts have resulted in an international consensus statement on its definition and now establishes a foundation of future research on LARS incidence, significance and treatment options. Amidst the myriad of prior treatment options, all efforts by surgeons to provide organ (anus) preservation surgery have unfortunately resulted in an increasing number of patients who intensely suffer from LARS. Perhaps historically considered only for failure of symptom management by both surgeons and patients alike, use of a permanent colostomy may be an appropriate surgical outcome outright when patients are fully informed of what post-operative bowel “dysfunction” is likely to be expected. Still, the future of LARS treatments is just beginning to be investigated and increased physician awareness of those new management strategies may offer hope for patients who continually struggle with their QoL following a restorative proctectomy.