I think it's going to be the next talk is going on extending the role of damage control so we're going to have Dr. Ravi Kiran is going to talk on the role of surgery for management of complications. I know Dr. Kiran for the last 13 years or so, from his clinic. He's an amazing surgeon. He's currently the chief of colorectal surgery and a professor of surgery at Columbia University. It's really a pleasure to have you Dr. Kiran, I look forward to your talk. Thank you for that presentation, I would like to thank Dr. Shen and Dr. Navaneethan for inviting me to give this talk. Great program and a pleasure to be invited. Interventional endoscopy for IBD requires a great amount of technical skill. There's a risk for perforation and bleeding in these patients. Signs are often appended in these patients who are ill, and a lot of immunosuppression, and their response to trauma is unpredictable. In general, when surgery for damage control is needed after intervention endoscopy for IBD, the common indications are bleeding and perforation. When bleeding occurs, conservative management is often possible. This includes resuscitation with intravenous fluids, and sometimes blood transfusion. We just heard from Dr. Raju about various advanced techniques for endoscopic intervention, and interventional radiology also plays a role. When surgery is needed, the location of the bleeding, and whether or not there is easy access, the severity, and the cause of the bleeding often determines the techniques employed. In general, we're able to use cautery, tamponade with localized pressure, suture ligation, and in some cases, resection as a way to control bleeding. In contrast, perforation can be more dramatic, and may either be immediately apparent, or it may be more subclinical. Some patients will present with nonspecific symptoms, such as pain, distention, and fever at variable times after the perforation. They may have failure to thrive. There may be a localized leak and perforation from a perforation that leads to an abscess collection. And rarely, patients may present with delayed obstructive symptoms that are subacute, an alteration of bowel habit, and a high risk of suspicion is needed to diagnose the condition. Retroperitoneal perforations can also present with subcutaneous emphysema either at the time of the endoscopy or at a later time. When free perforation occurs, on the other hand, patients will often present with peritonitis, and in some cases with free air, but with minimal symptoms. Clinical exam may be suggestive. Imaging in the form of plain film, CT scan, contrast studies, as well as a pouchogram in cases of perforation of the pouch are often revealing. Laboratory tests are a good adjunct to a diagnosis, and of course, endoscopy as well as laparoscopy help diagnose the condition. In these images here, we see a retroperitoneal perforation with the focus of air in the pelvis, and the gastrograph minima shows a wisp of a leak of the contrast corresponding to the CT scan finding. In general, perforations are managed with antibiotics, either with nil by mouth or with clear liquids, close clinical monitoring, and when there's a contained leak or abscess with drainage by means of interventional radiology. When surgery is required, the principles depend upon the findings, as well as the extent of the damage and the state of the tissues, as well as the condition of the patient. As to whether there is extensive contamination in a prepped or unprepped colon, whether the injury is localized or diffused, and the location, whether more distal or proximal, the presence or absence of previous surgery, and hence extensive adhesions, the potential risk and benefit of an ostomy in the particular patient, the need for intestinal conservation, especially in patients who've had multiple operations or have Crohn's disease, and the long-term goals for the patient in terms of preservation of function and avoiding an ostomy also need to be considered. When perforation in the inner rectum occurs, this is often secondary to structurotomies, dilatations, EMR, or ESD. Conservative management is often possible with antibiotics, interventional radiological drainage, or surgical drainage. When surgery is performed, again, the location, the extent of the damage and contamination dictate the management employed. If the perforation is below the peritoneal reflection, the treatment is usually diversion with an ostomy, drainage of the area where there's been a perforation, with or without repair of the area, depending upon whether the area is accessible and depending upon the extent of the injury. In contrast, when the perforation in the inner rectum occurs above the peritoneal reflection, in addition to either repair or resection, diversion is often employed. Colon injuries can also occur with similar mechanisms. In addition, as we heard in the previous talk, a difficult scope with looping within a rigid colon can lead to a hockey stick kind of configuration and injury, which can actually be pretty traumatic to the colon and extensive. Once again, conservative management can initially be employed. When surgery is required, once again, the location of the damage, the extent of the injury, amount of contamination, the physical state of the patient will often determine whether a repair can be performed. Repair can usually be employed when the extent of the injury is small. It does not involve more than half the circumference of the colon and the injury is clean. In contrast, when the injury is more extensive, a resection is usually performed. As you may know, this picture shows a perforation in the ascending colon in a patient who has got an inflammatory stricture. In a case such as this, resection, as we can see in the figure on the right, that involves an ileocolic resection may be the best course of action. When a resection is employed, the next decision the surgeon needs to make is as to whether or not to anastomose. When the injury is small, the surgery is swift. There's not a lot of peritoneal contamination and the patient's general condition is good. The patient's not on a lot of immunosuppression. Anastomosis without protection may be reasonable. However, when in doubt, a loop ileostomy or colostomy provides some support to the anastomosis, preventing a leak or at least the consequences of a leak. In some other circumstances where the patient's very ill or the perforation is very extensive with contamination, a complete disconnection with an end ileostomy or colostomy with a Hartman's type procedure may be more prudent. This is an example of a loop ileostomy. On the left, the diagram and on the right, the intraoperative photograph. When an extensive injury occurs or the patient has got severe disease, for example, a patient with extensive colitis from Crohn's or ulcerative colitis or indeterminate colitis, a subtotal colectomy with an end ileostomy may be needed as depicted here. On the other hand, we have the occasional patient who has severe disease with a perforation, may be very moribund in such circumstances. The better option may be a quick loop ileostomy with decompression colostomies as depicted here, with a subsequent return to the operating room and the patient's more stable for a completion colectomy. Similar to the colon, when injuries occur in the small intestine, repair is often feasible. The advantage of the small intestine is a better blood supply and hence it may be more amenable to repair unless there are extensive injuries, in which case resection may be needed. Resection is also needed when perforation occurs at the site of severe disease. This is an intraoperative picture of a stricture in Crohn's disease with transmural inflammation and a tight narrowing causing strictures. In circumstances such as this, a resection would be the best approach. Once again, when a resection is performed, the decision would be as to whether or not to anastomose with or without a loop ileostomy upstream to protect the anastomosis or instead disconnect the small bowel with an end ileostomy creation. Some special considerations need to be made in patients who have had previous extensive surgery or who have Crohn's disease where intestinal conservation is important. In such circumstances, some options include just exteriorizing the injured part of the small bowel so as not to resect, and this part of the bowel could function as an ostomy until at a later time the ostomy can be closed. This helps prevent further resection of the small bowel. And similarly, if a patient has extensive adhesions, simply bringing up that loop that is damaged as a loop ileostomy is a consideration. In rare circumstances, simple washout of the abdomen with drain placement or converting the injury at the site of a stricture called stricturoplasty may be the better option. This is one of those examples where a patient has extensive Crohn's disease with fat wrapping throughout the small bowel. And although this patient, this is just an interoperative demonstration of the extent of disease that we sometimes encounter, it is easy to imagine that if a patient with a perforation like this, some of the alternatives that are described would probably be a better option. When stricturoplasty is performed, it can be either in the form of a hynochemicalic stricturoplasty, wherein a longitudinal enterotomy is closed transversely, or instead a thinning procedure as depicted in this picture helps convert the perforation into a stricturoplasty. This is an example of an isoperistaltic stricturoplasty, wherein the small bowel can be divided at the site of the perforation, but the two areas that are strictured can be slit longitudinally and anastomosed to effectively widen the small intestine. Lastly, I would like to talk a little bit about the specific problems related to endoscopic injuries that can occur during interventional procedures related to the pouch. Once again, as in other locations, the options that are available depend upon the location of the injury within the pouch, the extent of the damage, the contamination, as well as the physical state of the patient and the tissues. A repair is possible in some circumstances without diversion. Resection of the pouch is extremely rare and is probably only required when there is an extensive shear injury of the entire pouch or a barotrauma. A diversion alone without exploring the pelvis may often be the best option. And in some cases where there's gross contamination, creation of an endoleostomy leaving the pouch in place may allow the patient to not have any further setbacks due to a fecal stream entering the damaged pouch. Once again, it's important to consider the other potential problems at surgery, including the need for testosterone conservation, extensive adhesions that may be noted, and so on and so forth. In a few instances where the adhesions are pretty prohibitive and exploration of the pelvis may be extremely difficult, a simple washout of the abdomen with a drain placement without anostomy may be the wisest choice. This is one of those examples, a figure on the left and the end result on the right of a patient with a potential perforation, wherein a drain can be placed deep in the pelvis posterior to a damaged pouch with a defunctioning ostomy created proximal to it. The important thing to consider in these patients, since patients with a pouch are often very attached to their pouch and do not want to have anostomy, any decisions that are made intraoperatively need to consider potential problems two steps further down the road, and decisions that will help preserve pouch salvage are often the best. In some circumstances, a repair of the pouch as depicted here with a temporary leucoleostomy is also an option. Thus, in summary, injuries that can occur during interventional IBD-GI endoscopic procedures can often be managed well. It's extremely important to have close collaboration between the surgeon and the endoscopist. And the surgical options that can be used depend upon the indication of the surgery, the location of the injury, the extent of the damage, the disease process and extent of it, the patient's protoplasm, and the need for bioconservation, as well as the future plan for the patient, and the need for preservation of intestinal continuity and awarding of anostomy. Thank you so much for the opportunity to share my thoughts today.

surgery

complications

interventional endoscopy

inflammatory bowel disease

collaboration