The session’s chair Richard Brady set the scene at the start of the IBD programme for Virtually Vilnius’ 2,600 viewers, noting the challenging year it has been so far for the profession with Covid-19 and how this has had an impact IBD treatment – putting both patients and surgeons in difficult circumstances.
But, while many have had to stop treatment, delayed operative management, and found themselves having to shield - resulting in a considerable secondary impact - Richard noted that the IBD field continues to innovate thanks to its team of global experts.
The first expert to keep us up to date with these innovations was Janindra Warusavitarne (UK) who gave a presentation on ‘Core Subject Update for EBSQ Coloproctology Examination: Perianal Crohn’s Disease’
Janindra introduced delegates to his four key messages for treatment of Perianal Crohn’s Disease. His first key message was to avoid delay in diagnosis, noting that if there is a delay in treatment or if Perianal Crohn’s goes undiagnosed, patient outcomes can be much worse.
His second piece of advice was to never work in isolation and to take a multidisciplinary approach; “working in team is the new gold standard”, he said, noting how surgeons can learn from different parties, for example, gastroenterologists, to achieve a better understanding of the full treatment path.
The biggest problem with Perianal Crohn’s Disease can be defining success, Janindra pointed out. There are various different treatment options for different classifications, but there is no consensus on how Perianal Crohn’s Disease is classified – even what is defined as simple and complex can be hard to agree on.
His third piece of advice was to know what your fistula anatomy is and to ensure adequate drainage, with his fourth piece of advice being to make sure you have local control of the fistula.
Throughout his talk, Janindra emphasised that it is of paramount importance that we engage with the patient so they know if they running into trouble, and that they should flag it as soon as possible, so that we can ensure that there is no delay in treatment.
Matteo Frasson (Spain) then took the mic to highlight the preliminary results from the MASC Trial, which set out to explore variabilities in the medical and surgical management of acute severe ulcerative colitis – which to this day is still a life threatening condition.
Steroid treatment for this condition fails in 30-40% of cases – and that’s when surgery is needed. But to reduce rates of mortality, we need to identify parameters which can predict the failure of medical treatment.
Matteo highlighted the findings of this prospective, observational, and multinational study, noting that there are a number of parameters that can predict which patients with acute ulcerative colitis may benefit from medical salvage therapy. He also highlighted factors which surgeons can use to predict the failure of medical treatment in the hope of reducing mortality rates.
The global study, which was carried out in more 120 centres in 23 countries highlighted previous admission for ulcerative colitis, tobacco use, previous appendectomy, and a CRP of > 50 mg/L as risk factors for surgical treatment.
Antonino Spinelli (Italy) followed Matteo’s great talk with his equally valuable contribution on ‘Ileocolic resection for Crohn’s disease: giving the gastroenterologist a fresh start’.
“There is a Ying and Yang balance between surgical therapy and medical therapy”, he started with saying, before talking the audience through the physiopathology of Crohn’s to help them understand the place and the order of each of the many treatment options.
It should be a straightforward treatment path: treat medically with drugs when Crohn’s is inflammatory, and to treat with surgery when it is fibrotic. But, Antonino pointed out that unfortunately this is not such an easy distinction to make in the real world.
In some cases – when the disease is not complicated - patients can go down both paths, so we must look carefully at the pros and cons of both medical treatment and surgery for their individual case.
Antonino shared study results that can be used to inform surgeon’s decisions, highlighting different remission rates for patients depending on how long they have had the disease for. He also made clear that surgery is effective at every stage of the disease – unlike medical treatment - but it’s at a much higher cost to the patient when we do surgery later, compared to when we do it earlier.
As he concluded, Antonino pointed to the LIRIC Trial, which he advised has the best evidence addressing the interesting topic of those patients with limited disease who have not developed symptoms.
Christianne Buskens (Netherlands) was up next to discuss the question on everyone’s lips: ‘How can the surgeon change the natural course of IBD?’
IBD used to be the field of the gastroenterologists, but times are changing and with developments in the field, surgeons have more to offer now; appendectomies area key reason for this.
Christianne shared some great insights on how an appendectomy can be used to prevent colectomy as they can ameliorate active disease activity and prevent flares. Christianne told viewers how appendectomies can change the course of Ulcerative Colitis, especially if performed in the early stage of the disease. A benefit of the appendectomy is that it can prevent relapses, but Christianne did warn that surgery results might be dependent on the inflammation of the appendix.
After some fascinating learnings, Christianne concluded by saying that if it was up to her to predict the future, she’d say that surgery will be considered in majority of cases. However, in a minority of cases, medical treatment will still be considered first.
Our last speaker for the IBD session was Caroline Nordenvall (Sweden), who gave her talk on ‘IRA, pouch, or Kock’s pouch for UC?’
Caroline talked us through the differences between the three procedures, giving a top line description on how each surgery is carried out.
She explained why we need to find out what is important for patients now and what will be important for them in the future when discussing treatment options. We must discuss bowel function, cancer risk and whether they want children, among other things.
When it comes to deciding between IRA and a Pouch, Caroline remarked that we must stop considering it to be a fight between the two treatment options. IRA should be considered an extra step in the surgical treatment ladder. Young people can have an IRA, create a family, and it can be converted to a pouch later on in life.
IRA does have higher rates of failure and it is not an option for all patients, but if we consider it to be a temporary measure, then we can ensure that patients can maintain a higher quality of life before giving them a pouch at a later stage.
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