INTRODUCTION

Most acute or chronic benign or malignant colorectal disorders require medical and/or surgical therapy at different stages with some patients being candidates for endoscopic therapy. Patients who underwent endoscopic or surgical therapy are at risk for the development of postprocedural or postoperative complications. To improve the outcomes of endoscopic and surgical therapy, the endoscopist and colorectal surgeon should be familiar with each other’s principles, techniques, devices, and team. They should have pre- and postprocedural and preoperative and postoperative management plans and salvage plans or exit strategies ( Fig. 35.1 ). A multidisciplinary approach is often needed for complex inflammatory bowel and colorectal diseases with the active participation of gastroenterologists, endoscopists, colorectal surgeons, gastrointestinal (GI) radiologists, GI pathologists, nutritionists, and clinical psychologists. For complex cases with advanced endoscopic or surgical procedures, discussion and contemplation of management in tumor board or inflammatory bowel disease (IBD) board are strongly recommended.

Interactions between medical, endoscopic, and surgical managements.

SELECTION BETWEEN ENDOSCOPIC VERSUS SURGICAL APPROACH

Patients with complex IBD or colorectal disorders often require care from experts of multiple specialties, including gastroenterologists, IBD specialists, endoscopists, colorectal surgeons, clinical nutrition specialists, clinical psychologists, and advanced care providers. The patient must have a primary care provider who can coordinate the care of various specialists. Shared electronic medical records and communications within the system have been helpful in multidisciplinary team (MDT) care.

Endoscopy and surgery are the main treatment modalities for structural (e.g., strictures) colorectal disorders, including IBD. In an elective, nonurgent setting, most patients with structural colorectal disorders can have an option of endoscopic or surgical therapy, such as endoscopic submucosal dissection (ESD) versus segmental colectomy for large dysplastic flat lesions or polyps. This is especially true in tertiary care centers that possess expertise in both endoscopic and surgical teams, along with expert gastrointestinal (GI) radiologists, GI pathologists, clinical nutritionists, and clinical psychologists. The choice between the endoscopic and surgical approaches can be difficult, as there is scant literature on randomized controlled trials (RCT) or even case-controlled studies. The triage to the endoscopy team or surgical team at the initial encounter with patients can, therefore, be difficult.

Typically, endoscopic therapy provides less invasive and effective but safer than the surgical approaches for the same candidate patients with disorders or lesions, such as CD-associated primary or ileocolonic anastomotic strictures. However, most patients undergoing endoscopic treatment require repeat endoscopic therapies, with shorter reintervention-free survival than more definitive therapy. The choice between less invasive and effective endoscopy therapy versus more invasive and effective surgical therapy depends on the following factors: (1) patients with the candidate, right disorders, and lesions; (2) right patients with or without significant comorbidities; (3) urgent or elective setting; (4) local expertise; and cost-effectiveness. The tumor board and IBD board are perfect models for the selection of treatment modalities. There have been multiple occasions in which patients with previous extensive abdominopelvic surgeries were urgently operated on for bowel obstruction from anastomotic strictures. Most patients, however, could have been managed conservatively and followed by elective endoscopic stricture therapy. At Columbia University Irving Medical Center and New York Presbyterian Hospital, we hold a monthly IBD Board involving 20 to 30 clinicians from different specialties. Multiparty communication within electronic medical record systems has been helpful. A shared clinic space with an endoscopy and surgery team is recommended.

While it is difficult to conduct RCTs in the clinical practice setting, the establishment of the registry and subsequent conduction of historical case-controlled trials has been the best alternative. ^, For example, there has been a debate about the best approach (EBD vs. surgical resection) for primary or anastomotic strictures in CD ( Fig. 35.2 ). Patients with CD strictures had been treated with EBD or surgery based on referral pattern, i.e., the first encounter with an IBD endoscopist or colorectal surgeon until clinical data were published. Based on the historical cohort studies, EBD is the preferred initial approach to CD-associated anastomotic strictures and is less preferable to primary CD strictures concerning alternative surgical resection. ^, A recent analysis showed that EBD for CD strictures is more cost-effective than surgical resection. Another example is endoscopic sinusotomy versus surgical pouch redo for presacral sinus in patients with proctocolectomy and ileal pouch-anal anastomosis (IPAA). Patients with pouch sinuses had a “random” chance to get endoscopic sinusotomy or surgical pouch redo with obvious referral bias until a case-controlled study was published. The results of the study favor the endoscopic approach which is more effective and safer than surgical pouch redo. Therefore, endoscopic sinusotomy has become our initial therapeutic approach for the treatment of presacral sinus in IPAA at our Center for Ileal Pouch Disorders at Columbia University/New York Presbyterian Hospital ( Fig. 35.3 ). Surgical pouch redo is performed for those with presacral who failed endoscopic therapy. On the contrary, recurrent presacral sinus after initial surgical pouch redo can still be treated with endoscopic sinusotomy. Endoscopic therapy and surgical therapy serve as each other’s exit strategies.

Endoscopic balloon dilation of Crohn’s disease stricture. (A) Nonulcerated stricture at end-to-side ileocolonic anastomosis; (B) endoscopic balloon dilation of the stricture.

Endoscopic sinusotomy. (A) A presacral sinus resulting from an anastomotic leak at the pouch-anal anastomosis; (B) endoscopic sinusotomy performed with an insulated-tip knife.

Exploratory laparotomy has been a part of standard practice for patients with abdominal disorders of unknown etiology. The surgical team should keep in mind that some patients may benefit from tissue diagnosis through indicated endoscopy to better prepare and plan the surgery. Patients with acute abdomen with an unknown diagnosis of underlying benign or malignant colorectal disorders normally require emergent surgical intervention. However, in selective cases with stable vital signs and clinical conditions, adequate intravenous nutrition and antibiotics may convert emergent to elective surgery with a reduction of postoperative complications and possible preoperative histologic diagnosis with colonoscopy ( Fig. 35.4 ).

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