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We're going to be um doing a, a mix of talks of some sort of more complicated um things that you might not be involved in every day. Um And we've got talks from Mr Davis, Mr Wilder and Prof Brown and I'm just seeing if Mr Davis is in the room. Yes, he is. So we're going to start off. Um I'd like to uh well, II don't think Mr Justin Davis necessarily needs an introduction. I'm sure you will know that he's now the current president of a CPG B. He's um I work for him in Cambridge. He's been a consultant there for 17 years and he has many different hats I would say in Adam Brooks uh including medical deputy director, but he's also very much got a special interest in inflammatory bowel disease. And so we're very lucky to have him come up here today to um give us an update on um things we should be considering uh about IBD as surgeons. So thank you very much. Thank you. Thanks for the kind introduction, Elise. Um And of course, you don't work for me. You work with me. Very important. Um So good welcome. Thank you for the kind invite. It's a real pleasure to be with you here today. Um And I should say that my main disclosure is although I look far too old for it to be true. I was myself a Jew club member back in the day. Remember these weekends? Very well and very fondly as does my now wife, then girlfriend, who said to me this morning, where are you going? I said to the Juice Club weekend and she said, oh, I remember that. That was good fun. So yeah, things go around very quickly and Elise and I both work here in Cambridge at the Cambridge Biomedical Campus. It's now the biggest biomedical campus in Europe. And we're pretty lucky to be sat amongst um a lot of biotechnology, a lot of research, our raw Papworth Heart and chest hospital and research center, a new train station being built on the campus with fast links to London within the next 12 months. So lots going on. So if you're looking for fellowships, if you're looking to come and join a collaborative consultant team, come and see us. So IBD is what I've been asked to talk about. And I think, you know, the joy and the challenge of IBD is the, is the diverse ages in particular of the patients that we treat. And my own practice goes from operating on Children from the age of 10 upwards, right through to the occasional patient that we operate on in their seventies etc, and there will be lots of guidelines that you can refer to. Um And Professor Steve Brown has been instrumental in in many of these. Uh And so I'm not gonna go through all of the stuff in all of these guidelines. And what Lilian asked me to do is concentrate more on the most recent echo guidelines that have been published um very recently earlier this year. So that's what I'm gonna try and do. But there's lots of stuff you can access and of course, we're all surgeons. Uh but there's lots of advances to an extent in medical therapy too. And, and I've been asked to touch a little bit on that and I will just give a, a few slides of update here. It's probably just worth pondering, you know what the role of medical therapy remains in steroid refractory, active, severe ulcerative colitis. And some recent data for the first time has looked at a network meta analysis. Now, for those of you not familiar with network metro analyses, I look at these fairly simply and it's a way of comparing different things to each other. And when you look at a diagram like this, for network meta analysis, the size of the circle gives you a clue as to the number of patients in that group. And you can see the Infliximab group is much bigger than for example, the Adalimumab group and the size of the line the thickness of the line between the circles gives you an indication of a number of patients in that direct comparison. So again, the thickest line in that group, one of them might be infliximab to tacrolimus. That means there's more patients in that group compared to some of the others, for example. So that's how you kind of look at these network meta analysis figures. But to cut a long story short, what they found was that Infliximab either at its standard dose or double dose tofacitinib. Uh and also um tacrolimus were the three drugs that actually do have a role in steroid refractory, acute UC. And of course, most of us would be, would be familiar with Infliximab being part of our standard approach there. I won't say much more about medical therapy in UC. I'll just touch on one main trial in Crohn's disease. Uh The profile trial run by um the gastroenterologist that I have the privilege of doing my joint IBD clinics with Professor Miles Parks in Cambridge. So this is just published this year in in Lancet gastroenterology, hepatology. And for those with an interest in IBD, I think it's an important piece of work. They basically looked at two approaches to patients with newly diagnosed uh Crohn's disease and they to cut a long story short, randomized the patients into two treatment arms, one where they hit them hard early on with Infliximab and immunomodulatory therapy and the other, the step up approach where they started off with steroids. And if they got better, they waited and if they relapsed, they put them back on steroids and then gradually introduced more immunomodulatory therapy. The profile study itself is shown here and you can see the top down which is the first group that I described, they're put on steroids straight away, it's tapered down fairly rapidly and they get put very quickly onto Infliximab and immunomodulators. Probably one of the key things about this trial is that the median time from the diagnosis of their acute Crohn's disease to the to the randomization within the trial was less than two weeks. So these patients are getting picked up and treated very quickly and to cut a long story short, if you look at sustained steroid free and surgery free remission, the top down group do very, very much better than the step up group. And the same is true for endoscopic remission. And when you look at actually the difference, it was very highly significant. So this was a although it was a biomarker study, the biomarker bit didn't work. So I'm not going to talk about that. What it did show was that the step down the top down hitting the patients hard early with anti TNF therapy. If medical therapy is the appropriate choice for that patient more to follow is the way to go rather than a gentle stepping up approach I would suggest and it goes even further than that. Um We were at the RSM in London yesterday and heard some very eloquent descriptions of functional genomics as to how you can now identify genes that have influence on inflammatory processes within macrophages, that influence expression of all of the mediators that we know are important in IBD, that you can then target with drug therapy. This recent paper in nature is well worth a read. It's a brilliant story again, James Lee was a colleague in Cambridge. He's now down at the Crick in London. It's a brilliant piece of work and shows us perhaps where the future of functional genomics is going both for IBD and I think other diseases and, you know, we'll see lots of this stuff about medical therapy. Uh and you know, there's no more need for us with our, with our surgical er, knives. Not true, absolutely not true. And I can't see for those of you with an interest in IBD that you're not going to have a fulfilling career for at least the vast majority of it operating on patients with IBD. That would be my guess for the next number of decades, it might change, but I don't think it's going to go away, but there are certainly lots of things that we as surgeons and in the teams we work in need to think about in terms of patients that we're going to operate on with IBD, particularly around preoperative optimization, appropriate timing of surgery, which should be elective when, when possible expedited, if necessary. But emergency very, very, very rarely, very rarely, indeed, minimally invasive surgery, I think is appropriate when it's safe and, and, and the right thing to do and, and I'll come back to that, there's still a role for open surgery and IBD, that's for sure. And everybody says it, but it's clearly true, close collaboration with our gastroenterology and wider IBD MDT colleagues is key And I personally like the sort of combination of a surgically aggressive gastroenterologist who really likes surgery in the appropriate settings and sometimes a surgeon, he goes back to the gastroenterologist and says occasionally, well, I think you could maybe try hard to hear. What about this medical therapy when surgery might not be the answer. So I think we have to know each other's strengths and weaknesses and question them openly and collaboratively. And surgical decision making is key and, and sometimes doing that in isolation is not the right thing to do. So this is an older photo, but it still, it still under represents the wider team that I work with in both pediatric and and adult IBD. So you can see there's lots of people and for us as the surgical consultant, I think sometimes we're a conductor and sometimes we're sat bang in the middle of the orchestra and going along with everybody else and doing the bit that we're meant to do. But sometimes when we need to lead the ship. That's what we need to do. And I think that that's important to recognize where we fit into that role. And that comes with understanding relationships with our patients, but also with our wider MDT colleagues. So let's start with Crohn's Disease. Um I'm going to run through some stuff about Crohn's and then some stuff about UC, I should say I was given special presidential dispensation to run for 20 minutes rather than 15. So uh just, just so that, you know, um so again, Steve and others have produced guidelines for the management of IBD in the UK and I was involved myself in both of these, but I'm going to as requested also update you more about the Echo guidelines that have just been published this year. And Echo do recommend that Crohn's disease surgery is performed in high volume specialist centers. They don't quite define what that means. But I think as a concept, it's got to be a good thing. I'm not gonna go into too much about preoperative optimization. We did publish this work which goes through it in quite a lot of detail about what we think the right way to go for preoperative optimization is. But needless to say the key factors relate to nutrition, weight, uh whether there's a role for exclusive enteral nutrition. Although that's a research topic and the ocean trial is up and running. I mean, we still use it pretty, pretty widely in our standard elective practice in both pediatrics and adult IBD rehabilitation in general. Um, thoughts of course around steroid use and whether it can be tapered or indeed, er, taken off, particularly with the use of enteral exclusive enteral nutrition. And I think we often forget the psychological impact of what's happening to our patients and, uh, and their families, er, at the time of illness. And this is an area that we need to be mindful of thinking about sepsis in surgical terms. And abdominal surgery. Clearly, our aim is to control sepsis prior to planned abdominal surgery. And that usually means of course, intravenous antibiotics and radiological drainage where possible. And that's what we need to try and aim for where we can echo suggests that if somebody has, if a patient has a resolution of their symptoms following intraabdominal sepsis, then it would be reasonable not to operate on that patient. And to perhaps think about optimizing their medical therapy but having a very low threshold to go back and reconsider surgery that is in the guidelines. I don't think it's unreasonable, but I think we need to have a very low threshold with these patients to keep a very close eye on them because they can suddenly find themselves back in the situation they were in when they started with recurrent sepsis. So I think it's reasonable to give them a shot if that's what they want to do and everybody's on board, but they need to be watched like a hawk and have a root back in if they're not doing well. I personally have a fairly low threshold. I still recommend a planned resection where that's appropriate in that setting, elective bowel resection over emergency resection is clearly important. I mentioned that a few times trying to get that message across and a laparoscopic approach as a first line in abdominal surgery is a recommended approach through echo notice. They don't say robotic, they say specifically laparoscopic. And I think it's fair to say that the evidence base whilst it might be building for robotic approaches in IBD very much at the moment remains single center series, low quality data. So laparoscopy is the is the first line approach for abdominal surgery. And of course, the lyric trial which you can look at in more detail, gives us evidence that, you know, offering laparoscopic surgery first up as an alternative to anti TNF therapy for patients with isolated, particularly small bowel or terminal disease need. An ileocecal resection is an appropriate way forward. And there will still be a small number of patients who who will want to do that. And I must say our adolescent practice, that's very much the thought of our pediatric gastroenterologist. They would much rather those patients have an early resection, keep the anti TNF therapy for later on. So they can get through their puberty, get back to school, get back to forming relationships grow and then and then reconsider matters later on. And I think whilst it's difficult for patients who are often younger to consider a stoma, sometimes it's absolutely the right thing to do if everything is not where you want it to be for a safe operation for your patient. In terms of steroids, nutrition, weight medication, a sepsis, a very low threshold for a stoma initially. And coming back when the patient is better to have a, a better chance of, of anastomosis that remains intact. So, if we're looking at resection and anastomosis in Crohn's disease echo suggest that there is insufficient evidence to recommend an extensive mesenteric excision in surgery for Crohn's disease. And I would suggest at the moment that that remains the case. There is some case study data from Calvin Coffey's group in the west of Ireland in Cork suggesting a much lower recurrence rate with a more radical mesenteric excision rather than what might be a more traditional closer mesenteric excision. Just this month. The spicy trial so called was published in Lancet Gastroenterology Hepatology. A randomized trial between centers in Italy and Holland comparing a more radical mesenteric excision with a closer standard mesenteric excision, small numbers 66 and 67 in each group, but essentially no difference in recurrence. But this is a small trial I would say and I think it may well be underpowered. But nonetheless, that's what the data suggests in terms of anastomotic technique or configuration echo again, would suggest that a stable side to side. Anastomosis is the appropriate one to consider. They do say that the cono s anastomosis can also be considered, I must say given the current evidence base, I find that a little surprising I'll come to that in a moment. For those of you not familiar the principles of the coos anastomosis remain a close mesenteric division, a supporting column for the anastomosis and an anti mesenteric joint. So basically close division of the mesentary dividing the bowel either side with a linear staple line perpendicular to that mesentary creation of the supporting columns by bringing those two ends of the bowel together. And then an anti mesenteric enterotomy on either side of that supporting column, which is closed a bit like a stricture of plasty in the opposite direction to give a hand sewn wide lumen on the anti mesenteric border that is excluded from the anastomosis. The reason I'm showing you diagrams is I don't do this anastomosis myself. Currently, it has been described robotically, it's also been described in a stapled fashion, but the vast majority of people do it hand. So the reason I was surprised that Echo said it's a reasonable thing to do is that, you know, there are data that suggest it might not be. So, here's the KKK study published this year from France, one of the G aid groups, non randomized data, but two groups 60 in the Cono s and double that number in the control group, no difference in recurrence post anastomotic, whichever anastomosis you do no difference. So great to have Steve in the audience. Because I think the most likely thing is that we still don't really know despite some trials producing some data, this Meerkat trial is something that everybody either should know about or if you don't, you do. Now, this is a tremendously well designed study I would suggest run by Steve and Laura from Manchester where they're actually randomizing into four different groups where they will be able to look at the impact of both the mesenteric excision and the coos or standard resection. And I think this is the trial that we need to wait for the outcome of to perhaps be able to give us guidance as to what is it that's impactful or not in these two areas. And I, and I think we look forward to hearing the results of this trial in due course. This is an interesting paper talking to us about the consensus on the management of fibrous stenosing small Bowel Crohn's disease. I would, I would suggest it's a good read to you. It's a good oversight in that, in that management. But essentially, I think the take home message is that for small bowel fibrous to disease, stricturoplasty remains a very appropriate treatment for these patients. And I would suggest that bowel length preservation remains an absolute priority for patients with Crohn's disease because we never know when their next operation is going to be despite advances and improvements in medical therapy after surgery, uh, 28 days of low molecular weight heparin is certainly our standard practice for all patients having surgery for IBD, both Crohn's and UC. And that, that concurs with echo guidelines, um, endoscopic surveillance within the 1st 12, 6 to 12 months. And then, uh a program of prophylaxis that is uh aggressively based on that I think is appropriate. Let's talk a little bit about perianal fistulizing Crohn's disease, a particularly challenging disease, especially for those patients who have to live with it very, very difficult. And again, I'm just going to run through some highlights of, of, of what the echo guidelines tell us. I think we'd all, we'd all be familiar with the fact that anti TNF therapy of one form or another remains the the mainstay of medical therapy for these patients seem to have lost my clicking ability. Do you have a quick, got it back. So, um, so anti TNF therapy and Seton drainage, which is key um either for longer term control or to gain, gain initial control prior to considering what other intervention may be needed. And, and you know, I think we need to just be mindful for all of us, for our patients that sitting on stuff like this with Big Knots is really not very nice. You can see them sometimes with nylon. Dare I say so I think we need to, this is a bad enough disease for these patients, let alone us make it worse for them. So I think low profile setons are a must for these patients by personal preferences. Number one E bond. If you ask multiple people in the room, they'll probably give you different answers. But I think something that's low profile and comfortable rather than knotty and bulky is the way to go. Phil Tozer led a group that, that has published a classification system for perianal Crohn's disease. And I would recommend this to you as a way of enabling us to think about what the treatment options might be for a particular patient where they are in their, in their process. And whether we're looking at actually repairing or controlling their perianal disease, laying open low fistula, particularly in the present in the absence of proctitis, I think is absolutely appropriate, obviously, in conjunction with the patient's wishes and that's a reasonable way forward. Lift is a reasonable way forward. Advancement flap is a reasonable way forward. Personally, I don't see many surgeons in the UK doing advancement flaps, but it is, it is an appropriate way forward and autologous adipose derived stem cells echo suggest is an appropriate treatment. I don't know anywhere in the UK that's taking adipose tissue from a patient and deriving stell stems from it and then putting it back to the same patient. So that is an autologous stem cell transplant. So for us in Cambridge, it's certainly not what we're doing. I don't know anywhere that is. Again, if you look at the echo guidelines, there's a very good um flow chart of uh appropriate treatment algorithms for patients with Perianal Crohn's disease. What shouldn't we do? So, the evidence would suggest that plugs and glue are not gonna have a role in the management of complex fistulizing perianal Crohn's disease. The evidence around VAF around lasers around over the scope clips is not solid enough to recommend it. And similarly, with allogenic stem cells, which are incredibly expensive, the evidence at the moment is not strong enough to recommend them. And at around 10,000 lbs a vile, that's a lot of money in the current climate. And it's really very interesting when you look at the admire studies and particularly you look at admire two and admire three. When you follow these patients up, the control groups do almost as well as the stem cell groups and the control groups of course, still have vigorous curettage of the fistula tracts and closing of the internal openings. So it's interesting to know how much the stem cells in addition to that add at what cost. So again, it's really important that we work out what it is that the patient finds most important and most troubling about what's going on. And sometimes I think we can be guilty of leaving things too long. And when we see patients with multiple fistulae medical therapy and they're still uncontrolled. We need to think about a diverting stoma preferably, I would suggest a colostomy most of the time for refractory refractory complex disease and a subsequent proctectomy with or without plastic surgical reconstruction, depending on the extent of tissue loss and what needs to be filled for those where a defunctioning stoma alone does not do the trick. And again, I would recommend the top class Perianal Crohn's disease classification system to you. I think it's an excellent resource to bear in mind to help us with our treatment algorithms for our patients. So I'll finish up with just a little bit about ulcerative colitis. And of course, the mainstay of initial treatment for most patients with ulcerative colitis is a sub total colectomy. I'll talk a little bit about ao anal pouch surgery. Although of course, the numbers of pouches being done seem to be reducing. Most of you will clearly know that the Staple J approach is the standard of care for most centers and most patients. And I guess in terms of technical innovations, minimally invasive approaches have been increasing in anal pouch surgery over time. Um Someone like Professor Sagar has been doing laparoscopic pouch surgery for over a decade, but for many centers, it is still increasing anastomotic techniques. There are still some things to consider there along with the use of ICG. I'll give you a little bit of an update of some interest on pouch configuration and the increasing use and availability of ENDO VC therapy and subsequent transanal anastomotic repair and salvage has led to the questioning of the routine use of a loop ileostomy in pouch surgery. If you polled who do p surgery, you'll find those that they'll usually have a fairly fixed view. I certainly do in my practice, Professor Brown will have a different view on his own. And I think this is an evolving space and it very much depends a lot on the set up you have in your hospital to get your patients back to theater quickly, to raise an ileostomy if they're not defunction and how easily you can get them back and forward to endoscopy or theater for endo VC changes. What do patients actually want to know about when they're thinking about making their decisions about po surgery? There's some data on that and importantly, they want early access to a surgeon to discuss their options. They want peer guidance. So they want to talk to you and meet patients who've had po surgery. They want time, they don't want to be rushed into a decision. They want information and I think we should give them as much information as they want both written, both electronic and access to specialist nursing advice is absolutely key. And I think the days of rushing patients into pouch surgery have gone, that would be my view. We certainly lost quite a few patients off our pouch waiting list during COVID when they really wanted to be in a rush to have their restoration of intestinal continuity and having waited for a year or 18 months. And then we contacted said, actually, you know what, the longer I've lived with this, the more I'm fine, I'll stick with my ileostomy. Thank you very much. And we need to remember as IBD surgeons, the only role for a pouch is quality of life for a patient who doesn't want an ileostomy If they're happy with their ileostomy. The worst thing we can do in my view is push them to a pouch. I have the opposite view. The patient should push us to give them a consideration for a pouch because these types of syndromes can be difficult for patients. And the last thing they want is to go back to symptoms that mirror their ulcerative colitis. And I think it's challenging because the way I describe it to them is here's an average functional outcome which I explained to them, what I think that's going to be and I sort of say to them that eight out of 10 people will probably end up somewhere in that ballpark. One will be much better than that and will be delighted and one will have an absolute nightmare for reasons that we can't explain. And that's a challenge. And so picking the winners remains difficult. Patients also want to talk about things like sexual function because of course, these are often a young patient group and a young cohort. And we, I think do this badly in terms of talking about these things because they're difficult conversations to have, but they're important conversations to have. But it's not always doom and gloom. The time I spent in Toronto, we did some research looking at sexual function after pouch surgery. And in fact, what we found there was that female sexual and function generally improved after pouch surgery, uh rather than what we often hear is that it may well decline. And I think there's, there's a lot in that. So when it comes to echo guidelines, echo are fairly clear that a two or three stage approach to pouch surgery is acceptable and that however, pouches should be operated on in what they term expert centers. My own approach is generally a three stage approach with a laparoscopic subtotal colectomy. A subsequent laparoscopic where possible proctectomy and pouch and I tend to routinely use of covering new BST toy or if it's in dysplasia or fap, it may well be for those who can't have an ileorectal, a restorative proctocolectomy with a defunction iost toy. Then others may go for a two stage approach which is not wrong. You just need back up to get that patient out of trouble. Anastomotic techniques. The hand sewn technique for primary pouch surgery, a hand sewn pouch, anal anastomosis with mucosectomy has largely gone from most people's practices including fap. It is an important technique for revisional pouch surgery. If a staple J is being converted into a hand sew in pouch, anal anastomosis. But other than that, it is rarely used these days. It's important to be able to do it though because there's sadly in everyone's career, a heart sink moment when the gun comes through the Staple line and you've got to convert what you thought was going to be 30 minutes more. Operating into two hours and a hand son anastomosis. I think the number of stable firings at the pelvic floor remains key. This is a bug bearer of mine. Um I know I'm getting older, sadly, I am old, not getting old. Um In 18 years of consultant practice, I've never stapled laparoscopically at the pelvic floor. That's just me. Um There is good data around anastomotic staple firing number and anastomotic leak. We know the more firings, the more risk of leak there is I think if it's going to be done, it should be done front to back. That gives you the best chance of going across in one possibly two firings. My personal approach is to always put this down. The contour is tried and tested one firing a fan and steel in all women. Some men or a very low midline in men, I think is easy to recover from. And a single firing of a contour gives you a very controlled level of division that can be checked and double checked and a single firing, which is important just to say we are about to run out of time. Thank you. And we're about to be done. The er transanal transection and single stapled anastomosis has come from Antonino Spinelli uh in, in Italy, this is another anastomotic technique to allow you to access the rectum and divide it from below in a position that is controlled can also be used with ICG. It's not something we have gone to. They have looked at their data in a non randomized fashion and leak rates are the same. There is a bit less urgency with a transanal transection. So again, minimally, invasive surgery is preferred. We know that enhanced recovery can be used with IBD patients in a safe fashion out of interest. There is a relatively newly described de configuration of a pouch which has potentially takes away the risk of the leak from the top of the day. I don't know anyone that's using this, but it's something just to bear in mind. And I guess time will tell in terms of ileorectal anastomosis in UC. The reality is there are a group of patients where it definitely shouldn't be done those with cancer proctitis despite therapy PSC in particular and a non distensible and stiff rectum. But I've got to say, I find it very difficult to find any patients in whom an Ileorectal is an appropriate way forward. Think about the patients and what they want, ask them what they want, ask them what's important to them, it's absolutely key. So in terms of finishing up pouch surgery itself, I think is a specialist procedure we have in the ACP GBI an accreditation system. Now, four units to become accredited pouch centers. Case volume is important as is the usual multidisciplinary management and dual consultant operating where appropriate for us, that's at the time of the anastomosis, it may be at other times too. Training remains a challenge in terms of you getting access to pouch cases and that's where fellowships come in more and more. And I guess for us as surgeons, we need to minimize the impact of our surgical access and the frequency of our complications whilst maximizing the functional outcomes from our patients. And I'll finish now with just some data that if I stop, you'll really be disappointed because nobody knows this data and it has just been submitted to the new England journal. So you really do want to know these data. So, appendicectomy may actually be the ultimate segmental colectomy for patients with UC. Why is the appendix important in UC? We don't really know there are some various hypotheses and it has a potential role in both active disease, particularly left sided and distant disease, vascular resections and advanced by malignancy. And I absolutely agree with him. But I would add that patients who've had multiple complex Crohn's disease resections, fistulizing disease. These may well also need an open operation and that is absolutely not the wrong thing. To do if it's a safe thing to do, it's the right thing to do and on that, uh, I'll stop.