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Uh So good evening. Um Welcome everybody to our first uh webinar series of 2025. Um I'm delighted to invite you all to the IBD MDT webinar series. So this is the first episode of three upcoming episodes which will be running until mid February. Um I'd like to hand you over to my IBD representative. That's Orestes. He's going to introduce uh this evening session and also our fantastic speakers. So, thank you very much and thank you to all our brilliant speakers over to you, Orestes. Thank you Charlotte. And um thank you very much to everyone who's joined us tonight for um this first webinar of the I IBD MDT series. Uh The plan for this is to run three webinars in an MDT like structure. So we've done our very best to have panels uh consisting of surgeons, uh gastroin controllers and radiologists and talk about cases in a similar fashion to an MDT. Um So for today, uh I will start uh by presenting the chair of the webinar. It's Mister Valeria Salento, uh who is a consultant, Colorectal and IBD surgeon at Chelsea and Westminster. Uh as well as an honorary senior lecturer at Imperial, who is also the chair uh of the IBD subcommittee for ACP GBI. Uh Thank you very much Valerie for joining us. Thank you for having me. Uh We also have uh Doctor Rachel Cooney, uh who is a consultant gastroenterologist in Birmingham and an honorary senior clinical lecturer at the University of Birmingham, as well as a member of the ACP GBI IBD subcommittee. Uh Thank you Rachel for joining us tonight. Uh Doctor Eugene Lee is also with us uh who is a consultant uh radiologist uh from Chelsea and Westminster. Thank you, Eugene. Glad to be here. Thanks. Thank you. And uh last but not least, uh Mister Guy Warley, uh who is a consultant IBD and if colorectal surgeon uh at the Royal London of uh but uh thank you very much for joining guy. Uh Thanks for the invitation. Thank you. Um So I will be handing over to Valeria to take us through uh the cases and the discussion. Thank you. Thank you so much. Uh Thanks to Dukes for uh all the hard work in organizing this series of educational event. And thanks to our faculty. Uh The way we would like this um webinar to go is that there is uh as much as possible interaction with the audience. Uh uh There is um a chat function that um uh can be used at any time to ask any questions in between myself. And the rest is we do what we can in order to uh bring the questions at the right time to the um speakers. Uh There are also some polls that we have pro um prepared and we will ask you to vote on uh mainly to highlight some of the challenges and controversies in managing these complex cases. Uh will be covering uh management of acute colitis and uh management uh of uh emergency presentation in Crohn's disease. Uh uh Both of them are quite frequent scenario that um you will encounter uh whether or not you decide to uh follow a subspecialty pathway in uh inflammatory bowel disease. And we will cover from the imaging to medical management and surgery. So please stay on line to uh hear all about it. Uh If we uh I will land over to Eugene for uh some imaging on acute colitis. Thank you. Yeah. Um So this first case is of a 37 year old male. Um Can you see my uh images? Yes. Yeah. OK. So um we start off with the uh abdominal radiograph. Um Now this as I'm sure, um you'll, you can see shows um loss of rations in the descending colon and um quite significant bowel wall thickening and also dilatation. And you went on to have a CT and I'll show you the axial first and we'll follow the bowel from the cecum downstream. It's coming off to the transverse and then the splenic flexure following the descending colon sorry and all the way down to the rectum. So this CT shows um pretty much a continuous uh segment of bowel thickening from the cecum to the rectum. I'm sorry, screen keeps on disappearing. And the worst thickening is from the splenic flexure to the rectum where there's loss of illustrations. And this thumbprinting with pseudopolyp uh formation and the pericolic vessels are engorged. Um And most concerning the transverse colon diameter, if I bring up my calipers here is uh above six centimeters, which is the normal limit above the normal limit. Um In, in terms of relevant negatives, I would report that there's no pneumatosis and there's no free gas or free fluid at present. But um my interpretation of this would be that there is a severe acute pancreatis with um dilatation of the large bowel concerning for uh toxic uh megacolon. Um I have another companion case uh which is of a 27 year old male and this also shows um loss loss of haustration and the thumbprinting is more uh conspicuous than on the previous scan, the previous patient. And um the bowel diameter in this case is also above six centimeters. And um on the CT uh which was done about two days later, you know that the dilatation is not so uh obvious. Now, in fact, it's, if you measure it, it's within normal limits, it's below six centimeters. But the loss of rations, the continuous bowel thickening the thumb printing they're all there. So um again, this is a case of severe acute pancolitis. And um we we have this maximum in radiology to not rely on the measurements too much. And I think toxic megacolon is definitely a instance where we don't just go by what the calipers tell us. Um the clinical picture is everything. And um yeah, in this case, this was also a patient with toxic megacolon. Um And I think Valera, you have some clinical background to give on these two patients. Yeah, I think um the the first one that you presented, uh he was um um actually taken to the within hours of presentation because he was uh systemically unwell. So I think everything worked out um pretty well in terms of the decision from um sur from presentation to surgery, I think it was quite obvious it was um clinically hemodynamically compromised. So he had almost an immediate operation. I think uh the second case actually created a bit more challenges because actually it was a patient that clinically was quite well and there was a new diagnosis of colitis. Therefore, there was quite significant uh uh reluctance uh for the patients to have um surgery that obviously would have resulted at least for a few months in a stoma. So for a series of reasons, uh he decided to decline surgery and um stayed as an inpatient for three weeks prior to eventually events precipitating and requiring an emergency colectomy at that stage. And I think um the outcome for both of them, both of them have done well eventually after surgery. But in the second case that the surgery was delayed, there was a uh significant stay in hospital uh with problems with nutrition and um uh postoperative complication in terms of intraabdominal sepsis. So I think uh uh exactly as you said, Eugene needs, um it's really important to put together the clinical presentation and hopefully guy will shed some light on which are the patients that we need to be very proactively in uh advising theater. So, over to Rachel for some gastroenterology input on acute colitis. Thank you. So I think these two cases are quite nicely representative. But what, what, what do the patients come in with? What's their symptoms and how do we manage them medically? And what stage should we call in the surgeons? Um So the definition of acute severe colitis really? It's quite old. Uh It's all the way back. These true liver width criteria have been going around for, for over 50 years now. And it's right, quite simple. It's not, it's kind of, it's stuck with this one. There are other ones, but the ones that are used most frequently are these because of their simplicity in looking at. So it's more than six stools in 24 hours and then one of the others, one or more of the following low HB raised DS or um many people now would say raised CRP, obviously, um, heart rate raise than 90 a temperature and, you know, we can get a little bit blase metics, I suppose, say these patients come in with a flare and just put them on steroids. But we have to remember before. But if these aren't recognized and aren't treated, are put onto steroids, the mortality rate can be quite high up to 24% of patients if they're not treated in a timely manner. But getting that timely treatment, getting it recognized on adequate doses and steroids and getting the patient on their venous thro thrombo lais on the supplements and as well as their steroids can have a much better outcome for patients. So this is a b borrowed a slide from a paper written by Christian Selinger. So these are the if you have someone diagnosed with fulfilling those true living with criteria for acute severe, the initial assessment should be obviously excluding infection. So thankfully, lots of hospitals now are switching over to these rapid PCR testing for infections. So we just, there's not so much of a delay but getting that stool sent off early from A&E ideally will really help, move the case along and help work out what's going on with this patient. I think you clinically and you know at work, the thing that really can slow it down is everyone goes, oh, it's an effective about waiting for that stool to come back. So getting it sent off early is absolutely key. If patients have been on um previous biologics or a known IBD patient or known colitis patient on biological etcetera, we sometimes worry about CMV as a consequence of that immunosuppression. So doing biopsies, it's not, it's not diagnosed on blood tests, it's on doing a biopsy, getting the immunohistochemistry, they can do quite quick. PCR if you ask them to try and find out is there any CMV that's contributing to this? Um And obviously getting that sigmoidoscopy to work out what's going on, looking at your hemoglobin, looking at your CRP and albumin. Why is albumin important? A very low albumin on admission can be AAA kind of prognostic factor of poor outcome. So it can be very helpful. It's not a nutrition, a marker of nutrition. It's a marker of severe inflammation and kind of a negative acute phase reactant and low albumin admission is associated with poor outcomes. So that these all these patients first line IV, hydrocortisone Q DSA 100 mg without monitoring of response. I think this is the absolute key thing is what happens with the steroids. Do they respond to steroids or not? The majority of patients will respond to steroids? But about 30% won't. And it said that day three, that day three from admission, day three of their steroids. Uh so at 72 hours, we should be reassessing seeing if they're responding to the steroids and if they're not, then it's for urgent escalation. So when do you get the surgeons involved? I think at any stage along this pathway, just like one of those cases I talked about is there are clearly, I mean, it's unstable and compromised when they come in. Initially, you need the surgeons involved there. And then um were meant to always involve the surgeons if they're getting escalated that if they're not responding to the surgeons, I think, you know, sometimes it does feel a little tick box, the surgeon comes along and say, well, let's see how they get on with the Infliximab. But I think it's really important for the patient to know that, you know, things aren't really going to plan here. You're not responding to the steroids, we're having to do something different. And just to, to because logically even knowing that surgery is an option or is something that might be needed, it might be required is really important in getting that surgeon involved. Day three, I think is really, really important, both both clinically and just preparing that patient. Just like the second case. Malaria said, it can be really hard for patients to get their head around this and having a timely surgery before they get too unwell can make all the difference of the outcome. So what do we treat with? There's two options there of the Infliximab cyclosporin. But the Infliximab as you all probably know is the one that we use most now, even though the both of them are equally beneficial. There's a study that's just been published called the Predict Going Well, what, what should we use high dose or regular dose of infliximab? And the short answer is much to our surprise, actually, standard doses really have make have just a good outcome at these accelerated higher doses, giving more of infliximab early. Uh So I think kind of we're turning back from using those high accelerated doses of Flix because really the date isn't there that there is any benefit, it's no harm, but it's no benefit looking at patients, you know, outcomes when they follow them up, um to see if they needed surgery or not or whether they recovered with, with the medical management, if they've already had Infliximab, cycloSPORINE is still an option for some patients. More and more people are using Ciib, it's not licensed. So this is an oral Jak inhibitor that's licensed for UC and Crohn's disease but not for acute severe UC. Uh there's, there's kind of more series and there was this kind of systematic review of 11 studies, 55 patients. And you can see there that, you know, the patient did quite well. And the nice thing about your position, if they, if they respond quickly, if it's going to work, it works quite quickly, you should see a response 3 to 5 days. Um you know, at most, it should take that long. There is a concern about the patients having um your DVTs pe on ciib, but obviously having active severe colitis is a high risk for um for clot for clots as well. So it's difficult to differentiate, which is it the drug or is it just having active disease? Thanks very much Rachel. So I'll move on to the surgical management of ulcerative colitis. Um Colectomy is a very effective treatment for, for an inverted commas that cures patients of their disease. It was established as the first really effective treatment in about the 19 fifties and nothing has really changed in in our surgical approach to a colectomy in in the next 70 years. But things have changed around it. Um It's not a failure of management. It mustn't be considered as such and it mustn't be phrased to patients as such as we so often here. Of course, it does come with an ileostomy at least on a temporary basis. And, and, and the whole thing is a, is a life changing event for people. Hopefully, attitudes towards uh IOST are changing with time and and around the time that there was such a push to develop the anal pouch because you know, patients living with an iost toy had an awful quality of life as per that picture on the left comparable to what they have in the modern day. So on a background of the prevalence of inflammatory bowel disease increasing internationally, there probably remains around about 20% lifetime colectomy rate and there is some conjecture about how quickly the rate of colectomy might be falling. If it is falling at all, it probably is falling the rate of colectomy, but in a slightly nuanced way, and I'm just going to refer back to some of the work that I'd done with, with a research group looking at our own nationwide data from England, which demonstrated that from data from 4016, that there was maybe a modest decline in the rate of elective colectomies for you see, um and but no decline in the emergency colectomy rate, which probably speaks to something to do with the way that we're managing patients. And this is within the advent of modern biologic medical therapy. And I think this graph is particularly telling in that for those patients who have been salvaged medically from an episode of acute severe colitis, the proportion of patients if they are going to have a colectomy, the within a year, the proportion of patients having an emergency colectomy is actually increasing with time and with it obviously increased morbidity mortality and, and decreased rates of laparoscopy. So it really is imperative that the surgical input doesn't finish if a patient leaves hospital having been salvaged medically and that we really still engage with close um dual er consultation follow up and make sure that the IBD nursing team keep them very closely on board because you know, we need that eight week, three month mark is highly important as per what they were looking at in the predict study. Um Rachel's reviewed some of this stuff already so I won't repeat it. Um And this is for you to either screenshot or take a picture of this is a, a chelation of the most up to date guidelines from the different organizations on the management of acute severe UC. I'll review some of the statements but not very many. But the, the one on the bottom right here from the A CPI think is particularly poignant that predicting the need for. And the timing of colectomy requires careful, continuous monitoring and good clinical judgment. And it's, and it's a highly nuanced situation. It's quite a particular um uh sort of counseling situation, particularly on the surgical side and it requires quite a lot of experience to get it right. And it's quite easy to be caught out. The BSG is fairly clear and that it's around the seven day mark. Um And that normally means after three of uh steroids and then uh five of uh uh rescue therapy that that's the time that if a patient is either deteriorating or not progressing. And that's the time to really strongly push the agenda for a colectomy, but it's not always easy to judge um whether a patient is improving or not. Um And if you're familiar with the IBD standards, then I'd, I'd encourage you to read through those, the textbook summary of principles are things that we've covered, things like early scanning baseline radiological investigation. And then I'd be interested on Eugene's thoughts as to serial imaging and the role for that um in modern management, particularly with plain films, um escalation to medical therapy, sorry, escalated um salvage therapy at day three after steroids um and sensitive counseling with early involvement of a stama nurse. Um always caveat this to a patient that it doesn't mean anything necessarily. But it really is very, very poignant and powerful for a patient to really understand what they're dealing with, with, with an ileostomy um with some of the kits and, and, and what it entails because there's a lot of anxiety and some of that might be misplaced. Um We talked about rescue therapy and, and just to reiterate the point that having a patient to get to the point of toxic dilatation or, or impending perforation or even perforation really is a failure of the MDT as a whole. Um So Rachel's reviewed some of the um uh predictive factors, so I won't go over that again. So the perioperative considerations. So, apart from the counseling and the sta sighting that we've talked about and trying to do that as early as possible. Um liaising with gastroenterologists and the anesthetic team and then the, the postoperative with the it team about steroid coverage, which depends on how long they've been uh having steroid therapy preoperatively and whether there's a potential for them becoming Ederson or not. Um, I think VT prophylaxis is imperative as Rachel said there are a higher risk of thromboembolic disease. Um, anyway, and, um, uh, at least a month of Lala Heparin postoperatively is appropriate. Um, thinking about anemia. Um, they could present, um, being quite anemic at, um, at presentation in which case, it might be that it's appropriate to consider IV infusion. But if they're gonna come to surgery and they've got an HB lingering in the eighties and you want to have it at least 100 around the time of the operation, we'll try to transfuse within a sort of 72 to 48 hour window for optimal oxygen transport rather than much closer to surgery if possible in terms of the operative considerations. Well, I definitely um encourage minimal, a minimally invasive approach if possible. But of course, being sensible. So in the context of somebody who is systemically compromised or has other comorbidities or previous surgery and adhesions, um a time of the operation is really important. Anything that's extending beyond five, you know, to seven hours is just not really appropriate. Um There are certain advantages with standard laparoscopy, with robotic surgery with, with um CS. Um and we can maybe discuss those a bit more later. I don't have any strong feelings about advising on the order of dissections. Some centers and surgeons will start at the middle colic, some start on the left, some start on the right. Um some people mark out the extent of their sigmoid th to begin with all these kind of things, they're all fair, gamers, trainees, you tend to do what your boss does try to collate all the different approaches and do what you are comfortable with when it comes to it. Being your decision. Be aware in the small number of people that there might be an oncologic considerations. There is, there are a certain proportion of people that come to a colectomy for UC who have known dysplasia preoperatively. And it's not unheard of that in the context of a preoperative diagnosis of high grade dysplasia, that there is a cancer demonstrated on the histology and that that can be at three in some cases. So it might just affect whether you consider taking the vessels or not. And then the the major point of conjecture between surgeons is is management of the rectal stump. So maybe if um Orestes has a pole ready to put out. Now, um I'd be interested in your thoughts. Um And what your practice is regarding management of the rectal stump. I do accept that some people might change it depending on the patient as well, which is fine, but I'll give you a couple of seconds to fill that out. Ok. So there we go. So uh half and the majority intraperitoneal closure. And then the next biggest group is those who put it in the subcutaneous layer, the presumably through something like a fan ST extraction site. So II don't think you need to be too dogmatic about the management of the rectal stump. The facts are that in a lot of the literature is relatively poor regarding studies, the rectal stump blow out. And that's the logic. So the idea is that in somebody who's got the same risk factors as they would have for an asthmatic leak. So, steroid smoking, a low body habitus, prolonged disease, you know, being physiologically compromised at the time that increases the chance that they'll have a rectal stent blow out. And that can be a really awful, you know, postoperative complication. It's gonna really severely interfere with their postoperative recovery and they can be septic and extremely unwell sometimes requiring repeat operations. So it's something to be, you know, to be feared. Um The, the in studies in the systematic review suggest that there's probably about a 4 to 6% rate of, of rectal stump. But the, but the se security of that can be variable. You can have people who you've brought out a subcutaneous. Um It sort of, it's a mucus fistula type uh approach and they can have a blowout in the skin. And if they have the same risk factors, it still can be an extremely comorbid situation with neck pal and fasciitis of the abdominal wall. So there's, there's no free lunch here. But if you drop it back in, that's undoubtedly the best thing with a short rectal stump symptomatically for a patient afterwards. And if it all goes well and what, what a lot of surgeons will do is leave her a catheter in the rectum for three days afterwards and then encourage patients to open their rectal stump on the toilet 23 times a day just to avoid any sort of pressure build up. And, uh, I think Valero wants to, maybe you have open a discussion at the end about the use of topical therapy. Don't be try to be too clever and leave a rectal stump too short because that can preclude um io anal pouch formation to a later date if it's too close to the anal canal. And and of course, if you are gonna even gonna come back for a completion proctectomy, if there's a load of small bowel beneath a very shrunken retracted rectal stem that can make things difficult. And on the the other end of that is leaving a very long rectal stump that's likely to be more symptomatic. So it some surgeons will bring a a rectal stump, sort of mucous fistula up to the ileostomy site. Some um but probably fewer now will make a sort of formal mucous fistula in the left iliac fossa. Um And a lot of uh surgeons will bring the uh rectal stump into the pharyngeal extraction site either within the abdominal wall or subcutaneous, some leave it open, some leave it closed. So there really are quite a few options and like I say, I wouldn't be too dogmatic. I would try to judge it case by case. Um, and you'll come up with something that you're comfortable with. Um, and the ACP guidance on that point is that it's your choice. Minimal access. Um, standard laparoscopy is probably the most common. I think there are real short and long term advantages to minimal access surgery. Um, I've, um, shown some pictures of SS and I'll put those in detail later. Um uh Everybody, particularly surgical trainees loves an operative video but um probably not the time and place on this webinar and there's lots of videos of surgery out there. But um er, so I won't linger on that now. Um The Sils is nice if you don't stretch up the ileostomy site too much and I've been in the habit of um Saint Mark's where I've just finished working that, that because it is surrounded by colleagues who did this technique um er, using this as well, which ends up in a, a scarless abdomen, albeit with an ileostomy. Um But the below picture is a more standard set up for, for straight laparoscopy with, again, with the phalangeal extraction site and the phalangeal then of course, can be used to manage the rectal stump and it means that you've got a nice perfectly apertured ileostomy. Um A reiteration that is all about IBD management. Uh sorry, the M BT um management. So, you know, it's a life changing event for patients, whether they're salvage or not, particularly if they're going through an operation. It's a huge thing. It's a very nuanced and difficult decision making scenario. So pool all your resources and get everybody involved as early as possible. My key messages are that if you're reading from textbooks or learning for your exams, it's often presented as a, as a very straightforward game of numbers and, and time based metrics. But ii, in my experience, it rarely proceeds to those, to those ideals. So don't, but don't let that put you off. The idea is that you should be expedient as an MDT by providing timely care, whether that be medical or surgical in, you know, in the right scenarios. And it's, it's a slightly odd decision making scenario for, for colorectal surgeons where you have to be proactive rather than reactive and it, and, and, and it's very easy to be caught out by a patient who feels very well, who is hungry, um, and who has a low C RP having been on steroids for a, for an amount of time and trying to, to counsel those people appropriately and convince them that if they don't get something done in a timely way, it's gonna be a lot worse. It's quite a difficult thing to do. As, as Valeria and Eugene highlighted at the start of the presentation, there are real practical barriers to providing those sort of IBD standards and timely care. It could be things that are very logistically based, like what provision of care at the weekend and whether you can get Infliximab over the weekend, whether the what day of the MDT is and whether that approves the, the, the medical therapy, um It's, it, we must be engaged as a surgical community. I think early review should never be a tick box exercise. And it's not just about seeing them once at the start and saying, call me, if things gets worse, it's about continued review because the trends are so important. But also it makes all the difference in the world for a patient to have built up a rapport with the surgical team during that care, whichever way it goes because for 25% of people, they're gonna come to a colectomy within the next two years anyway. And knowing that we're not just sharpening our eyes and have two heads is, you know, a big deal. Um The best thing you might be able to do for your unit is develop a local protocol, an S AP. And if you were to reach out to any tertiary IVD center, I'm sure they'd be more than happy to share those and support. Don't be misled by low CRP S or a lack of abdominal tenderness because of steroids. Um try to look for the pattern and then you're gonna have to defer to the lowest common factor. It might be that everything else is fine, but the stool frequency is persistent or there's still blood, um, you know, situations where patients haven't, um, improved appropriately after 4 to 5 days of their rescue therapy and they're not able to leave hospital. It's that time point that you've got to push the agenda for surgery. Um, timely follow up, even if they have been salvaged, it makes a huge difference as to where a patient has been in their disease course. Um As to whether this is they've just been diagnosed last week or whether they've had three episodes over the course of the last year and have already considered surgery or not. And do remember that it's a highly effective treatment. People do get better and go home, especially if everything's done in a timely fashion and it's not a failure of management. Thank you very much. Um So back to Rachel if that's ok for, I was just thinking the guy if you agree, um just to give a chance to the attendees to uh you know, interact with, um with all of you is whether or not we can go through some questions. So the first one, I would probably direct it to Rachel and that has to do with what the consensus uh for uh rectal stump surveillance after subtotal colectomy. And you see whether or not you have any recommendation on which patient needs to have it done more regularly compared to others. Good question. It's, it's a difficult one, there's not any clear consensus. I think they're trying to, there's kind of guidelines trying to be written and reviewed and come up with. The problem is differentiating with your diversion colitis and active UC. When you survey these rectal stumps because you know that diversion colitis is nearly ubiquitously. There, you get this kind of hemorrhagic mucosa and it can be very difficult to actually survey it properly, like with proper surveillance, doing dye spray, all this can be very difficult. If a patient has had dysplasia or cancer, they most definitely need to be surveyed regularly. How regularly, at least every 3 to 5 years, a lot of the higher risk, your PSE patients, they'll still need annual surveillance. So that should be just the same. Do you survey someone who's had their rectal stump for years and you are otherwise very well with no symptoms, probably not as frequently, maybe every five years for those patients. But that's really kind of a discussion with the patient and how they want to proceed. But if they have any change or if they have any change in the discharge, any blood, when they previously don't, they are all things to prompt you to do that earlier. Um, a review of the, of the do earlier stumps. Um but it kind of the guidelines essentially are the same as you would as if they had their colon in situ with without earlier, more aggressive surveillance medication with previous risk factors like psa and dysplasia. Thank you. And then I think the next one is probably more for which is uh is there any situation still referring to uh emergency presentation, whether you have considered removing the rectum at the same time of the colon during the proctocolectomy? And I think, um in um in my experience, I can definitely remember over the last five years, one case of a young patient who required to have a proctectomy two weeks after the subtotal colectomy because she was still systemically unwell uh because of the very severe proctitis. And then I think it's quite frequent for all of us who um review those patients who are admitted um acutely and the extent of disease is very distal is a proctitis or proctosigmoiditis. And the subtotal colectomy will leave most of the disease inside whether or not you have any advice, any thought on that uh guide, please. Um It's longstanding dogma, isn't it that there is, there is only one operation which is the subtotal colectomy. And it is enormously frustrating when you know that people have fairly limited distal disease and you're taking out a lot of healthy colon. Um But that dogma is so deep set that I've not had the opportunity in my short career to, to challenge it and, and um and defunction and it certainly would be a, it, it, it did. You wouldn't expect the defunction would get a bit, get better and you see that's actually a separate thing. I'll mention that in a second, but to do a um uh a segmental colectomy for distal disease, um it certainly would be a real fail if the patient then progressed to have, have colitis in their residual colon whilst aiming to recover from an episode of severe disease and an operation. And so I would, I would sort of uh encourage that the operation is a subtotal colectomy and that's it. Um in terms of uh considering pan proctocolectomy at the time. No, I don't, it would be very, very difficult to predict that that would be the right thing to do. And one of the, you, you are exposing a patient to real significant perineal wound morbidity if it, when considering a panproctocolectomy at the time of their acute severe disease, um you know, there's probably a 10 15% rate of, of residual sinus from, from the perineal dissection at, at the six month, three year mark. Anyway, having done a completion proctectomy when they're well and their perineum completely falling apart would be, would be a, a an awful um complication. Thank you guys. And then um uh before I move to the next question, I just wanted to summarize uh some of the technical steps that you have mentioned. So, in the emergency setting, uh you will not go for a high ligation of the vessels uh unless you have a concern over a malignancy or dysplasia. And then um um regarding the rectal stump for now, there, there is a difficult to the next question and, uh which is when you would consider doing the mucus fistula. The only consideration I would like to ask what you uh correctly said about the rectal stump is that obviously the mucus fistula, there is a proportion of patients that they will never get to a second stage surgery, they will require, you know, they will decide to stay with the endosy for uh several years. And therefore there is a chance that the open mucous fistula that we have created for them would be pretty much acting as a second stone a lifelong. So how, how do you feel about, uh giving patients an open mucus fistula? And when would you do it? Yeah. So I think it's becoming less and less common and anecdotally patients really hate their mucous fistulas. You know, it's, it's the one, sort of hangover of their disease if they have recovered and are doing really well in life with a, with a, with an Endo Iost toy. So II, um II probably would avoid formal mucus fistula at the, at the, with the preference to, to bring it um subcutaneously into, into an extraction site. The only caveat with that. And I'd be interested in your thoughts on this is for women of a childbearing age who may have a Cesarean section with a rectal stump that's in close proximity to a fan and steel. Yeah, I think we've been uh we've been taught to do it towards the left side of the potential fun. But II must say I'm, I'm personally not a um supporter of the mucus fistula. Uh unless those cases that you have described. Um uh but I think this will remain, remain controversial for a very long time, I think. Um um uh the final question was for Rachel. Um When you mentioned about the um review, daily review and the involvement of surgeons uh in the early process of patients with acute colitis, I just wanted to ask you whether or not you see also all there for a psychologist to go and see the patients because I've had instances where actually the help of the psychology staff supported the patient accepting surgery rather than having delays. Yeah, I am saying I don't have a psychologist. What my frustration. Yes, if you have absolutely get them involved early and in the absence and if you think about it around the country, I think there's three BD centers that have IBD psychologists. So a majority of people don't have access to that. And that's where like I said, it's that relationship with your surgeon. Is that speaking to the stoma or speaking to the BD nurse, giving them the opportunity to talk to other people who have stomas, all that can make a massive difference or how a patient co to stoma patients who really have just posttraumatic stress because they really felt it was all too much. They didn't have an option, particularly those patients who are new diagnosis and they come out with a stoma when they've only just got used to that idea that it's hugely traumatic for those patients. So any bit of hand holding any, a bit of preparation, getting that involve with the surgeon early meeting the surgeon again, again, getting the stone nurse, all that thing can make a huge difference to these patients. And yeah, just to reiterate, this guy says it's not a failure of management. It is just, it's, this is the best and safest option for you and that medication you're not responding that we want to, the medication and surgery is going to get you out of hospital and keep you well perfect. And uh shall we move to the Crohn's disease? Part of the talk? Because I think we're already uh past. Um, yeah, so I think very much moving from, from Crohn's. So you see, I think obviously what your acute severe you can be life, your surgery in your Crohn's disease. That kind of acute surgery is really very rarely required. You don't have that risk of perforation the same way with, without very thin ulcer colitis, um severely in bowel. So the big kind of thing for Crohn's disease is getting that timing, taking the heat out of your, your Crohn's patients and getting them ready for their surgery and optimized for surgery for their better outcomes. And just like in all other operations, there's a big focus now on this prehabilitation. I think there's a move to do similar things for Crohn's disease with all these various elements that you can see on the slide here. So moving on to a bit like like we talked about with a psychological preparation if you want to move on. Um that kind of that avoiding that term of failure of treatment. No patients want to hear about being failure. You just go to the next slide. Um And it's really important that we try and avoid that. You know, we can't treat our Children, our patients like naughty Children that won't listen to us. We've got to be able to work out what's, what's going to be the trigger for that patient. What's the important things for that patient? Understanding what their perception of risk is? So some patients will think you the worst thing possible is there medication that we want to give? And they may think that surgery is a better option for them. Again, that's important for us, gastroenterologists to talk to some patients with very isolated Crohn's disease, Cecal Crohn's disease, for example, to talk to them about surgery early, you know, patients with comorbidities with PSC and with their IBD, they're obviously higher risk of cancer. So they may want to go to surgery earlier. And professor a heart and ST Mark's talk about this tipping point and I really like it. It's a really quite, you see this with patients, you know, you're talking about, well, let's try the next drug, let's try the next drug and you're going to go, well, you were going to end up with surgery, but you have to wait for that tipping point when that patient is kind of ready and in the right place to have their operation and, but bringing up and talking about surgery, meeting the surgery, can surgeon can help them and that timing of their life, you know, patients don't want to be feeling that, you know, I'm just about to get married just about to do my P HDI don't want to have surgery. Now. It's getting the right timing and avoiding them feeling like they're a failure, they haven't responded. It's just their drug NC pod have done a really good review on looking at care and really the key message of that is talking to each other that MDT, that kind of coordinated care between the gastro control surgeon and postoperatively so that you know what we're doing with the drugs, what the plan for postoperative or the medication. That's really where the kind of the NHS services, the BD services are kind of making the biggest, um, kind of problems for patients is we're not talking to each other. There's not clear what the plan is preoperatively, postoperative for medications, nutrition, etc, um just going through the kind of talking about medication and about whether we just what to do with your medication perioperatively. Um, really very unusual for any Crohn's patients, apart from those isolated, um, aal patients, resection patients that won't have any IBD medication prior to seeing you guys. And really the question is what to do around the time of surgery with the medication. I don't want you to put up that poll or, um, on biologics now. I think that might be the right time. So, just to ask, well, what would you do? Do you think patients should have their biologics stopped uh preoperatively or can they be continued? And what's the right option for patients if you want to do that problem and have a, an idea of what you're thinking. So we the concern about infections perioperatively. I said some people to be worried about the drugs that we use and what's the, what's the right uh consensus. We've got a nice 5050. Um It's good to see. So hopefully we on to the next slide. Um The there's a kind of a echo topical review. They talked about this preoperative optimization. Getting that sweet spot in the II will answer the question in a minute. Getting that sweet thought between getting the patient nutritionally ready for surgery and getting that immunological status. So, trying to get their disease, taking the heat out of the disease, avoiding operating on that kind of hot Crohn's patient. Um Next, next slide. Um And they, they've done a Cochrane review some time ago. Now looking at what was the impact and you could and from that Cochrane review, there was overall infectious complications were increased in patients who had anti TNF agents. But there's a big but those studies were really kind of non randomized studies, not not there was risk of bias in the studies and a lot of these studies included. So it was really poor data. So now every next slide, we have some much better studies looking at this because really what we're trying to do is weigh up the pros and cons. So in the American studies, the Puccini study has now been published some time ago. Now looking at patients and good cohort, a prospective cohort, nearly 1000 patients included patients who are on biologics and immunosuppressants like your thy periods, azitine, etc who are going for surgery. And there was a mixture of both Crohn's disease surgery and ulcer surgery in this study. And essentially um being exposed to anti TNF preoperatively didn't make any difference to your surgical risks. It was um so any any infection and surgical site infection, what does make a big difference if the patient is on steroids going for their surgery and if they have a previous history of surgery. So patients who have multiple previous surgery are higher risk of infections and any infection and surgical site infection and patients with diabetes. There's another um sorry, the the slide just comes up but essentially, it's a French study showing very similar things. They looked at patients just undergoing Crohn's patient under Ileocecal resection. And they found no difference in patients and they actually measured your infliximab levels, for example, at the time of surgery and even patients with infliximab floating around their blood at the time of surgery, it made no difference. So really the kind of the um suggestion is now we don't have to delay surgery or alter the biologic um interval in patients going for, for surgery for inflammatory bowel disease, steroids is a different matter. Uh So a higher, higher dose of steroids for sure, increases your risk of um of all infections and of complications. It does, it is a dose related. So the higher doses greater than 40% of 40 M GS gives you the highest risk trying to get your steroids down. And this is all about that preoperative optimization. You give the biologic drugs, try and get the patients off steroids and optimize their nutrition. If you get down to less than 20 mgs, then the risk is much lower. And the big thing is whether you're making that anastomosis, if you're planning just a defunctioning stoma to form formation, you're not so worried about the steroid doses, but it's the anastomosis at risk of the anastomotic breakdown of the surgical site infection. These are really what you're worried about with the steroids. Anemia is another area to be looked at in your perioperative optimization. We know patients who are coming into surgery, anemic, going to stay in hospital longer and have poorer outcomes, increase infection rates, increased risk of blood transfusion, but how to treat it, it's difficult. So, a lot of your IBD patients will be anemic and it's a marker of their disease activity correction with, with iron um is quicker if it's IV versus oral. So definitely giving it to IV is quicker, but there is a large kind of or CT, there was no evidence that IV iron reduces an infection risks. There's no and this or CT, there was higher rates of postoperative he globin and lower readmission rates in patients who had IV iron. But it didn't achieve their hemoglobin levels weren't really that much difference. Smoking, talk to your patients, they will listen to you about smoking more than we realize. And even just stopping a few days before surgery can make a difference to their surgical site. Infection rate in that pin study. The real thing that I'm very, very passionate about is nutritional optimization and that doesn't have to be anything fancy. Just prescribing some 4640 juice, getting patients on some oral nutritional supplements can help your patients get through their surgery and have better outcomes. And don't forget the patients who are a bit tubby, they still may help to be nutritionally optimized. They may have micronutrient deficiencies and they may still also need oral nutritional supplementation. The dieticians will obviously help. Exclusive nutrition is used a lot in Children. It's used as steroids to, to bring patients to get them into remission for kind of inducing remission in patients with active Crohn's disease. We know it works for Children. What we don't really know is if it works for adults because we kind of perceive that adults won't accept this as treatment. The what we don't, the the kind of the thought process that we're hoping to prove in the trial that we're running is whether giving een preoperatively will have the same benefit as giving it to Children who have active Crohn's disease and inducing that mucosal healing and getting your patients better and getting them optimized for surgery. Next slide. Um The the there is interest in this because there is lots of small studies saying it probably will help. The systematic review says that definitely giving preoperative e to Crohn's disease patients improves their album, reduces their CRP, reduces complication rates and reduces stoma rates. It may give time to allow patients to wean off steroids, stop smoking and improve their nutritional status to try and see if this is a real finding or just something from small centers is the ocean study. A large randomized control trial. Looking at patients going on to six weeks, preoperative en any patient going for Crohn's disease surgery, not patients having say perianal fistula drained or someone just being defunction, but any other Crohn's disease surgery, we want to randomize patients to either six weeks of preoperative en or just standard care. We've got 31 sites open and a similar number of patients. It's a little slow to recruit. So if any of you are interested in getting involved, please let me know we trying to get more sites open and to try and get to really recruit to target for this patient. We've got a lot of patients we need to recruit in uh to make this study actually viable and feasible and see if we get some results out there at the moment. Some patients are getting it and some patients aren't and we need to make sure that all patients in the NHS get access to this. If it works. We've got two primary outcomes. One of them is driven by patients a kind of a quality of life type questionnaire and the other one is looking at surgical complications with the CC, we'll also look to loads of other secondary factors. Thank you. Thank you, Eugene. Do you, shall we move towards the imaging of Crohn's disease before arrest? This can present us a few cases? Thank you. Yeah. Um So I'm just gonna do the Crohn's with obstruction case, right. Yes. Or do you want me to do all the Crohn's cases? We are at time? Um Your shout, I think we are. Uh OK. So you mean do all the Crohn's cases? Probably makes sense. Yeah. OK. Um So this first one is a case of Crohn's with obstruction. Um, he's a 28 year old male. Um, now my main tip for, uh, following, uh, well reporting any Crohn's, uh, patient with a CT MRI started the T or the neoterminal I, if you had surgery and work your way backwards. So, in this case, um, we've got severe thickening of the terminal i over more than five centimeters and then you have this significant dilatation, Uh and bearing in mind this is a small bowel loop. We are more than double the uh normal diameter. And then we come to this uh stricter which is more than 10 centimeters and following it upward again, another segment of dilatation not as severe as the, the one we saw just now. Um And so this, this was a patient with known Crohn's. But um if we didn't have that history, the giveaway that this is Crohn's is obviously the skip lesions, the discontinuous distribution, the interloop dilatation. Um The mural stratification indicating chronicity. Um I'll show you a couple of other interesting um features that you would have seen intraoperatively, but we can also see on the scan. So, on this uh segment here, this structure, there's a little out pouching of uh bowel wall. Um And you know, you know that the bowel wall thickening is uh more severe on this side and on this side, on the mesenteric side. So that's a pseudo circulation and something I tell my registrars to be able to recognize because it can be confused for like a localized perforation. Um Yeah. So, well, in terms of relevant negatives, there's no fistula, no perforation and no abscess yet. And when I report these, I give the total length of disease involvement um including the spa segments. Um Yeah. Any comments for that. Yeah, I think uh ju just to give some clinical context. Um This was exactly as you say, an emergency presentation with obstruction of a young patient who has known Crohn's disease. He had been already on biologics uh previously with the relatively poor compliance. And uh when we had to look at these imaging, uh we found that uh surgery was needed at some point, we resisted from uh operating as an emergency. So we essentially um he was started already on steroids on admission. We weaned him off steroids, we put him on exclusive enteral nutrition. And eventually we planned elective surgery and uh which um proved actually quite challenging because the extent of disease was significant and we had to change our strategy rather than a resection. We did the uh Mila stricturoplasty in um uh in this patient. But I think um um yeah, and the Eugene nasty follow up imaging that demonstrates the uh classical complication. I think of the mi a. Do you want to tell us about it? Um Eugene uh yeah, I brought this up because it's a nice uh example of the role that uh fluoroscopy still has with uh in a mapping bowel. Um In this case, we did it because he was defunction. So we put the catheter down the limb and um just filled it up with contrast and uh we could see very nicely where there's where there were still strictures. Yeah. So we, we're going uh stre the afferent limb of the acid that we attempted dilating a few months later when um when we planned the reversing this Iost toy. But I think um the despite optimizing this was um was a very challenge, very, very challenging case. And I think perhaps this could um lead to the next uh poll or is that I think we were planning with Rachel, which is, how long should we wait to optimize patient prior to surgery? I don't know if you can launch that uh poll for us. So how long will it take to optimize the patient for surgery? One week, two weeks, four weeks or six weeks? While that polls coming through Valerios? Somebody put a question on the group which I thought was pointing, which is the difference between inflammatory or fibrotic strictures. Um One Eugene, how you might tell the difference on imaging. But also then I suppose Rachel, what the implications would be for medical management at the time of this kind of presentation if they were inflammatory. Uh so fibrotic strictures are would cause uh dilatation. So upstream or interloop dilatation. Um in terms of disease activity. It's a bit less sensitive with CT compared to MRI. Um But I do have a case coming up where you can see um the neural enhancement indicating disease activity. Uh We're on CT. Um So I guess to, yeah, the short answer is if there's dilatation um upstream of a narrowed segment, then you infer that it's fibrotic and if there is uh avid enhancement, uh early enhancement, then it indicates uh active inflammatory disease. Yeah. And I think sometimes the role of intestinal ultrasound if you have it available in your center can really help you with these strictures to work them out if they're more fibrotic. But with histologically, when you exam, when these are removed and look, they nearly even your fibrotic ones will have some element of inflammation. So giving some, you know, try to optimize your medication to try and bring down that inflammatory component like that echo thing. So he's trying to get that immune immunological sweet spot as well. Is important. I think even in your patients with fibrotic appearances on imaging, it's really difficult to differentiate them fully. And I think just to add to what you were saying, Valeria about this case been really tricky. I think your case would be much trickier if you had operated earlier. I think that just giving that period of pre optimization even though it was still a very difficult case. Um it would make all the difference though. Yeah, definitely And uh I think um looking at the results of the polls, I think people seems to be in agreement that the longer we can safely wait the better. So I think uh uh most of the responses will operate uh from four weeks onwards, which I think uh is probably, you know, what majority of us will do, try to uh optimize for at least 4 to 6 weeks and perhaps uh in the future, we'll do even even longer. I'm just uh uh aware of time and um I wonder if we should go to a couple more imaging um Eugene and then uh we leave uh five minutes for rest is just to wrap up on uh management of bowel obstruction. Um Yeah, my next two cases are of perforation. Do, do you want me to present those? Uh I think so. I think if, if there are some nice features of um the last few months. Yes, please. Ok. So as 33 year old female, um so I'm just showing you the abdominal radiograph, not often done nowadays where we work, but um this was a case where you could see free air uh on the uh abdominal X ray. So just this sliver of gas here between the liver and the ascending colon, it's much more obvious on the erect chest X ray. It's free air under the diaphragm. Now, um I'll show you the CT uh on the lung windows. That's how you pick up the free air just there. And as I said, with Crohn's patients start from the ICU valve and work your way backwards. In this case, we see a 10 centimeter long stricture some interloop dilatation. And as we follow this loop of bowel, you see this big defect with feces and gas spilling out, uh I'll show you on the Corona. So IC valve stricture upstream dilatation and that's the perforation there. Um Here's another case, uh very 55 year old man um who had a trauma scan because he said he'd fallen, but there wasn't much else history from him. And um there's again working backwards from the IC valve, significant uh narrowing. Well, Luminal narrowing with mural thickening of the distal and terminal is and then segment of dilatation, then narrowing again and dilatation. And on the coronal, you can see this very characteristic uh fat wrapping, uh fat proliferation. It's just isolating and pushing that uh distal terminal, they'll loop uh away and there's also the calm sign of the engorged uh vaso reca. Um So he, so he had a dilatation associated with his stricturing disease, but there was no perforation uh at the time and he had a CT uh six days later, which now you'll be able to recognize on the lung windows. There is free gas there. So he had perforated uh six days later. Um Valeria, you have some background. Yeah, I think uh I think, you know, you probably both the CTS you showed to demonstrate uh uh patients that basically have no cutaneous, no intraabdominal fat. So, I mean, this makes me think these were patients that had been lost either because of compliance or because of lack of engagement with medical services. I think they reached um uh hospital when actually was quite late for doing all the clever interventions to optimize them that Rachel described. I think here, we will all agree that this is obviously one of those likely quite rare situations where unfortunately there isn't much alternative options. They're going in with surgery and, uh, resecting what is needed and pulling up with stoma, which is obviously life saving for, uh, for these patients. And, um, uh, shall we give the war to arrest us now for the, uh, bowel obstruction slides? I think, uh, uh, I'm aware we are three minutes late, but I can see that there is still, um, uh, 50 people who have joined us. So perhaps if, uh, we gave a few extra minutes, if everyone is in agreement with, um, uh, some take home messages, please or so with the management of bowel obstruction and Crohn's disease. Yeah, absolutely. Um, I think we, we were ok to run for like 10 minutes or so. Uh, yeah, I just, um, had a, uh, kind of imaginary case, um, starting with a background. Um, we would obviously, in our level, we would see someone acutely, uh, unwell and acute presentation. Uh I was just at one quick point was uh about the previous background. So when we review the background, we find some previous imaging and some previous endoscopy. Um I think uh Eugene talked us through the findings on imaging. Um and there's a list there with uh you know, potential findings um on previous imaging, previous scans. Uh we do frequently see endoscopy reports. So I was going to ask Rachel about that. Uh when we see uh endoscopic scoring, uh what does that actually tell us as surgical trainees? What's the kind of uh quick idea we can get of that? Yeah. So the the commonest one you use for um Crohn's disease is this uh simple endoscopic scoring, Crohn's disease score that you've put up there and you're basically scoring every five different areas of the bowel, how many ulcerations, how much of it is ulcerated, how big are these ulcers? And essentially you, you kind of add up the scores and then you get a number of, of how severe the disease is. More severe disease is anything over 15, more moderate, is anything between seven and 15 and then mild disease below that. So it's just it's to try and improve. So if we're monitoring, if someone's responding to the drug or not, it is reduce that interobserver variation and have a much more um that we can relate to like, yeah, it's getting better. It's not, it's not responding or whatever. So it gives you an idea how severe we use the mayo skin system or the UC score for ulcerative colitis. Again, it's just a way of trying to document how severe the inflammation is and try to, you know, have a way of discussing this with each other and relaying how severe it is rather than just saying it looks really bad. Amazing. Thank you. Uh And then, yeah, in terms of the immediate acute management, I think uh the basics of obstruction uh for drainage and monitoring. Uh We've talked about imaging, I think that the, the images were amazing. Um And if we look at the next slide, please. Um Yeah. And then I think we've, we've been through uh all the considerations about the acute management, uh nutritional optimization and when a surgical intervention um is indicated. Um Yeah. And then, uh again, as I said, we could take some screenshots of that for, for the guidelines uh about further management. This touches upon uh more of the uh subsequent management after the acute episode. Uh I'm not sure if uh the panel has any thoughts or anything. We'd like to comment on that. I think there's always been one question whether or not there is any experience with the I knife um in terms of uh treating uh strictures, endoscopically. And uh my answer is no. Uh I don't know if um Rachel or uh guy, you have had any experience in endoscopic management of strictures Yeah, this was the, the recommended would be for us to do for dilatation, balloon dilatation. Um, would be the standard practice for the short strictures can be balloon dilated. But using iron knife, I have no experience of and I don't think it's necessarily recommended. And we've also, yeah, steroids and biologics. I think we've covered that already. I noticed someone in the chat, sorry, someone in the chat suggested before joining an anastomosis about they wouldn't, they would stop biologic for the anastomosis. It's really steroids are only what you put in your risk of your anastomosis falling apart, not your biologics. The risk is if you stop it, then the patient does that delay that we've seen in time again and again, they're waiting to come back to clinic for six months down the road. The Crohn's has gone out of control again and there are absolutely no benefit from the surgery. So continuing it to avoid that is really important. Amazing. Uh Thank you. Yeah. Um Thi this was, I think my final slide uh on the uh kind of subsequent uh management options and thoughts. That's excellent. Orestes. Thank you. And I have looked to the questions. Doesn't look like there is anything else which is uh unanswered. Um, uh, obviously you're showing up the, uh, serum training in IBD. And, uh, I think we are really grateful if, um, whoever hasn't done it yet could, um, complete it so that we have, uh, a state of the art on uh what training uh is provided and what I think needs trainees around um uh training in diabetes surgery. Thank you. Thank you, Val. Um We've launched this survey for now three or four months. Um It's looking at the IBD training of colorectal trainees in the U A and it's something that we are running jointly uh as the Dukes Club and the IBD uh ACP GBI subcommittee. And we're really hopeful that the answers uh will help us kind of shape up um training in IBD surgery and part part partially these webinars are inspired by the uh which has demonstrated the lack of um exposure to, to IBD MDT S. Excellent. Any, any other comments, Uh Guy Rachel, anything else you would like to add to everything that has been presented so far? I think we have still, I think more than 50 people online, which I think um means that they've really enjoyed your talks and your reflections and all of this. I think there's just two questions there that have been answered. When can you resume the biologics after surgery? I think once the there's no surgical obvious surgical site infection within a few days, there's no, you don't need to delay um restarting your biologics postoperatively again, this is where the harm can come. Patients. Now, if you've done, you've removed all the Crohn's disease and you've had patients who are coming in with just a ti resection and they've got, you know, no, no residual Crohn's disease. Well, that's that discussion. Whether they, most of those will be restarted. You'll wait for your six month postoperative colonoscopy to see if it's come back again. Um, but your patient that you're operating, who's got multifocal disease and active disease, you really try to avoid any delay in restarting it if at all possible to try and reduce that disease burden. And there was a question about terminal eis and whether you give antibiotics. Yeah, it's hard to know. I don't think you're doing any harm, giving some antibiotics. I can have some role in Crohn's disease management. Uh I don't, you know, it's difficult, as you said to differentiate active disease uh from infection clinically if there's no collection and you just want to cover it. I don't think there's much harm and metroNIDAZOLE r you would, you could consider it in the cases when you can't start your biologics too early. And even if I think all of us have had um most of the patients that find it really difficult to have metroNIDAZOLE for uh longer than a week. Yeah. Yeah. So there kind of, there is good data saying that your me a post your your ti resection for your patient with your isolated Ilio for Crohn's Disease can do very well in trying to reduce postoperative recurrence, but nobody can tolerate it. They all get pins and needles and nausea and they can't drink alcohol. And they hate it. So we've actually just stopped even doing it routine practice because it's just so poor, poorly tolerated. So we just rescope after six months and then decide there what to do with the patient at that stage. If there's score, this root guard score, looking at the anastomosis, if the Crohn's disease has recurred or not and then do it from that point of view. Then I think the last question, I think uh touches on um uh colitis again, uh which is uh uh I think for more for racial to uh whether or not patients after a subtotal colectomy, they will have topical treatment for the rectal stump. So whether or not they will go home on mesalazine or if not, when you will start the mesalazine to treat the rectal stump after emergency subtotal colectomy. Ok. Um So I, um I think it, it, it's probably a good thing, particularly if they're symptomatic. I think there's probably rarely that patients need to go home immediately with it. After their subtotal colectomy, you might have a flavor before discharge as to whether they're still symptomatic from their rectum or not, whether they've got some bleeding. Um But uh if not, then maybe starting it at the two month mark means that that would be the right time for their reassessment of their stump. And there is a bigger picture question about whether they would be suitable for an early recal anastomosis or not. Um, I did a paper to compare the practice between England and Sweden. And in Sweden, they'll do a lot more a rectal anastomosis, which ultimately results in a higher rate of people avoiding permanent stomas. And the protocol there is to have um is to use mesalazine suppositories, 1 g twice daily. Um And if there is a response, if there's a reduction in their mo score of their rectum, then it might be, they're suitable for an rectum arthensis. But I think practically speaking, that's probably a relatively small number of people. So delayed use for symptoms is the most common scenario for me. What do you think, Rachel? Yeah, I think, I don't, don't do it as part of routine practice. I think it patients are a bit alarmed when they start passing stool or no stool or mucus or anything from the rectum. They think nothing's going to come out. So I think it is important to warn patients that something will come out of the rectum. And I think that, yeah, just advising them if you're having any problems that you may need to start suppositories, steroid suppositories can work really well. A lot of the patients have come for surgery and need a colectomy for their UC have already kind of declared themselves not to be responsive to mesalazine. So probably would use a lot more steroid suppositories for the rectal stump than mesalazine, but definitely worth trying it in patients who are having, you know, symptoms, breath, blood mucus, etc, because it can be quite distressing for patients because it's unpredictable. So they feel incontinent and, you know, like they're swing themselves so warning the patients telling them what to do, maybe sending them home with a, as required. So s but not, I wouldn't start it routinely. Excellent. Well, I will just like to thank you Rachel or this guy and Eugene for um, uh sharing your um insight into management of these complex cases. Uh And uh I would like to thank all the uh attendees for staying with us. Is there any final remarks or this uh from you from Duke's Club per perspective? Um Yeah. Um Thank you so much uh to all the attendees for, for staying with us until now. And thank you so much all for, for, for participating in this webinar today. I think the aim was to run this as an MDT discussion, which I think uh we managed to do. I think it's really valuable for surgical trainees to get the gastroenterology perspective. And the so far management, it's, it's the knowledge that we are missing, but also quite importantly, uh the kind of interpretation of imaging because we are frequently uh left to, to check the scans ourselves and understand a few things on our own. So I think we, we really offered a, a very good overview of uh both uh UC emergencies and um Crohn's emergencies. Uh We will uh be advertising uh soon for the next two webinars which will follow a quite similar structure. So again MDT like and one will be focusing on uh C and well, one will be focusing on chromes. Um So yeah, I think if there's nothing else from your side, we can bring this to a close. Thank you very much, everyone for uh staying with us till now and thank you to the panel. Thank you. Good night. Thank you.