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The Association of Coloproctology of Great Britain and Ireland Consensus Guidelines in Surgery for Inflammatory Bowel Disease

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The Association of Coloproctology of Great Britain and Ireland Consensus Guidelines in Surgery for Inflammatory Bowel Disease Supplement article doi:10.1111/codi.14448 The Association of Coloproctology of Great Britain and Ireland consensus guidelines in surgery for inflammatory bowel disease S. R. Brown1 , N. S. Fearnhead2 , O. D. Faiz3 , J. F. Abercrombie4 , A. G. Acheson4 , R. G. Arnott5, S. K. Clark3 , S. Clifford6, R. J. Davies2 , M. M. Davies7 , W. J. P. Douie8 , M. G. Dunlop9 , J. C. Epstein10 , M. D. Evans11 , B. D. George12 , R. J. Guy12 , R. Hargest7 , A. B. Hawthorne7 , J. Hill13 , G. W. Hughes8, J. K. Limdi14 , C. A. Maxwell-Armstrong4 , P. R. O’Connell15 , T. D. Pinkney16 , J. Pipe5, P. M. Sagar17 , B. Singh18 , M. Soop10 , H. Terry19, J. Torkington7 , A. Verjee5, C. J. Walsh20 , J. H. Warusavitarne3 , A. B. Williams21 , G. L. Williams22 , R. G. Wilson9 , ACPGBI IBD Surgery Consensus Collaboration 1Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK, 2Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK, 3St Mark’s Hospital, Middlesex, Harrow, UK, 4Nottingham University Hospitals NHS Trust, Nottingham, UK, 5Patient Liaison Group, Association of Coloproctology of Great Britain and Ireland, Royal College of Surgeons of England, London, UK, 6IA, Danehurst Court, Rochford, UK, 7University Hospital of Wales, Cardiff, UK, 8University Hospitals Plymouth NHS Trust, Plymouth, UK, 9Western General Hospital, Edinburgh, UK, 10Salford Royal NHS Foundation Trust, Salford, UK, 11Morriston Hospital, Morriston, Swansea, UK, 12Oxford University Hospitals NHS Foundation Trust, Oxford, UK, 13Manchester Foundation Trust, Manchester, UK, 14The Pennine Acute Hospitals NHS Trust, Manchester, UK, 15St Vincent’s University Hospital, Dublin, Ireland, 16University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK, 17Leeds Teaching Hospitals NHS Trust, Leeds, UK, 18University Hospitals of Leicester NHS Trust, Leicester, UK, 19Crohn’s and Colitis UK, St Albans, UK, 20Wirral University Teaching Hospital NHS Foundation Trust, Arrowe Park Hospital, Upton, UK, 21Guy’s and St Thomas’ NHS Foundation Trust, London, UK, and 22Royal Gwent Hospital, Newport, UK Received 20 June 2018; accepted 17 September 2018 Abstract Aim There is a requirement of an expansive and up to then refined and submitted to a second vote. Only date review of surgical management of inflammatory those that achieved >80% consensus at level 5 bowel disease (IBD) that can dovetail with the medical (strongly agree) or level 4 (agree) after 2 votes were guidelines produced by the British Society of Gastroen- included in the guidelines. terology. Results All aspects of surgical care for IBD have been Methods Surgeons who are members of the ACPGBI included along with 157 recommendations for manage- with a recognised interest in IBD were invited to ment. contribute various sections of the guidelines. They Conclusion These guidelines provide an up to date and were directed to produce a procedure based docu- evidence based summary of the current surgical knowl- ment using literature searches that were systematic, edge in the management of IBD and will serve as a use- comprehensible, transparent and reproducible. Levels ful practical text for clinicians performing this type of of evidence were graded. An editorial board was con- surgery. vened to ensure consistency of style, presentation and quality. Each author was asked to provide a set of Keywords Inflammatory bowel disease, Crohn’s dis- recommendations which were evidence based and ease, ulcerative colitis, surgery, consensus, clinical guide- unambiguous. These recommendations were submitted line to the whole guideline group and scored. They were Correspondence to: Professor Steven R. Brown, Sheffield Teaching Hospitals NHS Foundation Trust, Herries Road, Sheffield S5 7AU, UK. E-mail: [email protected] ª 2018 Authors. Colorectal Disease published by John Wiley & Sons Ltd on behalf of Association of Coloproctology of Great Britain and Ireland. 20 (Suppl. 8), 3–117 3 This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited. IBD Surgical Guidelines ACPGBI IBD Surgery Consensus Collaboration on surgical aspects of IBD management. Each section Contents was written around either a procedure or a specific situ- ation. Authors were selected who are members of Introduction 1 ACPGBI and who have recognized expertise in the Methodology 2 1 General principles in IBD surgery 3 management of IBD. 2 Small bowel surgery in Crohn’s disease 8 Specific consideration was given where possible to 3 Ileocaecal resection in Crohn’s disease 11 indications for surgery and patient selection, technical 4 Colectomy for IBD 16 aspects of surgery, perioperative care, complications and 5 Proctectomy and proctocolectomy 27 their management, and long-term outcomes. Concerns 6 Ileoanal pouch surgery 29 about format and approach were discussed with the 7 Ileorectal anastomosis 36 Editorial Board. Searches for evidence in the literature – 8 Continent ileostomy the Kock pouch 39 were systematic, comprehensive, transparent and repro- 9 Surgery for perianal Crohn’s disease 45 ducible. Each author was asked to provide a set of rec- 10 Rectovaginal and pouch–vaginal fistula 51 ommendations which was evidence-based and 11 Duodenal Crohn’s disease 55 unambiguous for submission to the editorial group for 12 Surgery for recurrent ileocaecal Crohn’s disease 57 13 Revision and excision pouch surgery 60 review. Consensus statements were refined and collated 14 Intestinal failure in IBD 65 by the Editorial Board. 15 IBD surgery in adolescents and transition 71 The recommendations were then submitted to the 16 Surgery for IBD in pregnancy 73 entire colorectal expert panel, as well as representatives 17 Modes of delivery in pregnant women with IBD 78 from the BSG (ABH, JKL), charitable representatives 18 Impact of medication on surgery for IBD 81 from Crohn’s and Colitis UK (HT) and IA (the ileost- References 86 omy and internal pouch support group) (SC), ACPGBI patient representatives (RGA, JP, AV) and a consultant gynaecologist and obstetrician (GWH). Voting was car- Introduction ried out on a five-point Likert scale of 1 (strongly dis- agree) to 5 (strongly agree, SA). Any statement scoring Although guidelines exist for the surgical management 1–3 on the Likert scale could have suggestions made of inflammatory bowel disease [1–3] there are areas of with the intention to rephrase recommendations if practice that are not covered in detail. The British Soci- specific objections were raised during the first round. ety of Gastroenterology (BSG) have taken the view that Only those recommendations achieving 80% consensus there should be an expanded and updated version of at level 5 (SA) and level 4 (agree, A), after two rounds the guidelines for medical management that is particu- of voting have been included in the final guidelines. larly relevant to a UK audience. These BSG guidelines ACPGBI members were obliged to vote on all consen- will have some input from the surgical community but sus statements. All other participants were given the there was an opportunity to expand the surgical compo- right to abstain on any guideline if they wished. Patient nent. The Inflammatory Bowel Disease (IBD) Clinical representatives were specifically invited to comment on Advisory Group of the Association of Coloproctology any issues of which they had knowledge or experience. of Great Britain and Ireland (ACPGBI) have therefore The consultant obstetrician and gynaecologist represen- commissioned a set of guidelines focusing specifically tative only voted on Sections 16 and 17. on surgery for adults and adolescents with IBD. The The level of evidence and grading for each recom- guidelines are procedure-based and are intended to mendation [5] are listed in Tables 1 and 2. dovetail with the BSG’s comprehensive medically These guidelines represent ongoing work from the focused guidelines. The primary objective here is to period October 2016 to March 2018. We hope that provide detailed evidence-based guidelines on the surgi- they will provide an updated and evidence-based sum- cal management of IBD for the target audience of col- mary of the current surgical knowledge in the manage- orectal surgeons practising in Great Britain and Ireland. ment of IBD and will serve as a useful practical summary for clinicians practising in this area. Methodology The Editorial Board was convened to ensure consistency General principles in IBD surgery of style, presentation and quality across all the guide- Both ulcerative colitis and Crohn’s disease are charac- lines. The guidelines adhere to the published ACPGBI terized by chronic inflammation of the gastrointestinal guidelines on consensus statements [4] and concentrate system in individuals with a genetic predisposition ª 2018 Authors. 4 Colorectal Disease published by John Wiley & Sons Ltd on behalf of Association of Coloproctology of Great Britain and Ireland. 20 (Suppl. 8), 3–117 ACPGBI IBD Surgery Consensus Collaboration IBD Surgical Guidelines Table 1 Level of evidence. I Evidence obtained from a single randomized controlled trial or from a systematic review or meta-analysis of randomized controlled trials II Evidence obtained from at least one well-designed controlled study without randomization or at least one other well-designed quasi-experimental study III Evidence obtained from well-designed nonexperimental descriptive studies, correlation studies and case studies IV Evidence obtained from expert committee reports or
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