Procedures for Ulcerative Colitis

1. Procedures for Ulcerative Colitis By: Jeff Neale MD

2. Overview One of the two main categories of inflammatory bowel disease, other =Crohns. Characterized a.) Contiguous inflammation of the mucosa, (beginning in the rectum). b.) Cause is unknown. c.) Intermittent exacerbations of the disease, (bloody diarrhea, urgency and tenesmus. d.) Minority of patients = fulminant presentation that may be fatal without prompt surgical intervention. Medical therapy 1.) Control symptoms or managing the underlying inflammatory process 2.) It does not cure either the intestinal or the extraintestinal manifestations of CUC. Surgical therapy=CURE 1.) Intestinal manifestations 2.) Malignancy

3. Preoperative Evaluation Indications for Operation Two broad categories: 1.) Indications for emergency operation a.) Toxic megacolon b.) Fulminant colitis 2.) Indications for elective operation.

4. Fulminant Colitis 1.) A chronic disease that allows deliberate and coordinated care, 2.) 10% of patients initially present with severe disease. Characterized by 1.) The sudden onset of severe and frequent (> 10/day) bloody bowel movements, 2.) abdominal pain, 3.) dehydration, 4.) anemia. Diagnostic criteria for fulminant colitis (originally described by Truelove and Witts in 1955) include: 1.) The above signs and symptoms and at least two of the following: a.) Tachycardia, b.) Body temperature higher than 38.6° C (101.5° F), c.) Leukocytosis (> 10,500/mm3), and d.) Hypoalbuminemia.

5. Fulminant Colitis 1.) Extremely ill and require rapid = medical therapy, a.) Fluid resuscitation, b.) Correction of electrolyte abnormalities c.) Blood transfusions. d.) Nasogastric tube decompression if colonic distention. e.) If CUC is known to be present = high-dose intravenous steroid + stool cultures. f.) No diagnosis of CUC = endoscopic evaluation of the colon should be carried out expeditiously, goal (visualizing the rectal and distal colonic mucosa). f.) Stable = NO antibiotics g.) Very ill or has a high fever or leukocytosis, = broad-spectrum antibiotics should be initiated after cultures are obtained. Medical therapy =24-48hrs 1.) No improvement 2.) Patient's condition deteriorates, surgical treament is recommended. 3.) Peritonitis, hemodynamic instability, or perforation, the patient should be operated on immediately.

6. Toxic Megacolon 1.) Initial presentation of ulcerative colitis 2.) Represent a flare in a patient with long-standing disease. Where? 1.) Entire colon 2.) Isolated segment of the colon (usually the transverse or the left colon) is involved. Dx 1.) Radiographic definition of toxic megacolon exists (i.e., greater than 5.5 cm dilatation of the transverse colon on a supine abdominal film), 2.) Truly a clinical diagnosis. Medical treatment = fulminant colitis Emergency surgical management a.) Patient's clinical or radiographic status worsens, b.) Evidence of perforation, c.) No improvement 24 to 36 hours after aggressive medical therapy is begun. Delaying the operation increases the risk of perforation, which raises mortality from less than 5% to nearly 30%

7. Other Emergencies Colonic perforation 1.) Actual diagnosis might be Crohn disease vs other cause of perforation (e.g., a gastric or duodenal ulcer related to steroid use). Hemorrhage 1.) Severe enough to result in hemodynamic instability = unusual complication of CUC. 2.) Consultation with the treating gastroenterologist. Initial treatment 1.) Aggressive fluid and blood-product resuscitation. 2.) Any electrolyte or clotting deficiencies should be corrected. 3.) Upper GI endoscopy should be done to exclude the possibility that a gastric or duodenal ulcer is causing the bleeding. Surgery 1.) Hemodynamically after effective resuscitation, = OR WHY?? Medical therapy would take too long to decrease the mucosal inflammation responsible for the bleeding. 2.) Slow but continuing hemorrhage no hemodynamic instability =, high-dose steroid therapy may be tried for 48 to 72 hours before surgical intervention is considered.

8. Elective Operation Elective Operation May occur early in the course of a patient's disease or years of relatively mild disease. The major indications Re: failure of medical management to control symptoms (intractability) Presence of mucosal dysplasia, dysplasia-associated lesion or mass (DALM), Malignancy Extraintestinal manifestations of CUC and children with growth retardation.

9. Intractable Symptoms Intractable symptoms Can occur in either the acute or the chronic state of CUC. In an acute flare,= not able to control symptoms with maximal medical therapy; In the chronic state= not able to taper steroids to a reasonable maintenance dose or the development of severe drug-related side effects. Management of an acute flare I.V. steroid therapy for 5 to 10 days. No clinical improvement, elective operation is advisable. It is important that the patient receive adequate nutritional support (often in the form of total parenteral nutrition). If the patient's nutritional status declines significantly, a three-stage procedure may be necessary to improve surgical outcome.

10. Dysplasia or Malignancy Risk of colon cancer , 2% at 20 years, to 43% at 35 years. Increase risk high-grade dysplasia on random colon biopsies Most clinicians have recommended increases in the frequency of surveillance colonoscopies rather than surgery. Some preliminary reports = any degree of dysplasia not associated with a mass lesion = surgery should be recommended IF suspected or known colonic or rectal malignancy, The surgical options should be driven by oncologic principles. In most patients, ( except low rectal cancers or metastatic disease,) Procedure of choice= total colectomy with ileal pouch-anal anastomosis (IPAA). Why? Irradiation may severely compromise pouch function. Stage for stage, the prognosis for patients with malignancies who have CUC = who do not have CUC. CUC patients who have undergone surgical treatment, particularly with an IPAA procedure, tolerate chemotherapy as well as patients without CUC do

11. Procedure of Choice 1.) Total proctocolectomy with end (Brooke) ileostomy 2.) Total proctocolectomy with IPAA. 3.) Total abdominal colectomy with ileorectal anastomosis, may be considered in highly select groups of patients ( mild disease, contraindication to an ostomy (e.g., portal hypertension or ascites) and those who refuse an ileostomy, The choice of surgical procedure is individualized on the basis of The patient's underlying physical and medical condition, Social and psychological situation. IPAA First described in 1978 Preferred operation for most patients a.) Removes the diseased colon b.) Preserve fecal continence and Nearly normal defecation through the anus. Construction of the ileal pouch is the key to the success of this operation: The pouch provides a fecal reservoir that is adequate to allow voluntary defecation, Defecation at higher (but still manageable) daily frequency than is seen in patients with an intact rectum. In almost all series, the majority of IPAA patients report good functional results and a high degree of satisfaction with quality of life,

12. Emergent surgery or poor medical condition Three-stage procedure is performed. Stage I= total abdominal colectomy with a Hartmann closure and an end ileostomy ( meds tapered, Stage II= entailing either a completion proctectomy with end ileostomy or an IPAA with diverting loop ileostomy—is carried out. Stage III, which involves reversal of the ileostomy. why a proctectomy is not performed? If the rectum is left in place, a restorative operation can be performed later without the dissection planes in the pelvis having been disturbed. Emergency proctectomy is associated with a higher risk of bleeding and injury to the nerves of the pelvic floor, the bladder, and the genitalia.

13. Special considerations and Patient Selection Age Bimodal age distribution,. Many institutions have reported their long-term results with IPAA, few have regularly performed IPAA in elderly patients. Study In a Mayo Clinic survey of 1,386 patients who underwent IPAA, the median age at the time of operation was 32 years (range, 5 to 65 years) only 16% were older than 45 years, and none were older than 65 years. Functional outcomes— 1.) Determined on the basis of nocturnal stool frequency, daytime and nocturnal incontinence, 2.) Need for constipating medications—were significantly worse in patients who were older than 45 years at the time of the IPAA. 3.) Overall, advanced age is not an absolute contraindication to IPAA. The data suggest that in healthy older patients with good sphincter tone, functional results may be comparable to those in younger patients.

14. Fertility and Fecundity Fertility and fecundity A number of studies have evaluated fertility and the course of subsequent pregnancy after surgical treatment of Proctocolectomy with an end ileostomy or a Kock pouch can expect to have a normal pregnancy and delivery Patients often experience temporary stoma or Kock pouch dysfunction. Studies documented similar dysfunction in post-IPAA patients, who reported a slight increase in stool frequency, incontinence, and pad usage during pregnancy One analysis of the rate of pregnancy after IPAA reported a significant reduction in postoperative fertility. Women considering undergoing IPAA should be informed of the possibility of decreased fertility.

15. Technical Controversies Technical Controversies 1.) Choice of anastomotic technique and the question of whether a diverting ileostomy is needed. Depends on the patient's clinical situation and the surgeon's preference. a.) Double-stapled technique is easier to perform than a mucosectomy with a handsewn anastomosis and yields superior functional results in terms of episodes of incontinence or soiling. The double-stapled IPAA Had higher resting sphincter pressures (as measured by manometry) Tended to experience less nocturnal incontinence. Mucosectomy Proponents of handsewn anastomosis believe that this operation removes all of the anal canal mucosa at risk, Even after mucosectomy, islands of residual rectal mucosa remain.25,26 Taken as a whole, the evidence available at present suggests that double-stapled IPAA might yield slightly better functional results than handsewn IPAA.

16. A discussion of temporal ileosotmy v.s. a one stage procedure Questioned in several quarters. In most large series Ileostomy Goal: Divert the fecal stream from the pouch while the pouch staple line and the anastomosis heal. a.) decreases the rate of pelvic sepsis. One stage procedure , IPAA can be performed without an increased risk of pelvic sepsis. Avoids a second hospitalization and operation unnecessary, Lowers the total cost, Results in a shorter hospital stay, Decreases the incidence of small bowel obstruction. NOTE: In one large single-institution study, there were no differences in complication rate and functional outcome between patients who had not undergone diversion and those who had, nor was there any correlation between diversion and steroid use. Others have reported similar findings. Studys also demonstrate complications more sever if no protecting end ileostomy

17. Operative procedure (1) Removal of the intra-abdominal colon; (2) Dissection and removal of the rectum, with the pelvic nerves and the anal sphincter mechanism spared (3) Construction of an ileal reservoir (pouch); (4) Anastomosis of the ileal reservoir to the anal canal.

18. Open Proctocolectomy and Ileal Pouch-Anal Anastomosis Step 1: Initial Incision and Exploration of Abdomen Step 2: Mobilization and Division of Colon Step 3: Dissection and Division of Rectum Step 4: Construction of Ileal Pouch Step 5: Construction of Ileal Pouch-Anal Anastomosis Step 6: Later Reversal of Loop Ileostomy

19. Step 3 dissection and division

21. Laparoscopic Proctocolectomy and Ileal Pouch-Anal Anastomosis In more than 70 CUC patients since the initial pilot study involving seven patients. The indications for operative intervention The same for the laparoscopic approach as for the open approach. In a case-matched series of 40 patients undergoing laparoscopic IPAA, each of whom was matched to two open IPAA patients (with disease, age, gender, BMI, and date of operation controlled for), The laparoscopic group experienced significant benefits Time to clear liquid ingestion (1 versus 3 days; P < 0.001), Time to resumption of regular diet (3 versus 4 days; P < 0.001), Time to restoration of bowel function (2 versus 3 days; P < 0.001). The duration of narcotic use was shorter in the laparoscopic group (P < 0.001), length of stay was reduced as well (4 versus 7 days; P < 0.001). Operating time was longer in the laparoscopic group (270 versus 192 minutes; P < 0.001), but it decreased as the surgeon gained experience with the procedure, reaching an average of 3 to 3.5 hours. Other authors are reporting similar advantages.

22. Laparoscopic Proctocolectomy and Ileal Pouch-Anal Anastomosis Step 1: Placement of Trocars and Exploration of Abdomen Step 2: Mobilization of Intra-abdominal Colon Step 3: Pelvic Dissection Step 4: Exteriorization and Resection of Colon and Rectum; Creation of Pouch Step 5: Construction of Ileal Pouch-Anal Anastomosis

23. Postoperative day 1 a.) Clear liquids if no nausea and not distended. b.) Low-fiber diet is instituted on the following day. c.) Communication with the enterostomal therapist is important:

24. Complications Small bowel obstruction Leak Anastomotic strictures Fistulas Pouchitis

25. Complications The most common short-term and long-term = small bowel obstruction. Pouch leakage 1.) Associated pelvic sepsis are potentially devastating complications after IPAA. 2.) Incidence ranges from 5% to 14%. 3.) Majority (63%) of these patients required operative intervention; the remainder were treated with either antibiotics or a combination of antibiotics and CT-guided drainage. 4.) In this series and others, the rate of pouch leaks and episodes of pelvic sepsis declined as experience with the procedure increased. Anastomotic Stricture. There is no clear correlation between stricture formation and the type of anastomosis performed. anastomotic strictures can be treated with intermittent dilatation, can often be performed by the patient after an initial operative dilatation.

26. Fistulas Extremely difficult to treat. Pouch-vaginal fistulas and, more rarely, pouch-perineal fistulas can occur either in the perioperative period or years later. An early pouch fistula is generally the result of a technical error or a complication of a pouch leak or pelvic abscess. A late pouch fistula raises the possibility of Crohn disease. Most fistulas are low and originate at the level of the anastomosis. appear to occur equally frequently with handsewn anastomoses and with double-stapled anastomoses. The reported incidence of pouch-vaginal fistulas ranges from 4% to 12%. Managing a postpouch fistula are 1.) rule out Crohn disease and to initiate treatment by a surgeon experienced in treating these complications. 2.) exam anesthesia and biopsies performed to rule out the presence of Crohn disease. The basic principles of management are (1) local control of any septic process (2) repair of the fistula by interposing healthy tissue between the pouch and the vagina or the perineal opening. Repair Pouch-vaginal fistulas = transanal, transvaginal, transperineal, and transabdominal approaches, successful closure ranging from 10% to 78% simple interventions, such as seton fistulotomy. Severely symptomatic patients may eventually require pouch diversion or complete pouch excision with end ileostomy.

27. Pouchitis It is an acute inflammatory process of the pouch. < 10% of patients, however, pouchitis can become a chronic process. Chronic pouchitis may eventually lead to pouch failure that necessitates excision. Pouchitis occurs more frequently in patients who have extraintestinal manifestations of CUC than in those who do not incidence between 12% and 50%. Pouchitis = abdominal cramps, increased stool frequency, watery or bloody diarrhea, and flulike symptoms. Requires endoscopic visualization of the pouch, as well as histologic evaluation. The exact cause of pouchitis is unclear, Tx observation that antibiotic therapy (particularly with metronidazole) can successfully treat acute and chronic pouchitis In cases of chronic pouchitis, immunosuppressive agents may have to be added to achieve control of symptoms.

28. Overall Outcome 1.) Most patients report good to excellent pouch function. 2.) Markers of pouch function a.) the number of diurnal and nocturnal bowel movements, b.) the number of episodes of soiling, The number of episodes of incontinence, The extent to which medications are required to control bowel activity.