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SURGICAL MANAGEMENT IN
ULCERATIVE COLITIS
UC & CRC
INCIDENCE
CRC in UC appears at younger age than in sporadic CRC (40-50 yrs old vs 60).
5-10% after 20 years. 12-20% after 30 years.
RISK FACTORS
Duration of the disease Extent of the disease UC complicated by primary sclerosing
cholangitis Presence of post-inflammatory
pseudopolyp
CRC in UC…
Appears as: Polypoid Nodular Ulcerated Plaque like
Mostly adenocarcinoma. Mostly located in the rectum and
sigmoid It arises from areas of dysplasia.
Dysplastic areas may appear flat or slightly raised areas.
Dysplastic areas may occur within or near nodules, masses, polyps or plaque like lesion.
N.B.: Diagnosis of dysplasia in Pre Op colonoscopy has a: 81% sensitivity 79% specifty
Surgical management in UC
Indications for surgery in UC: SURGICAL EMERGENCIES
Massive life threatening hemorrhage Toxic megacolon with impending
perforation Fulminant colitis unresponsive to IV
corticosteroids Colonic perforation Total obstruction from stricture
Elective: Intractability despite max therapy. Mucosal dysplasia Dysplasia-associated lesion or mass (DALM) Intolerable side effects of medications Patient with significant risk to develop CRC Stricture formation without obstruction
Extraintestinal manifestations Growth retardation, primarily in children
and adolescents
Surgical Options
Emergency operation:
Subtotal colectomy with end ileostomy Proctocolectomy with end ileostomy Blow-hole colostomy with end ileostomy
Subtotal colectomy with end ileostomy
Advantages : Allows option for IPAA; low risk Disadvantages :
Requires second operation may develop rectal recurrence of disease
Contraindication : Massive hemorrhage from colon and rectum
Proctocolectomy with end ileostomy:
Advantages: Definitive treatment Disadvantages :
No option for IPAA moderate risk for perineal nerve damage
Contraindication : Severely toxic or unstable patient
Blow-hole colostomy with end ileostomy
Advantages: Short, simple decompression procedure
Disadvantages : Diseased colon and rectum retained
ELECTIVE PROCEDURES
Total proctocolectomy with Brooke ileostomy Subtotal colectomy with ileorectal anastomosis Total proctocolectomy with Kock pouch Total colectomy, mucosal proctectomy and
hand-sewn IPAA with temporary diverting loop ileostomy (two-stage operation)
Total proctocolectomy without mucosectomy and stapled IPAA with temporary diverting loop ileostomy (two-stage operation)
Laparoscopic total proctocolectomy with or without mucosectomy and IPAA
Total proctocolectomy with Brooke ileostomy
Indications : Patients wanting to avoid risks of IPAA; elderly; poor sphincter function; rectal cancer
Contraindications :Patient aversion to permanent ileostomy; obesity; life-threatening emergencies
Advantages: Eliminates all disease-bearing mucosa; single operation
Disadvantages: Potential for nerve injury in the perineal and pelvic dissection; permanent ileostomy; delayed perineal wound healing; mechanical problems with stoma; high risk of SBO
Subtotal colectomy with ileorectal anastomosis
Indications: No rectal involvement; avoid permanent stoma and IPAA; young women of childbearing age to preserve fertility
Contraindications : Poor sphincter tone or dysfunction; active rectal or perianal disease; colonic or rectal dysplasia; or frank cancer
Advantages: One-stage operation; complete continence with good function; low risk of pelvic nerve injury; eliminates stoma.
Disadvantages: 30% Recurrence rate requiring conversion to
ileostomy Risk of rectal cancer requiring lifelong
surveillance
Total proctocolectomy with Kock pouch
Indications : Alternative to conventional ileostomy for patients desiring to preserve continence; poor sphincter tone; low rectal cancer; failed IPAA; conversion from ileostomy
Contraindications : Possibility of Crohn's disease; previous resection of small bowel; patients over 60 years old; obesity; coexisting medical illness
Advantages: Avoids ileostomy; patients remain continent; good quality of live; improved body image over ileostomy
Disadvantages: High reoperation rate (35%) due to nipple valve dysfunction or failure; high fistula rate; pouchitis
Total Proctocolectomy with Ileal Pouch–Anal Anastomosis
Indications : Procedure of choice for ulcerative colitis; colonic dysplasia or cancer; indeterminate colitis
Contraindications : Poor resting tone or anal sphincter dysfunction; low rectal cancers
Advantages: Completely restorative; mucosectomy eliminates all disease-bearing mucosa; no disease recurrence; no cancer risk; good function, continence, and quality of life.
Disadvantages: Two-stage procedurepotential for nerve injury in the perineal
and pelvic dissectionreduced fertility in femalesmucosectomy and hand-sewn IPAA are
technically demanding and difficult to learn
septic complicationspouchitis
Operative Techniques:
Stage I : abdominal colectomy, mucosal proctectomy, endorectal IPAA, and diverting loop ileostomy
Stage II : clousre of ileostomy
preoperative work-up anal manometry Sigmoidoscopy bowel preparation
The Lone Star retractor
construction of the ileal pouch
ileal J-pouch faster less tedious to create use considerably less ileum have similar or better functional results
than other pouch configurations.
Post-IPAA: 4 weeks after - barium radiographic study 8 weeks after - anal manometry + clousre
of ileostomy 1 – 3 – 6 – 12 month F/U then every year flexible fiberoptic pouchoscopy with
surveillance biopsies of the ileal pouch approximately every 5 years.
Complications
Pouch Failure Pouchitis Crohn's Disease dysplasia and carcinoma of the ileal
pouch
Pouch Failure
significant long-term complication of IPAA Prior anal pathology Abnormal anal manometry Pouch-perineal or pouch-vaginal fistulae Pelvic sepsis Anastomotic stricture, and dehiscence
Brooke ileostomy or Kock pouch
Pouchitis
nonspecific, idiopathic inflammation of the ileal pouch
most common and significant late, long-term complication
> 50% of ulcerative colitis patients Rare in IPAA for FAP
Presentation : stool frequency watery diarrhea fecal urgency Incontinence abdominal cramping fever, and malaise
flexible ileal pouchoscopy
the greatest risk for experiencing an episode is during the initial 6-month period following closure of the temporary diverting loop ileostomy.
Risk continues to rise steadily for the next 18–36 months before leveling off at around 4 years
Management : Broad-spectrum antibiotics
Acute: Ciprofloxacin 250 mg BID Metronidazole 250 mg QID
Chronic: ( treatment for 3 months ) Ciprofloxacin 250 mg OD Metronidazole 250 mg OD topical anti-inflammatory agents, corticosteroids
Refractory : undiagnosed Crohn's disease ?
Crohn's Disease
severe morbidity and a significant risk of pouch excision
Predictors : complex perianal or pouch fistulae ileitis proximal to the pouch Afferent limb ulcers
biological therapies
THANK YOU