49
SURGICAL MANAGEMENT IN ULCERATIVE COLITIS

Surgical Management in Ulcerative Colitis

Embed Size (px)

Citation preview

Page 1: Surgical Management in Ulcerative Colitis

SURGICAL MANAGEMENT IN

ULCERATIVE COLITIS

Page 2: Surgical Management in Ulcerative Colitis

UC & CRC

Page 3: Surgical Management in Ulcerative Colitis

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.

Page 4: Surgical Management in Ulcerative Colitis

RISK FACTORS

Duration of the disease Extent of the disease UC complicated by primary sclerosing

cholangitis Presence of post-inflammatory

pseudopolyp

Page 5: Surgical Management in Ulcerative Colitis

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.

Page 6: Surgical Management in Ulcerative Colitis

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

Page 7: Surgical Management in Ulcerative Colitis

Surgical management in UC

Page 8: Surgical Management in Ulcerative Colitis

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

Page 9: Surgical Management in Ulcerative Colitis

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

Page 10: Surgical Management in Ulcerative Colitis

Extraintestinal manifestations Growth retardation, primarily in children

and adolescents

Page 11: Surgical Management in Ulcerative Colitis

Surgical Options

Page 12: Surgical Management in Ulcerative Colitis

Emergency operation:

Subtotal colectomy with end ileostomy Proctocolectomy with end ileostomy Blow-hole colostomy with end ileostomy

Page 13: Surgical Management in Ulcerative Colitis

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

Page 14: Surgical Management in Ulcerative Colitis

Proctocolectomy with end ileostomy:

Advantages: Definitive treatment Disadvantages :

No option for IPAA moderate risk for perineal nerve damage

Contraindication : Severely toxic or unstable patient

Page 15: Surgical Management in Ulcerative Colitis

Blow-hole colostomy with end ileostomy

Advantages: Short, simple decompression procedure

Disadvantages : Diseased colon and rectum retained

Page 16: Surgical Management in Ulcerative Colitis

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)

Page 17: Surgical Management in Ulcerative Colitis

Laparoscopic total proctocolectomy with or without mucosectomy and IPAA

Page 18: Surgical Management in Ulcerative Colitis

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

Page 19: Surgical Management in Ulcerative Colitis
Page 20: Surgical Management in Ulcerative Colitis

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.

Page 21: Surgical Management in Ulcerative Colitis

Disadvantages: 30% Recurrence rate requiring conversion to

ileostomy Risk of rectal cancer requiring lifelong

surveillance

Page 22: Surgical Management in Ulcerative Colitis
Page 23: Surgical Management in Ulcerative Colitis

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

Page 24: Surgical Management in Ulcerative Colitis

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

Page 25: Surgical Management in Ulcerative Colitis
Page 26: Surgical Management in Ulcerative Colitis

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.

Page 27: Surgical Management in Ulcerative Colitis

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

Page 28: Surgical Management in Ulcerative Colitis
Page 29: Surgical Management in Ulcerative Colitis

Operative Techniques:

Stage I : abdominal colectomy, mucosal proctectomy, endorectal IPAA, and diverting loop ileostomy

Stage II : clousre of ileostomy

Page 30: Surgical Management in Ulcerative Colitis

preoperative work-up anal manometry Sigmoidoscopy bowel preparation

Page 31: Surgical Management in Ulcerative Colitis
Page 32: Surgical Management in Ulcerative Colitis
Page 33: Surgical Management in Ulcerative Colitis

The Lone Star retractor

Page 34: Surgical Management in Ulcerative Colitis
Page 35: Surgical Management in Ulcerative Colitis

construction of the ileal pouch

Page 36: Surgical Management in Ulcerative Colitis

ileal J-pouch faster less tedious to create use considerably less ileum have similar or better functional results

than other pouch configurations.

Page 37: Surgical Management in Ulcerative Colitis
Page 38: Surgical Management in Ulcerative Colitis
Page 39: Surgical Management in Ulcerative Colitis
Page 40: Surgical Management in Ulcerative Colitis

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.

Page 41: Surgical Management in Ulcerative Colitis

Complications

Pouch Failure Pouchitis Crohn's Disease dysplasia and carcinoma of the ileal

pouch

Page 42: Surgical Management in Ulcerative Colitis

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

Page 43: Surgical Management in Ulcerative Colitis

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

Page 44: Surgical Management in Ulcerative Colitis

Presentation : stool frequency watery diarrhea fecal urgency Incontinence abdominal cramping fever, and malaise

flexible ileal pouchoscopy

Page 45: Surgical Management in Ulcerative Colitis
Page 46: Surgical Management in Ulcerative Colitis

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

Page 47: Surgical Management in Ulcerative Colitis

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 ?

Page 48: Surgical Management in Ulcerative Colitis

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

Page 49: Surgical Management in Ulcerative Colitis

THANK YOU