Surgical Management in Ulcerative Colitis
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Transcript of Surgical Management in Ulcerative Colitis
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SURGICAL MANAGEMENT IN
ULCERATIVE COLITIS
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UC & CRC
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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.
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RISK FACTORS
Duration of the disease Extent of the disease UC complicated by primary sclerosing
cholangitis Presence of post-inflammatory
pseudopolyp
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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.
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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
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Surgical management in UC
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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
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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
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Extraintestinal manifestations Growth retardation, primarily in children
and adolescents
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Surgical Options
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Emergency operation:
Subtotal colectomy with end ileostomy Proctocolectomy with end ileostomy Blow-hole colostomy with end ileostomy
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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
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Proctocolectomy with end ileostomy:
Advantages: Definitive treatment Disadvantages :
No option for IPAA moderate risk for perineal nerve damage
Contraindication : Severely toxic or unstable patient
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Blow-hole colostomy with end ileostomy
Advantages: Short, simple decompression procedure
Disadvantages : Diseased colon and rectum retained
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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)
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Laparoscopic total proctocolectomy with or without mucosectomy and IPAA
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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
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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.
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Disadvantages: 30% Recurrence rate requiring conversion to
ileostomy Risk of rectal cancer requiring lifelong
surveillance
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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
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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
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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.
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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
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Operative Techniques:
Stage I : abdominal colectomy, mucosal proctectomy, endorectal IPAA, and diverting loop ileostomy
Stage II : clousre of ileostomy
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preoperative work-up anal manometry Sigmoidoscopy bowel preparation
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The Lone Star retractor
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construction of the ileal pouch
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ileal J-pouch faster less tedious to create use considerably less ileum have similar or better functional results
than other pouch configurations.
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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.
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Complications
Pouch Failure Pouchitis Crohn's Disease dysplasia and carcinoma of the ileal
pouch
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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
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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
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Presentation : stool frequency watery diarrhea fecal urgency Incontinence abdominal cramping fever, and malaise
flexible ileal pouchoscopy
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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
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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 ?
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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
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THANK YOU