 |
       |
|
|
SURGERY FOR ULCERATIVE COLITIS : Our Experience
R D Bapat, C V Kantharia, G D Bakhshi
Dept of General Surgery and Gastroenterology, Seth GS Medical College and KEM Hospital, Parel, Mumbai - 400 012.
Ulcerative colitis is an inflammatory disease of the large bowel, its clinical course is characterised by clinical remission and exacerbation. Though the reported incidence in India is 9-10 per 10,000 hospital admission by Chuttani et al[1] and 1.3% in patients attending gastroenterology clinics in India.[2] Our institution sees 25-30 newly detected cases of ulcerative colitis per year. The reason for the reported low incidence in literature is either the non availability of diagnostic measures or the rampant prevalence of specific viral diarrhoeal diseases and dysenteries which mask disease in our population.[1]INDICATION OF SURGERY
Only 10-15% of patients with ulcerative colitis require surgical treatment. Depending upon the nature of illness whether acute or chronic, various indications have been described.
The
criteria for elective surgery are
Criteria for emergency surgery
- Toxic megacolon
- Perforation.
- Severe bleeding per rectum
Surgical treatment
The aim of surgery in ulcerative colitis is
- To excise all the diseased tissue.
- To restore continuity.
- It should be functionally normal.
- It should be socially and psychologically acceptable.
- It should facilitate early return to normal activity.
The standard surgical options available and practised are :
- Colectomy with Kock's continent ileostomy.
- Colectomy with ileorectal anastomoses.
- Restorative proctocolectomy with or without ileal pouch.
From Brook's ileostomy to restorative protocolectomy, various surgical techniques are available to treat ulcerative colitis.
Ileostomy has many obvious disadvantages and patient compliance is poor.
In India, AIIMS, New Delhi has studied the cost effectiveness of this procedure as it is vital in our set-up.[3] An Indian patient has to spend an extra Rs.400/- per month (range 200-2000/-) for the care of their ileostomies. It is difficult to procure the bags which are costly and are poor quality. Travel is difficult because of lack of facilities for the change of bags. They avoid visiting religious places because it is difficult to bend down and thepresence of bag gives them a feeling of uncleanliness. Similarly, social visits are avoided. So ileostomy after colectomy is unlikely to be accepted in India for the treatment of benign disease like ulcerative colitis.
Kock's continent pouches, avoid the disadvantages of external stomal appliance, but yet it has all the other shortcomings of ileostomy. In addition it has a high incidence of failure rate and intraabdominal complications. Concept of catheterisation of pouches is also not suitable to our patients.
Ileorectal anastomosis though restores the continuity of the bowel, has the disadvantages of leaving behind potential organ for the recurrence of disease in rectum.[4] Proctitis and proctosigmoiditis is the commonest presentation in Indian scene. So leaving behind rectum is out of question. In addition risk of development of malignancy in left over rectum is nil at the end of 10 years 6% at 20 years 9% at 25 years, 15% at 30 years 18% at 35 years and 32 æ 13% at the end of 43 years as is shown in study in Sinclair et al. Though the incidence is less compared to unoperated colitis bowel, still the risk is heavy which needs regular follow-up. Our unreliable patients cannot be thrown into this risk.
Ileoanal anastomoses with pouch has its own disadvantages. They are :
Our approach considers all pros and cons of different surgeries. We at our institute adopted single stage total colectomy rectal mucosectomy and straight ileoanal anastomoses as our approach in chronic cases of ulcerative colitis and two stage surgery in acute cases.
Straight ileoanal anastomosis after colectomy and rectal mucosectomy maintains the normal passage of faecal flow, eradicates the disease, protects the patients from complication and eliminates the complications of proctectomy.
It is simpler, less time consuming, technically easier operation with good functional results.[5] Though there is a certain degree of complications like pelvic sepsis, it should not bar the surgeon from proceeding with the concept. This septic complication is bound to be there as in any other colonic or pelvic bowel surgery.
The philosophy behind adopting this procedure is :
- Poor compliance of patients with ostomy.
- Indian dietic habit is high in residue.
- Incidence of constipation is low in our popula tion.
- It being easy to perform (hand sewn anastomoses).
- Requires less time.
- One stage procedure being always preferred in chronic cases and two stage procedure in acute cases.
- Extra peritonealisation being easy and better.
Besides this the physiological rationale of our technique was :
- Maintenance of anal sphincter.
- Anorectal angulation
- Capacity of rectum.
Sensory mechanism detecting the quality of rectal contents.
HAND SEWN ANASTOMOSES
Hand sewn anastomoses was done in all the patients of our study, however with the advent of staplers, many groups have advocated doing stapled anastomoses. A stapler may help considerably in reducing the duration of surgery but result of surgery does not vary with the technique, beside majority of our population cannot afford stapler. Also the innovations described in our techniques makes the hand sewn anastomoses feasible and easy. In a recent study published in British Journal of Surgery, comparing the results of the techniques it was found that there is no difference in the outcome. But stapler anastomoses had significantly high incidence of complications viz. anastomotic stricture as compared to hand sewn anastomoses. Postoperative complication occurred in 50% of patients in hand sewn group as against 60% in stapler group. Anastomotic stricture necessitating dilatation was in 1:4 ratio in hand sewn versus stapler anastomoses. In study in Britain in 1991.[6] Moreover staplers are expensive ranging from Rs.10,000/- to Rs.15,000/- which is not affordable by an average Indian.
Innovation in our technique of straight ileoanal anastomoses
- Use of right angled bronchial clamps for holding and lifting the rectal stump. It occludes and provides homeostasis during mucosal dissection and facilitates easy anastomosis within the depth of pelvis.
- Dissection with injection of plain saline using blind needle which helps in rectal mucosectomy.
- .The oblique cut on ileum with fish mouthing keeping more mesenteric border than antimesenteric border to ensure adequate blood supply. This also helps in overcoming the discrepancy between the two lumens to be anastomosed.
- Placement of soft flatus tube across the anastomosis till the return of peristalsis which helps in drainage of any collection in ileum.
- Extra peritonealisation of anastomosis.
Our Data
A total of 43 patients were operated by this technique, of which 33 were males and 10 were females. Nine of these patients presented with acute presentation of ulcerative colitis and were treated with steroids. Thirty four patients were operated by a single stage total colectomy and rectal mucosectomy and straight ileoanal anastomoses whereas nine patients underwent two staged procedure involving initial defunctioning ileostomy followed by total colectomy and rectal mucosectomy and straight ileoanal anastomoses.
Complications / mortality
Of the 43 patients operated six of them expired, two due to septicaemia, two due to leak and two deaths were not related to surgery. Of the remaining 37 patients; two of them had anastomotic leaks which were treated conservatively. Four had minor wound infections and two had strictures at the anastomotic site which responded to dilatation.
Follow-up results
The parameters assessed were :
- Frequency and nature of stools
- Need of anti-diarrhoeal.
- Weight gain.
- Impotence
- Colonisation of anastomosed ileum.
The frequency of stools in postoperative period progressively decreased in all surviving patients. From the mean frequency of 10/day in preoperative period the stool frequency decreased to 2-3/day with one or no nocturnal evacuation at the end of one year. This decrease in frequency is attributed to the adaptive changes in the distal ileum.
The mean frequency of stools in patients after one year of surgery is comparable to western patients with pelvic ileal reservoirs. This is in sharp contrast to mean frequency of 8-10/day in western patients with straight ileo-anal anastomoses. Our patients without pelvic ileal reservoirs behaved in the same way as the western patients with pouches, which suggests that pouches are not required in our patients. Less frequency of evacuation in our patients may be due to high fibre, high residue content in our diet. Improvement in the consistency of stools is associated with decrease in the frequency of evacuation. Increase in the residue content of food in Western diet resulted in decrease in frequency of stools in their patients too.
When some patients were passing liquid stools, in initial postoperative months they needed antidiarrhoeal agents. They were routinely given loperamide in the first few months. As the stools became semisolid, it was gradually withdrawn and none of the patients needed antidiarrhoeals at the end of one year.
Incontinence was never a problem in the patients in present study. All patients were spontaneously evacuating their bowel. There was no leakage of stools.
Weight gain
All our patients gained weight progressively. But significant weight gain was observed at the end of six months, after which weight remained either static or mildly increased. This is as a result of reversion to positive nitrogen balance after definitive surgery due to arrest of haemorrhage, no protein loss in the stools and better nutrition.
Impotence and bladder dysfunction
This is known to occur after pull through proctectomy due to disruption of pelvic autonomic nerves. But in mucosal proctectomy dissection is limited to the submucosal plane in the rectum, hence the nerves are not disturbed. In this study none of the patients had sexual dysfunction.
Colonisation of terminal ileum
One of the very important finding that was discovered in this study was colonisation of distal ileum. This adaptive changes of colonisation appear to begin from the anastomotic site and progressively ascend proximally. Four diagnostic criteria had been used to demonstrate colonisation. They are radiological, endoscopy, histopathologic and histochemical studies.
Barium studies
On barium studies, the anastomosed terminal ileum, showed progressive ballooning and assumed rectosigmoid appearance with complete disappearance of ileal characteristics in all the patients. Ileum developed haustrations which were evident on barium enema.
Endoscopic study
Sequential per rectal ileoscopies revealed loss of ileal folds, roomy distal segment and gradual transformation into a colonic type of mucosa with haustral pattern. In all patients the terminal ileum developed a pattern similar to the segment containing Houston's valve.
Histologic study
All patients showed progressive transformation from ileal to colonic type of mucosa, the changes being most marked distally. There was progressive blunting of villi and ultimately their disappearance. Increasing goblet cell population and moderate mononuclear cell infiltration of lamina propria. These changes were seen in first follow-up biopsies and progressed gradually such that at the end of one year all biopsy specimens above the anastomotic site were devoid of ileal features. Total colonisation was seen to ascend proximally.
Histochemical changes
Histochemical study was carried out by staining biopsy specimen with haematoxylin and eosin and high iron diamine (HID) followed by alcian blue (AB) at pH 2.5. This staining pattern distinguishes colonic sulphated mucin (staining brown black) from small intestinal non-sulphated sialic acid mucus (staining blue).
Three months after surgery, HID / AB staining of terminal ileal biopsy specimen revealed small intestinal nonsulphated sialic acid mucin staining blue despite the histological features of early colonisation. Subsequently sulphated mucin staining brown colour started appearing initially just above the anastomotic side and later more proximally too. At the end of 1 1/2 - 2 years histochemical evidence of total colonisation was seen in terminal 10-12 cm of ileum.
Two years after the surgery, two patients came back with bleeding P/R. Per rectal ileoscopy was done in both the patients which revealed gross changes of colitis in colonised ileum just above the anastomotic site, which showed changes of mucosal erosions, crypt abscesses depletion of goblet cell population in comparison to previous biopsy - features resembling ulcerative colitis. HID / AB staining revealed inflammatory changes in colonised small bowel. Both patients responded to short term oral steroid therapy following which there is no histological and clinical recurrence till date.
Thus the colonisation of ileum which takes place is proved not only radiologically and endoscopically but also histochemically.
CONCLUSIONS
- Our technique of total colectomy, rectal mucosectomy and straight ileoanal anastomoses is an innovative and ideal approach for surgical management of ulcerative colitis suited to our Indian habits.
- It is technically easy, less time consuming and with less complication rate.
- The functional results of our procedure are good allowing our patient to live a normal or near normal life.
- The colonisation of the anastomosed distal ileum noted in the follow up study is proved not only radiologically but also endoscopically, histologically and histochemically. It seems to ascend proximally starting from anastomatic site.
- Recurrence of disease though of minor magnitude is noted in terminal anastomosed ileum which responds to steroid therapy.
REFERENCES
- HK Chuttani et al. Ulcerative colitis in tropics. Br MJ Oct., 1967; 4 : 204.
- FP Antia et al. Ulcerative colitis - Prevalence in socioeconomic groups. Indian J Gastroenterology 1985; 4 (1).
- Surgery for ulcerative colitis, Editoral. Tropical gastroenterology. 1991; 12 (3).
- Comparison of morbidity and function after colectomy with ileorectal anastomosis or restorative proctocolectomy for UC and FA polyposis. BJS July, 1991; 78.
- Current status of mucosal proctectomy and ileoanal anastomosis in the surgical treatment of ulcerative colitis. NS William's BJS March. 1985; 72.
Prospective randomised trial comparing anal function after hand sewn ileoanal anastomosis with mucosectomy versus stapled ileo-anal anastomosis without mucosectomy in restorative proctocolectomy. BJS April, 1991; 78 : 430-4.
 |
