 |
       |
|
|
SURGICAL MANAGEMENT OF ULCERATIVE COLITIS
Pinky M Thapar, Surinder K Mathur
General Surgery; Clinical Assistant; Consultant GI Surgeon, Department of Surgical Gastroenterology, Bombay Hospital and Medical Research Centre, New Marine Lines, Mumbai.
INTRODUCTIONUlcerative colitis, a chronic inflammatory disease of the large bowel of unknown aetiology occurs predominantly in young adults.[1] The disease is not uncommon in India Although majority of patients with ulcerative colitis can be managed with medical management, approximately 20-30% of patients ultimately require surgical intervention.[2] In the past, surgery was offered as a last resort, as a result patients were often acutely or chronically ill and severely malnourished, resulting into poor outcome. Today, advances in the understanding of the role and timing of surgery, novel sphincter saving techniques that improve the quality of life after proctocolectomy and improvement in the care of stomas have all contributed to improved results following surgery.
Surgery has a central role in the management of ulcerative colitis because
1.It may save a patient's life.2.It eliminates the long-term risk of cancer.
3.It is curative of the disease.
Surgical intervention in cases of ulcerative colitis is required either as an emergency procedure or as an elective procedure in chronic ulcerative colitis.Indications for Emergency Surgery : Indications are given in Table 1
1.Fulminant Colitis : It is characterized by passage of more than 6 motions per day with blood, together with systemic manifestations like tachycardia, fever and hypoalbuminaemia.[3] These patients are treated with aggressive medical therapy. IV steroids 400 mg daily, steroid enemas and nutritional support. Failure of medical therapy occurs in approximately 40% of patients.4 Surgery should be undertaken if,
a. No significant improvement occurs within24 to 48 hours.
b. Continued deterioration is witnessed.
c. Relapse on consumption of oral diet.
With early operative approach mortality decreases to < than 3%.
2.Toxic megacolon : These patients usually appear severely ill with pulse > 100/minute, temperature more than 38oc and stool frequency > 9/day. Plain x-ray abdomen shows mucosal islands and transverse colonic diameter more than 5 cm.[5] These patients require emergency surgical intervention.
Indications for Elective Surgery : Indications are given in Table 2
Failure of medical therapy : It is the most common indication for surgery.[6] It is reflected by chronic physical disability and physiologic dysfunction. It is characterized by severe and persistent impairment of patient's quality of life, created by underlying disease or treatment required for the disease.
Extra intestinal manifestations : Most of the extracolonic manifestations improve as the disease severity declines. However if they continue to cause symptoms, proctocolectomy should be considered. Erythema nodosum, pyoderma gangrenosum, uveitis, iritis, peripheral neuropathy, vasculitis and sacroilitis regress after proctocolectomy.[10]
1. Fulminant Colitis (10%) -- > 6 motions with blood per day } not responding to
signs of toxemia} medical treatment2. Toxic megacolon (6% -- Transverse colon diameter 5 cms. 3. Perforation (1-3%) -- with or without toxic megacolon. 4. Haemorrhage (1-4%) -- Haemorrhage (1-4%)
1. Failure of medical therapy -failure to respond to medical therapy
-incomplete response
-relapse on reducing the dose of medication
-high dose of steroid requirement
-side effects/intolerance/complications related to medications
-non compliance with medication.2. Obstruction -benign stricture
-malignant stricture3. Risk of cancer -pancolitis of more than 10 year duration in young individuals 4. Growth retardation in children. 5. Extra intestinal manifestations of ulcerative colitis. Risk of cancer : Risk of cancer depends on the age of onset of disease, duration of disease and the extent of disease.[7] The risk of malignancy has been reported to increase 10-20% for every decade after 10 years.[8] The risk is more in patients with the onset of disease before the age of 15 years and patients with pancolitis. Patients with quiescent disease have a higher chance of developing malignancy because these patients do not follow up regularly. Patients with active disease or with repeated exacerbations undergo colectomy earlier and the risk of malignancy is thus eliminated.[9] Therefore there is general agreement that after patients have had the disease for 8-10 years and in those in whom the disease starts by the age of 15 years should either undergo prophylactic proctocolectomy or enter a close surveillance programme.[6],[9]
Extra intestinal manifestations : Erythema nodosum, pyoderma gangrenosum, uveitis, iritis, peripheral neuropathy, vasculitis and sacroilitis regress after proctocolectomy.10
CHOICE OF OPERATIVE PROCEDURES
A wide variety of surgical procedures have been available (Table 3). The choice of surgery depends on when, whether it is performed, as an elective procedure or as an emergency, patient's factors and surgical expertise, latter is particularly true for restorative surgery.
Blow hole colectomy with Ileostomy : Turnbull devised this technique for patients with toxic megacolon in whom due to poor general condition subtotal colectomy is not possible.[11] and also the risk of perforation during colectomy is very high.
Subtotal colectomy : It is the operation of choice in emergency situation[3] because
a.It gets rid of the diseased colon and thus helps in faster recovery.b.It leaves the option of restorative proctectomy at second stage.
Emergency Elective 1. Blowhole colostomy with Ileostomy 1. Proctocolectomy with Brooke's ileostomy. 2. Subtotal colectomy with:
- Hartmann's procedure
- Mucous fistula2. Proctocolectomy with
Kock continent ileostomy.3. Proctocolectomy with ileostomy 3. Total colectomy with ileorectal anastomosis 4. Total colectomy with rectal mucosectomy with straight ileoanal anastomosis. 5. Total colectomy with rectal mucosectomy with ileal pouch anal anastomosis. c.It can be performed by most general surgeons.
d.It is quick to perform.
It is advisable to leave a long rectal stump and exteriorize it through separate incision in left lower quadrant.Emergency proctocolectomy : In emergency, if massive haemorrhage is present from rectum or if patient is very old and not suitable for later restorative procedure, immediate proctectomy is preferable.[6]
The addition of proctectomy to subtotal colectomy increases the morbidity. The decision should be made on the basis of sigmoidoscopic appearance of the rectum at the time of surgery.
Proctocolectomy with brooke's ileostomy : It was considered as the standard procedure for many years. Its role is limited now but still it has a place in certain conditions.
Indications
1.Elderly patients not suitable for sphincter saving procedure.
2.Medically high risk patients in whom technically complex operations are risky.
3.Patients with malignancy in lower rectum.
4.Patients with significant anal disease, small bowel disease or in whom there is suspicion of Crohn's disease.
5.After failure of restorative surgery.
6.Personal preference of some patients.
7.When expertise to do restorative surgery is not available.
ADVANTAGES
1.Technically simple, low complication rate, can be performed by most general surgeons.
2.It eliminates the risk of disease recurrence and malignancy in colon and rectum.
3.It eliminates the need for anti inflammatory medication.
4.It can be performed as one stage procedure.
DISADVANTAGES
1.Patients have to live with permanent ileostomy.
2.Risk of pelvic nerve injury, perineal wound complications, development of chronic perineal sinus.
3.Psychosocial problems to the patient; particularly in our country, it is difficult to convince patients for permanent ileostomy.
COLECTOMY AND ILEO-RECTAL ANASTOMOSIS
It has a limited role since the introduction of IPAA and Kock's continent ileostomy.
INDICATIONS
1.Patients with rectal sparing disease.
2.Patients not suitable for restorative proctocolectomy due to age or technical reasons but who wish to maintain anal route of defaecation.
3.Patients in whom Crohn's disease cannot be excluded.
4.Patients with advanced malignancy of colon when life expectancy is limited, provided rectum is healthy.
CONTRAINDICATIONS
1.Patients with severe rectal disease; rigid non-pliable rectum.
2.Patients with pre-cancerous changes in colon and rectum.
3.Patients with extra-intestinal manifestations because these persist if the diseased rectal mucosa is not excised.
PROCTOCOLECTOMY WITH KOCK'S CONTINENT ILEOSTOMY
It is an alternative for those patients who would otherwise need Brooke's ileostomy. It includes an ileal reservoir constructed from a 30 cm segment of terminal ileum. Additional 10 cm of intussucepted ileum is interposed between reservoir and stoma.6
INDICATIONS
1.Young patients who have already undergone proctocolectomy.
2.Patients not suitable for ileal pouch and anastomosis (IPAA).
3.Patients with failed IPAA.
ADVANTAGES
1.No external appliance needs to be worn.
2.Patients can empty the reservoir 2-4 times daily, at their own convenience.
DISADVANTAGES
1.10-20% chances for revisional surgery for the valve.
2.Valve complications like slippage, ischaemia, prolapse can occur.
3.Poach related complications like pouchitis, small bowel obstruction, enterocutaneous fistula can occur.
Total colectomy with rectal mucosectomy with straight Ileo-anal anastomosis : This operation originally described by Ravitch and Sabisten in 1947 is done by pulling the ileum through preserved rectal muscle sleeve.[12] It has the complications of severe frequency, perianal irritation, urgency, hence it has become very unpopular.1ILEAL POUCH ANAL ANASTOMOSIS (IPAA)
This procedure, first introduced by Park's and Nicholl's has undergone several modifications. It has become the procedure of choice for most patients because all disease is excised yet trans-anal defaecation and faecal continence are maintained, thus avoiding a permanent stoma.[3] It has got a better psychological and social acceptance. The operation is usually performed in two or three stages, and rarely in one stage. It is suitable for most patients who are younger than 65 years provided they have effective anal sphincter tone.[6],[13]
SURGICAL TECHNIQUE
Salient Features
Proctocolectomy with permanent ileostomyIn proctocolectomy, to avoid the complications of pelvic nerve injury, perineal wound complications, the following steps should be considered.[14]
a.Rectum should be mobilized posteriorly by staying in the avascular plane between the presacral fascia and fascia propria of the rectum.b.Hypogastric nerves lying posterior to the presacral fascia should be protected.
c.To avoid injury to the parasympathetic nerves, below the peritoneal reflection, the mesorectum is divided close to the rectum and staying away from the pelvic sidewalls.
d.Anteriorly dissection should be performed on the rectal side of Denonvillers fascia, thus preserving the sympathetic and parasympathetic nerves.
e.Perineal proctectomy should be done using an intersphincteric technique. This leaves a smaller perineal wound and a stronger pelvic floor and thus lessens the chance of delayed healing.
To avoid the complications of ileostomy, Brooke's devised the technique of spouting ileostomy. If the ileostomy is sufficiently everted, it decreases the incidence of mucocutaneous fistula, excoriation and spillage.6IPAA
Variety of types of pouch reservoir can be made in IPAA. It includes J, H, W, S, K, J pouch (Utsunomiya et al 1980) and has become the most common option because of relative ease in constructing the pouch and also it has comparable functional results to more complex pouch designs.[15] IPAA can be done as a single staged operation in
a.Young, healthy, fit patients.b.Patients not on immunosuppressive drugs.
c.Pouch can be constructed without tension or technical difficulty.
The incidence of complications is higher when a defunctioning stoma is not used. (22% vs. 11%).[6],[15]To prevent involuntary, night time continence :
1.The muscular rectal cuff dissected from above must be preserved beginning just below peritoneal reflection to preserve sufficient internal sphincter.
2.The anastomosis must be performed without tension.
3.The mucosal rectal stump should not be everted to avoid injury to the delicate nerves.
4.Drainage is necessary to prevent fibrosis and scarring.
5.The preservation of ATZ is controversial.[13],[15] Several studies have shown that sphincter is greater when mucosa of proximal anal canal and ATZ is preserved. The debate is in leaving the ATZ, rectal mucosa is at risk of continued inflammation and neoplastic change.
MANAGEMENT OF COLO-RECTAL CARCINOMA IN ULCERATIVE COLITIS
For patients with synchronus, multiple lesions, those with advanced stage of disease (Astler Coller Stage C1 or C2) and those with lower rectal tumours, the operation of choice is total proctocolectomy with permanent ileostomy.[15] In patients with colon and upper rectal malignancy, the decision to perform IPAA should be based on the stage of the tumour. In patients with advanced disease, an anus sparing procedure such as ileostomy and preservation of rectal stump should be performed. Adjuvant chemo therapy should be given and a pouch may be considered 2-3 years later if there is no recurrent disease.[15] Patients with early stage tumour's who do not require radiation therapy attain long term functional results with IPAA comparable to those patients who have an IPAA for benign disease.[15]
COMPLICATIONS FOLLOWING PROCTOCOLECTOMY WITH ILEOSTOMY
Pelvic sepsis, delayed wound healing are common complications. Small bowel obstruction occurs in 9-13% of patients with a mortality of 0.7-3%. Approximately 15% of patients require operative intervention. The common complications requiring revision affect 5-15% of patients.[6] These patients are also prone to chronic dehydration, urinary stone disease and gallstone in the long run.
Complications Following IPAA are given in Table 4.
Pouchitis : It is the most common complication. Incidence varies from 18 to 31%.[13] It means non-specific inflammation of the pouch. It is characterized by spontaneous onset of watery often bloody diarrhoea, increased stool frequency, urgency, soilage, abdominal discomfort and fever. The mean interval from operation to first occurrence is 17 months and nearly 2/3rd of patients have more than 1 episode. The aetiology is not known. Higher recurrence rates are seen in patients with extra intestinal manifestations of ulcerative colitis. Treatment consists of oral antibiotics directed against anaerobic bacteria with response usually seen within 24-48 hours of starting treatment. Sulphasalazine, steroid enemas can be given in refractory cases. Pouch failure can occur in 6-20% of patients6,14 requiring excision and conversion to permanent ileostomy. However the incidence of pouch excision has declined, (average 2-7%) with increasing experience.[14],[16]
FUNCTIONAL RESULTS AND QUALITY OF LIFE
Following proctocolectomy with ileostomy, social, sexual and sporting activities are restricted. 80-90% of patients adapt to these limitations and lead a nearly normal lifestyle.[6],[14]
Following straight ileo anal anastomosis, due to the complications of stool frequency, perianal excoriation etc., the overall satisfaction rate is less. Taylor BM has compared results of straight ileo anal anastomosis v/s ileal pouch anal anastomosis which is given in Table 5.
Following IPAA, 95% patients are satisfied even though the operation is performed in stages. 94% of patients return to work. Social, sporting and sexual activities are higher in patients with IPAA than with Brooke's ileostomy or Kock's pouch. The average stool frequency is 5-6 per day and one in night. Night soiling occurs in 20-30% of patients. IPAA is the procedure of choice in children because the functional results and quality of life are better.[6],[13],[14]
In our experience, 10 patients of ulcerative colitis have undergone IPAA.
The functional results are excellent. The operation was performed in 2 or 3 stages.
Stool frequency has been 3-6 per day.
Night soiling was not seen in any of the patients.
None of the patients had incontinence.
Pouchitis occurred in 1 patient, which responded to treatment.
Anastomotic stricture occurred in 2 patients, which responded to dilatation.
Overall satisfaction was higher in patients with IPAA following closure of ileostomy than before.
Early Late 1. Pelvic infection 5% 1. Pouchitis 18-31% 2. Stricture at anastomotic site 5% 2. Sexual dysfunction 1.5-4% (in males) and 7% (in females). 3. Pouch perineal fistula 5%.
Comparative results of straight ileo anal anastomosis v/s ileal pouch anal anastomosis
Ileal pouch Anal Anastomosis A) Early results:
a) Local sepsis, Leak
b) Stricture
16%
4%11%
5%p v alue B) Late results:
Pouch failure requiring
Conversion to permanent ileostomy
32% 1.3% p<0.01 C) Functional results;
1. Stool frequency
1st 6 months
After 6 months
2.Anal sphincter
Major incontinence
3. Patient satisfaction score
20 ± 2 per day
11 ± 1 per day5%
6.29 ± 1 per day
7 ± 1 per day
5%
8.7p<0.01
p - ns
p<0.02SUMMARY
Most patients regardless of what operation is performed, experience better quality of life due to physical well being, which they experience after surgery.
A variety of operations are available for patients with ulcerative colitis. In emergency situation, sub-total colectomy with ileostomy with mucous fistula or Hartmann's procedure is a procedure of choice, except in patients with toxic megacolon where the general condition of patient is very poor. In these patients, Blow hole colostomy with loop ileostomy is recommended. In elective situation, proctocolectomy with rectal mucosectomy with IPAA has emerged as a gold standard operation. Majority of patients achieve satisfactory continence with excellent quality of life. Although not indicated for every colitic patient, IPAA offers several advantages and seems to be the procedure of choice for many patients. In our country, most patients who require surgical intervention, shy away from surgery because of inability to accept permanent ileostomy for socio-psychological reasons. Patients who are young-married or young-unmarried do not accept permanent ileostomy. IPAA should be the operation of choice for all these patients as it gives satisfactory functional results and freedom from permanent ileostomy.
REFERENCES
1.Goligher JC. Ulcerative colitis. Surgery of the Anus. Rectum and Colon 5th ed. 1984; 805-970.
2.Lee EC, Truelove S. Proctocolectomy for ulcerative colitis. World J Surgery 1980; 4 : 195-98.
3.Hawley PR. Emergency Surgery for ulcerative colitis. World J Surgery 1988; 12 : 169-73.
4.Michetti P, Peppercorn MA. Medical therapy of specific clinical presentations. Gastroenterology Clinic North America 1999; 28 (2) : 353-70.
5.Greenstein AJ, Sachar DE, Giban A, et al. Outcome of toxic dilatation in ulcerative and Crohn's colitis. J Clin Gastroenterol 1988; 7 : 137-44.
6.Juhasz ES, Goudet P, Dozois RR. Surgery in ulcerative colitis in Surgery of the Colon, Rectum and Anus. Mazier WP, Levien DH, Luchtefeld MA, et al. 1st ed; WB Saunders. 1995; 866-81.
7.Ekbom A, Helmick C, Zack M, et al. Ulcerative colitis and colorectal cancer : A population based study. N Eng J Med 1990; 323 : 1228-33.
8.Devroede G. Risk of cancer in inflammatory bowel disease. In Winawer SJ, Schottenfeld D, Sherlock P, eds. Colorectal cancer prevention, Epidemiology and screening. New York, Raven Press. 1980; 325-34.
9.Lewis JD, Deven JL, Lichtenstein GR. Cancer risk in patients with inflammatory bowel disease. Gastroenterology clinics of North America 1999; 28 (2) : 459-77.
10.Danzi JT. Extraintestinal manifestations of idiopathic inflammatory bowel disease. Arch Intern Med 1988; 148 : 297-302.
11.Turnbull RB, Jr. Hawak WA, Weakley FL. Surgical treatment of toxic megacolon. Ileostomy and colostomy to prepare patients for colectomy. Am J Surg 1971; 122 : 325.
12.Ravitch MM, Sabiston DC Jr. Anal ileostomy with preservation of the sphincter : A proposed operation in patients requiring total colectomy for benign lesions. Surg Gynecol Obstet 1947; 84 : 1095-99.
13.Grotz RL, John H, Pemberton. The Ileal pouch operation for ulcerative colitis. Surgical clinics of North America 1993; 73 (5) : 909-32.
14.Robin S, Mc leod. Chronic Ulcerative colitis. Surgical clinics of North America 1993; 73 (5) : 891-908.
15.Ridzuan F, Pemberton JH. Surgical operations in ulcerative colitis. Surgical clinics of North America 1997; 77 (1) : 85-93.
16.Galandiuk S, Scott NA, Dozois RR, et al. Ileal pouch anal anastomosis. Reoperation for pouch related complications. Ann Surg 1990; 212 : 446-54.
 |