SURGICAL SURGICAL TREATMENT OF TREATMENT OF

ULCERATIVE COLITISULCERATIVE COLITIS

S. S. BaratsisBaratsis

First Department of Surgery First Department of Surgery Evangelismos HospitalEvangelismos Hospital

Athens, GreeceAthens, Greece

SURGICAL TREATMENT OF SURGICAL TREATMENT OF ULCERATIVE COLITISULCERATIVE COLITIS

Affects the mucosa of the colon and Affects the mucosa of the colon and rectumrectumAssociated with extraAssociated with extra--intestinal intestinal manifestationsmanifestationsPresented as:Presented as:

a)a) Acute colitis with or without Acute colitis with or without complicationscomplications

b)b) Chronic diseaseChronic disease

Surgery in ulcerative colitisSurgery in ulcerative colitis

a.a. Is curative for the enteric component of Is curative for the enteric component of the disease the disease

b.b. Eliminates most of the extraintestinal Eliminates most of the extraintestinal manifestationsmanifestations

c.c. Eliminates the risk of malignancyEliminates the risk of malignancy

INDICATIONS OF SURGERYINDICATIONS OF SURGERY

Treatment of acute colitis refractory to Treatment of acute colitis refractory to conservative treatment conservative treatment Treatment of chronic colitis in symptomatic Treatment of chronic colitis in symptomatic disease when is poorly controlled or because disease when is poorly controlled or because of side effects of conservative therapy of side effects of conservative therapy Prophylactically to avoid development of Prophylactically to avoid development of cancer in long standing symptomatic or cancer in long standing symptomatic or asymptomatic disease asymptomatic disease

Conservative Treatment of UCConservative Treatment of UCThe philosophy is The philosophy is ““saving the colonsaving the colon”” by by drug therapydrug therapySeveral Questions arise:Several Questions arise:1. 1. Is this always possible ?Is this always possible ?2.2. What about side effects of the drugs ?What about side effects of the drugs ?3.3. Conservative treatment for how long ?Conservative treatment for how long ?4.4. Are the drugs always effective ?Are the drugs always effective ?5.5. What about the cost of treatment ?What about the cost of treatment ?

( drugs, colonoscopies, biopsies, ( drugs, colonoscopies, biopsies, hospitalisinghospitalising))

6.6. What is the QOL of the patients ?What is the QOL of the patients ?

INDICATIONS FOR SURGERY IN INDICATIONS FOR SURGERY IN THE ACUTE DISEASETHE ACUTE DISEASE

Severe colitis not responding to Severe colitis not responding to medical treatmentmedical treatmentFulminantFulminant colitis with acute colitis with acute abdomenabdomen

a.a. Toxic megacolonToxic megacolonb.b. WalledWalled--off perforationoff perforationc.c. Free perforationFree perforation

Hemorrhage Hemorrhage

INDICATIONS FOR SURGERY INDICATIONS FOR SURGERY IN THE ACUTE DISEASEIN THE ACUTE DISEASE

Absolute indications for surgeryAbsolute indications for surgery

1)1) Severe uncontrolled bleedingSevere uncontrolled bleeding

2)2) Perforation of the bowel, which is the Perforation of the bowel, which is the most fatal complication of acute colitis most fatal complication of acute colitis with or without megacolonwith or without megacolon

ReminderReminder

«« Mortality is raised when the time Mortality is raised when the time between perforation and surgery between perforation and surgery increases increases Persistence with conservative Persistence with conservative treatment by using treatment by using ““second linesecond line””agents can be hazardous agents can be hazardous »»

EMERGENCY SURGERY EMERGENCY SURGERY

Mortality rate :Mortality rate : 20% 20% Before Before 19701970 < 1% < 1% Today Today

What caused this reduction in What caused this reduction in mortality?mortality?

1.1. Enforcement of OXFORDEnforcement of OXFORD’’S 5S 5--day regimeday regime2.2. Change of operative surgery to staged Change of operative surgery to staged

proceduresprocedures3.3. Possibility of using Possibility of using CyACyA

ROLE OF ROLE OF CyACyA IN SEVERE COLITISIN SEVERE COLITIS

ADVANTAGESADVANTAGESCan be used in Can be used in cases refractory to cases refractory to steroidssteroidsRemission obtained Remission obtained in 50in 50--75% of 75% of patients with first patients with first attackattackCan be used as a Can be used as a bridge to elective bridge to elective surgerysurgery

DISADVANTAGESDISADVANTAGESToxicityToxicityLongLong--term results term results disappointingdisappointingAZT ?AZT ?

PREFERRED SURGICAL PROCEDURES IN PREFERRED SURGICAL PROCEDURES IN EMERGENCY SURGERYEMERGENCY SURGERY

Subtotal Subtotal colectomy and colectomy and mucus fistula or mucus fistula or HartmannHartmann

1.1. Lower morbidity and Lower morbidity and mortalitymortality

2.2. Leaves open all options Leaves open all options for future operationsfor future operations

In a few selected In a few selected cases IPAAcases IPAA

SUBTOTAL COLECTOMY AND

MUCUS FISTULA OR

HARTMANN

STAGEDPROCTOCOLECTOMY

IRAIPAA

INDICATIONS FOR ELECTIVE TREATMENTINDICATIONS FOR ELECTIVE TREATMENT

Failure of medical treatmentFailure of medical treatment–– Symptoms inadequately controlled in spite of the intensive Symptoms inadequately controlled in spite of the intensive

medical treatment and the QOL is worseningmedical treatment and the QOL is worsening–– Adequate control of the disease but the risks of chronic Adequate control of the disease but the risks of chronic

therapy may be therapy may be excesiveexcesive occurrence of drugoccurrence of drug--induced induced complicationscomplications

Failure to thrive in childrenFailure to thrive in childrenMalignant transformationMalignant transformation

1.1. CarcinomaCarcinoma2.2. Dysplasia (HGD, LGD)Dysplasia (HGD, LGD)3.3. DALMDALM

Conservative Treatment in Chronic Conservative Treatment in Chronic DiseaseDisease

AZT or 6AZT or 6--MP is back bone of treatmentMP is back bone of treatmentIs safer and better tolerated than steroidsIs safer and better tolerated than steroidsShould not be used in young patients who are Should not be used in young patients who are candidates for surgery candidates for surgery Also in patients unreliable to return for periodic Also in patients unreliable to return for periodic monitoringmonitoringNot effective in all patientsNot effective in all patientsThey have significant side effects They have significant side effects –– Lymphoma ???Lymphoma ???Relapse of UC if AZT is stopped Relapse of UC if AZT is stopped AZT for how long?AZT for how long?

Refractory Ulcerative ColitisRefractory Ulcerative Colitis

““ Surgery should not be put off as a last Surgery should not be put off as a last resort resort butbut should be part of overall should be part of overall

treatment plan treatment plan ””

Cancer risk factorsCancer risk factors

Extend of diseaseExtend of diseaseDurationDurationFamily history of colorectal CaFamily history of colorectal CaP.S. P.S. CholangitisCholangitisDeficiency of Folic AcidDeficiency of Folic Acid

Prevention of Ca in UCPrevention of Ca in UC

Colonoscopy every one or two yearsColonoscopy every one or two yearsEarly detection of Early detection of dysplasiadysplasia–– LGDLGD–– HGDHGD–– DALMDALMDetection of Detection of adenomatousadenomatous polypspolypsLGD in symptomatic stricture or LGD in symptomatic stricture or impassable by colonoscopyimpassable by colonoscopyProtective role of 5Protective role of 5--ASA, 6ASA, 6--MP, Folic AcidMP, Folic Acid

OPERATIONS IN ELECTIVE CASES OF UC

PROCTOCOLECTOMY AND ILEOSTOMY

SPHINCTER-SAVINGPROCEDURES

KOCK ILEOSTOMY

BROOKEILEOSTOMY

IRAIPAA

DOUBLESTAPLING MUCOSECTOMY

IlealIleal Pouch Anal Pouch Anal AnastomosisAnastomosis (IPAA)(IPAA)

ComplicationsComplications

MortalityMortality(1%)(1%)MorbidityMorbidity(13(13--58%)58%)

Intestinal obstructionIntestinal obstruction(10(10--22%)22%)Pelvic sepsis Pelvic sepsis ( 5( 5--17%)17%)StenosisStenosis (4(4--16%)16%)FistulaFistula (5(5--10%)10%)PouchitisPouchitis (7(7--46%)46%)Complications related to Complications related to ileostomyileostomy

Failure5%

IlealIleal Pouch Anal Pouch Anal AnastomosisAnastomosis (IPAA)(IPAA)

Complications relatedComplications relatedto pouchto pouch

StrictureStricture

Soft stricturesSoft strictures:: commoncommonPrevention (mild dilatation)Prevention (mild dilatation)

Significant Significant stenosisstenosis : 4: 4--16%16%Dilatation under general anesthesiaDilatation under general anesthesia

(60%) (60%) Major operation rarely neededMajor operation rarely needed

IlealIleal Pouch Anal Pouch Anal AnastomosisAnastomosis (IPAA)(IPAA)

Complications related toComplications related topouchpouch

SepsisSepsisPelvic SepsisPelvic Sepsis (5(5--6%)6%)Pelvic collection Pelvic collection (6%)(6%)

Conservative treatmentConservative treatment::Pouch preservePouch preserve 92%92%

ReoperationReoperation::Pouch excisionPouch excision: 41%: 41%

Satisfactory functionSatisfactory function: 29%: 29%

POUCH DYSFUNCTION POUCH DYSFUNCTION

Without Without pouchitispouchitisSmall bowel Small bowel dysfunctiondysfunctionProblems at the Problems at the pouchpouchProblems at the Problems at the exit of the pouch exit of the pouch

PouchitisPouchitisDistinctive clinical Distinctive clinical syndrome (clinical syndrome (clinical endoscopicendoscopic and and pathology findings)pathology findings)3535--50% of patients with 50% of patients with IPAA will have at least IPAA will have at least one episode of one episode of pouchitispouchitisin the first 10 years after in the first 10 years after the operationthe operationEvery effort must be Every effort must be made for a conservative made for a conservative treatment, based on treatment, based on antibiotics, and topical antibiotics, and topical agentsagents

Treatment of Treatment of pouchitispouchitisAntibioticsAntibiotics–– MetronidazoleMetronidazole–– CiprofloxacinCiprofloxacin–– ClarithromycinClarithromycin–– etcetc

EnemasEnemas–– BudesonideBudesonide–– MetronidazoleMetronidazole–– 55--ASAASA–– Short chain fatty acidsShort chain fatty acids

Novel treatmentsNovel treatments–– BismuthBismuth–– ProbioticsProbiotics (VSL # 3)(VSL # 3)–– PrebioticsPrebiotics–– AntiAnti--TNFTNF

PouchitisPouchitis: : Response to TreatmentResponse to Treatment

11Excision of pouchExcision of pouch

11Diversion Diversion ileostomyileostomy

Surgical treatmentSurgical treatment

88Continuous treatmentContinuous treatment

3030Response to repetitive schemesResponse to repetitive schemes

6060Response to single therapeutic schemeResponse to single therapeutic scheme

Conservative treatmentConservative treatment

% % patientspatientsType of treatmentType of treatment

Michelassi F et al Ann Surg 2003

Ulcerative ColitisUlcerative ColitisExperience of 1Experience of 1stst Surgical Department of Surgical Department of

““EVAGGELISMOSEVAGGELISMOS”” General HospitalGeneral HospitalIlealIleal Pouch Anal Pouch Anal AnastomosisAnastomosis

EXPERIENCE OF A SINGLE SURGEONEXPERIENCE OF A SINGLE SURGEON

PeriodPeriod 19819833--20020066OperationsOperations:: 463463MaleMale:: 217217FemaleFemale:: 246246AgeAge: 12: 12--8282 yy

ULCERATIVE COLITISULCERATIVE COLITIS-- OPERATIONSOPERATIONS

463463Total colectomy + mucosectomyTotal colectomy + mucosectomy ––ileal pouch anal anastomosisileal pouch anal anastomosis

1166Subtotal colectomy +Subtotal colectomy + mucous fistulamucous fistula

1144Subtotal colectomySubtotal colectomy –– ileoanal ileoanal anastomosisanastomosis

1144ProctocolectomyProctocolectomy –– permanent permanent ileostomyileostomy

Total: 507

Ulcerative Colitis Ulcerative Colitis –– Redo operationsRedo operations

ConversionConversion IRA to IPAA IRA to IPAA : 3: 3

Pouch Failure => excision and Pouch Failure => excision and reconstruction of IPAAreconstruction of IPAA: : 88

CONCLUSIONCONCLUSION

Surgery is not a defeat of Medicine, is an Surgery is not a defeat of Medicine, is an alternative treatment modality still very valid.alternative treatment modality still very valid.

The question is to decide which treatment will give The question is to decide which treatment will give the patient the optimal QOL?the patient the optimal QOL?

Difficult to answerDifficult to answerHowever modern surgery offers a definite However modern surgery offers a definite

treatment for UC and the price of loosing the treatment for UC and the price of loosing the colon is in most patients easy to overcome. colon is in most patients easy to overcome.