Surgical Management of Inflammatory Bowel Disease (Ulcerative Colitis)
Presented by: Happy Kagathara
14/09/2013
Department of Surgical Gastroenterology and Liver Transplantation,
Sir Ganga Ram Hospital, New Delhi
• Introduction
• Indications
• Pre-op preparation
• Surgery in emergency
• Elective surgical options
• Controversial issues
Introduction
• Contiguous inflammation of the colorectal mucosa
• Confined to the mucosal and sub-mucosa and always start from and involve the rectum
• Disease distribution– Proctitis / Procto-sigmoiditis – 45-50%– Left-sided colitis – 17-40%– Pan-colitis – 15-35%
• Clinically manifests as – Diarrhoea, abdominal pain, fever, weight loss, rectal
bleeding
• Removal of the affected organ is curative – Surgery has pivotal position
Indications
• Failure of medical management– Symptoms are not controlled
– Development of side effects or complications
• Cancer risk– Incidence - 6%
– Multiple
– Stricture – Harbor dysplasia or cancer
• Toxic megacolon– Incidence - 16%
– In pancolitis
– Surgery – 15%
• Hemorrhage– Uncommon - 6%-10%
• Perforation– In 2-3% of hospitalized UC pts
Pre-op Preparation
– Correcting anemia, fluid depletion, electrolyte and acid-base disorders, and nutritional deficiencies.
– Many pts require TPN and bowel rest – Eating may worsen symptoms – Difficult to demonstrate a significant impact on outcome
Dayton, MT. Problems in General Surgery. 1999;16:40.
– Most drugs can be discontinued without sequelae except corticosteroids
– Infliximab + Cyclosporin vs infliximab alone before surgery – Combination therapy has increased morbidity
Schluender SJ, Ippoliti A et al. Dis Colon Rectum. 2007;50(11):1747
– Three-stage IPAA is the optimal approach for pre-op combination therapy that includes infliximab
Selvasekar CR, Cima RR et al. J Am Coll Surg. 2007;204(5):956.
– Ostomy site selection by stoma therapist
– Mechanical bowel preparation• Not necessary
– Antimicrobial prophylaxis
Surgery in emergency
• Aim– Treatment of the fulminant state
– Restoration to previous state of health to perform a future restorative procedure
• The primary procedure– Total abdominal colectomy + End ileostomy, + Rectal
stump left behind.
• Avoid pouch formation– High doses of steroids (> 40 mg/day) and nutritionally
depleted• Able to discontinue all medications
• Preserve ileal branches of the ileo-colic vessels– For pouch construction
• Not necessary to mobilize the rectum– Decrease pelvic sepsis and preserve planes
• Remaining recto-sigmoind– Rectal stump closure - hazardous – A trans-anal rectal drain – To prevent leakage– Rectal stump – Diseased• Distal site of transaction –Matured mucous fistula–Buried within the abdominal incision
Elective surgery
• Total proctocolectomy + Brooke ileostomy
• Total proctocolectomy + Continent ileostomy
• Abdominal colectomy + Ileorectal anastomosis (IRA)
• Ileal pouch–anal anastomosis (IPAA)
• Total proctocolectomy + Brooke ileostomy
– Indications• Older age
• Distal rectal cancer
• Severely compromised anal function
• Patients preference
– Disadvantages• Loss of fecal continence
• High incidence of SAIO
– Complications• Delayed healing of the perineal wound
• Sexual complications
• Dyspareunia
–As a result of perineal scarring
• Intestinal obstruction
• Ileostomy related
– Skin irritation
– Stomal stenosis
– Stoma prolapse, and herniation
• Total proctocolectomy + Continent ileostomy
– Indications• Rectal cancer
• Poor anal sphincter function
• Occupations that may preclude frequent visits to the toilet
• Failed Brooke ileostomy
– Avoid in suspicion of Crohn’s disease
– Operative principles• Excision of a very short segment of terminal ileum
• Exclude CD – Essential
• Aperistaltic reservoir
– Terminal 45–60 cm of the ileum – S-pouch
– A wide plastic tube – Into the pouch for drainage in the early postoperative period.
– Drainage is achieved by intubating the pouch three times a day.
– Complications• Pouchitis
– Incidence - 25%
– Stasis and overgrowth of anaerobic bacteria
– Increased output, fever, weight loss, stomal bleeding
– Pouchoscopy
–Antibiotics + Continuous pouch drainage.
• Intestinal obstruction
– Incidence - 5%
• Fistulas
– Incidence - 10%.
–Bowel rest, TPN, continuous pouch drainage
• Abdominal colectomy + Ileorectal anastomosis
– Indications• Indeterminate colitis
• Upper rectal disease
–Rectal compliance remains adequate
– Advantages• Avoid perineal complications of procto-colectomy
• Minimal sexual dysfunction
• May provide perfect control of feces and flatus
– Disadvantages• Non achievement of total excision of colorectal mucosa.
– Frequency of defecation – Semi-liquid stools 2-5 / day
– Conversion to an IPAA• Poor rectal compliance
• Persistent proctitis
• Upper rectal cancer
– Complications• Nocturnal defecation
• Cancer risk (in remnant rectum)
– The overall risk - 6%
–Most cancers appear 15–20 years after operation. – Early lesions are not easily identified at
sigmoidoscopy – Semi-annual sigmoidoscopy + Biopsies
• Recurrent or persistent inflammation
– Incidence - 20%–45%
– Severe diarrhea, tenesmus, bleeding, urgency
– Topical or systemic therapies / Rectal excision if non responsive
• Ileal pouch–anal anastomosis (IPAA)– Near total procto-colectomy + Ileal reservoir – Preservation of anal sphincter – The original operation –Sir Alan Parks• Complete stripping of the anal mucosa
– Stapled anastomosis• Between pouch and anal canal cephalad to the dentate
line – Preservation of anal transition zone
– Topical 5-aminosalicylic acid or steroid enemas – Minimize rectal mucosal inflammation, facilitate mucosectomy
– Mobilisation of rectum• Ventrally to the level of the prostate / mid-portion of the
vagina• Posteriorly, past the end of the coccyx• Mobilization should be flush with fascia propria–Minimal damage to autonomic nerves to genitals
– Mucosal stripping• Perineal approach with Lone Star™ retractor – Good
exposure and minimal damage to the sphincter mechanism• Inject diluted epinephrine into the submucosal plane –
Minimize bleeding
• Ileal reserviour– The terminal ileum alignment – J configuration,15–
25 cm lengths of both limbs• Lengthening manoeuvres
–Apex of the pouch must reach beyond the symphysis pubis
– Superficial mesenteric incision on the anterior and posterior aspects along the SMA
– Selective ligation of mesenteric arcades
• Double-stapled technique–Anorectum division 2 cm above the dentate line
using a right-angle linear stapler–Anvil is tied in to the apex of pouch–Air insufflation test – To check Integrity of the
rectal staple line – Transanal placement of circular stapler
– Proximal defunctioning loop ileostomy
– Drain placement in the presacral space
– Sphincter strengthening exercises in Post-op period – Improve functional results after ileostomy closure
– Complications• Small bowel obstruction
– Incidence – 20%• Pelvic sepsis– Incidence – 5%–Abscess formation, perineal fistula – Fever, anal pain, tenesmus, and discharge of pus or
secondary hemorrhage –CT or MRI – For confirmation– IV antibiotics - Response within 24–36 hours–Ongoing sepsis / Organized abscess - Endoanal or
imaging-guided percutaneous drainage
• I-A anastomotic stricture
– Incidence – 5 – 38%
–Anastomotic tension – Leakage, infection
– Prevention
• Full mobilization of the mesentery
• Anchoring the pouch to surrounding tissues
–Repeated dilatations under GA - >50%
– Transanal excision of the stricture + advancement of pouch distally
– If recognized in contrast studies or DRE before ileostomy closure then ileostomy closure should be delayed
• Poucho-vaginal fistula
– Incidence – 3-16%.
– Injury to the vagina or rectovaginal septum
–Anastomotic dehiscence, pelvic sepsis
–CD
–Vaginal discharge
–Demonstration of fistula on examination
–Confirmed by contrast enema
– Seton placement, diverting ileostomy, drainage of sepsis + pouch repair
• Pouchitis
– Nonspecific inflammation
– Overgrowth of anaerobic bacteria
– Abdominal cramps, fever, pelvic pain, and sudden increase in stool frequency
– Biopsy – Marked inflammatory infiltrates with villous atrophy and crypt abscesses
– Antibiotics, probiotics (after resolution of the acute symptoms), steroid enemas, ileostomy ± pouch excision
• Incontinence
–Average number of bowel movements after IPAA – 6 / day
–Major incontinence – Unusual
–Minor incontinence – In 30% of pts
–Good perianal hygiene + Perineal pad
–Bulking agent or antidiarrheal medication – 50% pts
Controversial issues in Surgical Mangement
• Indeterminate Colitis– In 10% colitis pts, especially in fulminant colitis
– Inadequate diagnostic criteria for definitive diagnosis
– If CD can’t excluded• subtotal colectomy + ileostomy should be done
– IPAA for IC• Definitive pathologic diagnosis of UC
• IC without development of signs or symptoms of CD
– Long-term functional outcomes nearly identical to chronic UC
• Pouch loss
• Higher perineal complicationsYu CS, Pemberton JH, Larson D.Dis Colon Rectum. 2000;43(11):1487
• 2814 patients, IPAA for UC / IC, 184 patients (7%) had revised diagnosis of CD
–Higher rate of peri-anal fistula (6% vs. 2%)
–Higher rate of stricture (5% vs. 1.5%)
– Female gender (54% vs. 44%)Melton GB, Kiran RP et al. Colorectal Dis. 2010 Oct;12(10):1026-32
• Series of 70 children, total colectomy
–Clinical diagnosis of UC – 90%
– Intermediate colitis – 10%
–Revised diagnosis of CD – 10 pts (14.3%)
–Restorative pouch reconstruction – 9 pts
–Complications – 7 pts
• Anastomotic strictures, perianal fistulas, and perianal abscesses
Mortellaro VE, Green J et al.J Surg Res. 2011 Sep;170(1):38-40
• CRC + UC– Distant metastatic disease• contraindication to IPAA
• Segmental colectomy + IRA
– Middle and low rectal tumors• Not eligible
• Pre-op Radiation therapy
– Caecal cancers • Sacrify long segment of adjacent distal ileum with its
mesenteric vessels
• If a tension-free anastomosis cannot be ensured, a Brooke ileostomy may be necessary.
– Locally invasive cancers of the colon and upper rectum• Taylor et al
–UC + carcinoma had post-op complications and functional results identical to UC without cancer.
–Metastatic disease developed in a small number of patients
Taylor BA, et al. Dis Colon Rectum 1988; 31:358–362.
• In contrast, another study
–Almost 20% of UC pts who had an IPAA died of metastatic disease
– T3 cancers at time of surgeryWiltz O, et al. Dis Colon Rectum 1991;34: 805–809
– Conservative management approach
• UC + T3 cancer
–Abdominal colectomy + ileostomy
• Observation period of at least 12 months
– To ensure no recurrence
– To allow adjuvant chemo-radiation therapy
• Diversion ileostomy– Integral part of the original procedure.
– Mayo Clinic reported – Omission of a stoma didn’t significantly increase the complication rate
Metcalf AM, et al. Dis Colon Rectum 1986; 29:33–35.
– Omission of ileostomy• Septic complications and functional results are similar
to results after an ileostomy
• Fewer episodes of intestinal obstruction
• Decrease length of hospital stay
– Series at Cleveland Clinic, Florida• 110 pts
• No clinical evidence of leaks with diverting ileostomy
• 3 of the 36 patients without an ileostomy had leaks Weiss EG, et al. South Med J 1994;87:519.
– Ileostomy complications – 20%• High output of enteric fluid, dehydration, skin irritation,
stoma retraction, stoma prolapse
– Pouch-specific complications (without an ileostomy) – Repeat laparotomy + fecal diversion
Fonkalsrud EW, et al. J Am Coll Surg 2000;190:418–422
– The benefits must be weighed against the morbidity of an ileostomy – benefits > morbidity
– Avoidance of ileostomy• Experienced surgeon• Low-dose prednisone (<20 mg/day)• No immune-modulating agents• Uneventful operation
Remzi. Dis Colon Rectum 2006
• Role of laparoscopy– Early reports – increased morbidity
– Improved techniques and equipment• Early and late results are comparable to standard
laparotomy
– Lap assisted vs. open restorative proctocolectomy• Long-lasting positive impact on body image and
cosmesis
• Particularly for womenPolle SW, Dunker MS et al.Surg Endosc. 2007;21(8):1301
– Meta-analysis of nine cohort or case-matched series • 966 patients, total abdominal colectomy + end
ileostomy,
• Laparoscopical approach = 42
– Fewer wound infections
– Lower rate of intra-abdominal abscess
–Mean shorter length of hospital stay (mean difference 3.17 days
–Conversion rate – 5.5%Bartels SA, Gardenbroek TJ et al.Br J Surg. 2013;100(6):726
– IPAA with minimal access• Single–port and robotic assisted proctocolectomy with
IPAA
• Significantly fewer incisional, abdominal, and pelvic adhesions
• Safe, feasible, and effective procedure. (54,55)Indar AA, Efron JE et al.Surg Endosc. 2009;23(1):174
Hull TL, Joyce MR et al. Br J Surg. 2012 Feb;99(2):270-5
• IRA vs IPAA– In < 10% - IRA has been used
– Risk for persistence of symptoms and future malignancy.
– Retrospective analysis of the functional results after IRA for UC or IC
• 86 patients
• Rectum was eventually resected in 46 patients
–Refractory proctitis – 28%
–Rectal dysplasia – 17%
–Rectal cancer – 8%da Luz Moreira A, Kiran RP et al. Br J Surg. 2010;97(1):65
– In minimal rectal involvement• Not suitable for IPAA, who refuse an ileostomy
• May be suitable for IRA
– Reduce the risk of infertility in women of childbearing age
– Good choice in whom CD can’t be excluded or for colitis + advanced colonic malignancy
• Mucosectomy vs. Double Stapling– Ziv Y, et al. • Mucosectomy does not assure complete eradication of
disease• Stapled IPAA – safer in mucosal UC• Stapled technique – fewer septic complications, fewer
sepsis-related pouch excisionsAm J Surg 1996;171:320–323
– MacRae HM, et al. • Leak rate same for both approaches• Leaks from a stapled anastomosis have a better
prognosis Dis Colon Rectum 1997;40:257–262.
• Richard E. Lovegrove et al. – Meta-Analysis of 4183 Pts
– Both techniques had similar early post-op outcomes
– Stapled IPAA – Better nocturnal continence
– Better functional outcomes and less disruption of the anal sphincter mechanism
– Selective use of stapled anastomosis particularly in pts• Without CRC or rectal dysplasia• Older patients with compromised sphincter pressure
– Mucosectomy• FAP + polyps in the distal third of the rectum• Mucosal ulcerative colitis + synchronous CRC or rectal
dysplasia
• Shape or size of reservoir– Initial ileal reservoir – in late 1970s • Triple-loop S pouch
– S-pouches • Evacuation problems because of long (5-cm or more)
exit conduit
• Frequently requiring pouch catheterization
– Three other configurations• Double-loop J-pouch
• Quadruple-loop W-pouch
• Lateral isoperistaltic H-pouch
– The W-pouch • Favored by some surgeons
• Greater capacity – Fewer daily bowel movements
– Two randomized trials comparing the W- vs J-pouch• Same median number of stools per day
• No difference in functional outcome
• Similar functional results after 1 year of surgeryKeighley MRB, et al. Br J Surg
1998;75:1008–1011.
Johnston D, et al. Gut 1996;39:242–247
– Most centres perform a J-pouch because it is easier and faster to construct.
Summary
• Indications of surgery in UC– Disease complication– Failure and side effects of medical treatment
• Restorative proctocolectomy + IPAA –gold standard for elective surgical treatment– Safe, curative, and applicable to most patients– Morbidity still high
• However, transanal mucosectomy with hand-sewn anastomosis vs double stapling, diversion versus non-diversion, and the indications for surgery in indeterminate colitis are still debated and remain under active investigation.