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.

• Individualizing approach should be used to decide mucosectomy

• J pouch is the most common reservoir used worldwide

• Diverting ileostomy can be avoided only in selective group of patients.

• The laparoscopic approach remains to be further evaluated before it can be routinely recommended.