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confinedtothecolonandrectum.Whentheentirecolonisinflamed,
the surface area is verylarge and results in generalizedsickness.
Removalofthelargeintestineresultsincure.
Afewwordsonmedicaltherapy
As mentioned, gastroenterologists view surgery as failure of medical
therapyandmeasure their success by the lengthoftimewithout bowel
resection.Thebestgastroenterologistsarethosethatknowwhento
throwinthetowelandclearlystatetothepatient“itistimeforyour
colontoberemoved”—theoppositeisdepictedin Figure26.1...
Figure26.1.“Pancolitis,eh?Shouldn’tweincreasethesteroidsandaddImuran®?”
Overthelasttwodecadesavarietyofnewmedicationshaveemerged
forthetreatmentofinflammatoryboweldisease—primarilyacornucopia
ofanti-tumornecrosisfactor(TNF)drugs.Mostpatientsyouseewillhave
beentriedonanti-TNFdrugs in combination with a purine inhibitor and
highdosesofsteroids.Itiswellknownthattakingsteroidsincreasesthe
riskofwoundandsepticcomplications.Whatisnotsowellknownisthe
effectthatanti-TNFmedicationsmayhave onsurgical outcomes.Some
authors have reported significant increases in infectious complications
andevenmortalitywhenoperatingonpatientsreceivingsuchmedication;
othershaverefutedthis.Bethatasitmay,thereislittledoubtthata
patientwithseverecolitiswhorequiresurgentsurgery,andwhois
on multiple immunosuppressive medications, has increased
morbidityand mortalityascomparedto thosewhoarenot. It is for
thisreasonthatitiscrucialforthegastroenterologistandthesurgeonto
haveanexcellentworkingrelationshipandbeinconstantcommunication
whenmanagingpatientswithacutecolitis.
Surgeons are consulted to see patients with colitis in two
different scenarios: in the office, or in the hospital. In the office,
patients are referred due to failureof medical therapy, complicationsof
the disease or concern for malignancy. In the hospital, patients are
usually admitted due to a sudden deterioration and lack of response to
medicaltherapy.Itisalwaysbetterforthepatienttomeetthesurgeonas
anoutpatientandhavetimetoaskquestions,understandwhatitmeans
tohavesurgeryandbeseenbyastomanurseifneeded.
We request that a surgical consultation be obtained when a
patient is admitted for colitis even ifthe patientis notthought to
require surgery at the time of admission. Patients frequently have
misconceptions regarding surgical outcomes and life with a stoma and
maybenefit from aclearerexplanation ofsurgicaloptions so thatwhen
surgeryisrequiredtheyarementallypreparedfortheoutcome.
With escalating immunosuppression for the treatment of
ulcerative colitis priorto surgical intervention,many patients now
suffersuperinfectionswithClostridiumdifficileorCytomegalovirus
(CMV). It is important to exclude these diagnoses in patients admitted
with an exacerbation of ulcerative colitis. Clearly the treatment is very
differentifoneoftheseinfectionsisidentified.Mostacuteexacerbations
ofinflammatoryboweldisease,whetherCrohn’sorulcerativecolitis,are
treated with high-dose steroids and tend to respond well. (Steroids,
however, should never be considered for maintenance therapy.) In the
presence of CMV or Clostridium difficile infection, the
immunosuppressionmayneedtobetailored,whichmakestakingcareof
thesepatientsverychallenging.Wefindthat,evenwhenidentifiedand
treated appropriately, approximately 40% will still require
colectomy.
Colitisintheelderlydeservesaspecialmention.Youngerpatients
who have no other medical comorbidities are able to tolerate a much
bigger insult than elderly frail ones. With improved peri-operative care
andmanagementofcriticallyill patients,mortality fromcolectomyinthe
urgent setting is low. Elderly patients do not follow this treatment
paradigmandmayrequiresurgicalinterventionearlierifafavorable
outcomeistobeachieved.
When to operate? Severe colitis, fulminant colitis, and
toxiccolitis-megacolon
Patients with severe or fulminant colitis often do not appear
overtly ‘septic’; however, close watching of these patients is
essentialastheycan‘lookwell’forlongperiodsoftime(days,even
weeks)butcandeterioratesuddenlyandprogressontotoxiccolitis.
Patients with severe colitis require urgent colectomy, but waiting to
perform the operation in daylight hours is acceptable. On the other
hand,whenpatients progress to toxiccolitis,surgicalintervention
becomesanemergency.
Whendealingwithacutecolitisthereisreallynodifferenceineitherthe
surgical or medical management of ulcerative colitis, Crohn’s colitis, or
indeterminate colitis; but when using the terms ‘severe colitis’ or
‘fulminantcolitis’,mostindividualsarespeakingaboutulcerativecolitis.
Toidentifywhenandwhotooperateonwithcolitis,weneedfirst
toprovidesomedefinitions:
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Severecolitis: >5 bloody bowel movementsa day,cramps, fever,
heartrate>90,anemia,raisedESR(≥30mm/hour).
•
Fulminantcolitis: >9 bloodybowel movements a day, continuous
bleeding, pain, signs of toxic symptoms (anorexia, fever,
tachycardia).
•
Toxic colitis-megacolon: a patient with fulminant colitis and
radiographic evidence of distension of the colon; transverse colon
>6cm in diameter or cecum >9cm in diameter. Only 1-5% of
patients with inflammatory bowel disease ever develop toxic
megacolon.(Clostridiumdifficilecolitisontheotherhandcanresult
intoxic colitis — manifestingwitha massive colonic edemaonCT
ratherthanamegacolon—inupto3%andtheincidenceisrising.
Other causes of toxic megacolon are CMV colitis, Salmonella,
Shigella, Campylobacter, Entamoeba, and ischemic colitis. These
areallrare.)
TrueloveandWitts(BrMedJ1955;2:1041-8)developedanulcerative
colitisseverityindexwhichclassifiestheacuteepisodeasmild,moderate
or severe (Google it up....). In Table 26.1, we bring our simplified
versionwhichisahelpfulwayofthinkingaboutthesepatients.
There are different algorithms for medically managing severe colitis,
butfromourpointofview,ifsomeonehasseverecolitis(moderate
ontheTruelovescale)wethinkthatiftheyhaven’timprovedafter5
days of medical management (whichever drugs the
gastroenterologistsareusing),theyarenotgoingtoimprove,and
colectomyisrecommended.
Withfulminantcolitis(severeontheTruelovescale)wewillallow24
to 48 hours of further medical therapy with close observation, but will
recommend surgery after that time or if they start to deteriorate. We
obtaindailyX-raysonpatientswithfulminantcolitistolookattheir
transversecolonandcecumtoensuretheyarenotdevelopingtoxic
megacolon.Patients with toxic megacolon belong in the operating
room! As always, if a patient looks sick, or you feel they are
deteriorating, and your little voice is saying “operate” — then
operate!
Whenapatientisidentifiedashavingtoxicmegacolon,thecolon
is thought to be at risk for imminent perforation. When toxic
megacolon is suspected, an abdominal X-ray or CT scan should be
obtainedasmentionedabove.Particular attentionshould bepaidtothe
diameterofthetransversecolon(notthececum!).Apatientwithcolitis,
fever,tachycardiaanddistensionofthetransversecolontogreater
than 6cm is at great risk for perforation and needs to be taken
immediately to the operating room. Don’t be fooled by a benign
abdominal exam; by the time they develop peritoneal signs, it is
usually too lateand they have already perforated. The cecum may
also dilate but in acute colitis it is rare; however,a cecumgreater than
9cmin diameteris alsoconcerning. Indeedwhen wehaveencountered
perforationsin patients with acute colitis, they have always been in the
transversecolon.Whythisoccursisamysterytous.
Theoperationforseverecolitis,fulminantcolitis,ortoxic
megacolon
These patients do notrequire bowel preparation; theyare all usually
havingdiarrheaandhaven’tbeeneatingforawhile(theircoloncontains
onlybloodandmucus).Iftheyareonsteroids,andmostofthemare,or
havereceivedsteroidsinthelast6months,theyrequirea‘stressdose’
ofsteroidsatthetimeofinductionofanesthesia. Thepatient shouldbe
marked for a right lower quadrant ileostomy prior to entering the
operatingroombyeitherthesurgeonoranenterostomaltherapist.
Ingeneral,the proceduremaybe performedviaeitheralaparoscopic
or open technique.However, in septicpatients, or thosediagnosed
withtoxicmegacolon,anopenapproachisquickerandsafe,sothe
word ‘laparoscope’ should not even enter into the conversation.
But,iftheyarestableandareundergoingtheprocedurebecauseof
failed medical management, then we will attempt to remove the
colonviaalaparoscopictechnique.
Theoperationofchoiceforacutecolitisisatotalcolectomyand
endileostomywithdivisionofthebowelattherectosigmoidjunctionand
leavingtherectumasaHartmann’spouchthatwillberemovedatalater
date (when the patient is well) and an ileal J-pouch reconstruction is
performed. There is no role for a restorative proctocolectomy with
ileal pouch anal anastomosis or an ileorectal anastomosis in a
patientwithacutecolitis.Totalabdominalcolectomyisgenerallyeasier
inpatientswithulcerativecolitisasopposed toCD.Theserosalsurface
ofthecolonandmesenteryinpatientswithulcerativecolitisisoften,but
notalways,normal;whereasthemesenteryinapatientwithCDmaybe
thickenedandquitedifficulttomanipulateordivide.
Afewwordsabouttechnique
Thepatientneedstobeineitherthemodifiedlithotomypositionorthe
split-legpositiontohaveaccesstotheanusandrectum.
Thefactthatalaparotomyisbeingperformedindicatesthatthepatient
is either sick or the colon or its mesentery is distended, thickened or
inflamed. Once the bowel is mobilized, division of a mesentery
thickened from CD can be difficult and bloody. We use Kocher
clampswithgentleclamping andlargechromicsutures(zeroornumber
oneinthickness,i.e.liversutures)placedinau-stitchencompassingthe
clampedmesentery.
Whouseschromicnowadays?Ithoughtit’slongoutofthemarket…Danny
Reply:IstillusechromicforbadCrohn’smesenteryasdescribedhere.Jon
Keepahandundertheclamptocatchandreclampanybleedingthat
occurswhensecuringthesuture.Crohn’sbloodvesselsoftenretractand
can quickly bleed into the mesentery creating a large mesenteric
hematomathatisdifficulttomanage.
Management of the rectum in ulcerative and
indeterminatecolitis
Theclosureofthedividedrectum(attherectosigmoidjunction)is
pronetoleakage.Whentherectumisseverelyinflamedthestaplerwill
actuallycutitswall.Thus,weprefertoclosethethickenedandinflamed
wall with large absorbable sutures inan interrupted andsimple fashion
taking big, full-thickness bites of the bowel wall. We then irrigate the
stump and leave a rectal tube. In addition, we leave drains above the
stump.
Ifwearereallyconcernedabouttherectalstumpwesometimeslookat
thedistalsigmoid colonto seewhetheritisless inflamed.Ifso,leaving
10cm of sigmoid generally does not cause issues for the patient and
allows us toexteriorize the colonic stump as a mucous fistula. At this
point we wouldconsiderthis a subtotalcolectomy. We experience
one or two rectal stump leaks a year and these patients often require
reoperation because of peritonitis, so if you are concerned, think
mucousfistula.Wedonotfindleaving10cmofsigmoidcolonworsens
rectaldrainage,bleeding,orsepticsymptoms.Thedividingpointshould
be soft and pliable if possible and should not tear when placing the
stapler.Somepeoplewouldbringoutthemucousfistulaatthelowermost
end of the midline incision. But this could increase the risk of wound
complicationsandwerecommendagainstthis.
Trynottoleaveashortrectalstump.ShortHartmann’spouchesare
difficultto isolate,either to reversewithan ileorectalanastomosis,or to
excisebecauseofpersistentsymptoms(bleeding,drainage,orfistulizing
disease).Thebladder(rightat thelevel ofthe trigoneand thereforethe
ureters) tends to drape over the short stump making it difficult to find.
Thishasresultedinbladderandureteralinjuriesinourhandssowehate
shortrectalstumps!
EmergencysurgeryforCrohn’sdisease(CD)
The need for an emergency operation in CD should be rare indeed.
There are a few patients with acute colitis, which is clinically
indistinguishablefromacuteulcerativecolitisandthushandledalongthe
samelinesasdescribedabove—unlessthecolitisissegmental (see
below). Most of the time, however, the course and anatomical
appearance of the colitis suggest that it is CD rather than ulcerative
colitis.WhensmallbowelisinvolvedadiagnosisofCDisobvious.
CDofanyportionoftheGItractpresentsinitiallyasinflammation
ofasegmentofbowelthateventuallygoesontodevelopintoeither
perforating disease or obstructing disease. These two distinct
manifestations are not independent of each other as some patients
perforate due to obstruction and others obstruct from severe
inflammationandinfection.
The principles of management are the same no matter which
piece of bowel is involved. Controlling sepsis is a most important
principleinthemanagementofthesepatients,beitaroundtheanusorin
the abdomen. Another cardinal principle is the need for intestinal
economy.CDpatientswillnotbecuredbytheoperation—onlypalliated
—andmayneedadditionaloperationsinthefuture.Thus,choosingthe
most ‘bowel-sparing’operation and itstiming makesa difference to the
futurequalityoflife.
IntestinalperforationsinCD
Themanagementinsuchpatientsdependsontheclinicalpresentation
andtheimagingfindings.
Patientswithlocalizedperforationrequirepercutaneousdrainage
byinterventionalradiologyasafirststep.Oncetheacuteperforation
iscontrolled,many patients are able toavoidan operation and may be
started on anti-Crohn’s therapy. If a fistula develops and becomes
chronic, surgery is inevitable. Recent data suggest that delaying
surgeryforperforatingCrohn’sdiseasemayinfactresultinanincreased
number of structures involved in the inflammatory mass and increased
postoperative septic complications, therefore prompting the
gastroenterologist to consider consulting a surgeon soon after the
perforationisdiagnosed.Ingeneral,ifthepatientimprovesandthepain
resolves, with a follow-up CT showing resolution of the inflammatory
mass,thenmedicaltherapycanbestarted safely.Ifnot, surgeryshould
beconsideredsoonerratherthanlater.
Patientswithdiffuse peritonitis (lack of localization on CT) need
an urgent laparotomy. Also, complex abscesses, which fail
percutaneous drainage, should be operated upon; the involved
segmentofbowelhastoberesected.
Multiple studies have confirmed that resections for CD should be
limited to the grossly diseased bowel — histologically-freemargins are
notrequired.Whethertorestorebowelcontinuitywithananastomosis,or
exteriorize the bowel ends as a double-barrel stoma, depends on the
conditionofthepatient,hisabdomenandthebowel( Chapter14).The
risk of anastomotic failure is clearly higher in CD than in ordinary
colorectal surgery. This is particularly true in CD patients that are
operated on for intestinal fistula or abscess, and those with several
previousoperationsbecauseoftheinherentcomplexityoftheanatomy.It
isimportanttoavoidanyinadvertentbowelinjurybecausethisincreases
theriskofpostoperativeperforationandfistulaformation.
The best option is often to bring out the bowel ends in a
combined ileo-ileal or ileocolic stoma for later closure. Most
anastomoticfailuresnecessitateareoperationwithresectionofthefailed
anastomosis and stoma formation. Be mindful that a failed
anastomosis in a CD patient will wipe out a year of that patient’s
sociallifeand add two more operationsin that period (seealso
Chapter47).
ManagementoftherectuminCrohn’sdisease
Crohn’spatientsmayhavesegmentalcolitisorpanproctocolitis.
Whenweoperateonapatientforacutecolitiswetrytoleavetherectum
in place. Theabove mentioned techniques for closing the rectal stump
are very helpful when the rectum is inflamed from CD. Adding a
proctectomy to the colectomy in a Crohn’s patient with severe or
fulminantcolitisaddstotheoperation and the blood loss and we try to
leavethisforanothertimewhenthepatientishealthy.If,however,you
areforcedtoperform an emergency proctectomy in a patient with
CD,thenperformanintersphinctericdissectionfortheperinealpart
oftheoperation.Itrequiresasmallerincisionwithsignificantlyimproved
healing.Ifyouareplanningtoexcisetherectum,makeDAMNSUREthe
patient has Crohn’s as you are committing this patient to a permanent
stoma.
SpecialCD-relatedproblems
There are a few other instances, when emergency surgery is
considered in CD patients: small bowel obstruction, suspected
appendicitisandperi-analdisease.
Smallbowelobstruction(SBO)
SBO is common in patients with CD. Usually it is due to a narrow
segment of diseased terminal ileum but it may be caused by a more
proximalstrictureofaskiplesion.WhenthediagnosisofCDisknown
youshouldtreattheobstructiveepisodeconservatively:SBOinCD
is usually ‘simple obturation’ of the narrow segment and resolves
spontaneously—atleastuntilthenextexacerbation.Intheabsenceofa
previous diagnosis of CD, a careful history may reveal the typical
previous abdominal symptoms, including episodes of transient
obstipation,andsystemicsignsofinflammationthatarecompatiblewith
a diagnosis of CD. A CT showing typical segmental thickening of the
bowel wall and mesentery can provide the diagnosis. Conservative
management of SBO is discussed in Chapter 21. Steroids will be
required.
If you operate for SBO and find an inflamed and thickened
terminalileumcompatiblewithCD,whatthen?Itismuchbetter and
simpler to operate on CD in the elective situation, when the bowel is
empty and its inside can beinspected for strictureswith intra-operative
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