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52 Endometriosis
403
suture primary closure. However, if the lesion
is adjacent to the ileocecal valve or particularly large, a segmental bowel resection or
ileocecectomy may be warranted.
P. Rectosigmoid endometriosis can be readily
treated by sigmoid colectomy with margins
being grossly normal. A “segmental” operation is appropriate for this benign disease,
and thus high ligation of the IMA pedicle is
not warranted. Randomized data demonstrate
a superior pain and postoperative complication prole in a group of laparoscopically
performed colectomies when compared to
open techniques. Additionally, the laparoscopic approach offered a higher spontaneous pregnancy rate.
Q. Endometrial disease in the cul-de-sac of
Douglass that extends into the rectovaginal
septum is the most common site of intestinal
endometriosis and may require intestinal
resection. These diseased areas carry a strong
desmoplastic reaction, are often very deep
and brotic, and extend from the posterior
vagina to the uterosacral ligaments. There is
substantial distortion of the normal tissue
planes, requiring a more seasoned colorectal
surgeon. Pararectal spaces posteriorly and
laterally are dissected with circumferential
dissection around the nodule. Ureters are dissected appropriately, and the lesion can be
removed rst from the rectum and then dissected from the vaginal fornix. It is worthwhile to note that one must be careful to
avoid injuring the cervix in order to best preserve fertility. Rectal lesions that are removed
with rectal preservation (partial-thickness)
should be evaluated with a proctoscopic evaluation for air-leak and are often reinforced
with imbricating Lembert suturing. Deeper
lesions require careful and expert colorectal
evaluation. There are effectively two options
in these situations, full-thickness disc excision and segmental resection. We often perform full-thickness disc excision for single
lesions less than 3cm in diameter. However,
it is worth noting that the margins should be
very clearly normal, particularly given data
that demonstrated 40% of full-thickness disc
excisions of bowel implants were incomplete. We often delineate the disc-like area
with electrocautery with stay sutures on
either side of the implant. Full-thickness
excision is undertaken with cutting current,
while interrupted transverse sutures are
placed to close the defect.
R. Our experience with surgical therapy is very
promising, with 86% of patients having complete or near-complete relief of their preoperative pelvic pain. A 50% crude pregnancy
rate was achieved which was comparable
with milder disease, all achieved without any
anastomotic leaks and no documentation of
recurrent colorectal endometriosis.
S. A combination approach that utilizes preop-
erative medical therapy for 3–6months may
well be warranted to decrease inammation
and possibly size of endometrial implants as
well as vascularity. Our current use of combined therapy is a 3–6 month course of
GnRH-a prior to denitive resection of all
endometrial disease.
Suggested Reading
Bailey HR, Ott MT, Hartendorp P. Aggressive surgical
management for advanced colorectal endometriosis.
Dis Colon Rectum. 1994;37(8):747–53.
Kaufman LC, Smyrk TC, Levy MJ, Enders FT,
Oxentenko AS. Symptomatic intestinal endometriosis requiring surgical resection: clinical presentation and preoperative diagnosis. Am J Gastroenterol.
2011;106(7):1325–32.
Remorgida V, Ragni N, Ferrero S, Anserini P, Torelli P,
Fulcheri E.The involvement of the interstitial Cajal
cells and the enteric nervous system in bowel endometriosis. Hum Reprod Jan. 2005;20(1):264–71.
Wolthuis AM, Meuleman C, Tomassetti C, D’Hooghe T,
de Buck van Overstraeten A, D’Hoore A.Bowel endometriosis: colorectal surgeon’s perspective in a multidisciplinary surgical team. World J Gastroenterol.
2014;20(42):15616–23.
Colonic Conditions: Ulcerative Colitis
MeganC.Turner andJohnMigaly
53
Refer toAlgorithm inFig. 53.1
A. Introduction to UC:
Ulcerative colitis (UC) is an inammatory bowel condition of unknown etiology
affecting the mucosa of contiguous segments of colon and rectum. It manifests as
relapsing abdominal pain, fever, diarrhea,
blood per rectum, and weight loss. The
daily management of UC is medical in
nature, however 40% of UC patients will
ultimately require an operative intervention. The surgeon’s role in emergent, and
elective resection, for UC and its oncologic
sequelae cannot be understated (Fig.53.2).
B. Epidemiology: Ulcerative Colitis is pre-
dominantly diagnosed in early adulthood
following evaluation for abdominal pain,
weight loss, fevers, and bloody diarrhea.
There is no gender discrepancy. Race differences are present, with those of Jewish heritage most frequent affected, followed by
Caucasians, and African Americans. Lower
prevalence is seen amongst Hispanic, Native
American, African, and Asian populations.
M. C. Turner
Department ofSurgery, Duke University Medical
Center, Durham, NC, USA
J. Migaly (*)
Division ofAdvanced GI andOncology Surgery,
Duke University Medical Center, Durham, NC, USA
e-mail: jmigaly@dm.duke.edu
Globally, the incidence is variable, but as
common as 15/100,000 in industrialized
nations. Increasing prevalence in recently
industrialized regions supports environmental inuence on the development of the disease. Genetic and autoimmune associations
are being explored as well.
C. Clinical Presentation: Presentation can vary
widely, from emergent pan-colonic are
with hypotension and tachycardia, to indolent symptoms of persistent abdominal
pain. Proctosigmoiditis is the most common
presentation, and pan-colitis is the second
most common, with the two accounting for
greater than half of all presentations.
Symptoms correlate with disease severity.
Remission is characterized by the improvement of symptoms, and are associated with
the resolution of mucosal inammation on
endoscopic exam.
D. Radiologic Evidence: Radiographic imag-
ing is utilized for diagnosis of complications of UC.Abdominal radiographs assist
in diagnosis of obstruction and perforation,
followed by computed tomography (CT) in
the hemodynamically normal patient.
Double contrasted CT with barium enema
is used to detect longstanding colonic
changes such as absence of haustra, narrowing of the lumen, and ulceration. However,
these features are better visualized on
endoscopy. Additionally, CT plays a role in
© Springer Nature Switzerland AG 2020
S. R. Steele etal. (eds.), Clinical Decision Making in Colorectal Surgery,
https://doi.org/10.1007/978-3-319-65942-8_53
405
406
Fig. 53.1 Algorithm for the operative management of ulcerative colitis. UC ulcerative colitis, IPAA ileal pouch-anal
anastomosis, DALM dysplasia-associated lesion or mass. Superscript indicates corresponding chapter segment
Fig. 53.2 J Pouch
formation and pouchanal stapled anastomosis
ABC
M. C. Turner and J. Migaly
the diagnosis of postoperative complications following resection such as anastomotic leak or abscess formation. A
gastrografn enema is appropriate to rule
out complications such as anastomotic leak,
stula formation, and stricture prior to
diverting loop ileostomy take down.
E. Diagnostic Labs: Infectious colitides caused
by Cytomegalovirus, Clostridium difcile,
Escherichia coli, Salmonella, Shigella,
Campylobacter, and Entamoeba species
have presentations similar to UC, and
should be ruled out prior to invasive diagnostics. A comprehensive metabolic panel,
53 Colonic Conditions: Ulcerative Colitis
407
nutrition laboratories, and a complete blood
count can provide insight into the overall
debility of severely affected patients.
F. Endoscopy for Diagnostics: Endoscopy
with biopsy is the cornerstone of diagnostics
for UC.Direct visualization of the mucosa
plays an important role in differentiating UC
from Crohn’s Disease and infectious colitides. Visualization of the mucosa shows
ulceration and inammatory changes with
neovascularization present both contiguous
and conuent, beginning in the rectum and
progressing proximally. Full colonoscopy
allows for assessment of proximal extent of
colitis and presence of backwash ileitis in
patients who have involvement at the cecum.
Histologic evaluation shows inammatory
changes, goblet cell depletion, and vascular
congestion. Ulceration of the mucosa and
inltration of inammatory cells precedes
crypt abscess formation and rupture.
Persistent untreated disease ultimately leads
to atrophy of the mucosa.
G. Extracolonic Manifestations: Ulcerative
Colitis has a 20% incidence of extracolonic
disease. The most common manifestations
are musculoskeletal arthropathies, both axial
and peripheral, followed by ophthalmologic,
dermatologic, thromboembolic, and hepatobiliary. Following denitive proctocolectomy, peripheral mono- arthropathies,
erythema nodosum, and iritis resolve.
However, ankylosing spondylitis, primary
sclerosing cholangitis (PSC), uveitis, and
episcleritis persist, independent of colonic
disease. Additionally, the presence of PSC
dramatically increases the risk of colonic
malignancy, independent of colonic inammation. PSC may become severe enough to
require liver transplantation, and carries
substantial risk for cholangiocarcinoma.
H. Surveillance: Surveillance for dysplasia
becomes increasingly important for patients
with long-standing disease. It is postulated
that carcinoma develops from dysplastic
lesions in the affected hyper-inammatory
segments of the colon and rectum. Absolute
risk of colorectal cancer rises to 10% for
patients whom have had active disease for
20 years. Given this high risk, surveillance
guidelines are well established, but the indications and timing of proctocolectomy
continue to be debated. Colonoscopic surveillance should occur every 1–3years, beginning
ten years from diagnosis. Colonoscopy should
include deliberate inspection of the mucosa as
well as random biopsies for surveillance of
dysplasia every 10cm along the length of the
colon through the ileocecal valve as has been
historically recommended is under debate.
With newer endoscopic technologies “invisible dysplasia” likely accounts for less than
10% of patients diagnosed with dysplasia.
Identication of carcinoma requires not only
resection of the focal lesion, but total
proctocolectomy.
I. Management of dysplasia: When dysplasia
is identied from surveillance biopsies, the
specimens should be reviewed by independent pathologists to conrm congruent
assessment of the nature of the lesions. The
presence of dysplasia is a herald of disease
progression along the inammation-dysplasia-carcinoma pathway, and overall represents a eld defect for the entirety of the
colon and rectum. Synchronous tumors are
more common in UC related than in sporadic malignancy. This necessitates discussion with the patient of the value of
continued colonoscopic surveillance versus
resection. Current recommendations are to
proceed with repeat colonoscopy if the
lesion was endoscopically resectable and
discuss proctocolectomy for lesions that are
incompletely resectable. As lesions are generally endoscopically visible, descriptions
using the Paris classication and
Surveillance for Colorectal Endoscopic
Detection and Management in Inammatory
Bowel Disease International Consensus
Recommendation (SCENIC) descriptors
should utilized to describe them. Prior categorizations as dysplasia-associated lesion
or mass (DALMs), have been abandoned.
(a) Descriptions of visualized lesions
should include whether the lesion is
408
M. C. Turner and J. Migaly
within or outside the area of known
colitis. The morphology, borders, and
features of submucosal invasion should
be included. Additional features have
been described (Table 53.1).
(b) High-grade dysplasia: These lesions
are then categorized as endoscopically
resectable, or unresectable. i.
Resectable lesions include those with
distinct margins, execution of complete
removal with endoscopy, and histologic
Table 53.1 Terminology for reporting nding on colonoscopic surveillance of patients with inammatory
bowel disease
Term Denition
Visible dysplasia Dysplasia identied on targeted
Polypoid Lesion protruding from the
• Pedunculated Lesion attached to the mucosa
• Sessile Lesion not attached to the
Nonpolypoid Lesion with little (<2.5mm) or
• Supercial
elevated
• Flat Lesion without protrusion
• Depressed Lesion with at least a portion
General descriptors
• Ulcerated Ulceration (brinous-appearing
• Border
– Distinct
border
– Indistinct
border
Invisible dysplasia Dysplasia identied on random
Reproduced from Laine et al. 2015. Used with permission
from Elsevier Inc. All rights reserved
biopsies from a lesion
visualized at colonoscopy
mucosa into the lumen
≥2.5mm
by a stalk
mucosa by a stalk (entire base
is contiguous with the mucosa)
no protrusion above the mucosa
Lesion with protrusion but
<2.5mm above the lumen (less
than the height of the closed
cup of a biopsy forceps)
above mucosa
depressed below the level of
the mucosa
base with depth) within the
lesion
Lesion’s border is discrete and
can be distinguished from
surrounding mucosa
Lesion’s border is not discrete
and cannot be distinguished
from surrounding mucosa
(non-targeted) biopsies of colon
mucosa without a visible lesion
examination is consistent with complete removal. ii. Unresectable lesions
include those without distinct margins
and incomplete removal on endoscopy
either grossly or by histopathology. iii.
Kudo pit classication is not widely
accepted for lesion characterization.
However, Kudo pit classication I and
II may have utility in ruling out dysplastic changes.
(c) DALMs.
J. Medical Management: Steroids, amino-
salicylates, and immunomodulators are
used in medical management for patients
with UC via mechanisms that decrease
inammation and promote mucosal healing. Isolated proctitis is best managed with
topical therapies including mesalamine
suppositories, and steroid enemas. Oral
aminosalicylates are used for maintenance
therapy in proximal colitis. Oral steroids
and immunomodulators are added in a stepwise fashion for increasing disease severity.
Resolution of symptoms indicates remission, and should be conrmed with mucosal
visualization on endoscopy. Histologic
examination reveals absence of neutrophils
in the epithelial crypts indicating complete
remission. With severe symptom ares,
admission to the hospital, bowel rest, and
intravenous steroids are standard of care.
While intravenous antibiotics are routinely
used, there is not a denitive outcome benet based on the current literature.
Iniximab and cyclosporine have shown
short-term benet in small trials, but the
long-term impact on overall disease progression has not been determined.
Iniximab and cyclosporine should not be
used in combination as they substantially
increase the risk of infectious complications should urgent operation be required.
The majority of patients will respond to
medical therapy and will not require operative intervention during hospitalization. For
those who are medically managed to discharge, discussions regarding potential
future operative interventions should be
53 Colonic Conditions: Ulcerative Colitis
409
held. Specically, indications for resection,
timing of withholding steroids and immunologics prior to resection. In our practice,
steroids are tapered to off if symptoms permit. However, immunologics are discontinued for several weeks prior to surgery
(iniximab: 8 weeks, adalimumab:
4 weeks). Aminosalicylates are continued
up to the date of surgery.
K. Surgical Indications: Hemorrhage, per-
foration, toxic colitis refractory to medical intervention are indications for urgent/
emergent resection. Elective resection is
indicated for patients with refractory
symptoms, extracolonic manifestations,
growth retardation, dysplasia, and
carcinoma.
L. Emergent Operations: While emergent pre-
sentations of UC ares are increasingly
managed with advanced medical therapies
as described above, there remain a subset of
patients who require urgent operative intervention. Candidates include those with
toxic megacolon, fulminant colitis, hemorrhage, and perforation. In most urgent settings an open approach total abdominal
colectomy with end ileostomy is appropriate as described below.
M. Total Abdominal Colectomy (TAC): Total
abdominal colectomy with end ileostomy
addresses the systemic impact of inammatory colitis, diverts the fecal stream,
allows for improvement of the patient’s
hemodynamics, nutrition parameters, as
well as the tapering off of steroids, and the
holding of immunologic medications in
preparation for denitive resection, and
restoration of continence. The rectum is
preserved in these operations to maintain
dissection planes for future operations.
Management of the rectum may be stump
closure and observation, exteriorization
with a mucus stula, or placement of a rectal tube.
N. Postoperative Care Following TAC:
Observation, stabilization, and frequent
abdominal assessment are cornerstones of
management following TAC.Rectal stump
management has historically used the formation of a mucous stula to prevent subsequent pelvic sepsis. More recent literature
suggests that overall rates of pelvic sepsis
are approximately 10% with an intraperitoneal, or intrapelvic, closed stump. These
rates are similar to previously reported rates
of pelvic sepsis with a mucous stula, 7%,
leading many surgeons to close rectal
stumps instead of forming mucous stulas.
Following TAC for UC, approximately 50%
of patients ultimately undergo rectal resection. Half of these resections are for refractory proctitis, and half for dysplastic changes
or carcinoma of the residual rectum.
O. Elective Operations: The elective operation
of choice is a total proctocolectomy with
ileal pouch-anal anastomosis (IPAA) as it
removes all foci of disease allowing for
resolution of symptoms, management of
oncologic risk, and mitigation of extracolonic disease. Alternatives include total
proctocolectomy with end ileostomy, and
total abdominal colectomy with ileorectal
anastomosis, all of which can be performed
using minimally invasive techniques by
experienced surgeons. Candidates for resection are patients who have symptoms refractory to medical management, those with
dysplasia or progression to carcinoma, and
those with extracolonic manifestations that
are improved with colonic resection. Failure
to thrive and growth retardation are indications in the pediatric population.
Regardless of technique, bowel preparation with mechanical and enteral antibiotics
are administered preoperatively, IV antibiotics are administered one hour prior to
incision, and the patient is given prophylactic heparin to mitigate postoperative
complications.
P. Laparoscopic Technique for IPAA: The
laparoscopic technique utilizes positioning
in modied lithotomy with access to the
anus, and preparation amenable to open
conversion. Lighted ureteral stents may be
useful in obese patients, patients with prior
abdominal operations, or simply aid in the
410
M. C. Turner and J. Migaly
efcient location of ureters to expedite what
can be a lengthy case. A four working-port
technique is utilized; a 12 mm port in the
right iliac fossa, usually the site of the
future ileostomy, and 5mm ports in the left
upper quadrant, the right upper quadrant,
and the left iliac fossa. The camera port is
usually in the supraumbilical position. The
dissection is started with identication of
the right and left ureter by way of the lighted
stents, or by beginning the mobilization
underneath the Inferior Mesenteric Artery
(IMA). The sigmoid colon is placed on tension and the root of the mesentery is scored
to the root of the IMA. The dissection is
performed medial to lateral, skeletonizing
the IMA, identifying the left ureter, and taking both the IMA and inferior mesenteric
vein (IMV) with a vascular stapler. The left
and sigmoid colon are mobilized, followed
by freeing the transverse colon of the omentum, then mobilizing the splenic exure.
The right colon is approached placing the
cecum on tension and initially identifying
and preserving the ileocolic and the ileal
vessels which will ultimately supply the
pouch. Dissection is in the avascular plane
beneath the right colon and anterior to the
retroperitoneum with attention to identifying the right ureter and gonadal vessels.
Approaching cephalad, the duodenum is
identied and avoided. The ileocolic pedicle taken with electrocautery with high ligation. Once this is complete, the right colon
is mobilized in a medial to lateral fashion.
When the right colon is free it is repositioned medially and the white line of Toldt
is approached up to the hepatic exure. The
location of the duodenum is conrmed, and
moved out of the dissection eld. The root
of the small bowel mesentery is mobilized
to the origin of the Superior Mesenteric
Artery (SMA) at the third portion of the
duodenum for optimal length to maximize
the tension free reach of the pouch into the
pelvis. The colon is then devascularized
using an energy source along the transverse
mesocolon. At this point in the operation,
the colon is fully mobile from the cecum to
the rectosigmoid junction. Attention is
turned to the rectum, locating the plane
between the presacral fascia and the fascia
propria of the rectum. The circumferential
rectal dissection is performed down to the
levators, clearing the mesorectal attachments while avoiding the left and right
hypogastric nerves. In female patients, the
anterior dissection must remain clear of the
vagina. This can be facilitated by utilization
of a retractor placed within the vagina.
There are limitations to dividing the rectum
at a 90° angle along its long axis using an
endoscopic stapler. In our practice we use
an Endo-GIA stapler with a purple load to
divide the rectum ush with the levators.
This is facilitated by the assistant retracting
the rectum to the left, and approaching from
the right iliac fossa port using sequential
res of the stapler to transect the rectum.
The colon is then exteriorized through the
umbilical port site which is enlarged to
accommodate the specimen. Alternatively,
the colon can be exteriorized through the
ileostomy aperture. However, utilizing the
umbilical camera port site allows for easier
orientation of the mesentery and creation of
the pouch. The ileum is divided ush with
the ileocecal valve, and the colonic specimen is removed from the eld and sent to
pathology. If there are remaining concerns
for Crohn’s Disease, an examination by the
pathologist can be helpful for operative
planning at this time. Importantly, threestage procedure should be considered to
allow a more accurate diagnostic determination via permanent pathology. The terminal ileum is exteriorized at this time, and a
15–18cm J-pouch is created by folding the
distal ileum on itself. To conrm adequate
length, the tip of the pouch should reach
past the symphysis pubis. The J-pouch is
fashioned with GIA 80 staplers in sequential res. A 2-0 prolene purse-string suture
is placed and a 28-EEA anvil is secured at
the bottom of the J.The pouch/anvil combination is replaced into the abdomen, and
53 Colonic Conditions: Ulcerative Colitis
411
A
B
Fig. 53.3 Mesenteric rents to increase length for tensionfree anastomosis
insufation is resumed. The J-pouch is
placed within the pelvis with careful attention to avoidance of rotation, and assess for
easy reach without tension. The assistant
moves to the foot of the table, and transanally passes the stapler immediately adjacent to the rectal transection staple line. The
stapler and anvil are engaged with the surgeon grasping the anvil to prevent rotation
while the stapler is closed. The vagina is
retracted out of the reach of the stapler to
ensure it is not inadvertently incorporated
into the staple line (Fig.53.3). When complete, the stapler is removed and two anastomotic donuts can be visualized. The
pelvis is lled with irrigant at this time, and
rigid proctoscopy with ination is performed to conrm an airtight anastomosis
and pouch. The irrigant is evacuated and the
pouch is observed to lie in anatomic position. Our practice is to routinely create a
diverting ileostomy, but not leave pelvic
drains. A diverting loop ileostomy is then
formed 30cm proximal to the J-pouch in a
standard Brooke fashion.
Q. Troubleshooting IPAAs: Several techniques
can be used to obtain additional bowel
length when the pouch does not reach without tension into the pelvis. First, and likely
most important, it is appropriate to convert
to an open procedure at this time to safely
facilitate additional length into the pelvis.
One technique is to make sequential rents in
the small bowel mesentery (Fig. 53.3).
Additionally, selective ligation of branching vessels along the mesentery can provide
additional reach. Our approach is to use
bulldog vessel clamps on the vessels and
observe for appropriate perfusion along the
bowel prior to sacrice of the vessel.
Finally, the conguration of the pouch into
a ‘S’ or ‘W’ conguration can provide additional length. Some surgeons elect to
remove the colonic specimen and exteriorize the ileum through the future ileostomy
site. However, this creates difculty in
judging the orientation of the mesentery,
allowing it to rotate when replaced into the
abdomen. This can be avoided by exteriorizing through the umbilical site as described
above, where the free edge can be visualized down to the level of the origin of the
vessels.
R. Open Technique IPAA: The patient is
placed in modied lithotomy with adequate
access to the anus, and the abdomen is
prepped widely. The abdomen is entered at
the midline. The right colon is mobilized in
a lateral to medial direction with the lateral
peritoneal reection incised from the cecum
412
M. C. Turner and J. Migaly
to the hepatic exure. The right ureter and
duodenum are carefully identied and protected during mobilization. The transverse
colon is sharply divided from the greater
omentum. The splenic exure is then mobilized, and the left colon is reected medially with identication and protection of the
left ureter. The vascular supply of the terminal ileum via the ileocolic and ileal branches
are identied and preserved, and the terminal ileum transected with a linear stapler.
The mesentery is then divided. Attention is
turned to the rectum which is then elevated
out of the pelvis. Circumferential dissection
is achieved to the level of the levators,
identifying and protecting the hypogastric
nerves. The rectum is divided and the
entirety of the colon is passed off to pathology as a specimen. The terminal ileum is
folded onto itself in formation of the J
pouch. The pouch is placed into the pelvis
without tension or rotation. The apex of the
J is then brought through the muscular cuff
and sutured to the anus at the dentate line. A
diverting loop ileostomy is created, the
abdominal wall is closed, and the diverting
loop ileostomy is matured in a Brooke
fashion.
S. Total Proctocolectomy with End Ileostomy:
Standard of care for surgical management
of UC traditionally has been total proctocolectomy with end ileostomy. While
largely replaced by IPAA as described
above, it remains an appropriate operation
for those with poor sphincter function.
The patient is placed supine in lithotomy
position. The anus is sutured closed at the
start of the operation, and the abdomen and
anus are widely prepped. Entrance into the
abdomen is made through a vertical midline
incision, and attention is turned to the right
colon where a lateral to medial approach is
taken from the cecum to the hepatic exure.
Care must be taken to identify and protect
the right ureter and the duodenum. The
transverse colon is mobilized by sharp dissection of the omentum away from the
colon. The splenic exure and the left colon
are approached laterally to medially, reecting the colon medially. Care must be taken
to identify and protect the left ureter. When
the colon is fully mobilized, attention is
turned to the terminal ileum which is transected with a linear stapler. The peritoneum
is scored along the mesentery, then divided.
Attention is turned to the pelvis, and the
rectum is elevated for ease of circumferential dissection to the levators, while protecting the hypogastric nerves. The assistant
goes to the bottom of the table and incises
the skin around the anus. The levators are
incised anteriorly, and the specimen is
released and passed off to pathology. Drains
are placed in the pelvis. The terminal ileum
is brought through the abdominal wall, the
abdomen and perineum are closed, and the
end ileostomy is matured in a Brooke
fashion.
T. Turnbull Blowhole: The Turnbull
‘Blowhole’ procedure is utilized in decompensated UC patients. It is largely of historic signicance, and used in septic, steroid
dependent, malnourished patients who cannot withstand a more extensive resection,
though this is rare in modern surgical and
anesthetic care. The operation consists of
loop ileostomy and a transverse colostomy,
with or without a sigmoid colostomy for
rectal decompression. Diversion of the fecal
stream and decompression of the colon
allows for medical stabilization and nutritional optimization of the patient prior to
total abdominal colectomy. However, with
the colon remaining in-situ this approach
does not address the systemic inammatory
impact of the colitis, thus impairing rate of
recovery.
U. Continent Reconstruction: The decision for a
three stage, two stage, or single stage procedure is based on the physical robustness of
patient. With rates of pelvic sepsis following
proctectomy with IPAA in the range of 10%,
most surgeons advocate for the use of fecal
stream diversion. In a recent study, the lack
of diversion was associated with a nearly
ve- fold risk of pelvic sepsis. The most met-
53 Colonic Conditions: Ulcerative Colitis
413
abolically deranged patients, those who are
on high doses of steroids, or immunomodulators, those who have poor nutrition, and
those present with sepsis whom are resected
urgently are most appropriate for a three
stage procedure: total abdominal colectomy
with end ileostomy, IPAA with diverting
loop ileostomy, and loop ileostomy take
down. The interim allows for tapering of steroids, holding of immunomodulators, and
improvement of nutritional parameters to
mitigate risk of anastomotic and wound
breakdown. Elective resections are performed in a two-stage procedure: IPAA with
diverting loop ileostomy, and subsequent
ileostomy take down. This is the practice at
our institution, allotting for protection of the
ileoanal anastomosis in the immediate recovery period. A single stage procedure, IPAA
without diversion, is not currently practiced
at our institution given the risk of pelvic sepsis and its long-term sequelae. Patients who
potentially could be considered for a single
stage operation include those who are young,
t, nutritionally replete, not taking steroids
or immunomodulators.
V. Impact of Iniximab on Surgical Outcomes:
Iniximab is increasingly used for medical
management of UC, and the impact on
postoperative complications is the subject
of debate. The best literature to date suggests that there is an increased risk of postoperative complications for patients who
have used iniximab for medical management of their disease preoperatively. There
is an increased risk for a three-stage procedure. However, the data evaluated to generate these conclusions is heterogeneous, and
it has yet to be determined the effect of infliximab versus whether it is a surrogate for
more aggressive disease. While the half-life
of TNFa inhibition is understood, the duration of biologic activity is less clear, making
recommendations regarding timing of surgery relative to last dose a challenge.
W. Complications: Complications following
pouch surgery can be categorized as perioperative and long-term. Perioperative com-
plications following IPAA include
incontinence, early small bowel obstruction
and pelvic sepsis. Long-term complications
include small bowel obstruction, anastomotic stricture, stula formation, sexual
complications, and pouchitis.
(a) Pelvic Sepsis: Pelvic sepsis occurs at a
rate of 5% following IPAA in the setting of anastomotic leak, dehiscence, or
infection of postoperative hematoma.
Fever, tachycardia pelvic pain, and
decreased pouch function are indicative
of sepsis, and the diagnosis is conrmed with CT imaging. Management
can be with percutaneous drainage, or
with exploration, washout, revision of
the anastomosis with proximal diversion or end ileostomy. The sequelae of
pelvic sepsis predisposes the patient to
stula formation and can impact function of the pouch secondary to brosis.
Complications of higher severity may
require revision IPAA.
(b) Incontinence: Nearly half of patients
undergoing IPAA will experience initial nocturnal low volume incontinence
of stool, with rates of approximately
20% at 1 year. The majority of patients
with nocturnal soilage show improvement over time.
(c) Small Bowel Obstruction: Early small
bowel obstruction is uncommon, but
may require early operative reintervention. Conversely, adhesive
small bowel obstruction occurs in 30%
of patients who are followed for 10
years postoperatively. Non-operative
management is successful in 90% of
these occurrences, but hospitalization
and decompression represents signicant distress to the patient.
(d) Stricture: Anastomotic strictures occur
at a rate of 5–30% and can be the result
of technical error leading to narrowing
of the lumen, tension on the anastomosis, infection, or ischemia. Management
is serial dilations under anesthesia.
Reoperation is rarely indicated.