Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_927_Библиотеки_им_академика_М_И_Перельмана.pdf
COLON
181
hese medications only for patients with severe disease who are neither
t
toxic nor show signs of impending perforation. A rapid response within
3 to 5 days of starting treatment is expected; otherwise, patients should
have surgery. ese patients require very close observation, both clinically and with a daily plain lm of the abdomen. Intravenous antibiotics
are oen used but have been shown to be ineective and, in fact, could
exacerbate symptoms if an antibiotic-associated colitis develops.
General Recommendations f
or Patients with Severe
Ulcerative Colitis
est for C. difficile Toxin A and B
T
All patients with a severe exacerbation of UC should be tested for C.
dicile cytotoxin A and B. A supine and decubitus plain lm of the
abdomen are obtained upon admission. If thumbprinting, pneumatosis intestinalis, or megacolon is observed, surgery should be considered. If surgery is not undertaken, then daily imaging should be
performed until clear improvement in the patient’s condition occurs.
Flexible Sigmoidoscopy with Biopsies
In most patients with severe UC, a exible sigmoidoscopy is adequate
to determine disease severity and to obtain biopsy specimens for
CMV testing. e appearance of the mucosa alone is not adequate to
exclude C. dicile infection because 50% do not have pseudomembranes upon endoscopic examinations. erefore, performing biopsies is very important because the histologic features characteristic of
pseudomembranous colitis may be present.
Deep Vein Thrombosis Prophylaxis
Patients with active UC have a threefold risk of venous thromboembolism. Some of factors that contribute to this risk include thrombocytosis, inammatory cytokines, and bed rest. Bloody diarrhea is not
a contraindication for prophylaxis with heparin.
Evaluate for Tuberculosis and Hepatitis B
Initial treatment for the patient with severe ulcerative colitis is with intravenous steroids. It is important to evaluate for tuberculosis and hepatitis
B because if the patient does not respond to intravenous steroids, the
treatment options are iniximab, cyclosporine, or surgery. e preferred
test to evaluate for tuberculosis is QuantiFERON because patients may
have false-negative results related to nutritional status or treatment.
Avoid Narcotics and Antidiarrheal Medications
e use of narcotics and antidiarrheal medications increases the risk
of toxic megacolon. Unfortunately for patients who have abdominal
pain, no good alternatives are available. If any of these medications
are used, patients should have a daily kidney-ureter-bladder radiograph in the upright position to assess the diameter of the colon.
Do Not Use Antibiotics
Unless evidence of bacterial infection is noted, antibiotics do not have
a role in the treatment of patients with severe UC. Small clinical trials have compared metronidazole, metronidazole + tobramycin, and
ciprooxacin with placebo as adjuvant treatments in patients treated
with intravenous steroids and have not shown benet.
Diet as Tolerated
Except for patients in whom urgent surgery is indicated, diet should
be as tolerated. Nutrition is a predictor of postsurgical complications,
and there is no role for total parenteral nutrition as primary treatment in patients with severe UC.
Perform Close Observation and Consult Colorectal Surgery upon Admission
Patients should be evaluated on an ongoing basis, and a surgical consultation should be obtained when the patient is admitted to the hospital. Keep in mind the dierent predictors of colectomy (Table 35-7) and
do not delay surgery in patients who are not responding to treatment.
Vaccinations
e approach to vaccinations in patients with UC is described in
Table 35-8.
Pregnancy
Treating the mother is the most important watchword of medical
therapy in patients with UC. If the mother’s disease is under control,
the chance for premature labor or spontaneous abortion is no different from that for an unaected mother. e activity of IBD in the
mother during pregnancy is dependent on the disease activity at the
time of conception. If the disease is inactive at conception, the probability that a serious are will develop during pregnancy is low. Conversely, if conception occurs during a relapse, there is a 30% chance
of further worsening of symptoms during pregnancy.
Prednisone, 5-ASA agents, thiopurines, anti-TNF-α agents, and antiadhesion molecules are safe to use during pregnancy and should be used
if the mother requires these medications to maintain remission or control
symptoms. However, it is recommended that use of biologic agents be
discontinued during the third trimester of pregnancy. Low birth weight,
once believed to be a result of corticosteroid use during pregnancy, is
more likely related to disease activity and nutritional deciencies. Even
though sulfasalazine has a sulfa moiety, sulfasalazine does not cause kernicterus. Azathioprine and 6-MP are considered by the Food and Drug
Administration to be class D drugs and are not recommended during
pregnancy, and studies show an increased risk of congenital malformations when azathioprine or 6-MP were used during pregnancy in patients
with IBD. However, these studies are small and have limited power, and
these medications have been used oen in uneventful pregnancies. In a
systematic review and meta-analysis by Akbari etal, ve quality studies
of female patients with IBD who received thiopurines during pregnancy
(total: 3045 women) and three studies of male patients taking thiopurines (total: 217 men) were analyzed. e pooled analysis showed that
the risk of congenital malformations in babies of pregnant women was
not statistically signicant (OR, 1.45; 95% CI, 0.99 to 2.13); neither was
he incidence of congenital defects in infants born of fathers taking thio-
t
purines (OR, 1.87; 95% CI, 0.67 to 5.25, P = .236). A similar British study
published in 2014 by Ban etal compared 1703 children born to mothers with IBD from 1990-2010 with 384,811 children of mothers without
IBD. Major congenital abnormalities were seen in 2.7% of children born
to mothers with IBD and in 2.8% of children born to mothers without
IBD. e adjusted OR of major congenital malformations according to
drug use was 0.82 (95% CI, 0.42 to 1.61) for 5-ASA, 0.48 (95% CI, 0.15 to
1.15) for corticosteroids, and 1.27 (95% CI, 0.48 to 3.39) for thiopurines.
A multicenter national prospective study of pregnancy and neonatal outcomes in women with IBD (PIANO) in the United States was initiated in
2007. In a preliminary report in 2013, information was available on 279
patients exposed to thiopurines. No observed increase in the risk of congenital malformations or other complications was observed in infants
exposed to thiopurines compared with infants who were not exposed to
thiopurines during pregnancy.
Methotrexate is class X and thus is contraindicated during
pregnancy.
Cancer Risk
D
uring the course of the disease, colorectal cancer will occur in
approximately 6% of patients with UC and will be the cause of
182
Medic
al Trea
TMenT of UlceraTive coliTis
and oT
her coliTides
TABLE 35-7: Predictors of Colectomy in Patients with Ulcerative Colitis
er Oxford Criteria (Travis et
Mark
Clinical
ospitalization at diagnosis
H
Stool frequency >12/d
Fever >38°C
Tachycardia >100
Albumin <30 g/L on day 4
Attack lasting >6 wk
ESR >30 mm/hr, or CRP >25 mg/L
Need for anti-TNF-α
Evaluation aer 72 hr of IV steroids
8 bowel movements/24 hr or 3-8 bowel
movements + CRP >45 mg/L
Aer 7 days of treatment, patients with >3
stools/day or visible blood have a 60%
chance of continuous symptoms and a
40% chance of requiring a colectomy in
3-30 wk
Need for early use of immunomodulators
Endoscopic
xtensive deep ulceration
E
Mucosal detachment at edge of ulcer
Large mucosal abrasions
“Well-like” ulcers
Histologic
requent crypt abscesses
F
Focal and segmental mononuclear cell inltration
Paucity of eosinophils
al,
1996
) T
ruelove and Witts
≥3 criteria = 50% likelihood of urgent
colectomy
Bloody stool frequency of 6 or more per
day
Tachycardia (90 bpm)
Temperature >37.8°C
Anemia (hemoglobin <10.5 g/dL)
ESR >30 mm/hr
Radiologic
olonic dilatation
C
Small bowel dilatation
, C-reactive protein; ESR, erythrocyte sedimentation rate; IV, intravenous; TNF, tumor necrosis factor.
CRP
ath in 3% of patients with extensive disease. These rates are
de
much higher than for the general population. The risk for colorectal cancer is known to increase with increasing extent and duration of disease, with younger age at symptom onset, with chronic
active disease, and with primary sclerosing cholangitis. High-risk
patients should be advised to enroll in surveillance programs.
TABLE 35-8: Vaccinations in Patients with
Ulcerative Colitis
ariable Instructions
V
General Check vaccination history and check im-
The magnitude of the risk in these patients is controversial, and
recently a case series has suggested that the risk of colon cancer
has decreased. The American College of Gastroenterology (ACG),
At diagnosis Check hepatitis B serology, vaccinate if
American Gastroenterological Association (AGA), European
Crohn’s and Colitis Organization, the British Society of Gastroenterology, and the National Institute for Clinical Excellence recommend performing the first screening colonoscopy 8 to 10 years
after diagnosis in patients with both universal and left-sided colitis (Table 35-9). In patients with primary sclerosing cholangitis,
the risk of colon cancer is greatly increased, and screening starts
at the time of diagnosis. If dysplasia is not found, some variability
exists in the recommendations regarding the frequency of subsequent screening colonoscopic examinations, with the suggested
interval varying from yearly to every 5 years. From a practical
standpoint it is easier to follow the AGA and ACG recommendations, which are that screening colonoscopic examinations should
be performed every 1 to 3 years. With longer duration of disease,
the interval between screenings is shorter. European societies recommend screening with chromoendoscopy and use of targeted
biopsies, and if chromoendoscopy is not available, they recommend that a colonoscopy be performed with at least 33 random
Ye a rl y Inuenza
Every 5 yr Pneumococcal
Every 10 yr In adults, tetanus and diphtheria
Trav e l Refer to travel clinic 3 mo before traveling
Contraindicated
while taking an
immunosuppressant
biopsies. U.S. societies recommend chromoendoscopy only in
special cases; otherwise, the recommendation is to perform highdefinition colonoscopy with white light and a minimum of 33
biopsies.
e goal of colonoscopic screening is to decrease death from
colon cancer in patients with IBD. erefore, if either conrmed lowgrade dysplasia is found on consecutive colonoscopies or if conrmed
high-grade dysplasia is found, or if multifocal dysplasia or an asymptomatic cancer is detected, the patient should have a total proctocolectomy. Additional indications for colectomy include a stricture
or extensive pseudopolyposis that prevent adequate screening.
Although these recommendations have not been shown to reduce the
mune status
negative
Check hepatitis A serology, vaccinate if
negative
Pneumonia vaccine
Inuenza
Human papillomavirus
Herpes zoster or varicella, yellow fever,
rabies, triple viral vaccine, bacillus
Calmette–Guérin, polio (Sabin)
COLON
183
TABLE 35-9: Screening Guidelines of International Societies for Neoplasia in Persons with Ulcerative Colitis
ariable ECCO 2008 BSG 2010 (and NICE) AGA 2010 ACG 2010
V
st screening 8-10 yr 10 yr Maximum 8 yr 8-10 yr
Fir
Surveillance interval Extensive: 2 yearly to 20 yr then annually
Le sided: 2 yearly starting at 15 yr
PSC: 1 yearly
Chromoendoscopy 1-3 y
More oen at high risk (e.g., PSC)
Biopsies 33+ if no chromoendoscopy 33+ if no chromoendoscopy 33+ 33+
G, American College of Gastroenterology; AGA, American Gastroenterological Association; BSG, British Society of Gastroenterology; ECCO, European
AC
Crohn’s and Colitis Organization; NICE, National Institute for Clinical Excellence; PSC, primary sclerosing cholangitis.
ancer-related mortality rate compared with an unscreened popula-
c
tion, cancer surveillance for patients with UC has become the standard of care and must be oered to those who are eligible.
ectal Cancer Prevention
Color
In patients with IBD, the only medication that appears to decrease
the risk of colon cancer is 5-ASA. Folic acid supplementation may
decrease the risk of colon cancer in patients who do not have dysplasia. However, if dysplasia is present, folic acid supplementation
should be discontinued because it increases the risk of progression
to colon cancer.
THER COLITIDES
O
oscopic Colitis
Micr
icroscopic colitis (MC) includes collagenous and lymphocytic
M
colitis. Previously considered a rare disease, the prevalence of MC
has increased since the term was coined in 1980. For example, in
the years 1993-1995, the annual incidence of collagenous colitis per
100,000 inhabitants in Sweden was 3.7, and for lymphocytic colitis it
was 3.1. In the years 2004-2008, the incidence of collagenous colitis
in Sweden had increased to 5.8 per 100,000 inhabitants, and for lymphocytic colitis it increased to 4.5. In Olmstead County, Minnesota,
the incidence of MC increased from 0.8/100,000 inhabitants in 19851989 to 19.1/100,000 in 1998-2001.
MC is a signicant cause of chronic diarrhea. It accounts for
approximately 10% of cases of chronic nonbloody diarrhea, and at
least 20% of these patients are older than 70 years. It aects persons of all ages but is rare in children. At least 25% of patients are
younger than 45 years. Patients with MC are typically women older
than 65 years. Previous or current cigarette smoking is a risk factor
for both lymphocytic and collagenous colitis. Some medications such
as NSAIDs have been implicated as triggers of the disease, and in
some cases may cause the disease. Other drugs such as proton pump
inhibitors cause an increase in intraepithelial lymphocytes in the
colon, but they do not cause diarrhea in all the patients. e range
of drugs that have been associated with MC also include ticlopidine,
serotonin reuptake inhibitors, and simvastatin. Patients commonly
present with the sudden onset of liquid diarrhea. More than 20% of
patients have at least 10 bowel movements per day, and more than
25% have nocturnal bowel movements.
MC is often associated with other immune diseases including rheumatoid arthritis, scleroderma, atrophic gastritis, chronic
active hepatitis, primary biliary cirrhosis, hypothyroidism, and
celiac disease. The diagnosis can be confirmed by documenting
By risk: low, 5 yr; intermediate,
3 yr; high, 1 yr
Recommended Special cases Not yet
a secretory diarrhea, normal-appearing colonic mucosa at colonoscopy, and an abnormal histologic appearance. The histologic
abnormality in collagenous colitis is a thickened apical subepithelial collagen layer and irregular collagen deposition with a ragged,
spiculated deep edge. The collagen band is composed of type III
collagen and fibronectin, and it measures between 7 and 100 μm
in thickness. Other findings include a thickened basement membrane and an excess of lymphocytes, plasma cells, eosinophils,
and mast cells in the lamina propria. Patients with lymphocytic
colitis do not have subepithelial eosinophilic deposits. Histologic
abnormalities may be limited to the proximal colon, spare the rectum, and be discontinuous, and thus a colonoscopy and biopsies
of the right and left side are necessary to confirm or exclude the
diagnosis.
ersion Colitis
Div
version colitis, bypass colitis, exclusion colitis, and disuse colitis
Di
are synonyms for the colonic inammatory process that invariably
occurs when the fecal stream is diverted from a colonic segment.
If the patient did not have inammation prior to the surgery that
diverted the fecal stream, symptoms resolve with reanastomosis.
Examples of patients who experience diversion colitis are those who
have undergone diversion for diverticulitis, cancer, or anastomotic
leaks. Hematochezia and mucus discharge from the rectum or
mucous stula are the primary symptoms, and these symptoms can
present from 1 month to 3 years aer the diversion is performed.
However, some patients with diverted colons are asymptomatic,
with only pathologic or endoscopic ndings. Typical histologic
ndings include mucin depletion, mucosal edema, a decreased
number and depth of crypts, supercial ulcerations, expansion of
cellular elements of the lamina propria, granulocyte inltration,
and brosis of the lamina propria. e colonoscopic appearance
of a diverted segment may show typical features of colitis such as
narrowing, erythema, ulceration, friability, exudate, or a distorted
mucosal vascular pattern.
Colonocytes are nourished from the bloodstream and from
luminal contents by short-chain fatty acids (SCFAs) that are a
byproduct of the metabolism of carbohydrates by colonic bacteria.
In an intact colon in patients with a normal diet, a concentration
of 100 to 200 mmol/L of SCFAs is recovered in stool, whereas a
diverted segment has less than 5 mmol/L. Treatment with twicedaily 60-mL SCFA enemas delivered into the diverted segment
effectively improves symptoms and resolves endoscopic and histologic inflammation. One formulation that typically works well
is a combination of 60-mmol acetate, 30-mmol propionate, and
40-mmol butyrate with sufficient sodium chloride and sodium
hydroxide to bring the osmolality to 280 mOsm and the pH to 7.0;
100-mmol butyrate enemas at the same osmolality and pH also
1-3 yr
More oen at high risk
(e.g., PSC)
1-2 yr
184
hould be successful. Responses also have been seen with 5-ASA
s
Medic
al Trea
TMenT of UlceraTive coliTis
enemas. The best therapy for diversion colitis is reanastomosis.
However, enemas given daily or even every other day can be used
to maintain remission until reanastomosis becomes feasible.
Radiation Colopath
hen organs adjacent to the rectum are treated with radiation ther-
W
y
apy, a radiation colopathy develops in 5% to 10% of patients. With
newer concentrating techniques, the organ with dose-limiting tolerance of ionizing radiation has changed from the skin to the gastrointestinal tract. e most common malignancies that are usually treated
with radiation therapy that cause radiation colitis are transitional cell
carcinoma of the bladder, squamous cell carcinoma of the cervix,
endometrial cancer, and adenocarcinoma of the prostate or rectum.
Early radiation injury is caused by direct damage to the crypt cells
of the epithelium, and late injury is caused by damage to the vascular
endothelium and connective tissue. Half the patients who have 6000
cGy delivered to a region of the colon or 8000 cGy delivered to the
rectum will experience early or late radiation colopathy. Apparently,
the margin of safety is very narrow, because these doses are close to
those required for treatment of the tumor.
Early radiation colopathy oen occurs within the rst month of
therapy. With epithelial disruption, symptoms of diarrhea, hematochezia, tenesmus, and mucus discharge occur. Upon endoscopy,
the mucosal abnormalities are similar to those seen in UC. e
mucosa is edematous and friable, with supercial ulcerations, and
the mucosal vascular pattern is decreased. However, the mucosal
abnormalities are conned to the radiated part and are not continuous as in UC. Histologic ndings include a decrease in the
height of the epithelial cells, mucin depletion, ulceration, and crypt
abscesses. Anterior rectal ulcerations, luminal narrowing, radiologic “thumbprinting,” and loss of haustrations are additional signs
of early toxicity.
erapy of early radiation toxicity includes symptomatic treatment such as antispasmodic agents, antidiarrheal medications, bulking agents, and topical anesthetics. Steroid enemas may help, but
5-ASA agents are not eective. Attempts to minimize the risk of
developing early radiation injury include surgical xation of bowel
away from the anticipated port, administration of free radical scavengers such as diallyl sulde (garlic), use of cyclooxygenase inhibitors
such as aspirin, hyperbaric oxygen, and glutamine-supplemented
diets.
Late injury from radiation therapy often occurs within 5
years but may present several decades after therapy. Symptoms
are slowly progressive and are related to changes in the submucosal layers of the bowel. Common presenting symptoms include
abdominal pain and diarrhea related to the development of
fibrous strictures and partial obstruction. Fistulas, perforation,
and impaired motility also may occur. The symptoms in patients
with late radiation proctopathy are tenesmus, mucous discharge,
change in stool caliber, and hematochezia. Endoscopically, the
usual findings include telangiectasias, granularity, friability, discrete ulcers in the anterior rectum, and strictures. Late radiation
injury resembles ischemia with submucosal fibrosis, telangiectasias of small vessels, hyalinized endothelium of larger blood vessel
walls, fistulas, and fissures.
Treatment of late complications of radiation therapy is rarely
eective. Steroid enemas or other medical therapies are of marginal
benet; use of a neodymium:yttrium-aluminum-garnet laser or bipolar electrocoagulation of bleeding telangiectasia may help decrease
hematochezia. Occasionally, strictures can be dilated manually or
with endoscopically placed balloon dilators. Because of the brittle
nature of radiated bowel, perforation is a frequent complication of
bowel dilation. Surgery for obstruction, bleeding, stulas, or perforation is high risk because of frequent delayed healing of the wound
and surgical anastomosis.
and oT
her coliTides
Drug-Induced Colitis
ertain drugs may cause inammation of the colon that is endoscopi-
C
cally indistinguishable from IBD. e distinction, though, is most
important because drug-induced colitis is best treated by withdrawal
of the medication, and IBD oen requires the institution of potentially
toxic medications. Mucosal inammation of the colon is a rare adverse
eect from some commonly used medications such as NSAIDs and
contraceptives. Even if the incidence of colitis is exceedingly low, the
common use of these medications makes drug-induced colitis potentially a more important problem than IBD. Other medications that may
cause a drug-induced colitis include methyldopa, penicillamine, potassium supplements, 5-uorouracil, oral gold, and isotretinoin.
The colitis that can occur as a result of oral contraceptive
use can be indistinguishable from Crohn colitis, with patients
presenting with chronic diarrhea and aphthoid ulcers throughout the colon. Symptoms and signs of oral contraceptive colitis
completely resolve without sequelae upon discontinuation of the
hormone. The pathogenesis is believed to be due to an occlusive
vascular phenomenon.
e symptoms and endoscopic ndings of NSAID-induced colitis usually mimic UC. e inammation is diuse with supercial
ulcerations. e pathogenesis of NSAID-induced colitis involves
cyclooxygenase inhibition and the loss of cytoprotective prostaglandins. e dierentiation between IBD and NSAID-induced
colitis is further complicated because arthritis, a condition oen
treated with NSAIDs, may or may not be related to IBD. A patient
with arthritis who takes NSAIDs and experiences symptoms and
signs suggestive of UC should stop taking these medications. Other
eects of NSAIDs on the gastrointestinal tract include complicated
ulcer disease, stricture from submucosal brosis, perforation from
deep ulceration, and diaphragmatic-like narrowing in the small
bowel or colon.
u
S
Adler DJ, Korelitz BI. e therapeutic ecacy of 6-mercaptopurine in refrac-
Akbari M, Shah S, Velayos FS, etal. Systematic review and meta-analysis on
Ban L, Tata LJ, Fiaschi L, Card T. Limited risks of major congenital anomalies
Bernstein CN, Shanahan F, Weinstein WM, et al. Are we telling patients
Bjarnason I, Zanelli G, Smith T, et al. Nonsteroidal anti-inammatory
Boyko EJ, Koepsell TD, Perera DR, etal. Risk of ulcerative colitis among for-
Breuer RI, Soergel KH, Lashner BA, etal. Short chain fatty acid rectal irri-
Brzezinski A, Rankin GB, Seidner DL, etal. Use of old and new oral 5-ami-
Calkins BM. A meta-analysis of the role of smoking in inammatory bowel
Chang KH, Burke JP, Coey JC. Iniximab versus cyclosporine as rescue ther-
Connell WR, Lennard-Jones JE, Williams CB, etal. Factors aecting the out-
Dwarakanath AD, Yu LG, Brooks C, etal. “Sticky” neutrophils, pathergic ar-
East JE. Colonoscopic cancer surveillance in inammatory bowel disease:
S t
g g e
tory ulcerative colitis. Am J Gastroenterol. 1990;85:717–722.
the eects of thiopurines on birth outcomes from female and male patients
with inammatory bowel disease. Inamm Bowel Dis. 2013;19:15–22.
in children of mothers with IBD and eects of medications. Gastroenterol-
ogy. 2014;146:76–84.
the truth about surveillance colonoscopy in ulcerative colitis? Lancet.
1994;343:71–74.
drug-induced intestinal inammation in humans. Gastroenterology.
1987;93:480–489.
mer and current cigarette smokers. N Engl J Med. 1987;316:707–710.
gation for le-sided ulcerative colitis: a randomized, placebo-controlled
trial. Gut. 1997;40:485–491.
nosalicylic acid formulations in inammatory bowel disease. Cleve Clin J
Med. 1995;62:317–323.
disease. Dig Dis Sci. 1989;34:1841–1854.
apy in acute severe steroid-refractory ulcerative colitis: a systematic review
and meta-analysis. Int J Colorectal Dis. 2013;28:287–293.
come of endoscopic surveillance for cancer in ulcerative colitis. Gastroen-
terology. 1994;107:934–944.
thritis, and response to heparin in pyoderma gangrenosum complicating
ulcerative colitis. Gut. 1995;37:585–588.
what’s new beyond random biopsy? Clin Endosc. 2012;45:274–277.
e d
R
e
a d i n g
COLON
185
Ernest DL, Trier JS. Radiation enteritis and colitis. In: Sleisenger MH, Fordtran
JS, eds. Gastrointestinal Disease. Philadelphia: WB Saunders; 1993.
Farmer RG, Easley KA, Rankin GB, etal. Clinical patterns, natural history,
and progression of ulcerative colitis: a long-term follow-up of 1,116 patients. Dig Dis Sci. 1993;38:1137–1146.
Fernandez-Banares F, Bertran X, Esteve-Comas M, etal. Azathioprine is use-
ful in maintaining long-term remission induced by intravenous cyclosporine in steroid-refractory severe ulcerative colitis. Am J Gastroenterol.
1996;91:2498–2499.
Gies N, Kroeker KI, Wong K, Fedorak RN. Treatment of ulcerative colitis with
adalimumab or iniximab: long- term follow-up of a single-centre cohort.
Aliment Pharmacol er. 2010;32:522–528.
Harig JM, Soergel KH, Komorowski RA, etal. Treatment of diversion colitis
with short-chain fatty acid irrigation. N Engl J Med. 1989;320:23–28.
Hawthorne AB, Logan RFA, Hawkey CJ, etal. Randomized controlled trial
of azathioprine withdrawal in ulcerative colitis. Br Med J. 1992;305:20–22.
Järnerot G, Hertervig E, Friis-Liby I, etal. Iniximab as rescue therapy in se-
vere to moderately severe ulcerative colitis: a randomized, placebo- controlled study. Gastroenterology. 2005;128:1805–1811.
Kornbluth A, Sachar BD, etal. Ulcerative colitis practice guidelines in adults:
American College of Gastroenterology, Practice Parameters Committee.
Am J Gastroenterol. 2010;105:501–523.
Kozarek R, Bedard C, Patterson D, etal. Cyclosporine use in the precolectomy
chronic ulcerative colitis patient: a community experience and its relationship to prospective and controlled clinical trials. Am J Gastroenterol.
1995;90:2093–2096.
Lashner BA. Recommendations for colorectal cancer screening in ulcerative
colitis: a review of research from a single university-based surveillance
program. Am J Gastroenterol. 1992;87(2):168–175.
Lashner BA, Hanauer SB, Silverstein MD, etal. Testing nicotine gum for ul-
cerative colitis patients: experience with single patient trials. Dig Dis Sci.
1990;35:827–832.
Lashner BA, Kirsner JB. Inammatory bowel disease in older people. Clin
Geriatr Med. 1991;7:287–299.
Lashner BA, Shaheen MJ, Hanauer SB, etal. Passive smoking is associated
with an increased risk of developing inammatory bowel disease in children. Am J Gastroenterol. 1993;88:336–359.
Lawson MM, omas AG, Akobeng AK. Tumour necrosis factor alpha block-
ing agents for induction of remission in ulcerative colitis. Cochrane Data-
base Syst Rev. 2006;(3). CD005112.
Lemann M, Galian A, Rutgeerts P, et al. Comparison of budesonide and
5-aminosalicylic acid enemas in active distal ulcerative colitis. Aliment
Pharmacol er. 1995;9:557–562.
Lichtiger S, Present DH, Kornbluth A, etal. Cyclosporine in severe ulcerative
colitis refractory to steroid therapy. N Engl J Med. 1994;330:1841–1845.
Loerg R, Danielsson A, Suhr O, etal. Oral budesonide versus prednisolone
in patients with active extensive and le-sided ulcerative colitis. Gastroen-
terology. 1996;110:1713–1718.
Loerg R, Ostergaard omsen O. Budesonide versus prednisolone reten-
tion enemas in active distal ulcerative colitis. Aliment Pharmacol er.
1994;8:623–629.
Lv R, Qiao W, Wu Z, et al. Tumor necrosis factor alpha blocking agents as
treatment for ulcerative colitis intolerant or refractory to conventional
medical therapy: a meta-analysis. PLoS One. 2014;9(1):e86692.
Manz M, Nichetti P, Seibold F, etal. Treatment algorithm for moderate to
severe ulcerative colitis. Practical consensus recommendations. Swiss Med
Wkly. 2014;141:w13235.
Marteau P, Probert CS, Lindgren S, etal. Combined oral and enema treatment
with Pentasa (mesalazine) is superior to oral therapy alone in patients with
extensive mild/moderate active ulcerative colitis: a randomised, double
blind, placebo controlled study. Gut. 2005;54(7):960–965.
Meyers S, Sachar DB, Present DH, etal. Olsalazine sodium in the treatment of
ulcerative colitis among patients intolerant of sulfasalazine: a prospective,
randomized, placebo-controlled, double-blind, dose-ranging clinical trial.
Gastroenterology. 1987;93:1255–1262.
Nakada T, Kubota Y, Sasagawa I, et al. erapeutic experience of hyper-
baric oxygenation in radiation colitis: report of a case. Dis Colon Rectum.
1993;36:962–965.
Nguyen GC, Kaplan GG, Harris ML, Brant SR. A national survey of the preva-
lence and impact of Clostridium dicile infection among hospitalized
inammatory bowel disease patients. Am J Gastroenterol. 2008;103:1443–
1450.
Present DH, Meltzer SJ, Krumholz MP, etal. 6-Mercaptopurine in the man-
agement of inammatory bowel disease: short- and long-term toxicity.
Ann Intern Med. 1989;111:641–649.
Retsky JE, Kra SC. e extraintestinal manifestations of inammatory bowel
disease. In: Kirsner JB, Shorter RG, eds. Inammatory Bowel Disease. Bal-
timore: Williams & Wilkins; 1995.
Riddell RH, Goldman H, Ransoho DF, et al. Dysplasia in inammatory
bowel disease: standardized classication with provisional clinical applications. Hum Pathol. 1983;14(11):931–68.
Samuelsson S. Ulceros Colit och Proktit [dissertation]. Uppsala, Sweden: De-
partment of Social Medicine, University of Uppsala; 1976.
Sandborn WJ, Feagan BG, Marano C, etal. Subcutaneous golimumab induces
clinical response and remission in patients with moderate to severe ulcerative colitis. Gastroenterology. 2014;146:85–95.
Sandborn WJ, Feagan BG, Marano C, etal. Subcutaneous golimumab main-
tains clinical response in patients with moderate to severe ulcerative colitis. Gastroenterology. 2014;146:96–109.
Sandborn WJ, Tremaine WJ, Oord KP, et al. Transdermal nicotine
for mildly to moderately active ulcerative colitis. Ann Intern Med.
1997;126:364–371.
Sandborn WJ, Tremaine WJ, Schroeder KW, etal. A placebo-controlled trial
of cyclosporine enemas for mildly to moderately active le-sided ulcerative colitis. Gastroenterology. 1994;106:1429–1435.
Selhub J, Dhar GJ, Rosenberg IH, etal. Inhibition of folate enzymes by sul-
fasalazine. J Clin Invest. 1978;61:221–224.
Sheppach W, Sommer H, Kirchner T, etal. Eect of butyrate enemas on the
colonic mucosa in distal ulcerative colitis. Gastroenterology. 1992;103:51–
56.
Shetty K, Rybicki L, Brzezinski A, etal. e risk of cancer or dysplasia in ul-
cerative colitis patients with primary sclerosing cholangitis. Am J Gastro-
enterol. 1999;94:1643–1649.
Silverberg MS, Satsangi J, Ahmad T, et al. Toward an integrated clinical,
molecular and serological classication of inammatory bowel disease:
report of a Working Party of the 2005 Montreal World Congress of Gastroenterology. Can J Gastroenterol. 2005;19(suppl A):5–36.
Sloth H, Bisgaard C, Grove A, etal. Collagenous colitis: a prospective trial of
prednisolone in six patients. J Intern Med. 1991;229:443–446.
Stenson WF, Cort D, Rodgers J, etal. Dietary supplementation with sh oil in
ulcerative colitis. Ann Intern Med. 1992;116:609–614.
Tedesco FJ, Volpicelli NA, Moore FS, etal. Estrogen- and progesterone-asso-
ciated colitis: a disorder with clinical and endoscopic features mimicking
Crohn’s colitis. Gastrointest Endosc. 1982;28:247–249.
omas GA, Rhodes J, Ragunath K, et al. Transdermal nicotine compared
with oral prednisolone therapy for active ulcerative colitis. Eur J Gastroen-
terol Hepatol. 1996;8:769–776.
omas GAO, Rhodes J, Mani V, etal. Transdermal nicotine as maintenance
therapy for ulcerative colitis. N Engl J Med. 1995;332:988–992.
Travis SPL, Danese S, Kupcinskas L, etal. Once-daily budesonide MMX in
active, mild-to-moderate ulcerative colitis: results from the randomised
CORE II study. Gut. 2014;63:433–441.
Travis SPL, Farrant JM, Ricketts C, etal. Predicting outcome in severe ulcera-
tive colitis. Gut. 1996;38:905–910.
Tripodi J, Gorcey S, Burakoff R, etal. A case of diversion colitis treated
with 5-aminosalicylic acid enemas. Am J Gastroenterol. 1992;87:645–
647.
Truelove SC, Witts LJ. Cortisone in ulcerative colitis: nal report on a thera-
peutic trial. BMJ. 1955;2:1041–1048.
C U
C: S
O
vi P. Kiran
Ra
INTR
ODUCTION
D
espite major advances in the medical treatment of ulcerative colitis
(UC), surgery is still frequently required. Because the aim of surgery
is to cure the disease, elimination of all colorectal mucosa is ideal.
is operative strategy may need to be modied depending upon
patient-, disease-, and treatment-related factors, which may have an
impact on short- and long-term outcomes, as well as quality of life.
EV
OLUTION OF SURGERY FOR
ULCERATIVE COLITIS
Surgery for UC evolved from the initial description of a colostomy in the late nineteenth century, through appendicostomy or
cecostomy, to ileostomy with or without a blowhole colostomy,
especially for toxic megacolon. Total abdominal colectomy with
an ileorectal anastomosis subsequently developed as a technique
that allowed resection of diseased colon without a stoma. However,
patients who undergo this procedure have ongoing symptoms from
proctitis, function is unpredictable, and there is an increasing risk
of cancer in the rectum. ese disadvantages precluded widespread
adoption of the ileorectal anastomosis and raised questions about
its durability. Total proctocolectomy with end ileostomy allows
the elimination of all diseased mucosa, but it includes a permanent external appliance. e continent ileostomy developed as an
alternative. is procedure involves construction of an ileal pouch,
made continent by a valve in the eerent limb, and anastomosed to
the abdominal skin. It was not too much of a leap to use the anal
sphincters instead of a valve and to anastomose the pouch to the
anus instead of the abdominal skin. Construction of this ileoanal
pouch allows removal of all diseased mucosa but maintains per
anal defecation. It has become the standard surgical procedure for
the treatment of UC.
INDIC
PERSONS WITH ULCERATIVE COLITIS
1. F
ailure of medical treatment: e presence of intractable symp
t
oms despite maximal medical therapy is a common indication
for surgery. Failure of medical treatment also may be due to an
inability to tolerate a reasonable maintenance dose of antiinammatory medications that help patients avoid the development of
drug-related adverse eects or an overall poor quality of life.
omplications: Emergency surgery may be required for acute
2. C
co
acolon, perforation, and hemorrhage. Stricture, dysplasia, and
cancer are long-term complications that also may require surgery.
3. C
ancer: e risk of colon cancer in a patient with chronic UC has
een estimated to range from 2% at 20 years aer onset of disease
b
186
ATIONS FOR SURGERY IN
mplications such as severe acute or fulminant colitis, toxic meg-
o 43% at 35 years. e ndings of a meta-analysis suggested a
t
cumulative incidence of colorectal cancer of 8.5% at 20 years and
17.8% at 30 years. Patients begin colonoscopic surveillance with
biopsies at about 8 years aer the onset of their disease. When
dysplasia is detected and conrmed by pathologic review, factors
such as the location, type, and degree of dysplasia, its extent, and
the severity of associated background colitis determine the cancer
risk. Adenomatous dysplasia such as that found in a discrete adenoma is not necessarily an indication for colectomy as long as the
adenoma can be treated endoscopically.
ther: Extraintestinal manifestations of ulcerative colitis and
4. O
g
rowth retardation in children are other occasional indications
for surgery.
OPERA
TIONS FOR ULCERATIVE
COLITIS
Ileostom
A
n ileostomy may be temporary or permanent. Temporary fecal
diversion may protect a distal anastomosis, be part of the rst stage
of a proctocolectomy in a sick patient, or be part of the treatment of
a pouch complication. A permanent ileostomy may be needed when
an insoluble distal pouch problem exists, when a patient is not t to
undergo a staged proctectomy and creation of a pouch, or most commonly aer a total proctocolectomy (TPC).
Straight
A straight ileoanal anastomosis, which was initially performed in
the 1940s, was associated with high rates of fecal urgency and frequency, leading to low overall satisfaction and problems with continence. ese outcomes, which are expected in the absence of a fecal
reservoir, along with the anastomotic complications of the procedure, led to the creation of an ileostomy in a signicant proportion
of patients. A variation of the straight ileoanal anastomosis in which
multiple 3- to 4-cm longitudinal myotomies are performed at three
circumferential sites has been reported to have comparable function
to the ileal pouch–anal anastomosis (IPAA) except for nocturnal
soiling.
Subtotal Colectom
A s
toxic colitis or megacolon. It is less extensive than a proctocolectomy but avoids the risks associated with pelvic dissection and the
creation of an anastomosis. It is therefore suitable for a rst-step
y
Ileoanal Anastomosis
y
ubtotal colectomy and ileostomy is the procedure of choice for
COLON
187
rocedure in malnourished or moribund patients and in those
p
receiving large doses of steroids or immunosuppression, as well as
when potential problems with sexual dysfunction or fertility need
to be minimized. Performing a subtotal colectomy rather than a
one-stage restorative proctocolectomy is safer when a diagnosis of
Crohn disease cannot be excluded because it provides a large specimen for histologic evaluation and preserves options for denitive
treatment.
During a subtotal colectomy, preservation of the main trunk of the
inferior mesenteric artery with division of the mesenteric branches
minimizes damage to the autonomic nerves and allows easier identication of the stump when a subsequent proctectomy is performed.
Having a longer distal stump also allows the stapled end to reach the
anterior abdominal wall for subcutaneous placement. Subcutaneous
rather than intraperitoneal stump placement avoids the possibility of
rectal stump blowout, which can cause peritonitis or a pelvic abscess
and necessitates a repeat laparotomy. If the rectosigmoid stump is
very friable, it is matured primarily as a mucus stula or secondarily
aer 10 days of hanging out of the wound as a “tail” that is 10 cm in
length and wrapped in gauze. If a repeat anastomosis is not intended,
it is best to complete a proctectomy soon because the development of
a stricture in the rectal stump as a result of persistent inammation
may prevent adequate surveillance.
Abdominal Colectom
lectomy with ileorectal anastomosis (IRA) is technically simple
A co
and leads to rapid recovery, but bowel function is dependent upon
the distensibility of the rectum, the severity of residual disease,
and the adequacy of the anal sphincters. Transection of the rectum
should be performed at the level of the sacral promontory to preserve the full length of the rectum for optimal capacity. An ileosigmoid anastomosis is an alternative when the distal sigmoid is spared
from active disease. e risk of cancer in the rectum is 3% to 8% over
long-term follow-up, and the overall failure rate for an IRA reaches
54% over 20 years. e main advantage of an IRA is that it avoids the
hazards of pelvic dissection and thus merits consideration in specic
circumstances. It allows restoration of health, completion of education and pregnancy in some young patients prior to a subsequent
restorative proctocolectomy, and may be the denitive procedure in
elderly patients who do not want to undergo an ileostomy. One-stage
surgery is usually performed unless the patient has toxic colitis, intraabdominal sepsis, and signicant malnutrition or unless doubt exists
with regard to the normality of the rectal mucosa. In some circumstances, resection of diseased colon at an initial subtotal colectomy
may allow recovery of function and compliance of the rectum, which
then becomes usable. Favorable results have been reported aer
primary or secondary IRA, even when proctitis is present. e key
aspect of functionality is rectal compliance, which is best judged by
rigid proctoscopy. Anastomotic complications are similar whether
the ileum is anastomosed to diseased or macroscopically normal rectum, and a routine proximal ileostomy is not indicated. Equivalent
results have also been reported with both sutured and stapled anastomoses. e rectum needs to be monitored with yearly surveillance
because cancer has been reported to occur in both nonfunctioning
and functioning rectums.
Ileostom
e Turnbull blowhole colostomy and loop ileostomy described in
the 1960s has a role in extremely ill patients and in situations in which
colonic mobilization is hazardous, such as a contained perforation,
pregnancy, or a high-lying splenic exure. e main advantage of the
procedure is that the colon is not disturbed; the main disadvantage is
that the diseased colon is le behind and may lead to persistent toxicity. e procedure is contraindicated in patients with free perforation
y and Blowhole Colostomy
y with Ileorectal Anastomosis
or bleeding. A denitive procedure is performed aer the patient has
recovered.
otal Proctocolectomy and Ileostomy
T
with a Brooke ileostomy is curative and is reported to be asso-
A TPC
ciated with good quality of life. However, the need for an external
appliance, with the complications of leakage around the bag, skin
rashes and infections, potential psychosocial issues, and problems
with healing of the perineal wound, are disadvantages. Quality of
life may be better aer an IPAA than with an ileostomy. A TPC and
ileostomy is undoubtedly the best option for patients with poor anal
sphincter function and for patients who want to address their disease in the least complicated manner with one operation and a minimal chance of needing another operation. A single-stage procedure
is avoided in patients with fulminant disease, toxic megacolon, and
severe malnutrition or perianal sepsis. Although a subtotal colectomy
is the procedure usually performed for severe colonic hemorrhage, a
total proctocolectomy occasionally may be indicated for patients with
signicant rectal hemorrhage.
Proctectomy Surgical Technique
Aer the colectomy is completed, the rectum may be dissected within
the mesorectum to avoid damage to autonomic nerves, but this dissection is associated with greater blood loss. Dissection in the avascular plane between the investing layer of fascia of the rectum and
the presacral fascia to the lower border of the third sacral vertebra
followed by dissection close to the rectal wall results in less loss of
blood and still preserves the pelvic nerves. e lateral rectal dissection is kept close to the rectal wall at the level of the lateral ligament.
Anteriorly, the rectal dissection is carried out on the rectal side of
the fascia of Denonvilliers, exposing the vertical muscle bers of the
rectum but not the seminal vesicles, and the perineal proctectomy is
completed with use of the endoanal technique. An intersphincteric
dissection is performed, preserving the anal skin, external sphincter, and levator muscles, because this approach has been reported to
be associated with a lower incidence of impotence and a low rate of
unhealed perineal wound. Primary closure of the perineal wound is
then performed. Alternatively, the anus may be removed completely
or not at all. e rectum can be transected at the level of the levators, closing the rectal stump by sutures or staples and thus avoiding
a perianal wound altogether. A mucosal proctectomy with or without
closure of the anorectal stump has also been proposed.
Up to 11% of patients may have an unhealed perianal wound
that is managed by serial wound curettage and cautery, resurfacing with skin graing, or lling of cavities with vascularized pedicle
muscle gras such as gracilis, semimembranosus, rectus abdominis,
or omentum. An inferior gluteal myocutaneous gra has also been
used. When a proctocolectomy is performed in the acute setting, it is
associated with high mortality and morbidity rates. Pelvic dissection
may lead to a pelvic abscess, an enteric stula, or autonomic nerve
damage.
Continent Ileostom
Developed by Nils Kock, the continent ileostomy procedure provides
freedom from the need for an external appliance. It consists of the
creation of an ileal reservoir (pouch), which is connected to the skin
of the abdominal wall by a spout. By intussuscepting the bowel, a
nipple valve is created at the exit of the spout from the pouch; it is
stabilized by sutures or staples. is valve prevents leakage of stool.
Stool is evacuated by the intermittent insertion of a drainage catheter
though the ush ileostomy into the pouch. e pouch consists of an
S-shaped reservoir made of three 15-cm limbs of small bowel and
an exit conduit containing the valve. Patients with UC who are not
y
188
Chr
C UlCera
oni
tive Colitis:
sUrgiCal options
c
andidates for an IPAA, who prefer to avoid an IPAA, or whose IPAA
fails are potential candidates for the procedure. In the latter case,
the initial pouch can be modied for use as the continent ileostomy
pouch. Although most patients who undergo the continent ileostomy
procedure have a good quality of life, long-term pouch revision and
excision rates are high, predominantly because of slippage of the nipple valve. Various modications have been described to help anchor
of patients still require a repeat operation for valve slippage, prolapse,
and incontinence.
Restorativ
e restorative proctocolectomy procedure, developed in the 1970s,
e Proctocolectomy
is currently the gold standard operation for patients with UC who are
undergoing surgery. e components of this procedure are total colectomy, proctectomy, and construction of an ileal reservoir with the
creation of an IPAA. A compliant sac made up of loops of small bowel
constitutes the reservoir. e procedure may be performed in one,
two, or three stages, and the pouch-anal anastomosis is either stapled
or hand sewn. In the stapled procedure, the anal transitional zone
is preserved and anastomosis is performed 1 cm above the dentate
line. Annual biopsy surveillance of the anal transitional zone is then
performed. Patients who are poorly compliant at follow-up and those
with marked extraintestinal manifestations of UC are best treated
with an anal mucosectomy and a hand-sewn anastomosis.
A restorative proctocolectomy can be performed with acceptable complication rates, functional outcomes, and quality of life and
is applicable to several subgroups of patients. Satisfactory function
has been reported in children younger than 10 years and also in
elderly persons as long as they have reasonable sphincter function. In
indeterminate colitis, the short- and long-term results are similar to
those with UC; however, such patients who are then diagnosed with
Crohn disease have worse outcomes. IPAA has also been performed
in patients in whom colorectal carcinoma complicates inammatory
bowel disease, although deterioration in the function of the pouch
occurs when such patients undergo radiotherapy.
Pouch Configuration and Anastomosis
It is generally agreed that functional results of IPAA are the same
regardless of the pouch congurations (J, S, or W). Evacuation disorders are more common with the S pouch if the exit conduit is longer
than 2 cm because this conguration may lead to obstructive defecation. e J pouch conguration is the most popular because of
the simplicity of its construction. Some controversy exists regarding
the inuence of anastomotic technique on pouch function. A stapled
IPAA is associated with a lower incidence of sepsis and stretchinduced sphincter trauma and preserves the anal transitional zone.
e stapled anastomosis functions better, has fewer complications,
and is associated with a lower pouch excision rate.
Staging the Procedure
For carefully selected patients in whom the risk of anastomotic leak is
likely minimal, the procedure can be performed without a diverting
stoma (in one stage). However, an anastomotic leak can lead to signicant morbidity and potentially aects long-term pouch function,
predisposing to pouch failure. us, in the majority of instances, a
two-stage procedure is preferable in which the ileoanal pouch is protected with a temporary loop ileostomy because the ileostomy reduces
the consequences of an anastomotic leak. Patients with inactive or
mild colitis and those for whom steroids have either been discontinued or tapered to a low dose are candidates for such an approach.
For patients with more orid colitis and those taking high-dose
steroids or potent immunosuppressive medication and anti–tumor
necrosis factor agents (which may predispose to post-IPAA septic
complications), a three-stage approach is safest. An initial subtotal
colectomy minimizes disease and allows the withdrawal of medication and improvement of nutrition before a subsequent completion
proctectomy and IPAA. is approach has reduced surgical risks and
improved long-term pouch retention.
Technique of Creation of an Ileoanal J Pouch
Standard oral and mechanical bowel preparation is undertaken
before creation of an ileoanal J pouch. e operation begins with a
midline incision for open surgery or port placement for laparoscopy,
aer which the colon is mobilized from the pelvic brim proximal to
the middle colic vessels, which are preserved. High ligation of the
inferior mesenteric vessels is then performed. Dissection is continued into the pelvis using electrocautery in the plane between the presacral fascia and the investing fascia propria of the rectum. Dissection
in this plane is then carried down to the pelvic oor, aer which the
distal rectum is stapled across 1 cm above the dentate line. A J pouch
20 cm in length is fashioned from the distal ileum through the use of
staples and is anastomosed to the anal canal proximal to the dentate
line. In some circumstances in which problems may exist with reach
of the pouch to the anal canal, the S-shaped design allows the pouch
to reach an extra 2 cm. e pouch-anal anastomosis is completed
with the use of circular stapling device for a stapled anastomosis.
When a hand-sewn anastomosis is performed, mucosectomy of the
anorectal remnant is completed prior to anastomosis.
Problems with Reach of the Pouch
Minimal information is available on the rate of abandonment of IPAA
as a result of technical diculties; in two reported series, this rate has
been suggested to be 4.1% and 6%. e reach of the pouch is inuenced by the length of the superior mesenteric artery, the orientation of the small bowel, and the anatomy of the pelvis and mesentery.
Problems with pouch reach are traditionally considered to aect tall
patients and those with a high body mass index, especially when they
are men. Weight loss before surgery may be helpful. Some maneuvers
at the time of surgery may facilitate reach of the pouch to the anal
canal. ese maneuvers include high ligation of the ileocolic vessels, release of the small bowel mesentery from the retroperitoneum,
mobilization of the duodenum, excision of the redundant mesenteric
tissue lateral to the superior mesenteric vessels (“gib-sail”), and the
creation of peritoneal-releasing incisions along the mesenteric edge
of the small intestine. Although ligation of some of the branches or of
the main trunk of the superior mesenteric artery itself have also been
described, this maneuver is associated with a risk for compromise of
blood supply to the entire small intestine.
Diculty with reach of the pouch to the anal canal needs to be
anticipated prior to rectal transection so the operation may be modied accordingly to facilitate an ileal pouch rectal anastomosis. Prior
to transection of the rectum, a pouch is simulated and the most
dependent portion eventually destined to connect to the anal canal is
held in a Babcock forceps and delivered into the pelvis. e simultaneous passage of a gloved nger into the anal canal allows conrmation of reach of the Babcock forceps to the intended level of rectal
t
ransection. Alternatively, if the apex of the small bowel reaches below
the symphysis pubis, then an IPAA is likely to be feasible. If the signs
point to a problem with reach, the rectal stump may be intentionally
le slightly long to minimize tension on the IPAA. Orientation of the
pouch in such a way as to direct the pouch mesentery anteriorly may
produce less tension on the anastomosis. When preliminary assessment suggests that these eorts will fail, consideration may be given to
the creation of an “S” instead of a “J” pouch. In the rare circumstance
in which the pouch has been created but cannot then be mobilized
adequately for anastomosis to the anal canal, the end of the pouch
may be closed o. e pouch is then sewn in the pelvis and diverted
with a proximal ileostomy. Aer 2 years, an IPAA may be attempted
again in the hope that mesenteric lengthening has occurred.
COLON
189
OUTCOMES OF ILEAL POUCH–ANAL
ANAST
F
azio etal recently reported outcomes for a large number of patients
with prolonged follow-up aer IPAA, suggesting that excellent longterm functional outcomes and quality of life can be expected.
Complications after Ileal Pouch–Anal Anastomosis
P
ouch-related complications occur postoperatively in the intermediate and long term. Immediate postoperative sepsis occurs in 5%
to 20% of all cases, and the most common early complications are
anastomotic leak or stricture, abdominal wound infections, and
small bowel obstructions. Ileostomy-related complications include
small bowel obstruction, high output, prolapse, retraction, dehydration, electrolyte imbalance, stenosis, parastomal hernia, and leakage.
Ileostomy closure is associated with a 5% to 25% incidence of small
bowel obstruction and anastomotic complications. Other complications specic to restorative proctocolectomy include pouchitis, stulae (pouch-vaginal, pouch-cutaneous, or pouch-perineal), ischemia
of the pouch, water and electrolyte imbalance, and obstruction. Sexual disturbances as a result of damage to the autonomic nerves during rectal dissection and reactionary or secondary bleeding also may
occur. Pouchitis is discussed specically in Chapter 39.
Overall Quality of Life
e majority of patients are satised with their quality of life aer
surgery for ulcerative colitis, with good functional results expected
in the majority of patients even upon long-term follow-up. Quality
of life also continues to be excellent with minimal deterioration in
pouch function with time.
Function of the Pouch
e median daily stool frequency varies from 7.5 at 1 month postoperatively to 5.4 at 1 year postoperatively. When function stabilizes,
the stool frequency is expected to be ve during the day, whereas the
range of nighttime defecation is zero to three, depending on the time
of the evening meal. Although 18% to 40% of patients may experience some element of urgency, seepage, incontinence, or the use of
pads on prolonged follow-up, a similar proportion may be incontinent preoperatively. Regardless, most patients report satisfaction
with their medical situation. Similar long-term function results can
be expected aer creation of an IPAA in pediatric patients.
Pouchitis
e cumulative risk of pouchitis increases with increased duration
of follow-up. A signicantly lower incidence of pouchitis occurs
in nonsmokers and in patients with primary sclerosing cholangitis
compared with matched control subjects. Patients with extraintestinal manifestations of UC may be more prone to pouchitis than those
without such manifestations. Anastomotic strictures and excessively
large pouches that empty poorly may be predisposed to pouchitis.
Frequent attacks and attacks refractory to treatment may be due to
previously unrecognized Crohn disease.
Pouch Failure
P
ermanent pouch failure, dened as pouch excision or permanent
diversion, occurs in 5% to 20% of cases. e most common reasons
for pouch excision include pelvic sepsis, with or without a stula,
OMOSIS
and poor function. Most pouch failures occur in the rst 2 years aer
surgery, and dehiscence of IPAA, poor function, pouchitis, and perianal disease are the major causes of pouch failure. Ischemia of the
pouch, diagnosis of Crohn disease, chronic pouch sepsis, and refractory pouchitis are also causes of pouch failure. ere appears to be no
increased incidence in pediatric patients.
ouch Fistula
P
Fi
stulas involving the pouch occur in 3% to 17% of patients. Fistulae
may be pouch vaginal, pouch perineal, pouch cutaneous, and pouch
perianal. e most common is the pouch-vaginal stula. Successful
repair can be achieved in 60% of patients, although multiple procedures are oen required. Procedures that can be performed include
stulotomy, debridement, transanal closures, seton, vaginal ap
repairs, and endoanal ileal advancement aps with or without sphincteroplasty. Nonlocal treatment options include temporary diversion,
transabdominal closures, revision of the pouch, bulbocavernosus ap
repairs, vulval fat interpositions, and gracilis muscle ap repairs.
Risk of Car
ysplasia of the pouch remains a concern for patients with UC under-
D
going IPAA, and an association of villous atrophy with pouch dysplasia
has been reported. Carcinoma in the anal transition zone aer IPAA
is another potential concern. Data from long-term follow-up suggests
that dysplasia is infrequent, is most common in the rst 2 to 3 years
aer surgery, and may disappear on a repeat biopsy. When persistent
dysplasia develops in the anal transition zone, it can be managed by
removal of the diseased mucosa, with a transanal pouch–anal reanastomosis. Patients who are at a high risk of developing dysplasia or cancer
in the anal canal include those with colorectal cancer at index surgery,
rectal dysplasia, and any dysplasia in the colon identied preoperatively. A mucosectomy should be performed in these patients. Cancer
also may develop in patients who undergo a mucosectomy because of
incomplete stripping of the mucosa, with up to 21% of patients having
retained mucosal epithelial cells in the anal transitional zone. Pouch
and anal transition zone surveillance are indicated for every patient
with an IPAA and should be performed every 1 to 2 years depending
on circumstances and length of follow-up.
ertility, Sexual Problems, and Obstetric Outcome
F
IP
AA is associated with reduced fertility. Although some patients
report sexual dysfunction aer the procedure, the incidence of serious sexual dysfunction such as impotence (<1%) and retrograde
ejaculation (<5%) is low. In female patients, a signicant increase
in vaginal dryness and dyspareunia may occur postoperatively
without any change in sexual desire, arousal, or frequency of intercourse, whereas the majority of male patients report no change or an
improvement in their sexual relationship with their partner. Some
controversy exists with regard to whether pregnant patients with a
pouch should undergo vaginal delivery or cesarean section, but vaginal delivery appears to be safe and associated with good quality of life
even when some deterioration of pouch function has occurred.
Extraintestinal Manif
lthough some extraintestinal manifestations disappear aer col-
A
ctomy, others may continue to progress despite the elimination of
e
intestinal disease. romboembolic events and erythema nodosum
are commonly cured or improved aer proctocolectomy, whereas
ocular manifestations and primary sclerosing cholangitis are
unaected.
cinoma
estations
190
Chr
C UlCera
oni
tive Colitis:
sUrgiCal options
Quantification of Risk for Pouch Failure after Ileal
Pouch Anal Anastomosis Surgery
e Cleveland Clinic ileal pouch failure model was developed to predict
the risk of ileal pouch failure in clinical practice on a longitudinal basis.
Patient diagnosis, prior anal disease, abnormal anal manometry, patient
comorbidity, pouch-perineal or pouch-vaginal stulae, pelvic sepsis,
anastomotic stricture, and separation were found to be independent predictors of pouch survival and were used in the nal multivariate model.
Salvage of the Failed Pelvic Pouch
Pouch salvage may be possible in 50% to 95% of patients. e incidence
of early and late complications aer pouch salvage is high, and delayed
healing of the perineal wound is one of the common complications.
Indications for salvage surgery or major revision of the pouch include
a long eerent limb, a pouch or anastomotic-associated stula, peripouch sepsis, an anastomotic stricture, and previous pouch excision
(provided the anal sphincter function continues to be good). Salvage
by abdominoanal disconnection and repeat IPAA has been reported to
result in good function in patients with nonseptic complications, and
redo pouch is the procedure of choice for pouch dysfunction resulting from a long exit conduit and long strictures. Revision of the pouch
can also be performed with good results for septic complications, but a
worse outcome may be expected compared with salvage aer nonseptic
complications, and these patients should be warned of the possibility
of a permanent stoma when undergoing IPAA. In the absence of gross
sepsis or edema, local repairs are attempted rst, with stulas that are
close to the anal verge and for short strictures that are unresponsive
to dilation. A transabdominal redo pouch is indicated aer failure of
multiple local treatment procedures, presence of a long exit conduit,
long stricture, or chronic presacral sinus.
S
u
S t
g g e
C
ornish JA, Tan E, Teare J, et al. e eect of restorative proctocolectomy
on sexual function, urinary function, fertility, pregnancy and delivery: a
systematic review. Dis Colon Rectum. 2007;50(8):1128–1138.
da Luz Moreira A, Kiran RP, Lavery I. Clinical outcomes of ileorectal anasto-
mosis for ulcerative colitis. Br J Surg. 2010;97(1):65–69.
Fazio VW, Kiran RP, Remzi FH, etal. Ileal pouch anal anastomosis: analysis of
outcome and quality of life in 3707 patients. Ann Surg. 2013;257(4):679–
685.
Gu J, Remzi FH, Shen B, etal. Operative strategy modies risk of pouch-relat-
ed outcomes in patients with ulcerative colitis on preoperative anti-tumor
necrosis factor-α therapy. Dis Colon Rectum. 2013;56(11):1243–1252.
Gullberg K, Stahlberg D, Liljeqvist L, etal. Neoplastic transformation of the
pelvic pouch mucosa in patients with ulcerative colitis. Gastroenterology.
1997;112(5):1487–1492.
Kiran RP. e ideal design of the ileoanal pouch: one for each patient? Dis
Colon Rectum. 2012;55(12):1201–1202.
Kiran RP, Ahmed Ali U, Nisar PJ, etal. Risk and location of cancer in patients
with preoperative colitis-associated dysplasia undergoing proctocolecto my. Ann Surg. 2014;259(2):302–309.
McLeod RS, Lavery IC, Leatherman JR, etal. Factors aecting quality of life
with a conventional ileostomy. World J Surg. 1986;10(3):474–480.
Nicholls RJ. Restorative proctocolectomy with various types of reservoir.
World J Surg. 1987;11(6):751–762.
O’Riordain MG, Fazio VW, Lavery IC, et al. Incidence and natural history
of dysplasia of the anal transitional zone aer ileal pouch-anal anastomosis: results of a ve-year to ten-year follow-up. Dis Colon Rectum.
2000;43(12):1660–1665.
Reilly WT, Pemberton JH, Wol BG, et al. Randomized prospective trial
comparing ileal pouch-anal anastomosis performed by excising the anal
mucosa to ileal pouch-anal anastomosis performed by preserving the anal
mucosa. Ann Surg. 1997;225(6):666–676. discussion 676–677.
Sjodahl R, Lemon E, Nystrom PO, Olaison G. Complications, surgical re-
vision and quality of life with conventional and continent ileostomy.
Acta Chir Scand. 1990;156(5):403–407.
e d
R
e
a d i n g