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244
D.L. Beral and J.E. Hartley
18.2.1 Emergency
In the emergency situation, with sick patients, a total abdominal colectomy (TAC)
with end ileostomy (EI) is almost universally the operation of choice and will be
discussed in detail below. Rarely, where intractable bleeding occurs as a result of
severe proctitis, a proctocolectomy with EI may be considered. However, this should
be resisted due to the excess morbidity that results from the longer pelvic procedure
in a sick patient, and all attempts should be made to gain control of the bleeding
locally, including the use of interventional radiology.
18.2.2 Elective
Elective surgery for UC encompasses truly elective, planned surgery as well as
urgent or semi-elective operations. There are many indications that fall within this
category, as seen in Table 18.1 , and there may be overlap with more than one indica-
tion needing to be taken into account in the surgical decision-making process. Failed
medical management of chronic UC is one general indication which covers a vari-
ety of symptoms and signs including urgency and frequency of stool, bloody stools,
anemia, weight loss, low energy, and disruption to work and other social activities.
Extraintestinal manifestations of UC such as activity-related polyarthropathy and
pyoderma gangrenosum may benefi t from colorectal surgery; however, other
extraintestinal disorders such as primary sclerosing cholangitis, sacroiliitis, and
ankylosing spondylitis do not respond to surgery. Finally, it is well established that
extensive UC of long duration carries a risk of developing dysplasia and cancer. If
either is proven to have developed, then this is a clear indication for surgery.
Performing a colectomy to prevent the development of dysplasia and malignancy in
Table 18.1 Indications for
surgery in UC
Emergency Failed medical management of acute severe colitis
Acute colonic dilatation – “toxic megacolon”
Colonic perforation
Acute intractable colonic bleeding
Elective Failed medical management of chronic colitis
Steroid-dependent colitis
Side effects of prolonged steroid use
Intolerance of immunomodulating medications
Recurrent acute exacerbations of colitis
Failure to fully recover from an acute episode of
colitis
Growth retardation or disruption to schooling in
pediatric patients
Colonic dysplasia or malignancy
Activity-related polyarthropathy
Pyoderma gangrenosum
245
18 Surgical Options in Ulcerative Colitis
long-standing UC is diffi cult to justify, and most surgeons would opt for regular
colonoscopic surveillance.
The various surgical options available in UC are listed in Table
18.2 and will be
discussed in turn.
18.3 Total Abdominal Colectomy and End Ileostomy
TAC and EI is the procedure of choice in the emergency situation but may be used
to advantage in the elective or semi-elective situation. If timed appropriately and
undertaken by an experienced surgeon, TAC should be a relatively safe procedure
which aims to relieve the patient of the bulk of their disease, and it allows the patient
to be weaned off steroids and immunomodulating medications thus restoring good
health. However, depending upon the severity of symptoms from disease in the
retained rectal stump, there may be a requirement for ongoing topical therapy. In
those patients where there is a degree of uncertainty in the diagnosis of UC prior to
surgery, typically those patients labeled as indeterminate colitis or in whom there
are some clinical or histological features suggestive of Crohn’s colitis, a TAC speci-
men may allow the pathologist to reach a more defi nitive diagnosis than can be
made on preoperative endoscopic biopsies.
The majority of patients who have undergone TAC with EI will be offered a com-
pletion proctectomy at a future date with the option of an ileal pouch anal anastomosis
(IPAA) reconstruction in suitable candidates. The optimum timing for further surgery
is not clearly defi ned, but most surgeons would wait 4–6 months to allow full healing,
restoration of health, and cessation of immunosuppressant medication. During this
period, the experience of life with an ileostomy may be invaluable to those offered the
option of considering an IPAA versus a permanent ileostomy. A carefully performed
TAC leaves the pelvic planes undisturbed, thus facilitating subsequent nerve sparing
completion proctectomy with or without IPAA reconstruction.
Some patients will want to either defer or forego the proctectomy as they may be
experiencing little in the way of symptoms, are content with the ileostomy and happy
to be experiencing a period of good health, or may wish to complete their family.
These patients should undergo surveillance of the rectal stump for dysplastic and
malignant change, the timing and frequency of surveillance being determined by the
duration of disease and any evidence of dysplasia in the colectomy specimen.
Formation of a satisfactory stoma at the time of TAC is a vitally important point
which should not be neglected. Responsibility for siting the stoma ultimately lies
with the surgeon; however, in all but the direst of emergencies, consultation with a
Table 18.2 Surgical options
in UC
Total abdominal colectomy and end ileostomy
Conservative proctocolectomy and end ileostomy
Conventional proctocolectomy and end ileostomy
Restorative proctocolectomy and ileal pouch-anal anastomosis
Total colectomy and ileorectal anastomosis
246
D.L. Beral and J.E. Hartley
stoma therapist must be a priority. They will also begin the process of stoma educa-
tion with the patient. During construction of the stoma, the fascial defect must be
carefully judged to allow the ileum and mesentery to pass through without risk of
ischemia and subsequent stricture but not so large that prolapse or parastomal her-
niation is risked. The ileostomy should be adequately spouted to allow a close fi tting
stoma appliance plate that avoids the irritant stoma effl uent coming into contact
with the skin.
Management of the rectosigmoid stump following TAC is a source of debate, and
the options will be discussed below. The colonic division should always be in the
distal sigmoid, leaving a long rectosigmoid stump as this leaves all the management
options available. It should not be in the upper rectum and certainly not at the level
of the peritoneal refl ection as this leaves the stump diffi cult to fi nd at subsequent
proctectomy and impossible to exteriorize in the event of “blowout” of the stump
staple line.
18.3.1 Mucous Fistula Formation
A formal mucous fi stula is a certain requirement if the rectosigmoid stump is so
diseased as to be considered too friable to suture or staple closed successfully.
However, ongoing discharge from the fi stula can be a troublesome symptom for the
patient to have to deal with.
18.3.2 Intraperitoneal Stump
Leaving the rectosigmoid stump intraperitoneally is easier for the patient to manage
but carries with it the risk of stump breakdown and ensuing pelvic sepsis. This may
be managed with percutaneous and per-rectal drainage but will sometimes require
laparotomy to deal with the sepsis and possibly exteriorize the stump. Leaving a
rectal catheter to drain the stump at the time of surgery has also been advocated to
reduce stump breakdown. Stump breakdown and/or pelvic sepsis is not common,
only occurring in 2–12% patients in unselected case series and therefore leaving the
stump intraperitoneally may be considered relatively safe [ 3 ] .
18.3.3 Subcutaneous Stump
The compromise position is to bury the stump in the subcutaneous tissues where
stump breakdown usually only gives rise to local wound sepsis rather than pelvic
sepsis. It also has the benefi t of making the stump easy to locate at subsequent
proctectomy.
247
18 Surgical Options in Ulcerative Colitis
18.4 Conservative Proctocolectomy and End Ileostomy
This operation removes the colon and rectum but preserves the pelvic fl oor and the
anal canal. It is now largely a historical operation as it resulted in a high rate of
pelvic sepsis due to poor drainage of the anal canal through an intact anal sphincter.
A second stage ileoanal procedure was also rendered diffi cult due to the low level of
division and the previous pelvic surgery [
4 ] .
18.5 Conventional Proctocolectomy and End Ileostomy
This operation removes the colon, rectum, and anus and has stood the test of time as
a defi nitive treatment for UC. The only signifi cant drawback is the permanent ileo-
stomy, but some patients will fi nd this option superior to that of restorative procto-
colectomy (IPAA), which will be discussed later. There are also some patients in
whom restoration will be contraindicated, either relatively or absolutely. As dis-
cussed earlier, meticulous attention must be paid to the detail of the end ileostomy
construction to avoid potential morbidity.
18.5.1 Kock Pouch
The Kock continent ileostomy [ 5 ] is an operation that has now largely been super-
seded by IPAA reconstruction; however it may still be considered in those in whom
an IPAA is not an option, as an alternative to end ileostomy. A reservoir is created
from the terminal ileum, and the distal 15 cm of ileum invaginated into this reservoir
to form a nipple valve (Fig. 18.1 ). This may then be brought out fl ush, low on the
abdominal wall for cosmesis and after 10 days may be intermittently catheterized.
Complications include anastomotic leakage, fi stulation, valve prolapse, pouchitis,
and eventual pouch failure requiring excision [ 4 ] .
18.5.2 Planes of Dissection
Other important technical aspects of conventional proctectomy are the planes cho-
sen for both the rectal and perineal dissections. The usual approach to the rectum in
cancer surgery is to perform a total mesorectal excision (TME), and as this is famil-
iar to all colorectal surgeons, there is no reason why it should not be utilized in
surgery for UC. The most important aspect of this approach in surgery for UC is
preservation of the preaortic superior hypogastric plexus, the pelvic hypogastric
nerves, and the inferior hypogastric plexus, which together control bladder and
248
D.L. Beral and J.E. Hartley
sexual function. In a young UC patient, these functions are especially important to
preserve, and some surgeons may choose a close, perimuscular excision of the rec-
tum for this reason. However, this intramesorectal approach involves greater blood
loss, and there is some evidence that it does not signifi cantly reduce the risk of pel-
vic nerve damage [ 7 ] . Of course, if the rectum is being removed for dysplastic or
malignant change secondary to long-term UC, then TME is mandatory.
The perineal dissection should usually be carried out in the intersphincteric
plane. This results in a smaller perineal wound which is less prone to delayed heal-
ing or breakdown [ 8 ] . Again, dysplastic or malignant change in the low anorectum
will mandate a more oncological approach with a wider perineal dissection and
extrasphincteric dissection.
18.6 Restorative Proctocolectomy and IPAA
First described by Parks and Nicholls in 1978 [ 9 ] , this is a sphincter-preserving
procedure that has since become considered by many to be the “gold standard” in
elective surgery for UC. However, it is important to remember that the sole indica-
tion for this operation is the desire to avoid a permanent ileostomy. Appropriate case
Sutures placed laterally and medially
Rectus m
Suture
Fig. 18.1 Kock pouch (From Cohen and McLeod [ 6 ] )
249
18 Surgical Options in Ulcerative Colitis
selection is central to a successful outcome. Patients must be highly motivated and
well informed regarding the surgery, potential complications, likely functional
results, reduction in female fertility, and the risk of pouch failure, pouch excision,
and permanent ileostomy.
18.6.1 Complications
Pelvic sepsis as a result of anastomotic dehiscence or infected hematoma is the most
common acute complication of IPAA surgery. It may be managed conservatively
with antibiotics or require radiological or per-anal drainage. Occasionally, relaparo-
tomy may be required. Hemorrhage is the other common complication, usually
related to the pouch staple line. Small bowel obstruction also occurs in up to 20% of
patients over 10 years. Chronic pouch-related sepsis complicates 10–20% of IPAA
procedures leading to fi stulas (pouch-anal, pouch-vaginal, pouch-perineal, proximal
pouch) and anastomotic strictures. Pouch function is also worsened after pelvic sep-
sis. Pouch failure is defi ned as the need for pouch excision or the indefi nite need for
defunctioning ileostomy. Early pouch failure is usually associated with pelvic sep-
sis, while later failure is related to pouch function or the diagnosis of Crohn’s dis-
ease. The rate of failure is around 5–10% and increases with time [ 10 ] . Management
of the failing pouch will be discussed more fully in a separate chapter.
18.6.2 Pouch Function
The functional aim of IPAA is for the patient to have fi ve to six semi-formed motions
per day with no nighttime bowel motions and no incontinence. Not all patients will
achieve this, but many will still consider a degree of increased frequency acceptable
and preferable to permanent ileostomy. There are several causes of pouch dysfunc-
tion including unrecognized Crohn’s disease, irritable pouch syndrome, cuffi tis
(recurrence of UC within rectal mucosa not excised at the time of surgery), and
pouchitis [ 10 ] . Pouchitis is a relapsing, acute-on-chronic infl ammatory condition
which affects around 20% of pouches at 1 year, rising to 40% at 10 years and is
more common in patients with primary sclerosing cholangitis. Interestingly, it does
not appear to affect pouches formed for familial adenomatous polyposis (FAP).
18.6.3 IPAA in Women
IPAA in young women is associated with a reduction in female fertility with around
40% having diffi culty in subsequently falling pregnant [ 11 ] . Young women should
be counseled about this risk preoperatively and may decide, where possible, to defer
250
D.L. Beral and J.E. Hartley
proctectomy until they have completed their family. In addition, there has been con-
cern that occult sphincter injury during childbirth may have a signifi cant bearing on
pouch patients leading to worsened function and incontinence. However, the evi-
dence so far shows that pouch function is not signifi cantly affected by vaginal deliv-
ery, at least not in the short to medium term [
10 ] . Mode of delivery is therefore a
controversial area, and the decision needs to be made on a case by case basis and
fully discussed with the patient. Many patients will opt for an elective section rather
than risk compromise of pouch function.
18.6.4 IPAA in the Older Patient
There are two areas of particular controversy regarding the selection of patients for
pouch surgery: the older patient and the patient with indeterminate colitis. The older
patient (variably defi ned in the literature, but often >50 years) was initially not con-
sidered suitable for restorative proctocolectomy due to the potential for poorer func-
tional outcome secondary to a weaker anal sphincter complex. However, these fears
have not been borne out by the published data in the literature. There is a tendency
for older patients to have slightly inferior functional results when compared to
younger patients, and the results deteriorate over time, but these issues are counter-
balanced by high levels of patient satisfaction with the procedure. Also, surgical
complications and pouch failure rates seem to be independent of age [ 12 ] . Therefore,
it is appropriate to offer pouch surgery to older patients providing they are well
informed, highly motivated, and that they do not have any preceding sphincter
compromise.
18.6.5 IPAA in Indeterminate Colitis
Indeterminate colitis (IC), where a defi nitive histopathological diagnosis of UC or
Crohn’s colitis has not been possible, is the diagnosis in a signifi cant minority of
patients who come to proctocolectomy. It should be termed “infl ammatory bowel
disease – type unspecifi ed” (IBDU) where the diagnosis is based upon biopsy evi-
dence alone. IC is more accurately the label applied after colectomy for acute, severe
colitis where the degree of infl ammation and overlapping features of UC and Crohn’s
makes differentiation diffi cult [ 13 ] . The clinical pattern of disease will contribute to
the favored diagnosis, but it may still be diffi cult to completely rule out Crohn’s
disease. The distinction is important as IPAA in patients with Crohn’s has increased
rates of pelvic sepsis, pouch fi stula, and a 30–50% pouch failure rate and therefore
remains a controversial application of the ileal pouch (which will be discussed else-
where). Up to 15% of patients labeled as IC subsequently have their diagnosis
changed to Crohn’s disease, a much higher “conversion” rate than seen in those
initially diagnosed as UC. The published data on IPAA in IC patients demonstrate
251
18 Surgical Options in Ulcerative Colitis
higher rates of pelvic sepsis and pouch fi stula when compared to UC patients [ 13 ] .
However, the increased rates of pouch failure in some studies with small numbers of
IC patients have not been borne out by studies with larger series of IC patients
[
14– 16 ] . If patients with a subsequent diagnosis of Crohn’s are removed from the
analysis, then outcomes in IC patients are very similar to UC patients [ 14 ] . In the
future, more detailed histopathological analysis of colectomy specimens or the use
of serological markers may help to defi ne the subgroup of IC patients who are more
likely to behave like, or be subsequently diagnosed as Crohn’s disease [
13 ] . These
patients will be counseled against IPAA, whereas patients with IC that tends towards
UC can continue to be considered for pouch surgery, albeit perhaps still at some
increased risk of pelvic sepsis and fi stula.
18.6.6 Pouch Construction
After appropriate patient selection, there are a number of technical considerations with
regard to the construction of the ileal reservoir and the formation of the pouch-anal
anastomosis itself. The proctocolectomy itself proceeds in a standard fashion down to
the anorectal junction where the bowel may be divided. Before the pouch is created, it
is important to establish that there will be enough mobility in the small bowel mesen-
tery to allow the IPAA to be safely formed without tension. It is advisable to perform
a trial descent of the point of ileum that will be used for the anastomosis to the anal
canal. If the point of ileum chosen will reach the lower border of the symphysis pubis,
then the pouch is likely to reach without tension. However, if tension is demonstrated,
then there are several methods by which more mobility may be obtained including
division of mesenteric vessels and mesenteric relaxing incisions [ 17 ] .
Several different pouch conformations have been described including the three
loop “S” reservoir (Fig. 18.2 ), the four loop “W” reservoir (Fig. 18.3 ), and the two
loop “H” (Fig. 18.4 ) and “J” reservoirs (Fig. 18.5 ). Generally, the greater the capac-
ity of the reservoir, the lower the frequency of pouch emptying. The “J” reservoir is
the easiest to construct, either by hand suturing or most commonly with multiple
fi rings of a linear cutting stapler to give a pouch 15–20 cm in length. The “J” pouch
is therefore favored by most surgeons, and it also avoids the evacuation diffi culties
associated with some of the alternative pouch designs. Whichever pouch is con-
structed, it is important to inspect the suture/staple lines for bleeding before the
anastomosis is formed.
18.6.7 Hand-Sewn Versus Double-Stapled Anastomosis
There remains some controversy over the method of anastomosis of the pouch
to the anal canal, and Table 18.3 summarizes the comparison between the two
techniques.
252
D.L. Beral and J.E. Hartley
Fig. 18.3 Quadruple loop W-pouch (From
Michelassi et al. [
18 ] )
1-2 cm
10 cm
Duodenum
Fig. 18.2 Construction of a triple
loop S-pouch (From Michelassi et al.
[
18 ] )
253
18 Surgical Options in Ulcerative Colitis
The per-anal hand-sewn technique has the advantage of allowing the anastomo-
sis to be constructed precisely at the level of the dentate line and involves a muco-
sectomy – stripping of the cuff of columnar rectal epithelium remaining above the
dentate line after division of the bowel at the anorectal junction. This is intended to
prevent cuffi tis. In addition, removal of all of the columnar epithelium should theo-
retically remove the risk of dysplasia and malignancy. However, there are now a
number of ileal pouch adenocarcinomas reported in the literature [ 19 ] . Some of
these have occurred after mucosectomy [ 20 ] , suggesting that islands of rectal
mucosa may be left behind after mucosectomy which are then buried beneath the
ileal mucosa when the anastomosis is sutured, or perhaps dysplasia may develop
de novo in ileal pouch mucosa.
Until recently, the association between proctocolectomy for UC-associated rec-
tal dysplasia or malignancy and the development of pouch cancer has been sus-
pected but not clearly shown in the literature [ 19 ] . However, recently published
data from over 3,000 pouches performed at the Cleveland Clinic confi rms that a
Fig. 18.4 Isoperistaltic
H-pouch (From Michelassi
et al. [
18 ] )
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