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_1520_Библиотеки_им_академика_М_И_Перельмана
.pdf
275
19 Surgery for Fulminant Colitis
Differential IBD; Clostridium diffi cile, CMV; Ischaemic colitis in –
elderly; FBC, ESR/CRP, U&E, LFTs, Albumin every 24-48 hrs.
Daily examination; stool chart; stool culture. –
AXR – loss of haustration, mucosal thumb printing, small bowel disten- –
sion; toxic dilatation transverse colon >5.5cm uncommon [CT scan
more sensitive than AXR].
Flexible sigmoidoscopy – biopsy. –
Medical Therapies•
Joint Management –
IV fl uids & electrolyte replacement, with blood transfusion to main-
°
tain Hb >10g/dl; Subcutaneous heparin for thromboprophylaxis;
Nutritional support if malnourished.
Intravenous corticosteroid (hydrocortisone 400mg/day).
°
Third Day Evaluation –
A stool frequency of >8/day or CRP > 45mg/l at 3 days appears to
°
predict the need for surgery in 85% of cases.
No benefi t from intravenous steroids beyond 7-10 days.
°
Rescue medical therapy (ciclosporin/ infl iximab); surgery – stoma
°
counselling.
Surgical Therapy•
Challenge for surgery –
Surgical planning alongside increasingly complex medical therapy.
°
Timing versus novel therapies with no evidence base.
°
Incomplete response offered novel therapies unless evidence of
°
progression and/or signifi cant co-morbidity.
Subtotal colectomy leaving a long rectal stump, incorporated into the lower
end of the wound or exteriorised as a mucus fi stula. Avoid rectal stump blow-
out [Laparoscopic approach tempered by perforation risk of friable colon].
Case Scenario Answers 1
1. Answer (c)
This history and sigmoidoscopy fi ndings are consistent with ulcerative
colitis. The patient has moderate-severity disease as assessed by Truelove
and Witt’s criteria. Moderate fl ares of UC should be treated with high-dose
oral steroids and do not require hospital admission but should have early
outpatient follow-up. He should be commenced on prednisolone 40 mg od,
tapering over 8 weeks. Oral 5-ASA monotherapy may be used in mild
disease, with a rectal preparation preferable for distal disease and a combi-
nation of oral and rectal preparations for more extensive disease.
276
K. Futaba et al.
Case Scenario Answers 2
1. Answer (d)
This patient has acute severe ulcerative colitis as defi ned by Truelove and
Witt’s criteria. She should be admitted for treatment and commenced on
intravenous hydrocortisone, oral calcium supplementation, prophylactic
low molecular weight heparin, and rectal 5-ASA. There is no evidence of
benefi t for using oral 5-ASA in acute severe UC, and therefore, it is not
indicated. Furthermore, oral 5-ASA can occasionally cause diarrhea and
confuse the clinical picture.
2. Answer (b)
Monitoring of the patient should include daily record of 24-h stool fre-
quency and CRP measurement. After 72 h of steroid treatment, a stool
frequency of ³ 8 times/24 h or CRP >45 mg/L is associated with an 85%
chance of requiring surgery, from data prior to use of medical rescue ther-
apy. These patients should be considered for medical rescue therapy.
3. Answer (d)
There is no published data directly comparing cyclosporin A to infl ix-
imab, but current data suggest similar effi cacy rates. In this context, NICE
recommends cyclosporin A as fi rst-line therapy, although infl iximab has
gained favor due to its ease of administration and a possibly better side
effect profi le. Of the two agents, cyclosporin A has the faster onset of
action. Patients given cyclosporin A should have a serum cholesterol
level greater than 3 mmol/L and a serum magnesium level greater than
2. Answer (d)
Indications for azathioprine therapy include: following a severe fl are of
disease, a fl are within 3 months of completing steroids, more than two
fl ares requiring steroids within 12 months, and for steroid-dependent
patients. A standard course of steroids should taper over 8 weeks, and
therefore in answer e, the patient is following a typical weaning protocol
and would not be considered steroid dependent.
3. Answer (d)
TPMT should be checked prior to starting azathioprine. TPMT is absent in
1 in 400 with low levels in 20%. Thiopurines should not be used in patients
with absent TPMT. Patients with low levels of TPMT should receive half
the standard dose of azathioprine and should be carefully monitored for
myelosuppression. It is recommended to check for hepatitis B and C and
varicella zoster serology prior to treatment. Full blood count and liver
function tests should be monitored while on treatment, but there is no
requirement to check urea and electrolytes.
277
19 Surgery for Fulminant Colitis
References
1. Truelove SC, Witts LJ. Cortisone in ulcerative colitis; fi nal report on a therapeutic trial.
Br Med J. 1955;2(4947):1041–8.
2. Jones JH, Chapman M. Defi nition of megacolon in colitis. Gut. 1969;10(7):562–4.
3. Latella G, Vernia P, Viscido A, Frieri G, Cadau G, Cocco A, et al. GI distension in severe
ulcerative colitis. Am J Gastroenterol. 2002;97(5):1169–75.
4. Gore RM, Balthazar EJ, Ghahremani GG, Miller FH. CT features of ulcerative colitis and
Crohn’s disease. AJR Am J Roentgenol. 1996;167(1):3–15.
5. Ahualli J. The target sign: bowel wall. Radiology. 2005;234(2):549–50.
6. Carbonnel F, Gargouri D, Lemann M, Beaugerie L, Cattan S, Cosnes J, et al. Predictive factors
of outcome of intensive intravenous treatment for attacks of ulcerative colitis. Aliment
Pharmacol Ther. 2000;14(3):273–9.
7. Arnell TD. Surgical management of acute colitis and toxic megacolon. Clin Colon Rectal
Surg. 2004;17(1):71–4.
8. Travis SP, Farrant JM, Ricketts C, Nolan DJ, Mortensen NM, Kettlewell MG, et al. Predicting
outcome in severe ulcerative colitis. Gut. 1996;38(6):905–10.
9. Cacheux W, Seksik P, Lemann M, Marteau P, Nion-Larmurier I, Afchain P, et al. Predictive
factors of response to cyclosporine in steroid-refractory ulcerative colitis. Am J Gastroenterol.
2008;103(3):637–42.
10. Lennard-Jones JE, Ritchie JK, Hilder W, Spicer CC. Assessment of severity in colitis: a pre-
liminary study. Gut. 1975;16(8):579–84.
11. Munkholm P, Langholz E, Nielsen OH, Kreiner S, Binder V. Increased incidence of Crohn’s
disease in the county of Copenhagen. Ugeskr Laeger. 1993;155(40):3199–202.
12. Lamontagne F, Labbe AC, Haeck O, Lesur O, Lalancette M, Patino C, et al. Impact of emer-
gency colectomy on survival of patients with fulminant Clostridium diffi cile colitis during an
epidemic caused by a hypervirulent strain. Ann Surg. 2007;245(2):267–72.
13. Johnson S. Recurrent Clostridium diffi cile infection: a review of risk factors, treatments, and
outcomes. J Infect. 2009;58(6):403–10.
14. Zahariadis G, Connon JJ, Fong IW. Fulminant Clostridium diffi cile colitis without diarrhea:
lack of emphasis in diagnostic guidelines. Am J Gastroenterol. 2002;97(11):2929–30.
15. Greenstein AJ, Byrn JC, Zhang LP, Swedish KA, Jahn AE, Divino CM. Risk factors for the
development of fulminant Clostridium diffi cile colitis. Surgery. 2008;143(5):623–9.
16. Jaber MR, Olafsson S, Fung WL, Reeves ME. Clinical review of the management of fulminant
Clostridium diffi cile infection. Am J Gastroenterol. 2008;103(12):3195–203; quiz 204.
17. Koss K, Clark MA, Sanders DS, Morton D, Keighley MR, Goh J. The outcome of surgery in
fulminant Clostridium diffi cile colitis. Colorectal Dis. 2006;8(2):149–54.
18. Montoro MA, Brandt LJ, Santolaria S, Gomollon F, Puertolas BS, Vera J, et al. Clinical pat-
terns and outcomes of ischaemic colitis: results of the Working Group for the Study of
Ischaemic Colitis in Spain (CIE study). Scand J Gastroenterol. 2011;46(2):236–46.
19. Carter MJ, Lobo AJ, Travis SP. Guidelines for the management of infl ammatory bowel disease
in adults. Gut. 2004;53 Suppl 5:V1–16.
20. Turner D, Walsh CM, Steinhart AH, Griffi ths AM. Response to corticosteroids in severe ulcer-
ative colitis: a systematic review of the literature and a meta-regression. Clin Gastroenterol
Hepatol. 2007;5(1):103–10.
0.50 mmol/L as lower levels are associated with an increased risk of sei-
zures. Long-term colectomy free rates are around 25–50% for both agents.
Patients who do not respond to one agent should be offered colectomy. It
is not recommended to try a second rescue therapy.
278
K. Futaba et al.
21. Ng SC, Kamm MA. Therapeutic strategies for the management of ulcerative colitis. Infl amm
Bowel Dis. 2009;15(6):935–50.
22. Lichtiger S, Present DH, Kornbluth A, Gelernt I, Bauer J, Galler G, et al. Cyclosporine in
severe ulcerative colitis refractory to steroid therapy. N Engl J Med. 1994;330(26):1841–5.
23. Van Assche G, D’Haens G, Noman M, Vermeire S, Hiele M, Asnong K, et al. Randomized,
double-blind comparison of 4 mg/kg versus 2 mg/kg intravenous cyclosporine in severe ulcer-
ative colitis. Gastroenterology. 2003;125(4):1025–31.
24. Gisbert JP, Gonzalez-Lama Y, Mate J. Systematic review: infl iximab therapy in ulcerative
colitis. Aliment Pharmacol Ther. 2007;25(1):19–37.
25. Jarnerot G, Hertervig E, Friis-Liby I, Blomquist L, Karlen P, Granno C, et al. Infl iximab as
rescue therapy in severe to moderately severe ulcerative colitis: a randomized, placebo-con-
trolled study. Gastroenterology. 2005;128(7):1805–11.
26. Aratari A, Papi C, Clemente V, Moretti A, Luchetti R, Koch M, et al. Colectomy rate in acute
severe ulcerative colitis in the infl iximab era. Dig Liver Dis. 2008;40(10):821–6.
27. Maser EA, Deconda D, Lichtiger S, Ullman T, Present DH, Kornbluth A. Cyclosporine and
infl iximab as rescue therapy for each other in patients with steroid-refractory ulcerative colitis.
Clin Gastroenterol Hepatol. 2008;6(10):1112–6.
28. Goligher JC, de Dombal FT, Graham NG, Watkinson G. Early surgery in the management of
severe ulcerative colitis. Br Med J. 1967;3(5559):193–5.
29. Kaplan GG, McCarthy EP, Ayanian JZ, Korzenik J, Hodin R, Sands BE. Impact of hospital
volume on postoperative morbidity and mortality following a colectomy for ulcerative colitis.
Gastroenterology. 2008;134(3):680–7.
30. Cima RR. Timing and indications for colectomy in chronic ulcerative colitis: surgical consid-
eration. Dig Dis. 2010;28(3):501–7.
31. Marcello PW, Milsom JW, Wong SK, Brady K, Goormastic M, Fazio VW. Laparoscopic total
colectomy for acute colitis: a case-control study. Dis Colon Rectum. 2001;44(10):1441–5.
32. Bell RL, Seymour NE. Laparoscopic treatment of fulminant ulcerative colitis. Surg Endosc.
2002;16(12):1778–82.
33. Bohm G, O’Dwyer ST. The fate of the rectal stump after subtotal colectomy for ulcerative
colitis. Int J Colorectal Dis. 2007;22(3):277–82.
34. Subramanian V, Saxena S, Kang JY, Pollok RC. Preoperative steroid use and risk of postopera-
tive complications in patients with infl ammatory bowel disease undergoing abdominal surgery.
Am J Gastroenterol. 2008;103(9):2373–81.
35. Holubar SD, Cima RR, Pemberton JH. Does infl iximab increase complications after surgery
for infl ammatory bowel disease? F1000 Med Rep. 2009;1:10.
36. Subramanian V, Pollok RC, Kang JY, Kumar D. Systematic review of postoperative complica-
tions in patients with infl ammatory bowel disease treated with immunomodulators. Br J Surg.
2006;93(7):793–9.
279
S.R. Brown et al. (eds.), Contemporary Coloproctology,
DOI 10.1007/978-0-85729-889-8_20, © Springer-Verlag London Limited 2012
Restorative proctocolectomy with ileal pouch-anal anastomosis (RP/IPAA) is the
procedure of choice for patients with ulcerative colitis and selected patients with
familial adenomatous polyposis [ 1, 2 ] (Fig. 20.1 ). J-pouch is the most commonly
H. T. Kirat , M.D. • F. H. Remzi , M.D., FACS, FASCRS, FTSS (Hon) (*)
Department of Colorectal Surgery , Cleveland Clinic Foundation ,
9500 Euclid Avenue , 44195 Cleveland , OH , USA
e-mail: kirath@ccf.org ; remzif@ccf.org
Chapter 20
Failing Pouch
Hasan T. Kirat and Feza H. Remzi
Fig. 20.1 Restorative
proctocolectomy with ileal
pouch-anal anastomosis
280
H.T. Kirat and F.H. Remzi
ab c
Fig. 20.2 ( a ) J pouch, ( b ) S pouch, ( c ) W pouch
Fig. 20.3 Stapled ileal pouch-anal anastomosis
281
20 Failing Pouch
used reservoir because it is easier to construct compared with S or W pouches [ 2 ]
(Fig. 20.2 ). Stapled IPAA has become the preferred approach with good long-term
functional outcomes and quality of life (QOL) over a hand-sewn anastomosis [ 3 ]
(Fig.
20.3 ). In patients with toxic megacolon or severe fulminant colitis, RP/IPAA
is performed in multistages including subtotal colectomy and end ileostomy and
then in about 6 months completion proctectomy and IPAA with/without diverting
ileostomy. Ileostomy is closed in 3 months following IPAA after checking integrity
of pouch and IPAA using water-contrasted enema.
Although most patients have reported good QOL after IPAA, some patients
might develop complications. A recent meta-analysis of 43 studies on IPAA [
4 ]
reported 18.8% pouchitis, 9.5% pelvic sepsis, 9.2% stricture, and 5.5% fi stula being
the most common complications following IPAA (Box 20.1 ).
Despite increasing experience in the management of these complications, pouch
failure may occur and ranges from 0.5% to 24% [ 4 ] . In an ileal pouch failure model
created to predict the risk of ileal pouch failure [ 5 ] , patient diagnosis, prior anal
pathology, abnormal anal manometry, patient comorbidity, pouch-perineal or
pouch-vaginal fi stula, pelvic sepsis, and anastomotic stricture and separation were
found as independent predictors of pouch survival. Pouch failure rates decrease
signifi cantly over time. Fazio et al. [ 5 ] reported 14.6% pouch failure rate during
fi rst 3 years and 2.1% during last 3 years of their study period. They also reported
overall cumulative 3, 5, and 10-year pouch survival being 96.5%, 95.7%, and
93.4%, respectively (Box 20.2 ) .
Box 20.1: Failing Pouch
Early postoperative complications after IPAA:
Anastomotic leak •
Pelvic sepsis •
Stricture •
Fistula •
Late postoperative complications after IPAA:
Pouchitis •
Obstruction •
Pouch dysfunction •
Box 20.2: Factors Relevant to Pouch Failure
The Cleveland Clinic Foundation ileal pouch failure score
Diagnosis
FAP (0); CUC or indeterminate colitis (1); Crohn’s disease (1.5)
Patient comorbidity
No comorbid condition (0); 1 comorbid condition (0.5); 2 or more comor-
bid conditions (1)
282
H.T. Kirat and F.H. Remzi
20.1 Surgery for Ileoanal Pouch Failure
Good outcomes have been reported after salvage surgery for pouch failure including
transanal pouch mobilization or advancement, resection of an elongated IPAA spout
(efferent limb) (Fig. 20.4 ), and abdominoperineal reoperative pouch surgery [ 6– 16 ]
(Box 20.3 ) .
20.2 Transanal Reoperative Surgery
Fonkalsrud and Bustorff-Silva [ 10 ] reported outcomes after transanal resection of
an elongated IPAA spout in 58 patients. After a mean follow-up of 6.3 years, 98%
of patients had good to excellent results. Dehni et al. [ 6 ] used a transanal approach
for pouch revision in 23 patients. Indications for transanal approach were IPAA
Case Scenario
A 40-year-old woman presents with persistent large pelvic cavity and a large
presacral sinus with drainage of pus on EUA 10 months after transanal/tran-
sanastomotic drainage of pelvic abscess associated with anastomotic leak fol-
lowing IPAA and diverting ileostomy.
The most appropriate treatment would be?
(a) Ileostomy closure
(b) Drainage through the defect with a mushroom catheter
(c) Transanal reoperative surgery
(d) Abdominoperineal reoperative surgery
Prior anal pathology
No (0); Yes (1)
Anal manometry
Normal (0); abnormal [SP <100, RP <40] (1)
Anastomotic separation
No (0); Yes (1)
Anastomotic structure
No or asymptomatic (0); Yes (1)
Pelvic sepsis
No sepsis (1); 1 episode (1); 2 or more episodes (2)
283
20 Failing Pouch
stenosis and perianastomotic fi stula. In ten patients, an existing diverting stoma was
left in place, or a new stoma was created. Mean follow-up was 28 months. Four
patients required further abdominoperineal approach. One patient underwent pouch
excision due to Crohn’s disease. At last follow-up, 18 (78%) patients had a func-
tioning pouch. They concluded that transanal approach for pouch revision is a good
alternative. Shawki et al. [ 7 ] also reported 28 patients undergoing transanal reopera-
tive surgery for septic complications after IPAA with a 75% success rate.
Transperineal advancement was used in seven patients, and it was successful in six
patients (71%). Shah et al. [ 8 ] identifi ed 39 patients undergoing a transanal ileal
advancement fl ap for pouch-vaginal fi stula. Primary healing was achieved in 17
patients. Patients with a delayed diagnosis of Crohn’s disease had higher failure
rates than those without Crohn’s disease. Healing was better in patients with early
presentation of fi stula than those with late fi stula presentation. It was concluded that
transanal approach was associated with good outcomes for patients with pouch-
vaginal fi stula. If local repair is not feasible or fails, revision via a combined abdom-
inoperineal approach is an alternative.
Fig. 20.4 Obstruction of
efferent limb
Box 20.3: Salvage Surgery Strategies
Transanal reoperative surgery •
Abdominoperineal reoperative surgery •
284
H.T. Kirat and F.H. Remzi
20.3 Abdominoperineal Reoperative Surgery
Because outcomes after abdominoperineal repeat pouch surgery for failed pouch are
encouraging, it has been increasingly performed [ 6– 15 ] (Table 20.1 ). In a study [ 8 ]
including 16 patients with pouch-vaginal fi stula undergoing abdominoperineal
repeat pouch surgery, healing was obtained in 10 (62%) patients. Fazio et al. [ 11 ]
from our institution reported our initial experience in 35 patients undergoing repeat
pouch surgery because of septic complications after primary IPAA. Thirty patients
(85%) had a functioning pouch at 6 months after repeat pouch surgery. Pouch sur-
vival rate was 95% for patients with ulcerative colitis and 60% for those with Crohn’s
disease. Fifty-seven percent of patients with a functioning pouch stated that their
QOL was either good or excellent. It was concluded that pelvic pouches compli-
cated with perianastomotic or pelvic sepsis can be salvaged by repeat IPAA. Dehni
et al. [ 6 ] reported 45 patients with abdominoperineal repeat pouch surgery. The old
pouch was used if possible or small salvageable pouches were enlarged ( n = 20).
Otherwise the pouch was excised, and a new pouch was created. Early complica-
tions occurred in six patients. After a mean follow-up of 30 months, 42 patients had
a functioning pouch following reconstructive pouch surgery. MacLean et al. [ 9 ]
identifi ed 63 combined abdominal and perineal IPAA reconstructions in 57 patients.
The most common primary indication for surgery was pouch-vaginal fi stula ( n = 21).
All patients underwent a diverting ileostomy. After a mean follow-up of 69.1 months,
pouch salvage rate was 74%. More than 80% of patients stated that their physical
and psychological health was good or excellent. In another study, 90 patients under-
went either an abdominoperineal reconstruction or a new pouch creation due to
chronic dysfunction; 86 had good outcomes following salvage surgery [ 10 ] .
Baixauli et al. [ 12 ] from our institution reported our later experience in 100 patients
undergoing laparotomy, ileoanal disconnection, and redo IPAA. Median time between
primary IPAA and redo IPAA was 25 months. Sixty-fi ve patients had one or more
septic complications before redo IPAA. In 28 patients, a new pouch was constructed.
Ninety-fi ve patients had a hand-sewn anastomosis. Forty-six patients underwent sur-
gical procedures due to complications after redo IPAA. After a median follow-up of
Table 20.1 Recent reports of abdominoperineal pouch salvage surgery
Author Year Patients
Success rate (%)
Fazio [
11 ] 1998 35
86
Fonkalsrud and
Bustorff-Silva [
10 ]
1999 90 95
MacLean [
9 ] 2001 57 74
Shah [
8 ] 2003 16 62
Dehni [
6 ] 2005 45 93
Baixauli [
12 ] 2004 100 75
Tekkis [
14 ] 2006 112 79
Mathis [
13 ] 2009 51 89
Shawki [
7 ] 2009 23 69
Remzi [
15 ] 2009 241 85
Соседние файлы в папке Библиотека им академика М.И. Перельмана