Surgical Management in Ulcerative Colitis

1. SURGICAL MANAGEMENT
IN ULCERATIVE COLITIS

2. UC & CRC

3. INCIDENCE
CRC in UC appears at younger age than in
sporadic CRC (40-50 yrs old vs 60).
5-10% after 20 years.
12-20% after 30 years.

4. RISK FACTORS
Duration of the disease
Extent of the disease
UC complicated by primary sclerosing cholangitis
Presence of post-inflammatory pseudopolyp

5. CRC in UC…
Appears as:
Polypoid
Nodular
Ulcerated
Plaque like
Mostly adenocarcinoma.
Mostly located in the rectum and sigmoid
It arises from areas of dysplasia.

6. Dysplastic areas may appear flat or slightly raised
areas.
Dysplastic areas may occur within or near nodules,
masses, polyps or plaque like lesion.
N.B.: Diagnosis of dysplasia in Pre Op colonoscopy
has a:
 81% sensitivity
 79% specifty

7. Surgical management in UC

8. Indications for surgery in UC:
SURGICAL EMERGENCIES
Massive life threatening hemorrhage
Toxic megacolon with impending perforation
Fulminant colitis unresponsive to IV corticosteroids 
 Colonic perforation
 Total obstruction from stricture

9. Elective:
Intractability despite max therapy.
Mucosal dysplasia
Dysplasia-associated lesion or mass (DALM)
Intolerable side effects of medications
Patient with significant risk to develop CRC
Stricture formation without obstruction

10. Extraintestinal manifestations
Growth retardation, primarily in children and
adolescents

11. Surgical Options

12. Emergency operation:
Subtotal colectomy with end ileostomy
Proctocolectomy with end ileostomy
Blow-hole colostomy with end ileostomy

13. Subtotal colectomy with end ileostomy
Advantages : Allows option for IPAA; low risk
Disadvantages :
Requires second operation
may develop rectal recurrence of disease
Contraindication : Massive hemorrhage from colon and
rectum

14. Proctocolectomy with end ileostomy:
Advantages: Definitive treatment
Disadvantages :
No option for IPAA
moderate risk for perineal nerve damage
Contraindication : Severely toxic or unstable patient

15. Blow-hole colostomy with end ileostomy
Advantages: Short, simple decompression procedure
Disadvantages : Diseased colon and rectum retained

16. ELECTIVE PROCEDURES
Total proctocolectomy with Brooke ileostomy
Subtotal colectomy with ileorectal anastomosis
Total proctocolectomy with Kock pouch
Total colectomy, mucosal proctectomy and hand-sewn
IPAA with temporary diverting loop ileostomy (two-
stage operation)
Total proctocolectomy without mucosectomy and
stapled IPAA with temporary diverting loop ileostomy
(two-stage operation)

17. Laparoscopic total proctocolectomy with or without
mucosectomy and IPAA

18. Total proctocolectomy with Brooke ileostomy
Indications : Patients wanting to avoid risks of IPAA; elderly;
poor sphincter function; rectal cancer
Contraindications :Patient aversion to permanent ileostomy;
obesity; life-threatening emergencies
Advantages: Eliminates all disease-bearing mucosa; single
operation
Disadvantages: Potential for nerve injury in the perineal and
pelvic dissection; permanent ileostomy; delayed perineal
wound healing; mechanical problems with stoma; high risk of
SBO

20. Subtotal colectomy with ileorectal anastomosis
Indications: No rectal involvement; avoid permanent
stoma and IPAA; young women of childbearing age to
preserve fertility
Contraindications : Poor sphincter tone or dysfunction;
active rectal or perianal disease; colonic or rectal
dysplasia; or frank cancer
Advantages: One-stage operation; complete
continence with good function; low risk of pelvic nerve
injury; eliminates stoma.

21. Disadvantages:
30% Recurrence rate requiring conversion to ileostomy
Risk of rectal cancer requiring lifelong surveillance

23. Total proctocolectomy with Kock pouch
Indications : Alternative to conventional ileostomy for
patients desiring to preserve continence; poor sphincter
tone; low rectal cancer; failed IPAA; conversion from
ileostomy
Contraindications : Possibility of Crohn's disease;
previous resection of small bowel; patients over 60
years old; obesity; coexisting medical illness

24. Advantages: Avoids ileostomy; patients remain
continent; good quality of live; improved body image
over ileostomy
Disadvantages: High reoperation rate (35%) due to
nipple valve dysfunction or failure; high fistula rate;
pouchitis

26. Total Proctocolectomy with Ileal Pouch–Anal
Anastomosis
Indications : Procedure of choice for ulcerative colitis;
colonic dysplasia or cancer; indeterminate colitis
Contraindications : Poor resting tone or anal sphincter
dysfunction; low rectal cancers
Advantages: Completely restorative; mucosectomy
eliminates all disease-bearing mucosa; no disease
recurrence; no cancer risk; good function, continence,
and quality of life.

27. Disadvantages:
Two-stage procedure
potential for nerve injury in the perineal and pelvic
dissection
reduced fertility in females
mucosectomy and hand-sewn IPAA are technically
demanding and difficult to learn
septic complications
pouchitis

29. Operative Techniques:
Stage I : abdominal colectomy, mucosal proctectomy,
endorectal IPAA, and diverting loop ileostomy
Stage II : clousre of ileostomy

30. preoperative work-up
anal manometry
Sigmoidoscopy
bowel preparation

33. The Lone Star retractor

35. construction of the ileal pouch

36. ileal J-pouch
faster
less tedious to create
use considerably less ileum
have similar or better functional results than other
pouch configurations.

40. Post-IPAA:
4 weeks after - barium radiographic study
8 weeks after - anal manometry + clousre of ileostomy
1 – 3 – 6 – 12 month F/U then every year
flexible fiberoptic pouchoscopy with surveillance
biopsies of the ileal pouch approximately every 5
years.

41. Complications
Pouch Failure
Pouchitis
Crohn's Disease
dysplasia and carcinoma of the ileal pouch

42. Pouch Failure
significant long-term complication of IPAA
Prior anal pathology
Abnormal anal manometry
Pouch-perineal or pouch-vaginal fistulae
Pelvic sepsis
Anastomotic stricture, and dehiscence
Brooke ileostomy or Kock pouch

43. Pouchitis
nonspecific, idiopathic inflammation of the ileal
pouch
most common and significant late, long-term
complication
> 50% of ulcerative colitis patients
Rare in IPAA for FAP

44. Presentation :
stool frequency
watery diarrhea
fecal urgency
Incontinence
abdominal cramping
fever, and malaise
flexible ileal pouchoscopy

46. the greatest risk for experiencing an episode is
during the initial 6-month period following closure
of the temporary diverting loop ileostomy.
Risk continues to rise steadily for the next 18–36
months before leveling off at around 4 years

47. Management :
Broad-spectrum antibiotics
Acute:
Ciprofloxacin 250 mg BID
Metronidazole 250 mg QID
Chronic: ( treatment for 3 months )
Ciprofloxacin 250 mg OD
Metronidazole 250 mg OD
topical anti-inflammatory agents, corticosteroids
Refractory :
undiagnosed Crohn's disease ?

48. Crohn's Disease
severe morbidity and a significant risk of pouch
excision
Predictors :
complex perianal or pouch fistulae
ileitis proximal to the pouch
Afferent limb ulcers
biological therapies

49. THANK YOU