Surgicalnflammatory Bowel Disease (Ulcerative.pptx

surgical mx

1. Surgical Management of Inflammatory Bowel Disease (Ulcerative Colitis)

2. Contents • Introduction • Indications • Pre-op preparation • Surgery in emergency • Elective surgical options • Controversial issue

3. Introduction • Contiguous inflammation of the colorectal mucosa • Confined to the mucosal and sub-mucosa and always start from and involve the rectum • Disease distribution – Proctitis / Procto -sigmoiditis – 45-50% – Left-sided colitis – 17-40% – Pan-colitis – 15-35%

4. Clinically manifests as – Diarrhoea , abdominal pain, fever, weight loss, rectal bleeding Removal of the affected organ is curative – Surgery has pivotal position

5. Indications • Failure of medical management – Symptoms are not controlled – Development of side effects or complications • Cancer risk – Incidence - 6% – Multiple – Stricture – Harbor dysplasia or cancer

6. Pre Op preparation Correcting anemia, fluid depletion, electrolyte and acid-base disorders, and nutritional deficiencies. Many pts require TPN and bowel rest – Eating may worsen symptoms – Difficult to demonstrate a significant impact on. Most drugs can be discontinued without sequelae except corticosteroids Infliximab + Cyclosporin vs infliximab alone before surgery – Combination therapy has increased morbidity Three-stage IPAA is the optimal approach for pre-op combination therapy that includes infliximab

7. Total proctocolectomy + Brooke ileostomy – Indications • Older age • Distal rectal cancer • Severely compromised anal function • Patients preference – Disadvantages • Loss of fecal continence • High incidence of SAIO Complications • Delayed healing of the perineal wound • Sexual complications • Dyspareunia – As a result of perineal scarring • Intestinal obstruction • Ileostomy related – Skin irritation – Stomal stenosis – Stoma prolapse, and herniation

8. Total proctocolectomy + Continent ileostomy – Indications • Rectal cancer • Poor anal sphincter function • Occupations that may preclude frequent visits to the toilet • Failed Brooke ileostomy – Avoid in suspicion of Crohn’s disease Operative principles • Excision of a very short segment of terminal ileum • Exclude CD – Essential • Aperistaltic reservoir – Terminal 45–60 cm of the ileum – S-pouch – A wide plastic tube – Into the pouch for drainage in the early postoperative period. – Drainage is achieved by intubating the pouch three times a day.