Ulcerative colitis and Crohn’s disease are gastrointestinal disorders of modern society, and their frequency has increased in developed countries since the mid-20th century. The highest incidence and prevalence of inflammatory bowel disease are seen in North America and Northern Europe, whereas the lowest rates are seen in continental Asia.¹ Despite the use of biologics and other advances in medical treatment, up to 15% to 30% of patients with ulcerative colitis and up to 70% of patients with Crohn’s disease will require surgery during the course of their disease. Recent trends in inflammatory bowel disease have included the increased adoption of a laparoscopic or minimally invasive approach to surgery with the advantages of a faster recovery, fewer complications, less intra-abdominal adhesions, better cosmesis, and a shorter hospital stay. Biologics have changed the medical approach to inflammatory bowel disease, particularly in patients with Crohn’s disease, with an increasing usage of a “top down” approach to treatment in an attempt to rapidly induce remission in patients. With increasing usage of biologics for treatment of inflammatory bowel disease, there is increasing concern about the risk of infectious complications and other complications in patients on biologics who require surgery and the optimal perioperative management of these agents.

This perspective reviews trends in surgery for ulcerative colitis, the role and results of ileal pouch anal anastomosis surgery, the use of biologics around the time of surgery, and the management of dysplasia and cancer.

Since its introduction by Parks and Nicholls in 1978, restorative proctocolectomy with ileal pouch anal anastomosis has become the standard operative approach for the majority of patients who require surgery for ulcerative colitis. Despite over 35 years of experience, the procedure remains technically demanding and is associated with a number of potential complications that are balanced by the patient’s desire to avoid a permanent ileostomy. With appropriate expertise, outcomes are excellent and associated with improved quality of life and high patient satisfaction.

The ileoanal pouch procedure is performed in a staged approach, rarely in a single stage without an ileostomy and most commonly as a 2- or 3-stage procedure (Table 47-1). Indications for surgery for patients with ulcerative colitis include failure of medical therapy, intractable fulminant colitis, toxic colitis, perforation, uncontrolled bleeding, intolerable side effects of medications, strictures, growth retardation in children, high-grade or multifocal dysplasia and dysplasia-associated lesions or masses, and cancer. Patients with acute colitis or fulminant colitis and those who require emergency surgery are generally initially treated with total abdominal colectomy, ileostomy, and Hartmann closure of the rectum. In these nonelective situations, pouch construction is generally felt to be contraindicated.

Review of the Nationwide Inpatient Sample of over 1.5 million patients with ulcerative colitis admitted to a US hospital from 1991 to 2011 has shown an increase of ulcerative colitis–related admissions of 170% and an increase in the number of patients who required total abdominal colectomy of 44%.² In this time period, total abdominal colectomy increased by 15% (compared to proctocolectomy) and, since 2008, was more frequently performed as the initial operation for surgical intervention for ulcerative colitis.

Over the past several decades, there have been a number of refinements in the surgical technique or pouch construction. The ileoanal pouch procedure may be performed as a single stage in carefully selected patients. A number of centers have published series supporting the omission of a diverting ileostomy generally in young, healthy, low body mass index patients who are not anemic, are well nourished, and are not on immunosuppressive medications or biologics.³ The number of patients who undergo the procedure as a single stage omitting a diverting ileostomy remains quite small. Technical aspects of the surgery in patients who are optimal for omitting a diverting ileostomy include no significant blood loss, no tension on the anastomosis, and a technically excellent procedure. These studies have shown similar results in the diverted and nondiverted groups with respect to leak rates and rates of pelvic sepsis but generally have been biased because the decision for an ileostomy was left to the discretion of the surgeon. Although the use of an ileostomy does not prevent anastomotic leak, the clinically less severe consequences of the leak and pelvic sepsis in diverted patients is generally felt to have a favorable impact on subsequent pouch success and bowel function.

Pouch configuration, originally described as an S-pouch, now includes the J-pouch, the H-pouch, the S-pouch, and the W-pouch. Due to the ease and speed of construction, the J-pouch is the most common reservoir performed. A meta-analysis compared W-, J-, and S-pouches, and the functional results are essentially equivalent.⁴ S-pouches are more likely to require intubation for evacuation, and there was slightly less bowel frequency and need for antidiarrheal medications with W-compared to J-pouches. S-pouches can provide an additional length of several centimeters and may facilitate getting the pouch to reach the anus in cases where a J-pouch will not reach. The efferent limb of the S-pouch, which should be initially constructed to be no longer than 2 cm, may elongate with time and cause obstructed defecation, which may require revision of the limb.

Although mucosectomy and double-stapled procedures are both options for the ileoanal anastomosis, the majority of patients undergo the double-stapled technique, which is technically easier to perform. The potential advantages of the technique include less tension on the anastomosis, ease of technical performance, and potentially improved functional results because of less dilatation of the anal canal and the preservation of the transition zone. In small trials, including 3 prospective randomized trials and 1 comparative study, the functional results of a double-stapled technique and mucosectomy have been similar.^5-8

Recent studies have looked at the method of closure of the skin of the ileostomy takedown site and have demonstrated a marked reduction in surgical site infection with a purse string closure compared to primary closure in addition to higher satisfaction with the cosmetic outcome.⁹

A laparoscopic approach is increasingly used for the ileoanal pouch procedure with potential advantages of more rapid recovery and better cosmesis. Most series of laparoscopic pouches are small and avoid patients with a body mass index of greater than 30 kg/m². A Cochrane review of 11 trials and over 600 patients found similar length of stay, morbidity, reoperation, and readmission with a laparoscopic versus open pouch procedures.¹⁰ A laparoscopic approach was associated with longer operating time, a small incision, and improved cosmesis. An additional advantage of the laparoscopic approach is less intra-abdominal adhesions and less adnexal adhesions, which could result in a decreased risk of infertility and decreased incidence of postoperative bowel obstruction.¹¹ Laparoscopic approaches include laparoscopically assisted, hand-assisted, and single-incision laparoscopic techniques.