The management of IBD requires close liaison between physician and colorectal surgeon. Specialist nursing care, including that from a stoma therapist, is also necessary both pre- and postoperatively. Dietitians and counselors may also play a key role in preparing patients physically and psychologically for surgery. In most centers, surgery is undertaken laparoscopically although conversion to a conventional laparotomy incision may be required for safety reasons, particularly if adhesions or anatomic variants are encountered. Laparoscopy is less invasive than laparotomy and is preferable to patients; its clinical advantages include reduced perioperative morbidity with faster recovery time, reduced risk of adhesions and fewer incisional hernias.
Surgery rates have diminished in recent decades for both ulcerative colitis and Crohn’s disease. While innovative drug therapy may have contributed, other factors are probably more important and include a progressive shift from surgical to medical care, the development of specialist teams and practice guidelines, patient advocacy groups and earlier diagnosis. However, in some instances, surgery remains an appropriate early option, notably for localized or short-segment ileal disease that is fibrotic and causing obstructive symptoms.
Ulcerative colitis
Indications for surgery (Table 9.1) are as follows.
Emergency colectomy, after appropriate immediate resuscitation (see Chapter 7), is necessary for colonic perforation or massive hemorrhage.
Urgent colectomy is needed for patients with acute severe ulcerative colitis who deteriorate, do not respond to intensive medical treatment in 5–8 days or develop acute colonic dilatation that does not respond within 24 hours to more intense medical treatment (see Chapter 7).
Elective colectomy is indicated in refractory, often steroid-dependent chronic active ulcerative colitis, and dysplasia or frank carcinoma. Occasionally, elective colectomy may be necessary in children with chronically active disease to prevent growth retardation (see Chapter 10).
TABLE 9.1 | |
Indication | |
Emergency | Colonic perforation Massive colonic hemorrhage |
Urgent | Deterioration or non-response to medical treatment of acute severe ulcerative colitis in 5–8 days Acute colonic dilatation |
Elective | Chronic active (steroid-dependent or refractory) ulcerative colitis Dysplasia or cancer Growth retardation in children (rarely) |
Options Restorative proctocolectomy with ileoanal pouch Pan-proctocolectomy with ileostomy Colectomy with ileorectal anastomosis (exceptionally – see text) | |
Options for surgery are outlined below and summarized in Table 9.1 and Figure 9.1.
Pan-proctocolectomy with permanent ileostomy has the lowest morbidity and mortality of the available surgical options, is technically the easiest and involves only one operation.
Note: only under exceptional circumstances should colectomy with ileorectal anastomosis be considered (e.g. older patients with relative rectal sparing who could not cope with a stoma or are unsuitable for an ileoanal pouch because of frailty or poor anal sphincter function). It is contraindicated as a permanent solution in other patients with pronounced rectal inflammation, as they will continue to have bleeding, diarrhea and urgency postoperatively. It is also inappropriate in young patients in view of the long-term risk of cancer developing in the retained rectum, for which regular sigmoidoscopy with biopsies for dysplasia would be necessary indefinitely (see Chapter 7).
Restorative proctocolectomy with ileoanal pouch is the most recently devised procedure for ulcerative colitis, and avoids the need for permanent ileostomy. It is now the favored operation in younger patients (particularly those younger than 60 years) in whom preoperative confirmation of normal anal sphincter function minimizes the risk of postoperative incontinence of liquid pouch contents. The operation to fashion an ileoanal reservoir (‘pouch’) is technically difficult, usually requiring a temporary loop ileostomy that is closed at a second operation a few months later.
Complications of the different surgical options are as follows.
Ileostomy. Although proctocolectomy and ileostomy have the lowest morbidity and mortality of operations for ulcerative colitis, ileostomy incurs a readmission rate of about 50% in 10 years. Complications are listed in Table 9.2: specialist stoma therapists are crucial for their management. Because of its effects on body image, hygiene, and social and sexual function, a small minority of patients find an ileostomy impossible to adapt to psychologically.
Ileoanal pouch. Complications of ileoanal pouch surgery (Table 9.3) lead to excision of the pouch and conversion to permanent ileostomy (‘pouch failure’) in about 10% of patients. Early pouch failure is so common with Crohn’s colitis that formation of an ileoanal pouch is generally contraindicated after colectomy for Crohn’s disease or colitis of uncertain type or etiology (CUTE). Even in patients judged to have had successful pouch surgery, daytime stool frequency is four to seven, urgency is common and nocturnal incontinence is present in about 20%.
TABLE 9.2 | |
Complication | Comment |
Early | |
Skin problems | Rare now with stoma therapists and improved appliances |
Adhesive intestinal obstruction | May need surgery |
Necrosis, fistulas, retraction, parasternal herniation | Requires refashioning of stoma |
Excess stomal output (normal approximately 500 mL/day) | Improves with time postoperatively; avoid salt depletion in hot weather |
Psychological disturbance | Some patients cannot come to terms with stoma (see text) |
Late | |
Sexual dysfunction | Due to psychogenic factors or surgical pelvic nerve damage |
Uric acid renal stones | Due to excess alkaline stomal output |
Related posts:
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
