Surgery in ulcerative colitis

Surgery in ulcerative colitis

  • Indications for surgery include acute severe colitis, and at least moderate disease refractory to all medical therapy (mesalamine, steroids, immuno-modulators, and biological therapy if available)

  • Definitive indications include persisting toxic megacolon, perforation, massive bleeding and malignancy; and ASC refractory to "rescue" therapy

Patient referred for surgery

ECCO Statement 7T (UC 2012)

Prednisolone 20 mg daily or equivalent for more than six weeks is a risk factor for surgical complications [EL3b, RG C]. Therefore, corticosteroids should be weaned if possible

Further information

  • Ensure joint care required between physician and surgeon

  • Dietetic review to optimise nutrition

  • Thromboprophylaxis if immobile, and on admission to hospital

  • Correct electrolyte abnormalities (K+, Mg++)

  • Stoma nurse review & if available “expert” patient support

  • Continue medical treatment until surgery though try to wean steroid doses to < 20mg/day prednisolone

Optimise physiologic state

  • Ensure joint care required between physician and surgeon

  • Dietetic review to optimise nutrition

  • Thromboprophylaxis

  • Correct electrolyte abnormalities (K+, Mg++)

  • Stoma nurse review

  • Continue medical treatment until surgery; try to limit corticosteroid dose (e.g. << 20 mg Prednisolone daily)

Optimise physiologic state

ECCO statement 9C (UC 2017)

A covering loop ileostomy is generally recommended when performing a restorative procto-colectomy for ulcerative colitis [EL 3]

ECCO statement 9H (UC 2017)

There is no age limit for performing an ileal-pouch anal anastomosis as long the patient retains good anal sphincter function [EL 5]

ECCO statement 9I (UC 2017)

Under optimal circumstances, ileo-rectal anastomosis is a reasonable alternative to ileal-pouch anal anastomosis [EL5]. Advantages such as lower morbidity and preserved female fecundity need to be weighed against the need for rectal surveillance and subsequent protectomy in 50% of cases [EL3]

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Further information

  • Restorative proctocolectomy with ileal pouch anal-anastomosis (IPAA) is the standard operation, although occasional patients may require the continent “Kock” ileostomy

  • Usually staged surgery, initially with sub-total colectomy. The pouch is created 3-6 months later.

  • A defunctioning, covering loop ileostomy is often used to reduce complications if anastomotic leak occurs, though requires a suitable patient (e.g. thin abdominal wall; sufficient small bowel mesentery). This requires a third operation, to remove the ileostomy and restore intestinal continuity.

  • Laparoscopic IPAA is feasible if expertise is available

  • IPAA can be performed in all ages

  • IPAA can compromise female (and male) fecundity (30-70%), hence younger women should consider subtotal colectomy and end ileostomy or ilio-rectal anastomosis , until they have completed having children though balance the ongoing risk of having an inflamed rectum in situ. A rectal remnant still requires standard-interval surveillance

Obtain informed consent

ECCO statement 9C (UC 2017)

A covering loop ileostomy is generally recommended when performing a restorative procto-colectomy for ulcerative colitis [EL 3]

ECCO statement 9H (UC 2017)

There is no age limit for performing an ileal-pouch anal anastomosis as long the patient retains good anal sphincter function [EL 5]

ECCO statement 9I (UC 2017)

Under optimal circumstances, ileo-rectal anastomosis is a reasonable alternative to ileal-pouch anal anastomosis [EL5]. Advantages such as lower morbidity and preserved female fecundity need to be weighed against the need for rectal surveillance and subsequent protectomy in 50% of cases [EL3]

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Further information

  • Restorative proctocolectomy with ileal pouch anal-anastomosis (IPAA) is the standard operation, although occasional patients may require the continent “Kock” ileostomy

  • The rectum / rectum & distal sigmoid should be preserved during an emergency subtotal colectomy; with the proximal end brought out as a mucous fistula or closed and left in the subcutaneous fat

  • A defunctioning, covering loop ileostomy may reduce complications from an anastomotic leak, though requires a suitable patient (e.g. thin abdominal wall; sufficient small bowel mesentery)

  • Laparoscopic IPAA is feasible if expertise is available

  • IPAA can be performed in all ages

  • IPAA can compromise female (and male) fecundity (30-70%), hence younger women should consider subtotal colectomy and end ileostomy or ilio-rectal anastomosis, until they have completed having children though balance the ongoing risk of having an inflamed rectum in situ. A rectal remnant still requires standard-interval surveillance

Obtain informed consent

Surgery

Further information

  • Following surgery, rapidly reduce steroids to an equivalent of prednisolone 5 mg (am) / 2.5 mg (pm) except in those having taken steroids > 6 months who require a dose reduction of 1 mg/week

  • Dose reduction below a total daily dose of 7.5 mg depends on withdrawal symptoms

Discharge home when stable

ECCO statement 9A (UC 2017)

Delay in surgery is associated with an increased risk of surgical complications [EL 4]. A staged procedure, initially with sub-total colectomy, is recommended in acute colitis [EL 4] in patients taking ≥ 20 mg prednisolone daily for more than 6 weeks, or in those treated with anti-TNF [EL 3]. If the appropriate skills are available, a laparoscopic approach is preferred [EL 3]

ECCO statement 9B (UC 2017)

When performing pouch surgery, the maximum length of anorectal mucosa between the dentate line and the anastomosis should not exceed 2 cm [EL 4]

ECCO statement 9D (UC 2017)

Pouches should be performed in specialist referral centres. High-volume centres have lower complication rates and higher rates of pouch salvage following complications [EL 4]

ECCO statement 9G (UC 2017)

In a fertile female patient, alternative surgical options such as subtotal colectomy and end ileostomy or ileo-rectal anastomosis should be discussed with the patient, because fecundity is at risk after ileal-pouch anal anastomosis [EL3]. A laparoscopic approach is associated with better preservation of female fertility and is preferred [EL3]

ECCO Statement 7S (UC 2012)

In indeterminate colitis or colonic IBD yet-to-be classified, an IPAA can be offered with the information that there is an increased risk of complications and pouch failure [EL4, RG C]

Further information

  • Proceed to IPAA if Crohn’s disease excluded. Surgery normally occurs 3-6 months after sub-total colectomy

  • No more than 2cm anorectal mucosa should remain, to avoid “cuffitis”. Usually a stapled rather than hand-sewn anastomosis is performed

Proceed to IPAA

Good outcome

Complication

ECCO Statement 8E (UC 2012)

Probiotic therapy with VSL#3 (18 × 1011 of 8 bacterial strains for 9 or 12 months) has shown efficacy for maintaining antibiotic-induced remission [EL1b, RG B]. VSL#3 (9 × 1011 bacteria) has also shown efficacy for preventing pouchitis [EL2b, RG C]

Further information

  • The median stool frequency is 4-8 liquid motions daily, passing ≈ 3 times stool volume

  • Patients do not require regular follow up, other than the 20-30% who develop pouchitis

  • 3g (9x1011 bacteria) / day VSL#3 effectively maintains remission (in 90% cf. 60%) during the first year after surgery

Discharge to community care

  • Lifetime failure rates are ≈15%, due to septic complications, pouch dysfunction, re-diagnosis as Crohn’s disease or refractory pouchitis

Determine cause

ECCO statement 9F (UC 2017)

Annual pouchoscopy is recommended in patients with risk factors such as neoplasia and primary sclerosing cholangitis. No specific pouch follow-up protocol is required in asymptomatic patients [EL 3]

Further information

  • Patients with PSC, previous malignancy or dysplasia, or type C pouch mucosa (permanent, persistent atrophy and severe inflammation) require annual surveillance of the pouch, although there is no good supportive evidence

  • Some experts recommend pouchoscopy in lower risk patients 5-yearly, without supportive evidence

Endoscopic surveillance

Further information

  • It is not known whether irreversibly failed pouches should be excised

End-iliostomy +/- pouchectomy

ECCO statement 9D (UC 2017)

Pouches should be performed in specialist referral centres. High-volume centres have lower complication rates and higher rates of pouch salvage following complications [EL 4]

Further information

  • IPAA salvage surgery after a complication should be performed in a specialist referral centre

  • Salvage surgery has a success rate of ≈50%

Salvage surgery

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