Overview of Surgical Treatment for Ulcerative Colitis

Introduction

Ulcerative colitis (UC) is a chronic mucosal inflammatory disease of the colorectum that can have a widely varied presentation. Although many patients suffering from UC are successfully treated with various medical combinations that mitigate symptoms, there are several clinical scenarios in which the consideration of surgical intervention is warranted. A variety of surgical strategies exist for the treatment of UC, and all options must share a common goal: to alleviate symptoms of the disease and to reduce the risk for cancer development, all the while maintaining the highest patient quality of life (QOL).

There are several patient scenarios in which surgery is indicated. First, the patient presenting with peritonitis, massive uncontrolled hemorrhage, and/or visceral perforation warrant immediate surgical intervention. Next, the patient who fails to maintain acceptable QOL on aggressive medical therapy benefits from surgical discussion. Finally, the patient with good control of colitis-associated symptoms but who suffers from untoward side effects from medication use, or has findings of dysplasia on surveillance colonoscopy deserves the offerings of surgery. All of the above scenarios are best handled with a multidisciplinary approach, with early surgeon participation in the team.

Choosing the most appropriate surgical strategy should be individualized to each patient. Consideration is given to the patient's overall quality of health, his clinical status, and his personal goals of surgery, that is, preservation of bowel function, minimal number of surgeries, avoidance of ostomy, and so forth. Surgical options for treatment of UC will be discussed in the following text, with emphasis on patient selection and preservation of patient QOL. In addition, both common and uncommon methods of restoration of intestinal continuity and continence will be described and discussed.

Total Proctocolectomy With Permanent Ileostomy

Prior to the development of the ileal pouch-anal anastomosis (IPAA) in the early 1980s, total proctocolectomy with end ileostomy (TPC) was the most effective definitive surgery for UC ( Fig. 23.1 ). Although restorative proctocolectomy with IPAA has become the most commonly performed surgery for patients with UC requiring surgery, there still remains a role for TPC in selected patients who desire a definitive operation and are accepting of a permanent stoma.

The clinician should consider TPC in patients who choose not to undergo IPAA or who are not good candidates for IPAA. These patients include those with impaired anal sphincter function or those with reduced mobility or comorbid disease. Typically these are elderly patients, and TPC should be strongly considered in this population.

TPC is a desirable option in selected cases for several reasons. Most importantly, it is a safe and curative operation that allows for complete removal of at-risk colorectal mucosa, thus preventing disease-associated dysplasia or cancer development. This is best facilitated by using an intersphincteric technique for proctectomy ( Fig. 23.2 ) rather than low stapling with preservation of anal transition zone. TPC can often be performed in a single surgical setting (one operation) with less technical challenge than that required for IPAA. Although some have shown a similar morbidity between TPC and IPAA, TPC is associated with less-severe complications, a characteristic ideal for elderly UC patients requiring a surgical cure. Certainly, young and fit UC patients who need surgery may also choose this pathway for the benefits outlined above and should never be discouraged from TPC or convinced to pursue IPAA.

TPC is certainly not without its drawbacks, and arguably the most significant is the requirement for a permanent ileostomy, which carries with it the associated risks for pouching difficulties, parastomal hernia, and stomal prolapse. Permanent ileostomy may negatively impact body image and thus QOL, a parameter that is meant to improve after surgery in these patients. There is evidence that IPAA is associated with better perception of body image than a permanent stoma, even though QOL is similar compared to TPC in a matched study. Others have shown that patient QOL is restored to that of the general population after TPC for UC or is not significantly affected. Patients often experience difficulty in healing the perineal wound even when intersphincteric approach is utilized, and delayed wound healing may occur in 18%–25% of this population, creating great morbidity that is difficult to treat. Since pelvic dissection is unavoidable to complete TPC, patients must accept a risk for pelvic nerve damage similar to that with IPAA, which may lead to irreversible sexual and urinary dysfunction.