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Chronic Ulcerative Colitis: Surgical Options
Introduction
Despite major advances in the medical treatment of ulcerative colitis (UC), surgery is still frequently required. Because the aim of surgery is to cure the disease, elimination of all colorectal mucosa is ideal. This operative strategy may need to be modified depending upon patient-, disease-, and treatment-related factors, which may have an impact on short- and long-term outcomes, as well as quality of life.
Evolution of Surgery for Ulcerative Colitis
Surgery for UC evolved from the initial description of a colostomy in the late nineteenth century, through appendicostomy or cecostomy, to ileostomy with or without a blowhole colostomy, especially for toxic megacolon. Total abdominal colectomy with an ileorectal anastomosis subsequently developed as a technique that allowed resection of diseased colon without a stoma. However, patients who undergo this procedure have ongoing symptoms from proctitis, function is unpredictable, and there is an increasing risk of cancer in the rectum. These disadvantages precluded widespread adoption of the ileorectal anastomosis and raised questions about its durability. Total proctocolectomy with end ileostomy allows the elimination of all diseased mucosa, but it includes a permanent external appliance. The continent ileostomy developed as an alternative. This procedure involves construction of an ileal pouch, made continent by a valve in the efferent limb, and anastomosed to the abdominal skin. It was not too much of a leap to use the anal sphincters instead of a valve and to anastomose the pouch to the anus instead of the abdominal skin. Construction of this ileoanal pouch allows removal of all diseased mucosa but maintains per anal defecation. It has become the standard surgical procedure for the treatment of UC.
Indications for Surgery in Persons with Ulcerative Colitis
- 1.
Failure of medical treatment: The presence of intractable symptoms despite maximal medical therapy is a common indication for surgery. Failure of medical treatment also may be due to an inability to tolerate a reasonable maintenance dose of antiinflammatory medications that help patients avoid the development of drug-related adverse effects or an overall poor quality of life.
- 2.
Complications: Emergency surgery may be required for acute complications such as severe acute or fulminant colitis, toxic megacolon, perforation, and hemorrhage. Stricture, dysplasia, and cancer are long-term complications that also may require surgery.
- 3.
Cancer: The risk of colon cancer in a patient with chronic UC has been estimated to range from 2% at 20 years after onset of disease to 43% at 35 years. The findings of a meta-analysis suggested a cumulative incidence of colorectal cancer of 8.5% at 20 years and 17.8% at 30 years. Patients begin colonoscopic surveillance with biopsies at about 8 years after the onset of their disease. When dysplasia is detected and confirmed by pathologic review, factors such as the location, type, and degree of dysplasia, its extent, and the severity of associated background colitis determine the cancer risk. Adenomatous dysplasia such as that found in a discrete adenoma is not necessarily an indication for colectomy as long as the adenoma can be treated endoscopically.
- 4.
Other: Extraintestinal manifestations of ulcerative colitis and growth retardation in children are other occasional indications for surgery.
Operations for Ulcerative Colitis
Ileostomy
An ileostomy may be temporary or permanent. Temporary fecal diversion may protect a distal anastomosis, be part of the first stage of a proctocolectomy in a sick patient, or be part of the treatment of a pouch complication. A permanent ileostomy may be needed when an insoluble distal pouch problem exists, when a patient is not fit to undergo a staged proctectomy and creation of a pouch, or most commonly after a total proctocolectomy (TPC).
Straight Ileoanal Anastomosis
A straight ileoanal anastomosis, which was initially performed in the 1940s, was associated with high rates of fecal urgency and frequency, leading to low overall satisfaction and problems with continence. These outcomes, which are expected in the absence of a fecal reservoir, along with the anastomotic complications of the procedure, led to the creation of an ileostomy in a significant proportion of patients. A variation of the straight ileoanal anastomosis in which multiple 3- to 4-cm longitudinal myotomies are performed at three circumferential sites has been reported to have comparable function to the ileal pouch–anal anastomosis (IPAA) except for nocturnal soiling.
Subtotal Colectomy
A subtotal colectomy and ileostomy is the procedure of choice for toxic colitis or megacolon. It is less extensive than a proctocolectomy but avoids the risks associated with pelvic dissection and the creation of an anastomosis. It is therefore suitable for a first-step procedure in malnourished or moribund patients and in those receiving large doses of steroids or immunosuppression, as well as when potential problems with sexual dysfunction or fertility need to be minimized. Performing a subtotal colectomy rather than a one-stage restorative proctocolectomy is safer when a diagnosis of Crohn disease cannot be excluded because it provides a large specimen for histologic evaluation and preserves options for definitive treatment.
During a subtotal colectomy, preservation of the main trunk of the inferior mesenteric artery with division of the mesenteric branches minimizes damage to the autonomic nerves and allows easier identification of the stump when a subsequent proctectomy is performed. Having a longer distal stump also allows the stapled end to reach the anterior abdominal wall for subcutaneous placement. Subcutaneous rather than intraperitoneal stump placement avoids the possibility of rectal stump blowout, which can cause peritonitis or a pelvic abscess and necessitates a repeat laparotomy. If the rectosigmoid stump is very friable, it is matured primarily as a mucus fistula or secondarily after 10 days of hanging out of the wound as a “tail” that is 10 cm in length and wrapped in gauze. If a repeat anastomosis is not intended, it is best to complete a proctectomy soon because the development of a stricture in the rectal stump as a result of persistent inflammation may prevent adequate surveillance.
Abdominal Colectomy with Ileorectal Anastomosis
A colectomy with ileorectal anastomosis (IRA) is technically simple and leads to rapid recovery, but bowel function is dependent upon the distensibility of the rectum, the severity of residual disease, and the adequacy of the anal sphincters. Transection of the rectum should be performed at the level of the sacral promontory to preserve the full length of the rectum for optimal capacity. An ileosigmoid anastomosis is an alternative when the distal sigmoid is spared from active disease. The risk of cancer in the rectum is 3% to 8% over long-term follow-up, and the overall failure rate for an IRA reaches 54% over 20 years. The main advantage of an IRA is that it avoids the hazards of pelvic dissection and thus merits consideration in specific circumstances. It allows restoration of health, completion of education and pregnancy in some young patients prior to a subsequent restorative proctocolectomy, and may be the definitive procedure in elderly patients who do not want to undergo an ileostomy. One-stage surgery is usually performed unless the patient has toxic colitis, intra-abdominal sepsis, and significant malnutrition or unless doubt exists with regard to the normality of the rectal mucosa. In some circumstances, resection of diseased colon at an initial subtotal colectomy may allow recovery of function and compliance of the rectum, which then becomes usable. Favorable results have been reported after primary or secondary IRA, even when proctitis is present. The key aspect of functionality is rectal compliance, which is best judged by rigid proctoscopy. Anastomotic complications are similar whether the ileum is anastomosed to diseased or macroscopically normal rectum, and a routine proximal ileostomy is not indicated. Equivalent results have also been reported with both sutured and stapled anastomoses. The rectum needs to be monitored with yearly surveillance because cancer has been reported to occur in both nonfunctioning and functioning rectums.
Ileostomy and Blowhole Colostomy
The Turnbull blowhole colostomy and loop ileostomy described in the 1960s has a role in extremely ill patients and in situations in which colonic mobilization is hazardous, such as a contained perforation, pregnancy, or a high-lying splenic flexure. The main advantage of the procedure is that the colon is not disturbed; the main disadvantage is that the diseased colon is left behind and may lead to persistent toxicity. The procedure is contraindicated in patients with free perforation or bleeding. A definitive procedure is performed after the patient has recovered.
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