Surgical Options in Ulcerative Colitis

John Hartley, Surgical Options in Ulcerative Colitis

Consultant Colorectal Surgeon, Hull

The overall incidence of surgery in patients with mucosal ulcerative colitis (MUC) is in the region of 25-45%. The surgical options are governed in part by the indication for surgical intervention, as well as patient related factors, and are consider below.

Total abdominal colectomy and end ileostomy
Those patients who require urgent surgery for fulminant disease or toxic colitis are best served by total abdominal colectomy (TAC) with end ileostomy (EI). If timed appropriately and undertaken by an experienced surgeon this should be a relatively safe procedure which aims to render the patient free of the bulk of disease and restore good health. The majority of patients following TAC will be free of medications except, perhaps, for a variable requirement for topical therapy for symptoms of disease in the rectal stump. In those patients with an uncertain diagnosis prior to surgery the TAC specimen may allow the distinction between MUC and Crohn’s disease to be made with more certainty. There is controversy as to the management of the rectosigmoid stump after TAC. Leaving a long sigmoid stump and maturing this as a formal mucous fistula has merit in ensuring that the planes within the pelvis are unbroken for subsequent definitive surgery, and prevents the pelvic sepsis which may result from blow out of the an intraperitoneal staple line. However, some patients find the mucous fistula troublesome and in this may be an issue in the small group of patients who do not go on to completion proctectomy with or without ileal pouch anal anastomosis (IPAA). Leaving the rectosigmoid stump intraperitoneally has the advantage of ease of management for the patient but carries the risk of stump breakdown and pelvic sepsis which may require a percutaenous drain or occasionally laparotomy. Burying the stump in the subcutaneous tissues in the lower part of the wound is a compromise and should be given consideration.
The majority of patients following TAC and EI will at some point be asked to consider definitive proctectomy perhaps with the option of ileal pouch reconstruction (IPAA). The optimum timing for further surgery is unclear but a gap of 4 to 6 months would be the norm. Those who chose to forego or delay proctectomy should be offered surveillance of the stump as and when their duration of disease puts them at risk for malignant change in the residual mucosa. Stump surveillance carries practical difficulties.

Proctocolectomy and ileostomy
This operation has stood the test of time as definitive treatment for MUC and is associated with high degree of satisfaction and quality of life in appropriately selected patients. Occasionally this procedure is put forward as an option in the emergency situation in rectal bleeding from severe MUC, but this should be almost universally resisted because of the excess morbidity resulting from this procedure in an already ill patient. In the elective situation this procedure can be offered with a high degree of confidence to those patients who chose not to consider IPAA. Patients who have undergone TAC and EI as an emergent procedure may find their experience with an ileostomy helpful in their decision as to whether to undergo IPAA or simply completion colectomy. Important aspects of technique include meticulous attention to the detail of ileostomy construction, and an intersphincteric perineal dissection which may be of benefit in preventing major breakdown of the perineal wound.

Ileal pouch anal anastomosis (IPAA)
Sphincter saving procedures for MUC in the form of IPAA have in recent years become the norm and are considered by many to represent the gold standard in elective surgery for MUC. However, it should be remembered that the single indication IPAA in MUC is the desire to avoid a permanent ileostomy, and appropriate case selection is thus central to successful outcome. Patients must be highly motivated and be prepared for the likely functional results, as well as potential adverse outcomes including pelvic sepsis, small bowel obstruction, anastomotic stricture, pouchitis, and the risks of pouch failure and permanent ileostomy. Current areas of controversy include the application of IPAA in the elderly, the requirement for temporary faecal diversion at the time of pouch construction, the technique of IPAA with either a double stapled technique or mucosectomy and hand sewn IPAA, and the introduction of laparoscopic IPAA. The aetiology and treatment of pouchitis forms the focus of much ongoing research.

Total abdominal colectomy and ileorectal anastomosis (TAC + IRA)
This procedure was described by Stanley Aylett in the 1950’s as an alternative to TPC but has, with the advent of modern stoma appliances and latterly IPAA, until recently largely been a procedure of historical interest. Advantages include a relatively safe procedure which avoids an ileostomy, and may profer a functional outcome superior to that of IPAA. In addition, the avoidance of a pelvic dissection and thus the risk of nerve injury is of relevance in the younger population who typically require surgery for MUC. This procedure may therefore be considered in patients who have relative sparing of a distensible rectum and have a good sphincter. They must understand the risks of continued disease activity in the rectal remnant as well as the requirement for surveillance of the rectum. An IRA may be offered to a younger patient who fulfils these criteria and who wishes to avoid IPAA and yet is not ready to contemplate a permanent stoma. Clearly subsequent conversion to IPAA or permanent EI will be required in some patients for ongoing disease within the rectal remnant. There are suggestions that this procedure is being revisited in such circumstances by some surgeons, often utilising a laparoscopic approach.

In summary the choice of surgical intervention for MUC depends upon the indication for surgery and a number of patient factors including personal preference. TAC and EI is the procedure of choice in fulminant colitis, and in other circumstances may serve to restore good health, allow time with an ileostomy which may aid subsequent decision making, and confirm a precise diagnosis if this is unclear. These decisions along with selection for subsequent, or indeed primary, IPAA require careful counselling and preoperative preparation and should ideally be made within a multidisciplinary setting.

Laparoscopic proctocolectomy with ileal pouch-anal anastomosis
PM Sagar, The General Infirmary at Leeds.

Restorative proctocolectomy (RP) is accepted as the operative procedure of choice for most patients who require elective surgery for chronic ulcerative colits. Since its reintroduction in 1977, there has been much debate about a number of technical points especially the design of the ileal pouch and the choice of ileal pouch-anal anastomosis. Since 2000, the debate has centred on the use of laparoscopic methodology to achieve proctocolectomy and ileal pouch-anal anastomosis.
Laparoscopic assisted segmental resection has been shown to reduce morbidity, reduce the length of hospital stay, reduce post-operative pain and improve cosmesis in patients with benign and malignant disease.
The application of laparoscopic techniques to patients with chronic ulcerative colitis is attractive but relatively little reported, the data are less clear and the practice of laparoscopic-assisted restorative proctocolectomy appears to be restricted to a few specialist centres. The procedure is challenging, time consuming and technically demanding. Initial experience cited long operative times. More recent reports however, suggest that the technique is both feasible and safe. Furthermore, laparoscopy has the potential to provide an enhanced and clear view even within a narrow android pelvis with better visualisation of the pelvic nerves and their branches. By adhering to basic principals of laparoscopic colorectal surgery, surgeons have been able to successfully carry out total laparoscopic proctocolectomy with ileal pouch-anal anastomosis. Table 1 lists a number of technical tips that we have found useful .

Table 1

Table 2

OT = mean operating time

CR = conversion rate

References:

1. Marcello PW, Milsom JW, Wong SK, Hammerhofer KA, Goormastic M, Church JM, et al. Laparoscopic restorative proctocolectomy: Case-matched comparative study with open restorative proctocolectomy. Dis Colon Rectum 2000; 43(5): 604-8.

2. Larson DW, Cima RR, Dozois EJ, Davies M, Piotrowicz K, Barnes SA, et al. Safety, feasibility, and short-term outcomes of laparoscopic ileal-pouch-anal anastomosis: A single institutional case-matched experience. Ann Surg 2006; 243(5): 667-70; discussion 70-2.

3. Maartense S, Dunker MS, Slors JF, Cuesta MA, Gouma DJ, van Deventer SJ, et al. Hand-assisted laparoscopic versus open restorative proctocolectomy with ileal pouch anal anastomosis: A randomized trial. Ann Surg 2004; 240(6): 984-91; discussion 91-2.

4. Maartense S, Dunker MS, Slors JF, Gouma DJ, Bemelman WA. Restorative proctectomy after emergency laparoscopic colectomy for ulcerative colitis: A case-matched study. Colorectal Dis 2004; 6(4): 254-7.

5. Kienle P, Z'Graggen K, Schmidt J, Benner A, Weitz J, Buchler MW. Laparoscopic restorative proctocolectomy. Br J Surg 2005; 92(1): 88-93.

6. Ouaissi M, Alves A, Bouhnik Y, Valleur P, Panis Y. Three-step ileal pouch-anal anastomosis under total laparoscopic approach for acute or severe colitis complicating inflammatory bowel disease. J Am Coll Surg 2006; 202: 637-42