Ulcerative colitis (UC) is an inflammatory bowel disease that may be cured by surgery. One-third of the patients with UC undergo ulcerative colitis surgery, with most undergoing surgery within 10 years of initial diagnosis. Ulcerative colitis surgery is indicated for emergency situations, resulting from complications of fulminant disease, and elective indications. Emergencies include massive bleeding, toxic colitis, toxic megacolon, intestinal perforation, and severe nutritional deficiencies.
Common elective indications include failure or complications of medical therapy and evidence of dysplasia or cancer on surveillance colonoscopy. When a clear indication for surgery has been determined, selection of an operation is made from a variety of ulcerative colitis treatment. Selection of a specific operation must weigh the benefits of performing a more extensive procedure that maximizes cure of the disease, reduces the long-term cancer risk, and improves functional outcome versus a less extensive procedure that may be safer in specific clinical situations. Selecting a specific surgical option is a complex decision that requires knowledge of the patient’s medical and social situation and a detailed understanding of the technical aspects of proposed operations.
Approximately 20% of patients require urgent surgery for acute complications. These acute conditions include toxic colitis, toxic megacolon, perforation, and hemorrhage. The clinical features of toxic colitis include abdominal tenderness and systemic signs of toxicity, such as tachycardia, fever (>101_F), leukocytosis, anemia, and hypoalbuminemia. The ulcerative colitis treatment when the colon is toxic initially is with fluid resuscitation, nasogastric decompression, high-dose intravenous steroids, and broad-spectrum antibiotics. Nutritional supplementation with intravenous hyperalimentation may be used as an adjunct to prevent nutritional deterioration and correct preexisting deficiencies. Barium enema, narcotics, anticholinergic drugs, and antidiarrheal agents should be avoided because they may precipitate toxic megacolon.
is a life-threatening variant of toxic colitis in which the inflammation is serious enough to produce decompensation of the colon wall. This decompensation results in a dilated, edematous, thin-walled colon, which has a characteristic X-ray appearance. Ulcerative colitis surgery is indicated for toxic colitis that does not improve quickly with medical therapy (within 48 to 72 hours) or in patients who develop peritonitis or perforation. A subtotal colectomy with ileostomy and either a Hartman stump or mucous fistula is the preferred operation for this clinical situation. It removes the diseased part of the intestine, preserves future surgical options, and avoids a potentially difficult and hazardous pelvic dissection. Creation of an ileostomy without a primary anastomosis is crucial because of an unacceptably high anastomotic leak rate. Perforation is the most lethal complication of acute colitis and usually occurs in the setting of toxic megacolon. If a perforation occurs before or during surgery, the patient is managed better with a subtotal colectomy. In the past, toxic colitis was associated with significant mortality. More recently, improved medical management and aggressive surgical intervention have decreased the mortality.
accounts for 10% of all emergency colectomies for ulcerative colitis surgery.
Chronic debilitating conditions
Most UC patients (approximately 70%) undergo ulcerative colitis surgery for chronic problems. These patients have persistent symptoms, such as crampy abdominal pain, frequent bowel movements, and stool urgency that have a negative impact on the quality of life. Malnutrition and growth retardation are significant problems in pediatric patients. In severe, chronic cases, a restorative proctocolectomy is often performed in a staged fashion with an initial subtotal colectomy that removes most of the diseased part. Surgery to restore continence is performed after the patient has become nutritionally repleted and has had a chance to heal. Rarely, debilitating extraintestinal manifestations are an indication for a colectomy. Although most of these extraintestinal conditions regresss spontaneously postoperatively, the response is not uniformly predictable.
Complications of long-term steroid usage (e.g., diabetes mellitus, osteoporosis, and cataracts) are another frequent indication for ulcerative colitis surgery. These profound and devastating effects are related to steroid dosage and duration of treatment. Because effective surgical options are available to cure UC, it is unacceptable to maintain patients on steroids and delay surgical therapy excessively.
Of patients with UC, 10% undergo surgery for cancer or dysplasia. Risk factors for development of colorectal cancer are long duration of disease with pancolitis, early age of onset, concomitant primary sclerosing cholangitis, and dysplasia found on surveillance colonoscopy. Based on duration of disease, the cumulative probability of developing cancer has been estimated to be 3% at 15 years, 5% at 20 years, and 9% at 25 years. The development of mucosal dysplasia appears to precede development of cancer. Patients diagnosed with dysplasia or colon cancer should be referred for ulcerative colitis surgery.
Ulcerative Colitis Treatment: Surgical Options
There are 4 main surgical alternatives for managing patients with UC:
1. Subtotal colectomy with ileostomy
2. Segmental Colectomy
3. Proctocolectomy with Brooke ileostomy
4. Restorative Proctocolectomy with ileal anal pouch (Pouch procedure)
In general, selection of a specific operation is based on the following considerations: the age and health of the patient, urgency of operation, presence of dysplasia and risk of carcinoma, the patients desire for continence, the status of anal continence, and the diagnostic certainty that the disease is UC.
Subtotal colectomy with ileostomy
Subtotal colectomy with ileostomy is a less extensive ulcerative colitis treatment operation that has been performed for several decades to manage the sickest UC patients. This operation is suited ideally for emergencies, patients with minimal rectal disease, incontinent patients, and cases of indeterminate colitis. Most of the colon is removed, and an end-ileostomy is created. This operation has the advantage of avoiding a pelvic dissection and eliminating the risk of significant hemorrhage from inadvertent injury to the sacral veins. There is a decreased risk of impotence and neurogenic bladder that may result from injury to the pelvic autonomic nerves. By preserving the rectum, the operation also has the advantage of leaving the patient with future restorative options. If the patient elects for a permanent end ileostomy, the quality of life is quite good. The disadvantages of a permanent ileostomy include the requirement for an external appliance, the potential for associated skin excoriation, and the possibility of fluid and electrolyte depletion. Additional risks are associated with the retained rectum; specifically the risk of rectal cancer may be 13% to 20% after 20 to 30 years.
Colectomy with ileorectal anastomosis is similar to the previously described ulcerative colitis surgery but allows for maintaining anal continence. After removal of the colon, an anastomosis between the ileum and the rectum is performed at the level of the sacral promontory. This is a safe operation with a reported anastomotic leak rate of less than 2% and a mortality rate of 1.4%. Although bowel movements are looser than normal, function usually is acceptable, and bowel movements average 2 to 3 per day. (For patients with active isolated left-sided colitis, it is feasible to remove even less bowel for better intestinal function). With this operation, there is no pelvic dissection, and the patient is spared an ileostomy. The retained rectum is at risk, however, for recurrent disease and cancer development. This is an excellent operation for patients with minimal rectal disease, good sphincter function, and motivation to undergo lifelong endoscopic surveillance of the rectum. This operation is contraindicated in patients requiring emergency surgery because of the high risk of anastomotic leak.
Total proctocolectomy with Brooke ileostomy
One of the earliest operations for ulcerative colitis treatment performed for UC is total proctocolectomy with Brooke ileostomy. This operation has the longest track record of success and in the past was considered the gold standard. The entire colon and rectum are removed resulting in removal of all disease and elimination of the risk of future cancer. Added advantages include a relatively low morbidity and absence of the functional problems associated with a ileal-anal pouch. The main disadvantage is the permanent ileostomy which many patients fail to accept.
Restorative Proctocolectomy with ileal anal pouch (Pouch procedure)
This ulcerative colitis surgery involves removing all of the colon and most or all of the rectum and creating a pouch using the small bowel which is either stapled to the distal rectum or sewn inside the anal canal. The pouch procedure enables patients to be completely cured of their UC and maintain excellent intestinal function. Patients have excellent continence and on average have 4-12 small bowel movements in the first two years which decrease by 2 BM’s. This operation is suited well for young patients, patients who do not want to have a stoma and patients with dysplasia on biopsy who need their entire colon and rectum removed to avoid cancer progression. The operation is also performed after an emergency subtotal colectomy and ileostomy in patients who wish to regain continence and avoid a permanent "bag".
Dr. Blumberg has a long track record in treating patients with ulcerative colitis and is currently performing all of these operations laparoscopically.
Dr. Blumberg has previously reported the Ochsner experience with restorative proctocolectomy for ulcerative colitis (South Med J 2001; 94: 467-71.)
Dr. Blumberg was an invited author by the Gastroenterology Clinics of North America to review the field of ulcerative colitis surgery (Gastroenterol Clin N Am 2002: 31:219-35.)