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Acs0533 The Surgical Management Of Ulcerative Colitis 2004

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  • 1. © 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 Gastrointestinal Tract and Abdomen 33 Procedures for Ulcerative Colitis — 1 33 PROCEDURES FOR ULCERATIVE COLITIS Robert R. Cima, M.D., F.A.C.S., F.A.S.C.R.S.,Tonia Young-Fadok, M.D., M.S., F.A.C.S., F.A.S.C.R.S., and John H. Pemberton, M.D., F.A.C.S., F.A.S.C.R.S. Chronic ulcerative colitis (CUC) is one of the two main cate- gastric tube decompression may be required if colonic distention gories of inflammatory bowel disease (Crohn disease being the is a component of the presentation. If CUC is known to be pres- other). CUC is characterized by contiguous inflammation of the ent, high-dose intravenous steroid administration should be initi- mucosa, beginning in the rectum and progressing for variable dis- ated, and stool cultures should be obtained. If no diagnosis of tances proximally within the colon. Its cause is unknown. Patients CUC has yet been made, endoscopic evaluation of the colon typically experience intermittent exacerbations of the disease, should be carried out expeditiously, with the aim not of assessing which are notable for bloody diarrhea associated with urgency the entire colon but only of visualizing the rectal and distal colonic and tenesmus. In a minority of patients, the first episode of the mucosa. If the results of the endoscopic examination are obvious- disease is a fulminant presentation that may be fatal without ly consistent with CUC, the endoscope can be withdrawn; the prompt surgical intervention. remainder of the colon need not be evaluated. Medical therapy for CUC is aimed at controlling symptoms or If the patient is clinically stable, antibiotic therapy is not indi- managing the underlying inflammatory process; it does not cure cated. If, however, the patient is very ill or has a high fever or either the intestinal or the extraintestinal manifestations of CUC. leukocytosis, administration of appropriate broad-spectrum anti- The intestinal manifestations of CUC and the associated risk of biotics should be initiated after cultures are obtained.The patient malignancy can, however, be effectively cured by surgical inter- should be observed closely for 24 to 48 hours while on maximal vention, which involves removal of the entire large intestine. In medical therapy. If there is no improvement or if the patient’s what follows, we discuss the indications for surgical treatment of condition deteriorates, surgical treament is recommended. If CUC and describe the surgical options. there is evidence of peritonitis, hemodynamic instability, or per- foration, the patient should be operated on immediately. Preoperative Evaluation Toxic megacolon Toxic megacolon may be the initial pre- sentation of ulcerative colitis or may represent a flare in a patient INDICATIONS FOR OPERATION with long-standing disease. Either the entire colon or an isolated Surgical treatment of CUC is indicated in a variety of situa- segment of the colon (usually the transverse or the left colon) is tions. The easiest classification scheme divides these indications involved. Although a radiographic definition of toxic megacolon into two broad categories: indications for emergency operation exists (i.e., greater than 5.5 cm dilatation of the transverse colon and indications for elective operation. on a supine abdominal film), toxic megacolon is truly a clinical diagnosis. Emergency Operation Medical treatment of toxic megacolon is similar to that of ful- The main conditions calling for emergency operative treat- minant colitis—namely, an NPO regimen, nasogastric tube de- ment of CUC are fulminant colitis, toxic megacolon, and massive compression, correction of fluid deficits and electrolyte abnor- hemorrhage. In these situations, the primary surgical strategy is malities, administration of high-dose steroids, and initiation of to remove the bulk of the diseased colon to allow the patient’s antibiotic therapy if there is fever or an elevated leukocyte count. medical condition to improve; an important secondary consider- Emergency surgical management is indicated if the patient’s clin- ation is to perform an operation that will not preclude a future ical or radiographic status worsens, if there is evidence of perfo- restorative procedure. ration, or if there is no improvement 24 to 36 hours after aggres- sive medical therapy is begun. Delaying the operation increases Fulminant colitis Although as a rule, CUC is a chronic dis- the risk of perforation, which raises mortality from less than 5% ease that allows deliberate and coordinated care, approximately to nearly 30%.1 Fortunately, fewer patients are now seen with 10% of patients initially present with severe disease.1 Fulminant severe complications of CUC than was once the case, primarily colitis is characterized by the sudden onset of severe and frequent because of improved medical therapies and a general trend (> 10/day) bloody bowel movements, abdominal pain, dehydra- toward earlier surgical intervention for CUC. tion, and anemia. Diagnostic criteria for fulminant colitis (origi- nally described by Truelove and Witts in 1955) include the above Other surgical emergencies Colonic perforation without signs and symptoms and at least two of the following: tachycar- megacolon should raise concern that the actual diagnosis might dia, body temperature higher than 38.6° C (101.5° F), leukocy- be Crohn disease or that there might be another cause for the per- tosis (> 10,500/mm3), and hypoalbuminemia.2 foration (e.g., a gastric or duodenal ulcer related to steroid use). Patients with fulminant colitis are extremely ill and require Whatever the cause of the perforation, there is no role for con- rapid, aggressive medical therapy, including fluid resuscitation, servative therapy, and the patient should immediately undergo correction of electrolyte abnormalities, and, in some cases, blood surgical exploration. transfusions. A nihil per os (NPO) regimen is indicated. Naso- Hemorrhage severe enough to result in hemodynamic insta-
  • 2. © 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 Gastrointestinal Tract and Abdomen 33 Procedures for Ulcerative Colitis — 2 bility is an unusual complication of CUC. Decisions regarding become our practice. In addition, any colonic stricture significant intervention are made after consultation with the treating gas- enough to cause obstructive symptoms, even if it appears benign troenterologist. Initial treatment should consist of aggressive on endoscopy, should be considered to be potentially harboring fluid and blood-product resuscitation. Any electrolyte or clotting a malignancy and should be treated surgically. deficiencies should be corrected. Upper GI endoscopy should When there is a suspected or known colonic or rectal malig- be done to exclude the possibility that a gastric or duodenal nancy, the surgical options should be driven by oncologic princi- ulcer is causing the bleeding. The timing of operation is deter- ples. In most patients, except for those with low rectal cancers or mined by the clinical situation. If the patient is hemodynamical- metastatic disease, total colectomy with ileal pouch–anal anasto- ly unstable even after effective resuscitation, emergency opera- mosis (IPAA) is an acceptable surgical treatment modality.There tion is indicated because medical therapy would take too long to is a particular concern regarding the performance of an IPAA in decrease the mucosal inflammation responsible for the bleeding. the setting of a rectal cancer, in that the required irradiation may If there is slow but continuing hemorrhage that does not cause severely compromise pouch function. Stage for stage, the prog- hemodynamic instability or symptoms, high-dose steroid thera- nosis for patients with malignancies who have CUC is generally py may be tried for 48 to 72 hours before surgical intervention similar to that of patients with malignancies who do not have is considered. CUC. CUC patients who have undergone surgical treatment, particularly with an IPAA procedure, tolerate chemotherapy as Elective Operation well as patients without CUC do.8-10 As a rule, if oncologic prin- Given the chronic nature of CUC, the indications for elective ciples are not compromised, an IPAA procedure can be per- operation may occur early in the course of a patient’s disease or formed without any deleterious impact on oncologic outcome or may arise after years of relatively mild disease.The major indica- long-term IPAA function. tions for elective surgical treatment of CUC are failure of med- ical management to control symptoms (intractability) and the presence of mucosal dysplasia, dysplasia-associated lesion or Operative Planning mass (DALM), or malignancy. Elective surgical treament may CHOICE OF PROCEDURE also be indicated in patients with extraintestinal manifestations of CUC and children with growth retardation. Currently, there are two widely accepted surgical options for the treatment of CUC: total proctocolectomy with end (Brooke) Intractable symptoms Intractability is a clinically defined ileostomy and total proctocolectomy with IPAA. A third option, condition that can occur in either the acute or the chronic state total abdominal colectomy with ileorectal anastomosis, may be of CUC. In an acute flare, intractability refers to the inability to considered in highly select groups of patients—namely, those control a patient’s symptoms with maximal medical therapy; in who have relatively mild disease and who have a contraindication the chronic state, it refers to either the inability to taper steroids to an ostomy (e.g., portal hypertension or ascites) and those in to a reasonable maintenance dose or the development of severe whom an ileal pouch procedure would be technically impossible drug-related side effects. and who refuse an ileostomy. Previously, a fourth option, procto- In most cases, medical management of an acute CUC flare colectomy with construction of a continent ileostomy (or Kock consists of I.V. steroid therapy for 5 to 10 days. If this approach pouch), was employed; however, this procedure was associated does not bring about clinical improvement, elective operation is with such a high rate of pouch dysfunction (requiring surgical advisable. One study recommended I.V. or oral cyclosporine correction in the majority of patients) that it is no longer per- therapy for patients who are experiencing an acute flare of CUC formed. For this reason, as well as because the IPAA procedure that does not respond to I.V. steroid therapy3; however, a subse- has yielded outstanding functional results, the continent ileosto- quent report involving a larger number of patients and a longer my is now of historical interest only and thus will not be dis- follow-up period showed that nearly 50% of all patients treated cussed further. in this manner required colectomy within 1 year.4 During the The choice of surgical procedure is individualized on the basis treatment period for acute disease, it is important that the patient of the patient’s underlying physical and medical condition, as receive adequate nutritional support (often in the form of total well as of his or her social and psychological situation. At present, parenteral nutrition). If the patient’s nutritional status declines proctocolectomy with IPAA (first described in 197811,12) is the significantly, a three-stage procedure may be necessary to preferred operation for most patients because it removes the dis- improve surgical outcome.5 eased colon while preserving fecal continence and nearly normal defecation through the anus. Construction of the ileal pouch is Dysplasia or malignancy The development of malignan- the key to the success of this operation: the pouch provides a fecal cy in the setting of CUC has been well described. The risk of reservoir that is adequate to allow voluntary defecation, albeit at colon cancer in a CUC patient has been estimated to be any- a higher (but still manageable) daily frequency than is seen in where from 2% at 20 years after onset of CUC to 43% at 35 patients with an intact rectum. In almost all series, the majority years.6 A patient’s individual risk level for colon cancer appears of IPAA patients report good functional results and a high degree to increase when there is evidence of high-grade dysplasia on of satisfaction with quality of life, and these findings remain sta- random colon biopsies or if there is a DALM. The presence of ble over time.The decision to proceed with operations other than low-grade dysplasia on random biopsy is a more difficult clinical IPAA is based on individual patient circumstances or on the pres- situation. Traditionally, most clinicians have recommended ence of preexisting medical or physiologic conditions that are increases in the frequency of surveillance colonoscopies rather contraindications to this type of restorative procedure. than surgery. There are, however, some preliminary reports sug- In patients who require emergency surgery or are in poor med- gesting that the presence of any degree of dysplasia not associat- ical condition as a consequence of their underlying disease, a ed with a mass lesion should be viewed with a very high degree three-stage procedure is performed. Stage I consists of total of suspicion and that surgery should be recommended7; this has abdominal colectomy with a Hartmann closure and an end
  • 3. © 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 Gastrointestinal Tract and Abdomen 33 Procedures for Ulcerative Colitis — 3 ileostomy. The majority of the diseased colon is removed, the depend on obstetric issues. Although pregnancies and deliveries patient’s clinical condition is improved, and any immunosuppres- may be uneventful, patients often experience temporary stoma or sive medications the patient has been receiving can be tapered. Kock pouch dysfunction.17 Studies documented similar dysfunc- Once the patient has recovered and is clinically ready for another tion in post-IPAA patients, who reported a slight increase in stool operation, stage II—entailing either a completion proctectomy frequency, incontinence, and pad usage during pregnancy,19,20 with end ileostomy or an IPAA with diverting loop ileostomy—is though they returned to baseline pouch function after delivery. carried out. If the latter alternative is chosen, the patient must These studies noted a higher rate of cesarean sections in post- subsequently undergo stage III, which involves reversal of the IPAA patients than was seen in other studies that reported on ileostomy. modes of fetal delivery in patients with Kock pouches and end The reason why a proctectomy is not performed in an emer- ileostomies. It is unclear, however, whether this increase was due gency setting is that if the rectum is left in place, a restorative to uncertainty about how these patients would fare after vaginal operation can be performed later without the dissection planes in deliveries, because fewer than 50% of these cesarean sections the pelvis having been disturbed. In addition, emergency proc- were performed for obstetric indications. Overall, there appeared tectomy is associated with a higher risk of bleeding and injury to to be no contraindication to vaginal delivery, though the authors the nerves of the pelvic floor, the bladder, and the genitalia. suggested that women who have a scarred, stiff perineum might Usually, the small amount of diseased tissue left behind does not be best advised to avoid vaginal delivery. present a clinical problem. Although various studies have examined the course of preg- nancy and the development of complications after IPAA, the spe- Special Considerations in Patient Selection cific issue of fecundity (the ability to become pregnant) after Age Most CUC patients are relatively young and thus, unless IPAA has not been thoroughly investigated. One analysis of the there are unusual circumstances, should be offered proctocolec- rate of pregnancy after IPAA reported a significant reduction in tomy and IPAA. However, CUC is known to have a bimodal age postoperative fertility.18 In a subsequent study, the same authors distribution, and significant numbers of older CUC patients are examined young women with familial adenomatous polyposis being referred for surgical evaluation. Although many institutions and found that fecundity was significantly lower in those with an have reported their long-term results with IPAA, few have regu- ileal pouch than in those with an iliorectal anastomosis.21 The larly performed IPAA in elderly patients. In a Mayo Clinic survey basis of the decrease in fertility with IPAA is unknown, but it has of 1,386 patients who underwent IPAA, the median age at the been suggested that anatomic changes in the pelvis may con- time of operation was 32 years (range, 5 to 65 years)13; only 16% tribute to the problem. Until further studies are done to confirm were older than 45 years, and none were older than 65 years. and clarify these findings, women considering undergoing IPAA Functional outcomes—determined on the basis of nocturnal stool should be informed of the possibility of decreased fertility. frequency, daytime and nocturnal incontinence, and need for TECHNICAL CONTROVERSIES constipating medications—were significantly worse in patients who were older than 45 years at the time of the IPAA. The two main controversies regarding the technical aspects of Results such as those of this Mayo survey have often led gas- the IPAA procedure revolve around the choice of anastomotic troenterologists and surgeons not to recommend IPAA for elder- technique and the question of whether a diverting ileostomy is ly patients. Another study, however, came to somewhat different needed. conclusions.14 The investigators evaluated their experience with Ultimately, the choice of anastomotic technique depends on IPAA patients from the age of 50 years to past the age of 70 years. the patient’s clinical situation and the surgeon’s preference. Twenty-eight of 227 patients were older than 50 years when the Currently, most authorities believe that the double-stapled tech- IPAA was performed; of those 28, 10 were between 60 and 70 nique is easier to perform than a mucosectomy with a handsewn years of age and five were between 70 and 80. When the elderly anastomosis and yields superior functional results in terms of patients were compared with younger patients with CUC, there episodes of incontinence or soiling.22,23 Those surgeons who were no significant differences between the groups with respect to advocate the double-stapled pouch-anal anastomosis at the level the major complications (i.e., pelvic sepsis, pouch-related fistula, of the pelvic floor believe that leaving 1.5 to 2.0 cm of anal and anastomotic leakage); however, pouch-anal stenosis was sig- mucosa proximal to the dentate line improves the functional nificantly more common in the older patient group. In regard to result by enhancing anal canal sensation. Not all investigators functional outcome—determined on the basis of frequency of have found this to be the case, however. In a prospective trial from daytime and nighttime bowel movements, use of pads, and incon- the Mayo Clinic in which 41 patients with CUC were randomly tinence episodes—there were no significant differences. Overall, selected to undergo either mucosectomy and handsewn IPAA or advanced age is not an absolute contraindication to IPAA. The double-stapled IPAA, there was no significant difference between data suggest that in healthy older patients with good sphincter the groups with respect to functional outcome (determined on tone, functional results may be comparable to those in younger the basis of stool frequency or episodes of fecal incontinence) at patients. 6 months after ileostomy closure.24 However, the double-stapled IPAA group generally had higher resting sphincter pressures (as Fertility and fecundity Given that most patients diagnosed measured by manometry) and tended to experience less noctur- with CUC are in their childbearing years, the possible impact of nal incontinence. Although proponents of mucosectomy with a surgery on fertility is obviously an important consideration when handsewn anastomosis believe that this operation removes all of surgical management is being discussed with a young woman. A the anal canal mucosa at risk, analyses of the fate of the anal canal number of studies have evaluated fertility and the course of sub- mucosa after mucosectomy indicate that even after mucosecto- sequent pregnancy after surgical treatment of CUC.15-19 Patients my, islands of residual rectal mucosa remain.25,26 Taken as a who have undergone proctocolectomy with an end ileostomy or a whole, the evidence available at present suggests that double-sta- Kock pouch can expect to have a normal pregnancy and delivery; pled IPAA might yield slightly better functional results than the type of delivery chosen (vaginal or cesarean section) should handsewn IPAA.
  • 4. © 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 Gastrointestinal Tract and Abdomen 33 Procedures for Ulcerative Colitis — 4 the anal sphincter mechanism spared; (3) construction of an ileal reservoir (pouch); and (4) anastomosis of the ileal reservoir to the anal canal. The following descriptions illustrate the general open and laparoscopic approaches by which these phases are carried out at the Mayo Clinic. OPEN PROCTOCOLECTOMY AND ILEAL POUCH–ANAL ANASTOMOSIS A complete bowel preparation is performed on the evening before operation. After induction of anesthesia, the patient is placed in the modified lithotomy position, which allows easy access to both the abdomen and the perineum. Step 1: Initial Incision and Exploration of Abdomen The abdomen is entered through a midline vertical incision, and the abdomen is thoroughly explored to determine whether there are any technical or pathologic contraindications to the planned procedure. Figure 1 Open proctocolectomy and IPAA. Once the rectum has been dissected down to the level of the pelvic floor, it is divided with a stapler. The stapler is positioned 1 to 2 cm above the den- tate line and fired. This positioning ensures that the final pouch- anal anastomosis is within the anal canal and not in the rectum. The need for a temporary ileostomy has been questioned in several quarters. In most large series, the IPAA procedure has included a temporary ileostomy to divert the fecal stream from the pouch while the pouch staple line and the anastomosis heal.13,27-29 Proponents of this approach believe that the diverting ileostomy decreases the rate of pelvic sepsis, which is known to result in worse long-term functional results. Supporters of a one- stage procedure, on the other hand, believe that an IPAA can be performed without an increased risk of pelvic sepsis.30-35 In addi- tion to avoiding an ileostomy, a one-stage procedure renders a second hospitalization and operation unnecessary, lowers the total cost, results in a shorter hospital stay, and perhaps even 15 cm decreases the incidence of small bowel obstruction. In one large single-institution study, there were no differences in complication rate and functional outcome between patients who had not 75 mm undergone diversion and those who had, nor was there any cor- relation between diversion and steroid use.27 Others have report- ed similar findings.32,36 Although there might be no significant difference in the rate of complications without a diverting ileosto- my, one study suggested that complications might be more severe in patients who lack a protecting ileostomy.37 Our view is that in properly selected patients who are undergoing uncomplicated procedures performed by experienced surgeons, a one-stage IPAA might be appropriate. However, the surgeon and the patient care team must be vigilant for the early signs of pelvic sep- sis, aggressively investigate any possibility of leakage from the pouch or the anastomosis, and intervene as needed. Operative Technique Since its introduction, proctocolectomy with IPAA has contin- ued to evolve, especially with the application of new technologies Figure 2 Open proctocolectomy and IPAA. The ileal pouch is such as laparoscopy.37-39 Conceptually, the operation can be divid- constructed by dividing the common wall of the afferent and ed into four phases: (1) removal of the intra-abdominal colon; (2) efferent limbs of the distal ileum by means of multiple firings of a dissection and removal of the rectum, with the pelvic nerves and linear cutting stapler.
  • 5. © 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 Gastrointestinal Tract and Abdomen 33 Procedures for Ulcerative Colitis — 5 Step 2: Mobilization and Division of Colon The entire colon is mobilized away from its retroperitoneal attachments.The transverse colon is freed from the greater omen- tum, which is preserved if it is of good quality and quantity. Once the intra-abdominal colon has been mobilized, the terminal ileum is divided from the right colon adjacent to the ileocecal junction with a linear stapler.The mesentery is divided as close to the right colon as possible so as not to injure the ileocolic vessels supplying the terminal ileum. Once the right colon has been mobilized, the remainder of the colon is divided from its mesentery. Step 3: Dissection and Division of Rectum When the intra-abdominal colon has been fully mobilized and the mesentery has been divided, the patient is placed in a steep Trendelenburg position to facilitate the pelvic dissection of the rectum. The rectum is freed down to the pelvic floor. Great care is taken to avoid the pelvic nerves that lie in the interface between the mesorectum and the presacral fascia.The rectum is divided at the pelvic floor with a stapler [see Figure 1].The colon and the rec- tum are then sent in their entirety for pathologic evaluation. Step 4: Construction of Ileal Pouch After the colon has been removed, the ileal reservoir is con- structed. The small bowel mesentery is completely mobilized from the retroperitoneum up to the inferior border of the pan- creas; this mobilization is crucial for ensuring that there is ade- quate small bowel length to allow the ileal pouch to reach the pelvic floor. To increase the length further, the visceral peri- toneum should be scored along the right side of the superior mesenteric vessel. Once the mesentery has been mobilized, the pouch is fash- ioned. Our practice is to use a J-shaped reservoir (J pouch) con- structed from the last 30 to 35 cm of the terminal ileum. J pouch- es are simpler to construct, use less small bowel length, and are associated with fewer complications related to pouch-emptying Figure 3 Open proctocolectomy and IPAA. After the pouch is problems than W or S pouches are.The ultimate reservoir capac- constructed, the head of an EEA stapler is secured in the apex of ity of the pouch should be approximately 400 ml. Construction is the pouch and connected to the pin of the stapler, which was begun by folding the terminal ileum into a J shape. The hook of placed upward through the anus. the J should be approximately 15 cm long. This efferent limb of the J is loosely secured to the afferent limb of the small bowel. secured in the apex of the pouch with a purse-string suture [see The reservoir is then formed by firing a 75 mm linear cutting sta- Figure 3]. The stapler is then advanced into the anus, and the pler twice from the apex of the pouch, thereby dividing the com- attachment pin is placed adjacent to the staple line marking the mon wall between the two limbs of the pouch [see Figure 2]. point where the rectum was divided at the level of the pelvic floor. Whether an adequate length of small bowel is available must be The pouch is brought down into the pelvis, with proper orientation determined before the reservoir is constructed. To confirm that maintained, the head of the stapler is fitted onto the pin, and the the pouch will reach the pelvic floor and the region of the anas- stapler is fired to anastomose the pouch to the anus [see Figure 4]. tomosis without tension, it should be possible to pull the apex of The second option is to perform a mucosectomy of the anal the pouch 3 to 5 cm below the upper aspect of the pubic symphy- canal and the lower rectal remnant. The dentate line area is sis. If, after full mesenteric mobilization and scoring of the viscer- exposed with the help of a self-retaining retractor. A dilute solu- al peritoneum, the pouch does not easily reach the pelvic floor, it tion of epinephrine is injected into the submucosa to facilitate cir- may be necessary to divide either the ileocolic vessel or one of the cumferential excision of the anal canal mucosa; the muscularis proximal branches of the superior mesenteric vessels.When there propria is left intact. The excision is extended proximally to the is a concern that a J pouch will not reach the pelvic floor satis- level of the stapled rectum. Once the staple line is reached, the full factorily, an S or a W pouch may be constructed instead. thickness of the rectal wall is divided, and the intact lower rectal remnant and the anal canal mucosa are removed. A long Babcock Step 5: Construction of Ileal Pouch–Anal Anastomosis clamp is placed into the pelvis through the anal opening, and the Before the pouch is brought down to the anus, one must verify apex of the pouch is drawn down to the level of the dentate line. that the small intestine from the ligament of Treitz to the ileal A side-to-end handsewn anastomosis between the apex of the pouch is not twisted. At this point in the operation, there are, as pouch and the dentate line is performed with absorbable inter- noted [see Operative Planning, Technical Controversies, above], rupted sutures. Once the anastomosis is completed, one or two two options for performing the anastomosis. The first is to secure closed suction drains are placed behind the pouch and brought the pouch to the anal canal by means of a double-stapled tech- out of separate left abdominal stab wounds. In the majority of pa- nique. The head of an end-to-end anastomosis (EEA) stapler is tients, a loop ileostomy is constructed in the right lower abdomen.
  • 6. © 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 Gastrointestinal Tract and Abdomen 33 Procedures for Ulcerative Colitis — 6 plified operation differs from the original version in several key respects: only four ports are placed [see Figure 5], the right and the left colon are dissected in a lateral-to-medial direction, the rectum is mobilized intracorporeally, a 4 to 5 cm periumbilical incision is employed for specimen extraction, and the right lower quadrant port site is used for the ileostomy. As work proceeds in different quadrants of the abdomen and the pelvis, the monitors are moved between the patient’s shoul- ders and ankles, in line with the surgeon’s field of view. An instru- ment stand is placed above the head, and a larger instrument table is placed behind the scrub nurse. The patient’s arms are tucked adjacent to the body, and the thighs are kept level with the abdomen to prevent interference with the instruments placed in the lower ports. Because steep position changes are used, the patient is carefully secured (e.g., with padded straps or a bean bag). The bladder is decompressed with a urinary catheter, and the stomach is decompressed with an orogastric tube, which is removed at the end of the procedure. In general, the first assistant stands opposite the surgeon, and the camera-holder stands next to the surgeon. Step 1: Placement of Trocars and Exploration of Abdomen A 12 mm blunt port is placed above the umbilicus via cut- down; this port is used for a 30° laparoscope. After abdominal exploration, three additional trocars are placed so as to form a diamond shape with the first trocar [see Figure 5]. One 5 mm tro- Figure 4 Open proctocolectomy and IPAA. Shown is the com- car is placed in the left lower quadrant, and another in the supra- pleted ileal J pouch with the circular stapled anastomosis within pubic midline. If a loop ileostomy is planned, an appropriate site the anal canal, just above the dentate line. in the right lower quadrant is marked before operation, and a 12 mm trocar is placed at this location. This trocar is used for pas- Step 6: Later Reversal of Loop Ileostomy sage of the stapler, and its site does not require closure, because Approximately 3 months after the original operation, a barium it becomes the stoma site. A disk of skin and subcutaneous fat is study through the anus is performed to determine whether the excised from the planned stoma site before the trocar is placed pouch has healed. If the reservoir and the anastomosis have directly through the fascia. healed completely, the loop ileostomy can be reversed during a Step 2: Mobilization of Intra-abdominal Colon second operation. Often, the ileostomy can be closed by mobiliz- ing it through a small transverse biconvex incision around the Left colon The patient is placed in the Trendelenburg posi- stoma. The loop of ileum is then fully mobilized, and an end-to- end handsewn anastomosis or a stapled side-to-side functional end-to-end anastomosis can be done. LAPAROSCOPIC PROCTOCOLECTOMY AND ILEAL POUCH–ANAL ANASTOMOSIS Laparoscopic approaches to IPAA were developed to reduce the impact of the procedure on patients who are already physio- logically stressed. Initial descriptions of laparoscopic IPAA, how- ever, were not encouraging. In a comparison of five open cases with five laparoscopic cases, operating time was markedly longer in the laparoscopic group, as were hospital stay and the duration 10/12 mm of postoperative ileus.40 The study did, however, show that the 10/12 mm procedure was feasible. The procedure described in the initial 5 mm reports was complex, using seven incisions—five for the ports, a separate Pfannenstiel incision for rectal dissection, and another incision for the ileostomy. Other early series also reported very long operating times, in the range of 380 to 710 minutes,41-43 as 5 mm well as high complication rates.44,45 A 2000 study, however, doc- umented benefits from a minimally invasive approach, with a reduction in hospital stay from 8 days to 7 days (P = 0.02), Figure 5 Laparoscopic proctocolectomy and IPAA. Four trocars though operating times were still significantly longer than with are placed in a diamond-shaped pattern: a 12 mm trocar is open IPAA (330 minutes versus 225 minutes).46 placed supraumbilically for the camera, another 12 mm trocar is The technical issues surrounding laparoscopic IPAA have been placed in the right lower quadrant, a 5 mm trocar is placed in the addressed by developing a simplified version of the procedure, left lower quadrant, and another 5 mm trocar is placed above the based on lessons learned from segmental procedures.47 The sim- pubis. A disk of skin and fat is excised for the ileostomy.
  • 7. © 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 Gastrointestinal Tract and Abdomen 33 Procedures for Ulcerative Colitis — 7 tion, with the left side tilted up. Gravity moves the omentum and the small bowel away from the operative site. With the laparo- scope in the supraumbilical port, the surgeon faces the left colon, using the suprapubic and left lower quadrant ports. The first assistant provides retraction via the right lower quadrant port. The left ureter is identified after the left lateral peritoneal reflec- tion is opened, and the descending colon and the sigmoid colon are mobilized medially [see Figure 6]. Splenic flexure The patient is then placed in the reverse Trendelenburg position, with the left side still tilted up. The sur- geon moves to a position between the legs. Mobilization of the splenic flexure requires a combination of lateral dissection off the retroperitoneum and dissection of the omentum off the distal transverse colon [see Figure 7]. The first assistant elevates the omentum, which is dissected away from the medial aspect of the splenic flexure sufficiently to allow the flexure to reach below the level of the umbilicus; this facilitates subsequent exteriorization [see Step 4, below]. Right colon The patient is returned to the Trendelenburg position, but with the right side tilted up. In slim patients, the right ureter is identified before the peritoneum is opened; in heav- ier patients, it is identified after the peritoneum has been opened. The correct retroperitoneal plane is entered by scoring the peri- toneum around the base of the cecum and the terminal ileum. The ascending colon is mobilized medially after the right lateral Figure 6 Laparoscopic proctocolectomy and IPAA. Illustrated is peritoneal reflection is opened [see Figure 8]. Medially, the peri- mobilization of the left colon. With the patient in the Trendelen- toneal attachments of the terminal ileum are divided up to the burg position and the left side tilted up, the left lateral peritoneal inferior border of the duodenum to ensure that the terminal reflection is opened and the left ureter identified. The descending ileum is sufficiently mobilized. colon and the sigmoid colon are mobilized medially. Hepatic flexure The patient is again placed in the reverse Trendelenburg position, but with the right side still tilted up.The attachments of the hepatic flexure are exposed. From the point where the previous dissection ended, the gastrocolic ligament is grasped immediately cephalad to the transverse colon and ele- vated. The duodenum is identified and protected as dissection proceeds medially [see Figure 9]. When the hepatic flexure can be brought down to the level of the umbilicus, it is sufficiently mobilized.43 Step 3: Pelvic Dissection The patient is once more moved into the Trendelenburg posi- tion, but tilted neither to the left nor to the right. The surgeon may stand on either the right or the left, in either case perform- ing the dissection on the near side of the pelvis and exposing the planes for the assistant during dissection of the far side. The pre- sacral space is entered by scoring the left pararectal peritoneum, and the plane is developed posteriorly and laterally. The right pararectal peritoneum is similarly scored, the presacral space is entered, and the plane is developed so as to join the previous dis- section. Anteriorly, in male patients, care is taken to identify the seminal vesicles and the prostate. To obtain anterior exposure in female patients, the uterus is suspended either with two sutures passed through the abdominal wall or with a fan retractor (which would require an additional port).The rectum is circumferential- ly dissected down to the pelvic floor, where digital rectal exami- Figure 7 Laparoscopic proctocolectomy and IPAA. Illustrated is nation confirms the level of the dissection [see Figure 10].The rec- mobilization of the splenic flexure. With the patient in the reverse tum is transected at the pelvic floor with a laparoscopic articulat- Trendelenburg position and the left side tilted up, the splenic ed linear stapler introduced through the 12 mm right lower quad- flexure is mobilized off the retroperitoneum and the omentum rant port. If mucosectomy is indicated, it is performed at this dissected off the distal transverse colon. point.
  • 8. © 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 Gastrointestinal Tract and Abdomen 33 Procedures for Ulcerative Colitis — 8 returned to the abdomen, which is then irrigated. The midline incision is closed with interrupted sutures, two of which are used to secure the blunt port in the incision. Pneumoperitoneum is reestablished. Step 5: Construction of Ileal Pouch–Anal Anastomosis The circular stapler is inserted into the anus, and the spike is brought out adjacent to the staple line. The pouch mesentery is traced from the pouch to the duodenum to confirm correct orien- tation.The pouch and the anvil are then placed onto the handle of the stapler, which is approximated and fired. A drain is left adjacent to the pouch and brought out through the suprapubic port site. To create an ileostomy, an appropriate point on the ileum is identified and brought up through the right lower quadrant trocar site after the anterior and posterior rectus fasciae have been incised in a cruciate fashion. The ileostomy is drawn through the site under direct vision to ensure correct orientation.The remain- ing trocars are removed, the sites are inspected for hemostasis, the skin incisions are closed, and the stoma is matured. Postoperative Care On postoperative day 1, clear liquids are started if the patient is not experiencing nausea and if the abdomen is not distended. A Figure 8 Laparoscopic proctocolectomy and IPAA. Illustrated is mobilization of the right colon. With the patient in the Trendelen- burg position and the right side tilted up, the peritoneum around the cecum and the terminal ileum is scored to enter the correct retroperitoneal plane. Step 4: Exteriorization and Resection of Colon and Rectum; Creation of Pouch The supraumbilical trocar incision is enlarged around the umbilicus to a length of 4 to 5 cm. The specimen is exterior- ized from the terminal ileum to the transected distal rectum; the omentum may be preserved or removed with the specimen. The mesentery is divided and ligated; the ileocolic pedicle may be preserved if desired. In lean patients (body mass index [BMI] < 25), the mesenteric vessels are divided at their origin, but in heavier patients, the vessels must be divided closer to the colon. (This is not a critical consideration in the setting of benign disease.) Alternatively, the mesentery may be divided intracorporeally; however, the method we describe here is faster, safer (because bleeding is readily controlled), and cheaper (because multiple clips or stapler applications are unnecessary). The terminal ileum is divided with a linear stapler. The small bowel is exteriorized to allow inspection for Crohn disease, then replaced into the abdomen, with care taken to maintain the cor- Figure 9 Laparoscopic proctocolectomy and IPAA. Illustrated is rect orientation of the cut edge of the small bowel mesentery. A mobilization of the hepatic flexure. With the patient in the standard 15 cm J pouch is constructed, and the head of a circu- reverse Trendelenburg position and the right side tilted up, the lar stapler is secured in the apex of the pouch. The pouch is gastrocolic ligament is elevated.
  • 9. © 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 Gastrointestinal Tract and Abdomen 33 Procedures for Ulcerative Colitis — 9 such complications ranges from 5% to 14%.36,48,53 In the Mayo Clinic study just cited (see above), sepsis occurred in 74 (6%) of 1,310 patients, 73 of whom had pelvic sepsis as the result of the pouch procedure.48 The majority (63%) of these patients required operative intervention; the remainder were treated with either antibiotics or a combination of antibiotics and CT-guided drainage. In this series and others, the rate of pouch leaks and episodes of pelvic sepsis declined as experience with the proce- dure increased. Another fairly common complication of IPAA procedures is the formation of an anastomotic stricture. In one study, 42 (37%) of the 114 patients who required reoperative treatment for pouch-related complications had symptomatic anastomotic stric- tures.54 There is no clear correlation between stricture formation and the type of anastomosis performed. In many cases, anasto- motic strictures can be treated with intermittent dilatation, which can often be performed by the patient after an initial operative dilatation. Fistulas after IPAA procedures are extremely difficult to treat. Pouch-vaginal fistulas and, more rarely, pouch-perineal fistulas can occur either in the perioperative period or years later. An early pouch fistula is generally the result of a technical error or a com- plication of a pouch leak or pelvic abscess. A late pouch fistula raises the possibility of Crohn disease. Most fistulas are low and Figure 10 Laparoscopic proctocolectomy and IPAA. Illustrated originate at the level of the anastomosis. They appear to occur is mobilization of the rectum. With the patient in the Trendelen- equally frequently with handsewn anastomoses and with double- burg position and the table tilted neither to the left nor to the stapled anastomoses.The reported incidence of pouch-vaginal fis- right, the left pararectal peritoneum is scored and the presacral tulas ranges from 4% to 12%.27,55-59 space entered. The most important considerations in managing a postpouch fistula are to rule out Crohn disease and to initiate treatment by a surgeon experienced in treating these complications. Before any low-fiber diet is instituted on the following day if clear liquids are surgical treatment of a fistula, the patient should be examined tolerated. Communication with the enterostomal therapist is under anesthesia and biopsies performed to rule out the presence important: patients are often sufficiently comfortable on postop- of Crohn disease. The basic principles of management are (1) erative day 1 to be receptive to teaching, and some patients are local control of any septic process and (2) repair of the fistula by ready for discharge by postoperative day 3. interposing healthy tissue between the pouch and the vagina or the perineal opening. Pouch-vaginal fistulas have been repaired via transanal, transvaginal, transperineal, and transabdominal Complications approaches, with rates of successful closure ranging from 10% to Total proctocolectomy with IPAA is a technically demanding 78%55,56,58,59; however, both these fistulas and pouch-perineal fis- procedure: the patient commonly must endure two, and some- tulas can often be successfully managed with simple interven- times three, operations. A number of significant complications tions, such as seton fistulotomy.55 Severely symptomatic patients have been reported.48-52 Of these, the most frequently encoun- may eventually require pouch diversion or complete pouch exci- tered are small bowel obstruction, pouch leakage, pelvic abscess, sion with end ileostomy. anastomotic stricture, pouch fistula, and pouchitis. Pouchitis is a late complication of IPAA. It is an acute inflam- The most common short-term and long-term complication matory process of the pouch. In a minority (< 10%) of patients, after IPAA is small bowel obstruction. In a series of 1,310 patients however, pouchitis can become a chronic process. Chronic who underwent an open IPAA at the Mayo Clinic, the incidence pouchitis may eventually lead to pouch failure that necessitates of this complication in the perioperative period was 15%,48 and excision of the pouch; fortunately, this is a quite rare event. 24% of patients required early reoperation to resolve the obstruc- Pouchitis occurs more frequently in patients who have extrain- tion. Other groups have reported similar incidences, albeit with testinal manifestations of CUC than in those who do not.60 generally lower rates of reoperation.27,50 The long-term incidence Measuring the exact incidence of pouchitis is difficult because of small bowel obstruction is also relatively high: one review of the of variations in presentation and differences in diagnostic crite- literature on late small bowel obstruction after IPAA report- ria, but most series report figures between 12% and 50%.13,48,61 ed incidences of 18% at 1 year, 27% at 5 years, and 31% at 10 Pouchitis should be suspected in any patient who experiences years.50 The majority of patients responded to conservative man- abdominal cramps, increased stool frequency, watery or bloody agement, but the rate of operative treatment increased from 2.7% diarrhea, and flulike symptoms. Although many patients are at 1 year to 7.5% at 10 years. The most common operative find- treated on clinical grounds alone, accurate diagnosis requires ings in patients who required exploration for relief of the obstruc- endoscopic visualization of the pouch, as well as histologic tion were pelvic adhesions (32%) and adhesions to the ileostomy evaluation. closure site (20%). The exact cause of pouchitis is unclear, but the observation that Pouch leakage and the associated pelvic sepsis are potentially antibiotic therapy (particularly with metronidazole) can success- devastating complications after IPAA. The reported incidence of fully treat acute and chronic pouchitis lends support to the theo-
  • 10. © 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 Gastrointestinal Tract and Abdomen 33 Procedures for Ulcerative Colitis — 10 ry that interaction between pouch bacteria levels and the mucos- that the IPAA is the treatment of choice for all CUC patients or al immune system plays an important role in pathogenesis. that CUC patients who either request an end ileostomy or are In cases of chronic pouchitis, immunosuppressive agents may unable to have an IPAA will necessarily have a poorer postopera- have to be added to achieve control of symptoms. Fewer than tive quality of life. Several reports have shown that quality of life 8% of patients who undergo an IPAA procedure experience improves after operation regardless of what procedure is per- chronic severe pouchitis, and about half of these require pouch formed, probably as a consequence of eradication of the underly- excision.13,60 ing disease.68-70 It is generally accepted that avoiding an abdominal stoma improves a patient’s body image, but it is unclear whether the route Outcome Evaluation of bowel emptying (i.e., through a pouch or through a stoma) has Perhaps surprisingly, given the complexity of the IPAA proce- any real effect on quality of life. A study in which patients were dure and the often debilitated condition of the patients, quite sim- asked to place a monetary value on the disability they believe ilar functional results have been obtained by many different sur- themselves to be experiencing as a result of their condition found geons and many different institutions.13,27,30,31,36,48-50,61 Most no difference between ileostomy patients and IPAA patients.71 patients report good to excellent pouch function. The most com- In fact, when patients were asked to rank the impact of altered monly used markers of pouch function are the number of diurnal bowel emptying on quality of life and disability, those with pelvic and nocturnal bowel movements, the number of episodes of soil- pouches considered altered bowel emptying a significantly worse ing, the number of episodes of incontinence, and the extent to problem than those with stomas did.These findings suggest, again, which medications are required to control bowel activity. In the that the choice of operation for CUC must be individualized on Mayo Clinic series of open IPAA patients cited earlier [see the basis of various health and personal factors specific to each Operative Planning, Choice of Procedure, Special Considerations patient. in Patient Selection, above], the average number of diurnal bowel LAPAROSCOPIC IPAA movements at the time of discharge after closure of the ileostomy was six, and the average number of nocturnal bowel movements Laparoscopic proctocolectomy with IPAA has been performed was one.13,48 Nearly 80% of patients had complete diurnal conti- in more than 70 CUC patients since the initial pilot study involv- nence, whereas 19% had occasional episodes of incontinence and ing seven patients.72 The indications for operative intervention [see 2% had frequent episodes. Occasional nocturnal incontinence Preoperative Evaluation, Indications for Operation, above] are the occurred in 49% of patients. Nearly 50% of patients were dis- same for the laparoscopic approach as for the open approach. In a charged on some type of medication to slow their bowels or pro- case-matched series of 40 patients undergoing laparoscopic IPAA, vide dietary bulk. In patients who had had an ileal pouch for each of whom was matched to two open IPAA patients (with dis- longer than 10 years, stool frequency and continence remained ease, age, gender, BMI, and date of operation controlled for), the remarkably stable over time. When all patients were considered, laparoscopic group experienced significant benefits with respect to however, episodes of incontinence increased slightly, with 73% of time to clear liquid ingestion (1 versus 3 days; P < 0.001), time to patients reporting complete continence at 10 years (a modest resumption of regular diet (3 versus 4 days; P < 0.001), and time decrease from the initial 80%). Many groups have reported simi- to restoration of bowel function (2 versus 3 days; P < 0.001).73 The larly stable functional results.61-63 duration of narcotic use was shorter in the laparoscopic group A number of studies have investigated patients’ quality of life (P < 0.001), and length of stay was reduced as well (4 versus 7 after surgical treatment of CUC. One group found that quality of days; P < 0.001). Operating time was longer in the laparoscopic life after IPAA is comparable to the norms for the general healthy group (270 versus 192 minutes; P < 0.001), but it decreased as population in the United States.64 Others reported that quality-of- the surgeon gained experience with the procedure, reaching an life measures yielded better results after an IPAA than after an end average of 3 to 3.5 hours. Other authors are reporting similar or continent ileostomy.65-67 These results do not, however, mean advantages.39,74 References 1. 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