About inflammatory bowel disease, surgical principles,

1. Surgical Management of Inflammatory
Bowel Disease (Ulcerative Colitis)
Presented by: Happy Kagathara
14/09/2013
Department of Surgical Gastroenterology and Liver Transplantation,
Sir Ganga Ram Hospital, New Delhi

2. • Introduction
• Indications
• Pre-op preparation
• Surgery in emergency
• Elective surgical options
• Controversial issues

3. Introduction
• Contiguous inflammation of the colorectal mucosa
• Confined to the mucosal and sub-mucosa and always start
from and involve the rectum
• Disease distribution
– Proctitis / Procto-sigmoiditis – 45-50%
– Left-sided colitis – 17-40%
– Pan-colitis – 15-35%

4. • Clinically manifests as
– Diarrhoea, abdominal pain, fever, weight loss, rectal
bleeding
• Removal of the affected organ is curative – Surgery has
pivotal position

5. Indications
• Failure of medical management
– Symptoms are not controlled
– Development of side effects or complications
• Cancer risk
– Incidence - 6%
– Multiple
– Stricture – Harbor dysplasia or cancer

6. • Toxic megacolon
– Incidence - 16%
– In pancolitis
– Surgery – 15%
• Hemorrhage
– Uncommon - 6%-10%
• Perforation
– In 2-3% of hospitalized UC pts

7. Pre-op Preparation
– Correcting anemia, fluid depletion, electrolyte and
acid-base disorders, and nutritional deficiencies.
– Many pts require TPN and bowel rest – Eating may
worsen symptoms – Difficult to demonstrate a
significant impact on outcome
Dayton, MT. Problems in General Surgery. 1999;16:40.
– Most drugs can be discontinued without sequelae
except corticosteroids
– Infliximab + Cyclosporin vs infliximab alone before
surgery – Combination therapy has increased
morbidity
Schluender SJ, Ippoliti A et al. Dis Colon Rectum. 2007;50(11):1747

8. – Three-stage IPAA is the optimal approach for pre-op
combination therapy that includes infliximab
Selvasekar CR, Cima RR et al. J Am Coll Surg. 2007;204(5):956.
– Ostomy site selection by stoma therapist
– Mechanical bowel preparation
• Not necessary
– Antimicrobial prophylaxis

9. Surgery in emergency
• Aim
– Treatment of the fulminant state
– Restoration to previous state of health to perform a
future restorative procedure
• The primary procedure
– Total abdominal colectomy + End ileostomy, + Rectal
stump left behind.
• Avoid pouch formation
– High doses of steroids (> 40 mg/day) and nutritionally
depleted
• Able to discontinue all medications

10. • Preserve ileal branches of the ileo-colic vessels
– For pouch construction
• Not necessary to mobilize the rectum
– Decrease pelvic sepsis and preserve planes
• Remaining recto-sigmoind
– Rectal stump closure - hazardous
– A trans-anal rectal drain – To prevent leakage
– Rectal stump – Diseased
• Distal site of transaction
– Matured mucous fistula
– Buried within the abdominal incision

11. Elective surgery
• Total proctocolectomy + Brooke ileostomy
• Total proctocolectomy + Continent ileostomy
• Abdominal colectomy + Ileorectal anastomosis (IRA)
• Ileal pouch–anal anastomosis (IPAA)

12. • Total proctocolectomy + Brooke ileostomy
– Indications
• Older age
• Distal rectal cancer
• Severely compromised anal function
• Patients preference
– Disadvantages
• Loss of fecal continence
• High incidence of SAIO

13. – Complications
• Delayed healing of the perineal wound
• Sexual complications
• Dyspareunia
– As a result of perineal scarring
• Intestinal obstruction
• Ileostomy related
– Skin irritation
– Stomal stenosis
– Stoma prolapse, and herniation

14. • Total proctocolectomy + Continent ileostomy
– Indications
• Rectal cancer
• Poor anal sphincter function
• Occupations that may preclude frequent visits to the
toilet
• Failed Brooke ileostomy
– Avoid in suspicion of Crohn’s disease

15. – Operative principles
• Excision of a very short segment of terminal ileum
• Exclude CD – Essential
• Aperistaltic reservoir
– Terminal 45–60 cm of the ileum – S-pouch
– A wide plastic tube – Into the pouch for drainage in
the early postoperative period.
– Drainage is achieved by intubating the pouch three
times a day.

16. – Complications
• Pouchitis
– Incidence - 25%
– Stasis and overgrowth of anaerobic bacteria
– Increased output, fever, weight loss, stomal bleeding
– Pouchoscopy
– Antibiotics + Continuous pouch drainage.
• Intestinal obstruction
– Incidence - 5%
• Fistulas
– Incidence - 10%.
– Bowel rest, TPN, continuous pouch drainage

17. • Abdominal colectomy + Ileorectal anastomosis
– Indications
• Indeterminate colitis
• Upper rectal disease
– Rectal compliance remains adequate
– Advantages
• Avoid perineal complications of procto-colectomy
• Minimal sexual dysfunction
• May provide perfect control of feces and flatus
– Disadvantages
• Non achievement of total excision of colorectal mucosa.

18. – Frequency of defecation – Semi-liquid stools 2-5 / day
– Conversion to an IPAA
• Poor rectal compliance
• Persistent proctitis
• Upper rectal cancer

19. – Complications
• Nocturnal defecation
• Cancer risk (in remnant rectum)
– The overall risk - 6%
– Most cancers appear 15–20 years after operation.
– Early lesions are not easily identified at
sigmoidoscopy – Semi-annual sigmoidoscopy +
Biopsies

20. • Recurrent or persistent inflammation
– Incidence - 20%–45%
– Severe diarrhea, tenesmus, bleeding, urgency
– Topical or systemic therapies / Rectal excision if
non responsive

21. • Ileal pouch–anal anastomosis (IPAA)
– Near total procto-colectomy + Ileal reservoir
– Preservation of anal sphincter
– The original operation –Sir Alan Parks
• Complete stripping of the anal mucosa
– Stapled anastomosis
• Between pouch and anal canal cephalad to the dentate
line – Preservation of anal transition zone
– Topical 5-aminosalicylic acid or steroid enemas –
Minimize rectal mucosal inflammation, facilitate
mucosectomy

22. – Mobilisation of rectum
• Ventrally to the level of the prostate / mid-portion of the
vagina
• Posteriorly, past the end of the coccyx
• Mobilization should be flush with fascia propria
– Minimal damage to autonomic nerves to genitals
– Mucosal stripping
• Perineal approach with Lone Star™ retractor – Good
exposure and minimal damage to the sphincter
mechanism
• Inject diluted epinephrine into the submucosal plane –
Minimize bleeding

23. • Ileal reserviour
– The terminal ileum alignment – J configuration,15–
25 cm lengths of both limbs
• Lengthening manoeuvres
– Apex of the pouch must reach beyond the
symphysis pubis
– Superficial mesenteric incision on the anterior and
posterior aspects along the SMA
– Selective ligation of mesenteric arcades

24. • Double-stapled technique
– Anorectum division 2 cm above the dentate line
using a right-angle linear stapler
– Anvil is tied in to the apex of pouch
– Air insufflation test – To check Integrity of the
rectal staple line
– Transanal placement of circular stapler
– Proximal defunctioning loop ileostomy
– Drain placement in the presacral space
– Sphincter strengthening exercises in Post-op period –
Improve functional results after ileostomy closure

25. – Complications
• Small bowel obstruction
– Incidence – 20%
• Pelvic sepsis
– Incidence – 5%
– Abscess formation, perineal fistula
– Fever, anal pain, tenesmus, and discharge of pus or
secondary hemorrhage
– CT or MRI – For confirmation
– IV antibiotics - Response within 24–36 hours
– Ongoing sepsis / Organized abscess - Endoanal or
imaging-guided percutaneous drainage

26. • I-A anastomotic stricture
– Incidence – 5 – 38%
– Anastomotic tension – Leakage, infection
– Prevention
• Full mobilization of the mesentery
• Anchoring the pouch to surrounding tissues
– Repeated dilatations under GA - >50%
– Transanal excision of the stricture + advancement of
pouch distally
– If recognized in contrast studies or DRE before
ileostomy closure then ileostomy closure should be
delayed

27. • Poucho-vaginal fistula
– Incidence – 3-16%.
– Injury to the vagina or rectovaginal septum
– Anastomotic dehiscence, pelvic sepsis
– CD
– Vaginal discharge
– Demonstration of fistula on examination
– Confirmed by contrast enema
– Seton placement, diverting ileostomy, drainage of
sepsis + pouch repair

28. • Pouchitis
– Nonspecific inflammation
– Overgrowth of anaerobic bacteria
– Abdominal cramps, fever, pelvic pain, and sudden
increase in stool frequency
– Biopsy – Marked inflammatory infiltrates with villous
atrophy and crypt abscesses
– Antibiotics, probiotics (after resolution of the acute
symptoms), steroid enemas, ileostomy ± pouch excision

29. • Incontinence
– Average number of bowel movements after IPAA –
6 / day
– Major incontinence – Unusual
– Minor incontinence – In 30% of pts
– Good perianal hygiene + Perineal pad
– Bulking agent or antidiarrheal medication – 50% pts

30. Controversial issues in Surgical
Mangement
• Indeterminate Colitis
– In 10% colitis pts, especially in fulminant colitis
– Inadequate diagnostic criteria for definitive diagnosis
– If CD can’t excluded
• subtotal colectomy + ileostomy should be done
– IPAA for IC
• Definitive pathologic diagnosis of UC
• IC without development of signs or symptoms of CD
– Long-term functional outcomes nearly identical to
chronic UC

31. • Pouch loss
• Higher perineal complications
Yu CS, Pemberton JH, Larson D.Dis Colon Rectum. 2000;43(11):1487
• 2814 patients, IPAA for UC / IC, 184 patients (7%) had
revised diagnosis of CD
– Higher rate of peri-anal fistula (6% vs. 2%)
– Higher rate of stricture (5% vs. 1.5%)
– Female gender (54% vs. 44%)
Melton GB, Kiran RP et al. Colorectal Dis. 2010 Oct;12(10):1026-32

32. • Series of 70 children, total colectomy
– Clinical diagnosis of UC – 90%
– Intermediate colitis – 10%
– Revised diagnosis of CD – 10 pts (14.3%)
– Restorative pouch reconstruction – 9 pts
– Complications – 7 pts
• Anastomotic strictures, perianal fistulas, and
perianal abscesses
Mortellaro VE, Green J et al.J Surg Res. 2011 Sep;170(1):38-40

33. • CRC + UC
– Distant metastatic disease
• contraindication to IPAA
• Segmental colectomy + IRA
– Middle and low rectal tumors
• Not eligible
• Pre-op Radiation therapy
– Caecal cancers
• Sacrify long segment of adjacent distal ileum with its
mesenteric vessels
• If a tension-free anastomosis cannot be ensured, a
Brooke ileostomy may be necessary.

34. – Locally invasive cancers of the colon and upper
rectum
• Taylor et al
– UC + carcinoma had post-op complications and
functional results identical to UC without cancer.
– Metastatic disease developed in a small number of
patients
Taylor BA, et al. Dis Colon Rectum 1988; 31:358–362.
• In contrast, another study
– Almost 20% of UC pts who had an IPAA died of
metastatic disease
– T3 cancers at time of surgery
Wiltz O, et al. Dis Colon Rectum 1991;34: 805–809

35. – Conservative management approach
• UC + T3 cancer
– Abdominal colectomy + ileostomy
• Observation period of at least 12 months
– To ensure no recurrence
– To allow adjuvant chemo-radiation therapy

36. • Diversion ileostomy
– Integral part of the original procedure.
– Mayo Clinic reported – Omission of a stoma didn’t
significantly increase the complication rate
Metcalf AM, et al. Dis Colon Rectum 1986; 29:33–35.
– Omission of ileostomy
• Septic complications and functional results are similar
to results after an ileostomy
• Fewer episodes of intestinal obstruction
• Decrease length of hospital stay

37. – Series at Cleveland Clinic, Florida
• 110 pts
• No clinical evidence of leaks with diverting ileostomy
• 3 of the 36 patients without an ileostomy had leaks
Weiss EG, et al. South Med J 1994;87:519.
– Ileostomy complications – 20%
• High output of enteric fluid, dehydration, skin irritation,
stoma retraction, stoma prolapse
– Pouch-specific complications (without an ileostomy) –
Repeat laparotomy + fecal diversion
Fonkalsrud EW, et al. J Am Coll Surg 2000;190:418–422

38. – The benefits must be weighed against the morbidity of
an ileostomy – benefits > morbidity
– Avoidance of ileostomy
• Experienced surgeon
• Low-dose prednisone (<20 mg/day)
• No immune-modulating agents
• Uneventful operation
Remzi. Dis Colon Rectum 2006

39. • Role of laparoscopy
– Early reports – increased morbidity
– Improved techniques and equipment
• Early and late results are comparable to standard
laparotomy
– Lap assisted vs. open restorative proctocolectomy
• Long-lasting positive impact on body image and
cosmesis
• Particularly for women
Polle SW, Dunker MS et al.Surg Endosc. 2007;21(8):1301

40. – Meta-analysis of nine cohort or case-matched series
• 966 patients, total abdominal colectomy + end
ileostomy,
• Laparoscopical approach = 42
– Fewer wound infections
– Lower rate of intra-abdominal abscess
– Mean shorter length of hospital stay (mean
difference 3.17 days
– Conversion rate – 5.5%
Bartels SA, Gardenbroek TJ et al.Br J Surg. 2013;100(6):726

41. – IPAA with minimal access
• Single–port and robotic assisted proctocolectomy with
IPAA
• Significantly fewer incisional, abdominal, and pelvic
adhesions
• Safe, feasible, and effective procedure. (54,55)
Indar AA, Efron JE et al.Surg Endosc. 2009;23(1):174
Hull TL, Joyce MR et al. Br J Surg. 2012 Feb;99(2):270-5

42. • IRA vs IPAA
– In < 10% - IRA has been used
– Risk for persistence of symptoms and future malignancy.
– Retrospective analysis of the functional results after IRA
for UC or IC
• 86 patients
• Rectum was eventually resected in 46 patients
– Refractory proctitis – 28%
– Rectal dysplasia – 17%
– Rectal cancer – 8%
da Luz Moreira A, Kiran RP et al. Br J Surg. 2010;97(1):65

43. – In minimal rectal involvement
• Not suitable for IPAA, who refuse an ileostomy
• May be suitable for IRA
– Reduce the risk of infertility in women of childbearing
age
– Good choice in whom CD can’t be excluded or for
colitis + advanced colonic malignancy

44. • Mucosectomy vs. Double Stapling
– Ziv Y, et al.
• Mucosectomy does not assure complete eradication of
disease
• Stapled IPAA – safer in mucosal UC
• Stapled technique – fewer septic complications, fewer
sepsis-related pouch excisions
Am J Surg 1996;171:320–323
– MacRae HM, et al.
• Leak rate same for both approaches
• Leaks from a stapled anastomosis have a better
prognosis
Dis Colon Rectum 1997;40:257–262.

45. • Richard E. Lovegrove et al.
– Meta-Analysis of 4183 Pts
– Both techniques had similar early post-op outcomes
– Stapled IPAA – Better nocturnal continence
– Better functional outcomes and less disruption of the
anal sphincter mechanism
– Selective use of stapled anastomosis particularly in pts
• Without CRC or rectal dysplasia
• Older patients with compromised sphincter pressure

46. – Mucosectomy
• FAP + polyps in the distal third of the rectum
• Mucosal ulcerative colitis + synchronous CRC or rectal
dysplasia

47. • Shape or size of reservoir
– Initial ileal reservoir – in late 1970s
• Triple-loop S pouch
– S-pouches
• Evacuation problems because of long (5-cm or more)
exit conduit
• Frequently requiring pouch catheterization

48. – Three other configurations
• Double-loop J-pouch
• Quadruple-loop W-pouch
• Lateral isoperistaltic H-pouch

49. – The W-pouch
• Favored by some surgeons
• Greater capacity – Fewer daily bowel movements
– Two randomized trials comparing the W- vs J-pouch
• Same median number of stools per day
• No difference in functional outcome
• Similar functional results after 1 year of surgery
Keighley MRB, et al. Br J Surg 1998;75:1008–1011.
Johnston D, et al. Gut 1996;39:242–247
– Most centres perform a J-pouch because it is easier
and faster to construct.

50. Summary
• Indications of surgery in UC
– Disease complication
– Failure and side effects of medical treatment
• Restorative proctocolectomy + IPAA –gold standard for elective
surgical treatment
– Safe, curative, and applicable to most patients
– Morbidity still high
• However, transanal mucosectomy with hand-sewn anastomosis vs
double stapling, diversion versus non-diversion, and the indications
for surgery in indeterminate colitis are still debated and remain
under active investigation.

51. • Individualizing approach should be used to decide mucosectomy
• J pouch is the most common reservoir used worldwide
• Diverting ileostomy can be avoided only in selective group of
patients.
• The laparoscopic approach remains to be further evaluated before it
can be routinely recommended.