3. Emergency surgical complications
Prevalence of inflammatory bowel disease
(IBD)
• West – 20 to 30 per 1 lakh population
• Asia – 0.5 to 1 per 1 lakh population.
Siew C. Ng et, al. gastroenterol hepatol 20
Around 16 to 20% of UC patients needs resection after 10 yrs. of diagnosis.
Frolkis AD, Dykeman J, Negron ME, et al.
Gastroenterology 2013
BURDEN
4. TOXIC COLITIS
The observed incidence of toxic colitis is approximately 10% in
all patients with UC
Marion JF, Present DH. Eur J Gastroenterol Hepatol 1998
• 6% of hospital admissions,
• Lifetime incidence of 1- 2.5%.
• 30% developing in the first 3 months of diagnosis.
BURDEN
9. Diagnosis
Criteria
imaging
Stool culture
Antigen testing in stool
Sigmoidoscopy guided biopsy
For C diff
Antibiotic
• Oral vancomycin
• IV metronidazole
For CMV
Antiviral
• IV ganciclovir
followed by oral
valganciclovir.
• Intravenous methylprednisolone, 60 mg per day,
in divided doses or,
• Hydrocortisone, 300 mg in divided doses
TOXIC COLITIS
Robert N. Goldstone, et, al. Surg Clin N Am 99
(2019)
1
2 3
10. Some patients might be
steroid resistant 5 ASA with tapering of steroid
5 ASA with tapering of steroid
TOXIC COLITIS
Robert N. Goldstone, et, al. Surg Clin N Am 99
45
67
11. Total abdominal
(subtotal) colectomy
• Why not total proctocolectomy ?
• When to remove rectum also?
• What to do with the distal stump?
Bring out as DMF
Close and keep intraabdominally
Close and keep subcutaneously
TOXIC COLITIS
15. A total proctocolectomy should be avoided
• It is associated with greater postoperative morbidity and mortality
• Subtotal colectomy allows for future reconstructive options elective
completion proctectomy with ileal pouch anal anastomosis.
• Patients without a definitive diagnosis of either UC or CD, a subtotal
colectomy may assist with establishing the correct diagnosis thus guide
future interventions
Indication of emergency proctocolectomy
• Acute perforation of the rectum or exsanguinating hemorrhage.
Berg DF, Bahadursingh AM, Kaminski DL, et al. Am J Surg
2002
TOXIC COLITIS
20. DEFINING THE ATZ
“The zone interposed between uninterrupted crypt
bearing colorectal-type mucosa above and
uninterrupted squamous epithelium below” 1
Alcian dye technique
• Columnar epithelium stains dark blue, the
squamous epithelium does not stain, and the
ATZ stains pale blue
• 6 mm below to 20 mm above the dentate line[
Computer mapping
• The median upper and lower borders
of the ATZ, measured from the lower
margin of the internal sphincter, were
1.82 and 1.27 cm
Fenger C. The anal transitional zone. Acta Pathol Microbiol Scand [A]
1979
Thompson-Fawcett MW, Br J Surg 1998
Anal Transitional Zone
22. The rectum is able to sense distension, however, that results in a brief reflexive relaxation of
the internal anal sphincter and contraction of the external anal sphincter, thus allowing the anal
mucosa to sample the rectal contents. This sampling is thought to aid the ATZ in
discrimination between gas, liquid, and solid stool.
The retained ATZ following stapled RPC IPAA is therefore at risk for chronic
inflammation from recurrent or persistent disease, dysplasia, and possibly malignancy.
Pouch failure and pouch excision World J Gastroenterol 2009 February 21Jennifer Holder-Murray
DEFINING THE ATZ
Vansar
24. Surgical and Mechanical Complications
Anastomotic Leaks
Anastomotic leak is defined as anastomotic separation leading to exodus of pouch
luminal content.
Soluble contrast enemas can help detect the leaks.
Percutaneous drainage of the collection
Surgical repair with diversion ileostomy
Management
Oncel M, Remzi FH, Church JM, et al. Dis Colon
25. Pelvic Sepsis and Pouch Abscess
Surgical and Mechanical Complications
Pelvic sepsis can be defined as any infective process present in the peripouch area or at the true pelvis
distal to the pelvic inlet.
• 5% to 20%
• Associated with anastomotic leak in 34%, fistulae in 25%, and even mortality in 3% of patients.
Pelvic abscess is defined as a collection of purulent exudates without demonstrable anastomotic leaks.
Sagap I, Remzi FH, Hammel JP, et ala multivariate analysis.
Usual management is drainage (surgical or intervention radiology guided)
PELVIC COLLECTION
DRAIN
26. Surgical and Mechanical Complications
Pouch Sinuses
A sequela or a later presentation of initial anastomotic
leaks.
Magnetic resonance imaging often is needed for
assessing both the depth and extent of the sinuses
and to distinguish them from fistulae
Pouch endoscopy with careful examination usually
can detect openings of sinuses.
• Periodic incision and drainage of the chronically
infected superficial sinuses to promote secondary
healing and closure
• Redo pouch procedure.
Swain BT, Ellis CN. Dis Colon Rectum
27. Pouch Fistulae
Surgical and Mechanical Complications
Fistula is defined as an abnormal passage from one epithelial surface (eg, the ileal pouch) to another
epithelial surface (eg, the vagina or skin).
Classified into
1. CD-related fistulae
Previous indeterminate
colitis
Late fistula
Fistula without previous
leak
Multiple and complex fistula
2. Non-CD–related fistulae
Diagnosed by
• MRI fistulogram
• Endoscopy
Medical or surgical management
Keighley MR, Grobler SP. Br J Surg 1993.
Pouch vaginal fistula
28. Surgical and Mechanical Complications
Strictures 11% for patients with underlying UC
MANAGEMENT
• Endoscopic
• Bougie dilations
• Surgical stricturoplasty
• Pouch diversion or
excision.
Shen B, et al. Endoscopic balloon dilation of ileal pouch
strictures. Am J Gastroenterol 2004
30. Afferent Limb Syndrome
Surgical and Mechanical Complications
Distal small-bowel obstruction
junction to the pouch is called
afferent limb syndrome.
• Adhesions,
• NSAID-induced strictures,
• Fibrostenotic CD, Acute angulation,
• Prolapse, or
• Intussusceptions of the afferent limb
Management is usually surgical exploration
31. Surgical and Mechanical Complications
Efferent Limb Syndrome
Causes
• Dysfunctional or excessively long efferent limb
• Markedly long rectal stump.
• Patients sometimes must catheterize
the pouch reservoir to evacuate feces.
• Surgical correction often is needed
34. Inflammatory Disorders
Cuffitis
Inflammation of the rectal cuff in the
area between the anastomosis and
dentate line.
May be a variant of UC or simply
represent a flare of UC in the rectal
cuff, and is particularly common in
IPAA constructed with stapled
anastomosis without
mucosectomy
35. Inflammatory Disorders
Irritable pouch syndrome
The irritable pouch syndrome is a functional disorder of unclear cause
in patients with IPAA.
Symptoms of pouchitis without endoscopic or histologic evidence of
inflammation in the pouch mucosa
A diagnosis of exclusion
44. Crohn’s Disease of the Pouch
• Previously known Crohn’s disease with no previous perianal and ileal disease
• Pathologically diagnosed as Crohn’s disease
• Crohn’s disease in pouch of previously diagnosed ulcerative colitis
Cumulative frequencies of CD of the pouch ranged from 2.7%
to 13%CD of the pouch can be classified
into
• Inflammatory,
• Fibrostenotic, or
• Fistulizing phenotypes
These patients can be also categorized
into
• CD of the small bowel and upper
gastrointestinal tract,
• CD of the neoterminal ileum,
• CD of the pouch,
• Perianal CD, or
Risk Factors for de novo CD of the Ileoanal Pouch
Keighley MR. Acta Chir Iugosl. 2000
45. Crohn’s Disease of the Pouch
CD OR BACKWASH ILITIES
Lesion within 10 cm of pouch
outlet (BACKWASH ILITIES)
CD
BACKWASH ILITIES
Pouch vaginal fistula
Typical Chron’s disease
Surgical overview is already discussed by my senior dr nirajan so I will be talking on 2 aspects of ulcerative colitis
Colorectal malignancy in ulcerative colitis need to be address separately so it will be not discussed in this presentation
MOST IMPORTANT SURGICAL EMERGENCY IN ULCERATIVE COLITIS IS TOXIC COLITIS
AS DISCUSSED IN PREV CLASSES MODIFIED TRULOVE AND WITTS CRITERIA IS IMPORTANT CLASS
Dilated transverse colon more than 6 cm
If more than 8 cm there is high chance of perforation
BROOKS METHOD IS COMMONLY FOLLOWED TECHNIQUE FOR CREATING ILEOSTOMY
WHERE AROUND 4 CM OF
MATURATION OF ILEOSTOMY IS DONE BY THREE POINT SUTURING OF THE STOMA
preservation of the ATZ, should be reserved for those patients in whom multiple preoperative endoscopic biopsies rule out dysplasia or carcinoma in the entire colon. Transanal mucosectomy and handsewn IPAA should be performed in patients with biopsy-proven dysplasia, irrespective of the location and severity.
Pochitis pathogenesis is not well understood
Many factors comes into play particularly flora, local immune
