Elective and Emergent Operative Management of Ulcerative Colitis

https://doi.org/10.1016/j.suc.2007.03.009Get rights and content

Surgical therapy of ulcerative colitis is effective, safe, and provides an improved quality of life in those whose disease cannot be managed medically. In the elective setting, widespread acceptance of restorative proctocolectomy has made surgical therapy an attractive option in the overall management of ulcerative colitis. Enthusiasm for this procedure should be tempered by the acknowledgment of the significant incidence of pouchitis in the long term, however. Proctocolectomy with ileostomy remains a good surgical option for patients who are unsuitable for restorative procedures. The standard therapy for fulminant colitis or toxic megacolon remains subtotal colectomy with ileostomy. Patients undergoing subtotal colectomy are candidates for conversion to restorative procedures.

Section snippets

Indications for surgical treatment

Intractable disease is the most common indication for elective operative management of ulcerative colitis. Intractable disease is considered to be present when medical therapy fails to adequately control symptoms or when symptoms are only controlled by therapy that carries an excessive long-term risk for morbidity (for example, high-dose corticosteroids). Growth failure in pediatric patients is considered to reflect intractable disease and should prompt consideration of surgical therapy [1].

Indications for operative intervention

The indication for urgent or emergent surgical intervention includes patients who have fulminant colitis, toxic megacolon, or significant hemorrhage. Approximately 15% of patients who have ulcerative colitis present initially with severe colitis requiring hospitalization. Severe colitis as defined as more than 6 bloody stools per day, fever (temperature >37.5°C), tachycardia, anemia (hemoglobin <75% of normal), and elevated sedimentation rate. Fulminant colitis is defined as more than 10 bloody

Summary

Surgical therapy of ulcerative colitis is effective, safe, and provides an improved quality of life in those whose disease cannot be managed medically. It is life saving for patients who have dysplasia, cancer, or fulminant disease. In the elective setting, widespread acceptance of restorative proctocolectomy has made surgical therapy an attractive option in the overall management of ulcerative colitis. Enthusiasm for this procedure should be tempered by the acknowledgment of the significant

References (54)

  • R.S. McLeod et al.

    Quality of life of patients with inflammatory bowel disease after surgery

    World J Surg

    (1998)
  • J.L. Cohen et al.

    Practice parameters for the surgical treatment of ulcerative colitis

    Dis Colon Rectum

    (2005)
  • M.F. Dixon et al.

    Observer variation in the assessment of dysplasia in ulcerative colitis

    Histopathology

    (1988)
  • C.N. Bernstein et al.

    Are we telling patients the truth about surveillance colonoscopy in ulcerative colitis?

    Lancet

    (1994)
  • R. Befrits et al.

    Low grade dysplasia in extensive, long-standing inflammatory bowel disease: a follow-up study

    Dis Colon Rectum

    (2002)
  • V. Gumaste et al.

    Benign and malignant colorectal strictures in ulcerative colitis

    Gut

    (1992)
  • B.A. Lashner et al.

    Dysplasia and cancer complicating strictures in ulcerative colitis

    Dig Dis Sci

    (1990)
  • J.R. Reiser et al.

    Adenocarcinoma in strictures of ulcerative colitis without antecedent dysplasia by colonoscopy

    Am J Gastroenterol

    (1994)
  • G.A. Moody et al.

    Long-term therapy with sulphasalazine protects against colorectal cancer in ulcerative colitis; a retrospective study of colorectal cancer risk and compliance with treatment in Leicestershire

    Eur J Gastroenterol Hepatol

    (1996)
  • J. Eaden et al.

    Colorectal cancer prevention in ulcerative colitis; a case-control study

    Aliment Pharmacol Ther

    (2000)
  • D.W. Larson et al.

    Safety, feasibility, and short-term outcomes of laparoscopic ileal-pouch-anal anastomosis: a single institutional case-matched experience

    Ann Surg

    (2006)
  • S. Choen et al.

    Prospective randomized trial comparing anal function after hand-sewn ileoanal anastomosis with mucosectomy versus stapled ileoanal anastomosis without mucosectomy in restorative proctocolectomy

    Br J Surg

    (1991)
  • W.T. Reilly et al.

    Randomized prospective trial comparing ileal pouch-anal anastomosis performed by excising the anal mucosa to ileal pouch-anal anastomosis performed by preserving the anal mucosa

    Ann Surg

    (1997)
  • K.S. Ho et al.

    Ileal pouch anal anastomosis for ulcerative colitis is feasible for septuagenarians

    Colorectal Dis

    (2006)
  • P.P. Tekkis et al.

    Long-term outcomes of restorative proctocolectomy for Crohn's disease and indeterminate colitis

    Colorectal Dis

    (2005)
  • V.W. Fazio et al.

    Ileal pouch-anal anastomosis complications and function in 1005 patients

    Ann Surg

    (1995)
  • A.P. Meagher et al.

    J ileal pouch-anal anastomosis for chronic ulcerative colitis: complications and long-term outcome in 1310 patients

    Br J Surg

    (1998)

    • Cited by (24)

    • Diagnosis and treatment of inflammatory bowel disease: First Latin American Consensus of the Pan American Crohn's and Colitis Organisation

      2017, Revista de Gastroenterologia de Mexico

    • Indications and Options for Surgery in Ulcerative Colitis

      2015, Surgical Clinics of North America
      Citation Excerpt :

      Patients with indeterminate colitis should be counseled regarding these increased risks before reconstructive surgery. Use of serologic markers to identify patients with indeterminate colitis who are at increased risk for these complications may inform individual patient decision making.25 Patients who require elective surgery for UC may undergo a TPC with end ileostomy.

    • Elective versus emergency surgery for ulcerative colitis: A National Surgical Quality Improvement Program analysis

      2013, American Journal of Surgery

    • Care of Patients with Inflammatory Bowel Disease

      2009, AORN Journal
      Citation Excerpt :

      A patient with ulcerative colitis may have had an internal pouch created that needs to be monitored for infection. A patient may get pouchitis at any time after the pouch is created, and this is the most frequent complication of a colectomy for ulcerative colitis.6,7 Signs of pouchitis include diarrhea, abdominal cramps, fever, malaise, and loss of anorectal function.6

    • Risk of post-operative complications associated with anti-TNF therapy in inflammatory bowel disease

      2012, World Journal of Gastroenterology

    • State-of-the-art surgery for ulcerative colitis

      2021, Langenbeck's Archives of Surgery
    View all citing articles on Scopus
    View full text
    Copyright © 2007 Published by Elsevier Inc.