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Complications of the Surgical Treatment of Ulcerative Colitis
Complications of the Surgical Treatment of Ulcerative Colitis BENTLEY P. COLCOCK
IT IS now recognized that a certain number of patients with chronic ulcerative colitis will require surgical intervention, either because of the development of a complication of the disease or because medical treatment has failed. Surgical intervention may, indeed, become urgent when medical treatment fails to halt the progressive course of the disease and there is a steady deterioration in the condition of the patient. Conservative treatment must also be considered to have failed if the disease reaches a stage in which, as a result of severe anemia, uncontrolled diarrhea, or general debility, the patient becomes a chronic invalid. The percentage of patients in whom surgical intervention will be found necessary will depend upon the number of patients seen with the more severe and more extensive form of ulcerative colitis. In our experience, this figure now approaches 40 per cent. With surgery required in over a third of the patients, we are seeing a relatively high percentage of patients with extensive or severe disease. In spite of this the mortality at the present time is less than 5 per cent. The morbidity associated with the surgical treatment of ulcerative colitis has also been reduced. Not onlyhas the incidence of all of the common complications of ulcerative colitis been lowered but the severity of these complications shows a marked improvement over that of a few years ago. * The fact that we are operating upon these patients earlier is partly responsible for the improved mortality and the morbidity. Another important factor is that these complications are now recognized more promptly and treated more effectively. We are now able to prevent many of these complications. Although a few patients with ulcerative colitis localized to the right colon may be cured by a right colectomy with anastomosis of the terminal ileum to the transverse colon, the great majority of those patients who require surgery will need a permanent ileostomy and total colectomy. Many of the complications associated with the surgical treatment of * Colcock, B. P. and Mathiesen, W. L.: Complications of the surgical treatment of chronic ulcerative colitis. Arch. Surge 72: 399-404 (Mar.) 1956. 725
Bentley P. Colcock
726
this disease are directly related to the ileostomy itself. Others are complications of the disease but must be dealt with in the course of its surgical management. COMPLICATIONS
Skin Irritation
One of the problems associated with the establishment of an ileostomy for chronic ulcerative colitis has been the prevention and treatment of excoriation of the skin around the ileostomy. Today irritation of the skin rarely occurs. The protection of the skin around the ileostomy from the very beginning and the early application of the ileostomy bag have been responsible for this change. Tincture of benzoin or other skin protecting agent should be applied to the surrounding skin immediately, if it is necessary to leave the ileostomy bag off for any period of time. An ill-fitting ileostomy bag which permits wetting of the adjacent skin will also soon result in marked skin excoriation if the situation is not corrected. The weeping, excoriated skin makes it difficult to secure adherence of the bag, and thus a vicious cycle is produced. Fistula Formation
Since a fistula at or below the level of the skin will pour the ileostomy content directly onto the skin and prevent adherence of the bag, it represents a serious complication. A fistula at this level is an indication for early revision of the ileostomy with excision of the fistulous area and exteriorization of sufficient ileum so that the intestinal content will empty directly into the bag. This procedure should be done before the skin becomes excoriated. The principal reasons for the formation of a fistula in the side of the ileostomy are (1) suturing of the bowel wall to the parietal peritoneum, and (2) pressure necrosis from an ileostomy bag that fits too tightly. When the patient is fitted with an ileostomy bag, additional space of at least ~ inch should be allowed between the ileostomy and the margin of the bag opening. The patient should also be warned of the danger of pressure from the margins of the bag should edema of the ileostomy occur. Although the ileostomy must be fixed to prevent prolapse or retraction, the fixation should utilize the mesentery of the terminal ileum and not the intestinal wall. Prolapse and Retraction
In the past, an ileostomy in a patient with ulcerative colitis has been notorious for its tendency to prolapse or retract. Occasionally this complication will develop long after the operation, but it no longer occurs during the postoperative period. This is due to adequate and secure fixation of the ileostomy to the anterior abdominal wall at the time the ileostomy is established. As noted above, this fixation is achieved by suturing the peritoneum of the ileal mesentery to the parietal peritoneum.
Complications of Surgical Treatment of Ulcerative Colitis
727
Late prolapse of a mild degree is not serious and does not require reoperation. Late prolapse sufficient to produce edema of the exteriorized segment, however, will require revision of the ileostomy. Revision will also be required if the ileostomy retracts to the skin level since such retraction may prevent adequate fixation of the ileostomy bag. This leads to soiling and irritation of the surrounding skin. The technique of fixation will vary depending upon whether a stab wound is used for the ileostomy or the ileostomy is brought out the operative incision. In either case it should unite the peritoneum of the mesentery to the peritoneum of the abdominal wall up to the margin of the bowel and the margin of the incision. Postoperative Electrolyte Im.balance
Once the newly established ileostomy begins to function, these patients may lose large amounts of fluid in the course of 24 hours. Large quantities of sodium, potassium and chloride may also be lost in a short period of time. This fluid and electrolyte loss must be replaced either by oral or by intravenous administration. After a few days the amount of ileostomy drainage becomes stabilized, the ileostomy content thickens, and if the patient is able to take sufficient fluid and food by mouth, this complication is no longer a problem. He should be warned, however, that if at any time in the future there is excessive discharge from his ileostomy or any interruption in the normal oral intake of fluid and salt, he should consult his physician promptly. The discharge from the ileostomy of a watery, thin fluid, even though copious in amounts, particularly if associated with abdominal cramps, may be the first indication of partial obstruction of the small bowel. Obstruction
Some degree of obstruction of the small bowel has been a frequent complication in patients who have had an ileostomy for ulcerative colitis. It can often be relieved by simple dilatation or by catheter irrigation of the ileostomy. If the obstruction is not at the stoma and cannot be reached by the catheter, a Miller-Abbott tube must be introduced from above. As the distended, obstructed loops of bowel are emptied the obstruction is usually relieved and the ileostomy begins to function. Only occasionally is reoperation necessary in these patients. Eversion of the terminal ileum with suture of the mucosa to the skin margin plus the removal of a circular segment of skin and fascia at the site of the ileostomy has tended to prevent obstruction at the level of the abdominal wall. We also believe that these technical details will decrease the incidence of late stricture at the skin level. Careful peritonealization of the right and left lumbar gutters, including the ligated and divided mesenteric vessels, and the construction of an intact peritonealized pelvic floor have done much to prevent small bowel obstruc-
728
Bentley P. Colcock
tion proximal to the stoma. Obstruction of any degree in any patient with an ileostomy must be relieved promptly; if it is not corrected, it will quickly result in a serious electrolyte and fluid imbalance. If conservative measures such as catheter irrigation of the ileostomy stoma plus the introduction of a long intestinal tube from above do not relieve the obstruction, the patient should be operated upon before his general condition deteriorates. Hernornhuge
Today, most patients with chronic ulcerative colitis come to operation in sufficiently good condition that a subtotal colectomy can be performed at the time the ileostomy is established. Since we believe that an ileostomy alone can be carried out with a lower mortality rate than an ileostomy plus colectomy, we continue to do just an ileostomy in patients who are extremely poor operative risks. There is one type of patient, however, who may require more than an ileostomy even though his condition would seem to contraindicate it, and that is the patient with hemorrhagic bleeding. Of 15 patients who were operated upon primarily because of severe bleeding, the bleeding was controlled by ileostomy in only three. In the remaining 12 patients colectomy was required to stop the bleeding. In many patients this will mean the removal of the rectum by abdominoperineal resection. Indeed, since the ulcerative process is often most marked in the rectum, the surgeon may be forced to carry out an abdominoperineal resection as the first procedure in these patients. The fact that profuse rectal bleeding may occur in a patient who has had an ileostomy for many years is another reason for advising colectomy and abdominoperineal resection in any patient who requires an ileostomy for control of his ulcerative colitis. Carcrnorna
Carcinoma represents one of the most serious complications of chronic ulcerative colitis. The markedly increased vascularity of the bowel and the ease with which the symptoms of carcinoma may be masked by the symptoms of ulcerative colitis have resulted in a poor prognosis when this complication develops. The frequency with which carcinoma occurs in these patients increases with the number of years they have had the disease. From an over-all incidence of 4 to 5 per cent for all patients with chronic ulcerative colitis it increases to approximately 25 per cent in patients who have had severe disease of the bowel for ten years or more. It has become an important reason for periodic check-up examinations for any patient with ulcerative colitis who has had the disease for many years. The development of cancer of the colon should be seriously considered when a patient with long-standing ulcerative colitis has an exacerbation of his symptoms, such as an increase in abdominal pain or
Complications of Surgical Treatment of Ulcerative Colitis
729
rectal bleeding. It is an additional reason for carrying out a colectomy in all patients who require an ileostomy. Pregnancy
Since many patients with ulcerative colitis are young women, the problem of pregnancy may complicate the surgical management of the disease. Ten of our patients became pregnant after ileostomy and five of the ten had normal deliveries at or near term. Two of the remaining five patients had acute exacerbations of ulcerative colitis and one of these two had a spontaneous abortion. Two patients required therapeutic abortion and one patient died of eclampsia at term. All five patients in whom pregnancy represented a serious complication had part or all of the diseased colon present. For this reason we believe that it is inadvisable for a patient with an ileostomy to become pregnant before her colon has been removed. Although half of these patients had no trouble with delivery at or near term, there is likely to be some disturbance in the function of the ileostomy around the eighth month of pregnancy. It is probably unwise for these patients to go through more than one, or at the most, two pregnancies. Regional Ileitis
It may be that regional ileitis and chronic ulcerative colitis are essentially the same disease affecting different portions of the gastrointestinal tract. The fact is that they are occasionally associated, and when they do coexist, they represent a most serious problem from the point of view of surgical management. It is much more difficult to maintain normal fluid and electrolyte balance in a patient who requires a resection of the small intestine for regional ileitis following an ileostomy and colectomy for ulcerative colitis. The ileitis may produce obstruction either at the stoma or at any point along the ileum or jejunum. Even without the development of small bowel obstruction, the regional ileitis leads to excessive function of the ileostomy and results in fluid and electrolyte imbalance. We have had ten patients who required surgical intervention for ileitis in addition to the surgical treatment of ulcerative colitis; in five of the ten patients the regional ileitis followed the ulcerative colitis, in four it was coexistent and in one patient the ulcerative colitis occurred six years after resection of the small intestine for ileitis. At the present time we know of no way to prevent this serious complication. Recurrence of Disease
The complication of recurrence arises in cases in which partial colectomy and primary anastomosis have been carried out for ulcerative colitis which appeared to be localized to the right colon. In our experience, ulcerative colitis will develop in the remaining colon in the majority of these patients and they will require further surgical intervention. It is
Bentley P. Colcock
730
extremely difficult to be certain from proctoscopic examination, x-ray studies and even the appearance of the bowel at operation, that the colitis is limited to anyone segment of the colon. Patients whose disease appears to be limited to the rectum have occasionally been subjected to abdominoperineal resection with the establishment of a sigmoid colostomy. Colostomy has also proved to be an unsatisfactory operation for ulcerative colitis since in most of these patients disease will subsequently develop in the remaining colon. The question may arise as to whether intestinal continuity can be restored in a patient who has had an ileostomy for a period of time, who is free of symptoms and whose colon appears to be normal on proctoscopic and barium enema examinations. Knowing the difficulty of being certain that the inflammatory process is actually cured, we have restored intestinal continuity in only a few carefully selected patients. In spite of our caution, recurrence has developed in approximately two-thirds of these patients and a second ileostomy with colectomy has been required. SUMMARY
The surgical management of chronic ulcerative colitis is subject to a number of potentially dangerous complications. Increasing experience and refinements in technique have resulted in a steady decrease in the number of these complications; many can now be avoided entirely and the remainder, by prompt and effective treatment, can be corrected before they become serious.
IT IS now recognized that a certain number of patients with chronic ulcerative colitis will require surgical intervention, either because of the development of a complication of the disease or because medical treatment has failed. Surgical intervention may, indeed, become urgent when medical treatment fails to halt the progressive course of the disease and there is a steady deterioration in the condition of the patient. Conservative treatment must also be considered to have failed if the disease reaches a stage in which, as a result of severe anemia, uncontrolled diarrhea, or general debility, the patient becomes a chronic invalid. The percentage of patients in whom surgical intervention will be found necessary will depend upon the number of patients seen with the more severe and more extensive form of ulcerative colitis. In our experience, this figure now approaches 40 per cent. With surgery required in over a third of the patients, we are seeing a relatively high percentage of patients with extensive or severe disease. In spite of this the mortality at the present time is less than 5 per cent. The morbidity associated with the surgical treatment of ulcerative colitis has also been reduced. Not onlyhas the incidence of all of the common complications of ulcerative colitis been lowered but the severity of these complications shows a marked improvement over that of a few years ago. * The fact that we are operating upon these patients earlier is partly responsible for the improved mortality and the morbidity. Another important factor is that these complications are now recognized more promptly and treated more effectively. We are now able to prevent many of these complications. Although a few patients with ulcerative colitis localized to the right colon may be cured by a right colectomy with anastomosis of the terminal ileum to the transverse colon, the great majority of those patients who require surgery will need a permanent ileostomy and total colectomy. Many of the complications associated with the surgical treatment of * Colcock, B. P. and Mathiesen, W. L.: Complications of the surgical treatment of chronic ulcerative colitis. Arch. Surge 72: 399-404 (Mar.) 1956. 725
Bentley P. Colcock
726
this disease are directly related to the ileostomy itself. Others are complications of the disease but must be dealt with in the course of its surgical management. COMPLICATIONS
Skin Irritation
One of the problems associated with the establishment of an ileostomy for chronic ulcerative colitis has been the prevention and treatment of excoriation of the skin around the ileostomy. Today irritation of the skin rarely occurs. The protection of the skin around the ileostomy from the very beginning and the early application of the ileostomy bag have been responsible for this change. Tincture of benzoin or other skin protecting agent should be applied to the surrounding skin immediately, if it is necessary to leave the ileostomy bag off for any period of time. An ill-fitting ileostomy bag which permits wetting of the adjacent skin will also soon result in marked skin excoriation if the situation is not corrected. The weeping, excoriated skin makes it difficult to secure adherence of the bag, and thus a vicious cycle is produced. Fistula Formation
Since a fistula at or below the level of the skin will pour the ileostomy content directly onto the skin and prevent adherence of the bag, it represents a serious complication. A fistula at this level is an indication for early revision of the ileostomy with excision of the fistulous area and exteriorization of sufficient ileum so that the intestinal content will empty directly into the bag. This procedure should be done before the skin becomes excoriated. The principal reasons for the formation of a fistula in the side of the ileostomy are (1) suturing of the bowel wall to the parietal peritoneum, and (2) pressure necrosis from an ileostomy bag that fits too tightly. When the patient is fitted with an ileostomy bag, additional space of at least ~ inch should be allowed between the ileostomy and the margin of the bag opening. The patient should also be warned of the danger of pressure from the margins of the bag should edema of the ileostomy occur. Although the ileostomy must be fixed to prevent prolapse or retraction, the fixation should utilize the mesentery of the terminal ileum and not the intestinal wall. Prolapse and Retraction
In the past, an ileostomy in a patient with ulcerative colitis has been notorious for its tendency to prolapse or retract. Occasionally this complication will develop long after the operation, but it no longer occurs during the postoperative period. This is due to adequate and secure fixation of the ileostomy to the anterior abdominal wall at the time the ileostomy is established. As noted above, this fixation is achieved by suturing the peritoneum of the ileal mesentery to the parietal peritoneum.
Complications of Surgical Treatment of Ulcerative Colitis
727
Late prolapse of a mild degree is not serious and does not require reoperation. Late prolapse sufficient to produce edema of the exteriorized segment, however, will require revision of the ileostomy. Revision will also be required if the ileostomy retracts to the skin level since such retraction may prevent adequate fixation of the ileostomy bag. This leads to soiling and irritation of the surrounding skin. The technique of fixation will vary depending upon whether a stab wound is used for the ileostomy or the ileostomy is brought out the operative incision. In either case it should unite the peritoneum of the mesentery to the peritoneum of the abdominal wall up to the margin of the bowel and the margin of the incision. Postoperative Electrolyte Im.balance
Once the newly established ileostomy begins to function, these patients may lose large amounts of fluid in the course of 24 hours. Large quantities of sodium, potassium and chloride may also be lost in a short period of time. This fluid and electrolyte loss must be replaced either by oral or by intravenous administration. After a few days the amount of ileostomy drainage becomes stabilized, the ileostomy content thickens, and if the patient is able to take sufficient fluid and food by mouth, this complication is no longer a problem. He should be warned, however, that if at any time in the future there is excessive discharge from his ileostomy or any interruption in the normal oral intake of fluid and salt, he should consult his physician promptly. The discharge from the ileostomy of a watery, thin fluid, even though copious in amounts, particularly if associated with abdominal cramps, may be the first indication of partial obstruction of the small bowel. Obstruction
Some degree of obstruction of the small bowel has been a frequent complication in patients who have had an ileostomy for ulcerative colitis. It can often be relieved by simple dilatation or by catheter irrigation of the ileostomy. If the obstruction is not at the stoma and cannot be reached by the catheter, a Miller-Abbott tube must be introduced from above. As the distended, obstructed loops of bowel are emptied the obstruction is usually relieved and the ileostomy begins to function. Only occasionally is reoperation necessary in these patients. Eversion of the terminal ileum with suture of the mucosa to the skin margin plus the removal of a circular segment of skin and fascia at the site of the ileostomy has tended to prevent obstruction at the level of the abdominal wall. We also believe that these technical details will decrease the incidence of late stricture at the skin level. Careful peritonealization of the right and left lumbar gutters, including the ligated and divided mesenteric vessels, and the construction of an intact peritonealized pelvic floor have done much to prevent small bowel obstruc-
728
Bentley P. Colcock
tion proximal to the stoma. Obstruction of any degree in any patient with an ileostomy must be relieved promptly; if it is not corrected, it will quickly result in a serious electrolyte and fluid imbalance. If conservative measures such as catheter irrigation of the ileostomy stoma plus the introduction of a long intestinal tube from above do not relieve the obstruction, the patient should be operated upon before his general condition deteriorates. Hernornhuge
Today, most patients with chronic ulcerative colitis come to operation in sufficiently good condition that a subtotal colectomy can be performed at the time the ileostomy is established. Since we believe that an ileostomy alone can be carried out with a lower mortality rate than an ileostomy plus colectomy, we continue to do just an ileostomy in patients who are extremely poor operative risks. There is one type of patient, however, who may require more than an ileostomy even though his condition would seem to contraindicate it, and that is the patient with hemorrhagic bleeding. Of 15 patients who were operated upon primarily because of severe bleeding, the bleeding was controlled by ileostomy in only three. In the remaining 12 patients colectomy was required to stop the bleeding. In many patients this will mean the removal of the rectum by abdominoperineal resection. Indeed, since the ulcerative process is often most marked in the rectum, the surgeon may be forced to carry out an abdominoperineal resection as the first procedure in these patients. The fact that profuse rectal bleeding may occur in a patient who has had an ileostomy for many years is another reason for advising colectomy and abdominoperineal resection in any patient who requires an ileostomy for control of his ulcerative colitis. Carcrnorna
Carcinoma represents one of the most serious complications of chronic ulcerative colitis. The markedly increased vascularity of the bowel and the ease with which the symptoms of carcinoma may be masked by the symptoms of ulcerative colitis have resulted in a poor prognosis when this complication develops. The frequency with which carcinoma occurs in these patients increases with the number of years they have had the disease. From an over-all incidence of 4 to 5 per cent for all patients with chronic ulcerative colitis it increases to approximately 25 per cent in patients who have had severe disease of the bowel for ten years or more. It has become an important reason for periodic check-up examinations for any patient with ulcerative colitis who has had the disease for many years. The development of cancer of the colon should be seriously considered when a patient with long-standing ulcerative colitis has an exacerbation of his symptoms, such as an increase in abdominal pain or
Complications of Surgical Treatment of Ulcerative Colitis
729
rectal bleeding. It is an additional reason for carrying out a colectomy in all patients who require an ileostomy. Pregnancy
Since many patients with ulcerative colitis are young women, the problem of pregnancy may complicate the surgical management of the disease. Ten of our patients became pregnant after ileostomy and five of the ten had normal deliveries at or near term. Two of the remaining five patients had acute exacerbations of ulcerative colitis and one of these two had a spontaneous abortion. Two patients required therapeutic abortion and one patient died of eclampsia at term. All five patients in whom pregnancy represented a serious complication had part or all of the diseased colon present. For this reason we believe that it is inadvisable for a patient with an ileostomy to become pregnant before her colon has been removed. Although half of these patients had no trouble with delivery at or near term, there is likely to be some disturbance in the function of the ileostomy around the eighth month of pregnancy. It is probably unwise for these patients to go through more than one, or at the most, two pregnancies. Regional Ileitis
It may be that regional ileitis and chronic ulcerative colitis are essentially the same disease affecting different portions of the gastrointestinal tract. The fact is that they are occasionally associated, and when they do coexist, they represent a most serious problem from the point of view of surgical management. It is much more difficult to maintain normal fluid and electrolyte balance in a patient who requires a resection of the small intestine for regional ileitis following an ileostomy and colectomy for ulcerative colitis. The ileitis may produce obstruction either at the stoma or at any point along the ileum or jejunum. Even without the development of small bowel obstruction, the regional ileitis leads to excessive function of the ileostomy and results in fluid and electrolyte imbalance. We have had ten patients who required surgical intervention for ileitis in addition to the surgical treatment of ulcerative colitis; in five of the ten patients the regional ileitis followed the ulcerative colitis, in four it was coexistent and in one patient the ulcerative colitis occurred six years after resection of the small intestine for ileitis. At the present time we know of no way to prevent this serious complication. Recurrence of Disease
The complication of recurrence arises in cases in which partial colectomy and primary anastomosis have been carried out for ulcerative colitis which appeared to be localized to the right colon. In our experience, ulcerative colitis will develop in the remaining colon in the majority of these patients and they will require further surgical intervention. It is
Bentley P. Colcock
730
extremely difficult to be certain from proctoscopic examination, x-ray studies and even the appearance of the bowel at operation, that the colitis is limited to anyone segment of the colon. Patients whose disease appears to be limited to the rectum have occasionally been subjected to abdominoperineal resection with the establishment of a sigmoid colostomy. Colostomy has also proved to be an unsatisfactory operation for ulcerative colitis since in most of these patients disease will subsequently develop in the remaining colon. The question may arise as to whether intestinal continuity can be restored in a patient who has had an ileostomy for a period of time, who is free of symptoms and whose colon appears to be normal on proctoscopic and barium enema examinations. Knowing the difficulty of being certain that the inflammatory process is actually cured, we have restored intestinal continuity in only a few carefully selected patients. In spite of our caution, recurrence has developed in approximately two-thirds of these patients and a second ileostomy with colectomy has been required. SUMMARY
The surgical management of chronic ulcerative colitis is subject to a number of potentially dangerous complications. Increasing experience and refinements in technique have resulted in a steady decrease in the number of these complications; many can now be avoided entirely and the remainder, by prompt and effective treatment, can be corrected before they become serious.