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Surgery for ulcerative colitis
Review Article M. Vella M. R. Masood W. S. Hendry
Surgery for ulcerative colitis
Department of Surgery, Stirling Royal Inrmary Correspondence to: Wilson S. Hendry, 15 Randolph Road, Stirling, FK8 2AW Tel: +44 (0)1786 434438 Fax: +44 (0)1786 450588 Email: [email protected]
Ulcerative colitis is an in ammatory condition of unknown aetiology affecting all or part of the rectum and colon. The mainstay of treatment is medical but there are speci c indications for surgical intervention. This article reviews the evolution of surgical management and in particular compares outcome from proctocolectomy and pouch surgery. A number of factors determining choice of procedure are examined, including elective or emergency presentation, patient selection, technical issues, morbidity and quality of life. Emphasis is made regarding a full explanation of these factors so that the patient is fully involved in the nal decision regarding choice of procedure. Keywords: Ulcerative colitis, proctocolectomy, ileoanal pouch, patient selection, quality of life Surgeon, 1 December 356-62
INTRODUCTION Ulcerative colitis is a disease of unknown aetiology affecting all or part of the large bowel. The mainstay of treatment is medical. However, it is estimated that 20–30% of patients will ultimately require surgery. The criteria for surgical intervention are well established (Table 1). Deciding what constitutes failure to improve with maximum medical treatment is more subjective. Various predictive indices have been proposed; examples include >eight stools a day and C-reactive protein >45mg/L on day three of admission.1 Regular review by experienced physicians and surgeons is essential. The patient should be involved and understand the expected bene ts and potential side effects of any proposed treatment. Unlike Crohn’s disease, ulcerative colitis is surgically curable; this must be remembered when considering long-term major immunosuppression. Patients who are properly counselled about the balance of risks might opt for an early colectomy. Little has been published regarding surgery for patients with distal colitis causing debilitating symptoms unresponsive to, or intolerant of, medical treatment. The available data suggest that these patients are likely to do as well in terms of function and quality of life improvement as patients with extensive colitis.2,3
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EVOLUTION OF SURGICAL PROCEDURES The rst attempts at surgical management of colitis were based on the premise that colonic irrigation might allow mucosal healing. Fulton Weir described appendicostomy, and later Brown described caecostomy as a means of irrigating the colon. Irrigation remained the basis of surgical management for decades.4,5 Hurst in 1935 was sceptical and suggested that faecal diversion might be a better option.6 He described a split ileostomy, a sophisticated procedure at the time. McKittrick in 1949 reported a series of patients who had undergone ileostomy.7 Although a number of remissions occurred, patients with severe disease rarely responded and relapses were frequent. It became clear that morbidity and mortality were largely due to the presence of diseased colon and that resection was necessary. However, the lack of a satisfactory method of controlling the ef fuent from a ush ileostomy was a major deterrent. In 1944, Strauss enlisted the help of a patient to design a leak proof appliance.8 This revolutionised the means of collecting ileostomy ef fuent but problems with skin excoriation remained. The all-important step of eversion was undertaken by Brooke in 1949.9 These developments allowed resection of the diseased large bowel, initially as staged procedures.
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TABLE 1. INDICATIONS FOR SURGERY Frequent relapse Intolerance of medical treatment Intestinal dysplasia/mass lesion Malignancy Acute attack not settling with medical treatment Toxic megacolon Perforation Haemorrhage
Developments continued throughout the 1950s and a one stage proctocolectomy became standard, with acceptable morbidity and mortality. By the early 1960s the procedure had largely evolved to that practised today. Some patients were unhappy with a permanent stoma. Kock developed an intra-abdominal reservoir in the late 1960s.10 He later introduced a leak-proof one way nipple valve. Revision was required in up to 50%. Recent improvements have reduced this, but the procedure is technically demanding and carried out in few centres. Avoidance of a permanent appliance remained attractive and led to the evolution of restorative proctocolectomy. Total colectomy and ileorectal anastomosis was rst described in 1957.11 The main problems were that the procedure is only suited to patients with rectal sparing, and the cancer risk in the remaining mucosa requires follow-up. The aim therefore was to develop a procedure which would remove all affected mucosa but maintain continence. Attempts to carry out an ileoanal anastomosis were complicated by excessive stool frequency.12,13 Kock’s work conrmed that a small bowel reservoir functioned satisfactorily.10 Amalgamating the concepts of an ileal reservoir with ileoanal pull-through led to pouch surgery. Total colectomy, proximal proctectomy, distal mucosal proctectomy and ileoanal anastomosis were rst described by Parks and Nicholls in 1978.14 The reservoir was initially an ‘S’ pouch with three 10cm long limbs of ileum. Utsonomiya described the ‘J’ pouch in 1980.15 The absence of an efferent limb eliminated the evacuation problems experienced with some ‘S’ pouches. One of the most popular procedures currently is a totally stapled ‘J’ pouch-anal anastomosis just above the anal transitional zone (ATZ), without mucosal stripping.16 The ‘W’ pouch was described by Nicholls in 1987.17 This has the largest capacity but is complex to fashion, uses more small bowel and is dif fcult to place in a narrow pelvis. The other development was a progressive reduction in the length of the rectal muscular cuff.
CHOICE OF PROCEDURE The choice of procedure depends on indication, comorbidity, patient preference, local expertise and referral patterns. Satisfactory quality of life and function also depend on patient expectations and understanding of expected outcomes. Audit of personal results helps provide realistic expectations. Subtotal colectomy and end ileostomy remains the procedure © 2007 Surgeon 5; 6: 356-62
t patients of choice in patients with acute complications, in un and in suspected but unproven Crohn’s colitis. This procedure leaves all options open, provides the ultimate pathology specimen, and allows optimisation of the patient’s condition and discontinuation of immunomodulatory medication. Most surgeons leave a long rectal stump, avoiding pelvic dissection in the unt patient, allowing easier identication at subsequent surgery and leaving a virgin pelvic plane.18 The stump may be exteriorised or sealed and left intraperitoneally. Our preference is to incorporate the stump in the fascial closure, allowing easier subsequent identication and resulting in wound infection or a mucous stula, rather than pelvic sepsis, in the event of stump dehiscence.19 Most patients eventually come to completion proctectomy, with or without pouch-anal anastomosis. In a recent small study, most (>85%) patients having subtotal colectomy underwent a further procedure.20 For elective surgery, the choice lies between proctocolectomy with end ileostomy or restorative proctocolectomy with ileal pouch-anal anastomosis. Proctocolectomy and permanent end ileostomy is a relatively safe one stage option for the denitive management of ulcerative colitis. Some choose this option to avoid potential pouch complications, the potential for multiple procedures and potential problems with stool frequency. Patients with clinical impairment of sphincter function, un t patients and those with a failed pouch are good candidates for this procedure. The risk of an unhealed perineal wound is smaller with ulcerative colitis than with Crohn’s disease.21 There is potential for ileostomy related complications, the incidence of which varies widely between studies.22 Restorative proctocolectomy is a well accepted treatment option in the surgical management of ulcerative colitis. Indeed, its proponents consider it to represent the gold standard. It aims to avoid a permanent ileostomy while providing reasonable function. Success depends on patient selection, patient commitment, careful counselling, support and expedient management of complications. Although widely accepted, there remain areas of controversy.
PATIENT SELECTION Following the introduction of the double stapled technique, more elderly patients have undergone restorative proctocolectomy. Some studies suggest that stool frequency and episodes of incontinence increase with age.23-26 Complications, pouch The Royal Colleges of Surgeons of Edinburgh and Ireland
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longevity, quality of life and satisfaction with the procedure are age independent.26 Good outcomes have been reported in septuagenarians.27 The current consensus is that age should not be the sole exclusion criterion. Decisions should be based on tness, pre-operative continence, motivation and understanding of expected outcomes. Obese patients present technical issues that make surgery, particularly restorative proctocolectomy, more challenging. They are at risk of increased complications, including a higher risk of inability to achieve adequate length for anastomosis and a higher risk of ileostomy related complications.28 Long-term function is unaffected. Obesity is considered a relative contraindication to restorative proctocolectomy. Many surgeons would consider multifocal dysplasia, or lower rectal dysplasia or malignancy to be indications for mucosectomy.29 5-Fluorouracil based chemotherapy appears to be well tolerated following restorative proctocolectomy irrespective of whether a diverting ileostomy is fashioned.30 Low rectal cancers requiring an abdominoperineal approach for adequate clearance obviously preclude a restorative procedure. As the effect of radiotherapy on pouch function is unknown, low or bulky rectal cancers are relative contraindications to a restorative procedure. Patients on high dose steroids or immunomodulators could be more prone to complications, although this nding has not been universal.31 If in doubt, patients should be offered subtotal colectomy to optimise their condition before proceeding with proctectomy, with or without an ileal pouch. Even after repeated clinical, endoscopic, histological and radiological assessment, 1–15% of patients with in ammatory bowel disease cannot be classi ed as having ulcerative colitis or Crohn’s disease and are considered to have indeterminate colitis. Whilst Crohn’s remains a contraindication to restorative proctocolectomy in most centres due to the high rate of pouch failure and pelvic/perineal sepsis, indeterminate colitis is no longer a contraindication.32-36 Prior subtotal colectomy may help exclude Crohn’s disease; indeed many pathologists argue that the term indeterminate colitis should only be applied after histological evaluation of the colectomy specimen. Functional outcomes and complication rates are similar if this de nition is applied. Patients should be counselled about the risk of pouch failure from poor function or sepsis if Crohn’s is diagnosed subsequently.
TECHNICAL ISSUES Laparoscopic procedures are feasible and advances have been made in the available instrumentation.37,38 The learning curve is steep and operative times prolonged. Obesity, previous surgery and thickening of the mesentery add to the complexity. Function and quality of life are no different compared to open surgery, though recovery and hospital stay may be shorter.37 Patients appreciate the improved cosmesis. The potential long-term reduction in risk of small bowel obstruction remains unproven. Some technical issues are common to both elective procedures, including the need to avoid damage to the pelvic autonomic nerves during rectal dissection. Perimuscular dissection, common practice of which prior to total mesorectal excision being widely accepted, is time consuming and associated with increased blood loss, and has been largely replaced by close mesorectal dissection. Other technical issues are procedure speci c. 358
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Proctocolectomy, end ileostomy In the absence of low rectal cancer, the surgeons perform intersphincteric dissection of the anal canal. The plane is relatively bloodless, and perineal wound closure less likely to be under tension and consequently more likely to heal.39 Restorative proctocolectomy Most centres now employ a 20cm ‘J’ pouch.16 This is relatively easy to fashion, empties spontaneously and utilises 40cm of terminal ileum, minimising the length of small bowel lost in the event of pouch failure. Complications are more likely earlier in a surgeon’s learning curve. A halving of pouch failure rates after 10 years’ experience has been reported.40 Structured training is essential to minimise this effect. Case load may be important with a trend to higher leak rates reported in smaller series.41 The rate of intra-operative inability to perform the procedure is rarely reported, but it is at least 4%, almost half for technical reasons, the remainder due to unexpected pathology.42 There has been considerable debate since the introduction of the double stapled technique as to whether mucosectomy is essential. The double stapled technique creates an anastomosis 2–3cm from the anal verge, leaving a 1.5–2.0cm cuff of columnar mucosa as well as the ATZ (around 0.5cm) above the dentate line.43 This cuff is at risk of ongoing inammation (cuf ftis), dysplasia and malignant transformation. On the other hand, the ATZ is thought to play a part in continence. Mucosectomy necessitates prolonged sphincter dilatation, raising concerns of long-term functional decits. It increases duration and complexity, and requires more length for tensionfree anastomosis. The debate centres around function, risk of malignant transformation and the clinical signicance of cuf ftis. Many retrospective series and two small randomised studies report an increased incidence of incontinence after mucosectomy.44,45 Leak and pouch failure rates are comparable. The relative impact on function of ATZ removal and sphincter dilatation is unknown. Cuf ftis was present in 94% of cuff biopsies taken on a surveillance programme following a double stapled procedure, but was the cause of symptoms in only 7% of 61 patients with post-operative pouch symptoms.46,47 It responds well to topical mesalazine or steroids.48 The incidence of cuff dysplasia is unknown but probably very low, although it is more common if dysplasia or cancer was present in the initial specimen. In fact, dysplasia or cancer was present in the initial specimen in most reported cases following restorative proctocolectomy.49 In the aforementioned cuff surveillance study, no cuff dysplasia or cancer was detected at a median 56 month follow-up.46 The natural history of cuff dysplasia has not been determined, although regression has been reported. Cuff surveillance remains controversial. Biopsies may be unrepresentative, and the frequency and method of sampling, as well as what to do if dysplasia is detected, has not been standardised. Inter-pathologist variation in diagnosing dysplasia is an issue. Most authors would advocate mucosectomy and pouch advancement if high grade dysplasia is detected. However, mucosectomy has been shown to leave islands of rectal mucosa inaccessible to sampling between the rectal muscularis and the pouch serosa.50 Most cancers following ileal pouch-anal anastomosis have been reported following © 2007 Surgeon 5; 6: 356-62
mucosectomy.49 This may be explained in part by the greater likelihood of patients with rectal dysplasia or malignancy having mucosectomy. Current knowledge suggests a putative role for mucosectomy in select patients, such as those with high grade dysplasia or cancer pre-operatively. The double stapled technique is likely to be employed in most technicallt demanding patients, particularly in the obese, technically demanding operations and in the elderly when concerns regarding continence are likely to outweigh concerns of dysplasia. Patients undergoing proctocolectomy and end ileostomy should be aware of the small risk of malignant change in their ileostomy in the long-term; 31 ileostomy cancers, mostly adenocarcinomas, have been reported.51 When considering a one-stage procedure, avoiding a defunctioning loop ileostomy, the patient must be aware that leak rates may be as high as 10%, and relaparotomy and pouch failure rates may be higher than for a two-stage procedure.52-54 This is offset by the morbidity associated with ileostomy formation and closure, and the need for a further hospital admission. In a study from Toronto, 20% of cases of late small bowel obstruction requiring relaparotomy were due to adhesions to the ileostomy closure site.22,55 Given the lack of randomised studies, a one-stage procedure may be considered in a t, well counselled patient, if the procedure is straightforward and the anastomosis well perfused and tension free. Close observation post-operatively is mandatory, with a low threshold for imaging or relaparotomy. Although this approach has been shown to be safe, long-term function and quality of life after a leak remain a concern.56 Ten per cent of pouches fail long-term, most after the rst year. Pouch salvage has good results when performed by experienced surgeons, with more than 75% retaining a functioning pouch.57,58 Functional outcomes are worse than for primary reconstructive proctocolectomy, but most patients are satis ed. Associated morbidity is high. Salvage is more successful when performed for functional problems than for sepsis.57
OUTCOME Mortality from both restorative proctocolectomy and proctocolectomy with end ileostomy is consistently below 1%.40 Reported morbidity varies, but it is more common after restorative proctocolectomy, and more likely to require surgery. After proctocolectomy and end ileostomy, most early morbidity relates to the perineal wound. Late morbidity is generally ileostomy related. The range of potential morbidity after a restorative procedure is daunting, affecting around 50% in many series, but most patients keep a functioning pouch in the long-term and are satis ed with its function. Function A good functional result comprises six semi-formed stools per day, none at night, no urgency, no episodes of incontinence and no need to wear pads. A proportion of patients require lifelong antidiarrhoeals to achieve this. Concerns have been raised about the longevity of good pouch function as capacity and compliance change, and deterioration of sphincter function may occur in the long-term. Function and quality of life appeared to be well preserved in 409 patients followed-up for 15 years, and, given the comparable functional results in elderly patients, the expectation is that good function will be maintained in the longer term.59
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Early complications The risk of anastomotic leak and pelvic sepsis has decreased to 3–7% since the nineties.60 Early treatment is essential to minimise the impact on long-term function. Many require laparotomy, others can be drained per anus or radiologically. Patients having had a one-stage procedure are diverted. Patients who have an anastomotic leak are often relegated to worse function, higher stula rates and poorer quality of life.56 Early pouch failure , pouch excision or long-term diversion within a year, occurs in up to 3%. Late complications More than 75% of pouch failures occur after the rst year, with failure rates of 9–13% at 10 years being reported.40,60 Late pouch failures continue to occur with increasing time from surgery. Pelvic sepsis and poor function account for up to 80%; pouchitis accounts for a further 10%.40 Pouch-vaginal stulae, pouch-perineal stulae and pouchabdominal wall stulae have been reported in 5%, 3.6% and 1.5% of patients respectively at four years median follow-up.61 Fistulae are more likely after pelvic sepsis, when technical problems are encountered, or if Crohn’s is subsequently diagnosed.61 An asymptomatic stula may be observed and managed with a seton or brin glue. Diversion decreases symptoms, and there have been reports of spontaneous closure. Results of surgery are variable, with better results reported for early stulae, probably as fewer are Crohn’s-related. Most patients require an advancement ap or a transvaginal repair.62,63 Fistulae above the anastomosis usually require an abdominal approach, but pouch advancement is only feasible after stapled anastomosis. Anastomotic strictures occur in 4–18%, more commonly following hand sewn than stapled anastomosis. Although most respond to dilatation, with 40% requiring one dilatation only, a small group with brotic strictures require a mucosal advancement ap, and 0.5–4% eventually require pouch excision.64 Pouchitis affects up to 60% after restorative proctocolectomy depending on the criteria used.65 It is less common in familial adenomatous polyposis, suggesting a genetic predisposition. It does not occur in diverted pouches, implicating a bacterial aetiology. Clinical symptoms include increased frequency, urgency, rectal bleeding and pain. The diagnosis should be veri ed by endoscopy and histology. Small bowel obstruction occurs in up to 30% at 10 years. Most settle with conservative treatment; 7% require surgery, with the risk of requiring further resection.55 Sexual function Thirty-six per cent of patients reported reduced sexual activity or abstinence pre-operatively compared with 19% post-operatively.66 Dyspareunia and seepage during intercourse were experienced by 11% and 3% respectively of women with pouches. Male sexual function is preserved or improved in most.67 Erectile dysfunction affects 4% post-operatively; most respond to sildena l. Retrograde or no ejaculation was reported by 3% of men after 10 years.68 Quality of life Quality of life is impaired in even mild ulcerative colitis, but improves to approximately that of the general population post-operatively. This improvement is maintained long-term and is related to the functional outcome.59,69 Better body image The Royal Colleges of Surgeons of Edinburgh and Ireland
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but worse function results in similar scores in patients with a pouch as in those with a stoma.70 In the event of pouch failure, quality of life similar to that after one stage proctocolectomy is achieved.71 Fertility Many female ulcerative colitis patients are in their reproductive years. Fertility is unaffected by ulcerative colitis, or non-operative treatment. Studies on post-operative fertility are mainly retrospective. However, female infertility rates are consistently increased by restorative proctocolectomy; this should be discussed pre-operatively. No comparisons of fertility after proctocolectomy and end ileostomy to that after restorative proctocolectomy are available.72 Pregnancy and delivery During pregnancy, many pouch patients experience worsening continence and frequency from the mechanical and hormonal effects of pregnancy, particularly in the third trimester. These changes usually normalise promptly post-partum. A study of 29 pouch patients having 49 deliveries concluded that vaginal delivery was safe, but numbers were small and follow-up short.73 Similar results were observed in a study from the Mayo Clinic, with pouch function maintained, although they were slightly worse after complicated vaginal delivery.74 Follow-up was long, but numbers small and the patients still relatively young. The high risk of occult sphincter damage, the dif fculty of predicting complicated vaginal delivery and the unknown effects of ageing makes many surgeons reluctant to encourage vaginal delivery.75 The potential complications of Caesarean section should be borne in mind. Informed patients should be involved in decision making with their surgeon and obstetrician.
SUMMARY Proctocolectomy and end ileostomy remains a relatively safe and reliable option for the surgical cure of ulcerative colitis in one procedure. Restorative proctocolectomy has stood the test of time as an attractive option for elective surgical treatment of ulcerative colitis. Despite the high morbidity and the fact that often multiple procedures are required, most patients are satis ed and have a good quality of life. Patients should be well informed of the objectives of each procedure and the range of expected outcomes, and be involved in the decision making process. Copyright © 11 April 2007
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23. Dayton MT, Larsen KR. Should older patients undergo ileal pouch-anal anastomosis? Am J Surg g 1996; 172: 444-7 24. Delaney CP, Fazio VW, Remzi FH, et al. Prospective, agerelated analysis of surgical results, functional outcome, and quality of life after ileal pouch-anal anastomosis. Ann Surg 2003; 238: 221-8 25. Ho KS, Chang CC, Baig MK et al. Ileal pouch anal anastomosis for ulcerative colitis is feasible for septugenarians. Colorect Dis 2006 ; 8: 235-8 26. Chapman JR, Larson DW, Wolff BG, et al. Ileal pouch-anal anastomosis: does age at the time of surgery affect outcome? Arch Surg g 2005; 140: 534-9 27. Delaney CP, Dadvand B, Remzi FH, et al. Functional outcome, quality of life, and complications after ileal pouch-anal anastomosis in selected septuagenarians. Dis Colon Rectum 2002; 45: 890-4 28. Efron JE, Uriburu JP, Wexner SD, et al. Restorative proctocolectomy with ileal pouch-anal anastomosis in obese patients. Obes Surg g 2001; 11: 246-51 29. Remzi FH, Preen M. Rectal cancer and ulcerative colitis: does it change the therapeutic approach? Colorect Dis 2003; 5:483-5 30. Gor ne SR, Harris MT, Bub DS, et al. Restorative proctocolectomy for ulcerative colitis complicated by colorectal cancer. Dis Colon Rectum 2004; 47: 1377-85 31. Heuschen UA, Hinz U, Allemeyer EH, et al. Risk factors for ileoanal J pouch-related septic complications in ulcerative colitis and familial adenomatous polyposis. Ann Surg g 2002; 235: 207-16 32. Yu CS, Pemberton JH, Larson D. Ileal pouch-anal anastmosis in patients with indeterminate colitis: long-term results. Dis Colon Rectum 2000; 43: 1487-96 33. Dayton MT, Larsen KR, Christiansen DD. Similar functional results and complications after ileal pouch-anal anastmosis in patients with indeterminate colitis vs ulcerative colitis. Arch Surg g 2002; 137: 690-4 34. Delaney CP, Remzi FH, Gramlich T, et al. Equivalent function, quality of life and pouch survival rates after ileal pouch-anal anastomosis for indeterminate and ulcerative colitis. Ann Surg 2002; 236: 43-8 35. Brown CJ, Maclean AR, Cohen Z, et al. Crohn’s disease and indeterminate colitis and the ileal pouch-anal anastomosis: outcome and patterns of failure. Dis Colon Rectum 2005; 48: 1542-9 36. Tekkis PP, Heriot AG, Smith O, et al. Long-term outcomes of restorative proctocolectomy for Crohn’s disease and indeterminate colitis. Colorectal Dis 2005; 7: 218-23 37. Larson DW, Cima RR, Dozois EJ, et al. Safety, feasibility, and short-term outcomes of laparoscopic ileal pouch-anal anastomosis. A single institutional case-matched experience. Ann Surg g 2006; 243: 667-72 38. Kienle P, Z’graggen K, Schmidt J, et al. Laparoscopic restorative proctocolectomy. Br J Surg g 2005; 92: 88-93 39. Whitlow CB, Opelka FG, Hicks TC, et al. Perineal wound complications following proctectomy. Perspect Colon Rect Surg 2000; 13: 69-77 40. Tulchinsky H, Hawley PR, Nicholls J. Long-term failure after restorative proctocolectomy for ulcerative colitis. Ann Surg 2003; 238: 229-34 41. Tekkis PP, Fazio VW, Lavery IC, et al. Evaluation of the learning curve in ileal pouch-anal anastomosis surgery. Ann Surg g 2005; 241: 262-8
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42. Browning SM, Nivatvongs S. Intraoperative abandonment of ileal pouch to anal anastomosis - the Mayo Clinic experience. J Am Coll Surg. 1998; 186: 441-6 43. Thompson-Fawcett MW, Warren BF, Mortensen NJ. A new look at the anal transitional zone with reference to restorative proctocolectomy and the columnar cuff. Br J Surg g 1998; 85: 1517-21 44. Hallgren TA, Fasth SB, Oresland T, et al. Ileal pouch anal function after endoanal mucosectomy and handsewn ileoanal anastomosis compared with stapled anastomosis without mucosectomy. Eur J Surg g 1995; 161: 915-21 45. Reilly WT, Pemberton JH, Wolff BG, 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; 225: 666-76 46. Coull DB, Lee FD, Henderson AP, et al. Risk of dysplasia in the columnar cuff after stapled restorative proctocolectomy. Br J Surg g 2003; 90: 72–5 47. Shen B, Achkar JP, Lashner BA, et al. Irritable pouch syndrome: a new category of diagnosis for symptomatic patients with ileal pouch-anal anastomosis. Am J Gastroenteroll 2002; 97: 972-7 48. Shen B, Lashner BA, Bennett A, et al. Treatment of rectal cuff in ammation (cufftis) in patients with ulcerative colitis following restorative proctocolectomy and ileal pouch-anal anastomosis. Am J Gastroenteroll 2004; 99: 1527-31 49. Lee SW, Sonoda T, Milsom J. Three cases of adenocarcinoma following restorative proctocolectomy with hand-sewn anastomosis for ulcerative colitis: a review of reported cases in the literature. Colorectal Dis 2005; 7: 591-7 50. O’Connell PR, Pemberton JH, Weiland LH, et al. Does rectal mucosa regenerate after ileoanal anastomosis? Dis Colon Rectum 1987; 30: 1–5 51. Quah HM, Samad A, Maw A. Ileostomy carcinomas a review: the latent risk after colectomy for ulcerative colitis and familial adenomatous polyposis. Colorectal Dis 2005; 7: 538-44 52. Sagar PM, Lewis W, Holdsworth PJ. One-stage restorative proctocolectomy without temporary defunctioning ileostomy. Dis Colon Rectum 1992; 135: 582-8 53. Tjandra JJ, Fazio VW, Milsom JW, et al. Omission of temporary diversion in restorative proctocolectomy—is it safe? Dis Colon Rectum 1993; 36: 1007-14 54. Gor ne SR, Gelrent IM, Bauer JJ, et al. Restorative proctocolectomy without diverting ileostomy. Dis Colon Rectum 1995; 38(2): 188-94 55. MacLean AR, Cohen Z, MacRae HM, et al. Risk of small bowel obstruction after the ileal pouch–anal anastomosis. Ann Surg g 2002; 235: 200-6 56. Farouk R, Dozois RR, Pemberton JH, et al. Incidence and subsequent impact of pelvic abscess after ileal pouch-anal anastomosis for chronic ulcerative colitis. Dis Colon Rectum 1998; 41: 1239-43 57. Tekkis PP, Heriot AG, Smith JJ, et al. Long-term results of abdominal salvage surgery following restorative proctocolectomy. Br J Surg g 2006; 93: 231-7 58. Dehni N, Remacle G, Dozois RR, et al. Salvage reoperation for complications after ileal anastomosis. Br J Surg g 2005; 92: 748-53 59. Hahnloser D, Pemberton JH, Wolff BG, et al. The effect of ageing on function and quality of life in ileal pouch patients: a single cohort experience of 409 patients with chronic ulcerative colitis. Ann Surg g 2004; 240: 615-21
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60. Meagher AP, Farouk R, Dozole RR, et al. J ileal pouch-anal anastomosis for chronic ulcerative colitis: complications and long-term outcome in 1310 patients. Br J Surg g 1998, 85: 800-3 61. Tekkis PP, Fazio VW, Remzi F, et al. Risk factors associated with ileal pouch-related stula following restorative proctocolectomy. Br J Surg g 2005; 92: 1270-6 62 Heriot AG, Tekkis PP, Smith JJ, et al. Management and outcome of pouch-vaginal stulas following restorative proctocolectomy. Dis Colon Rectum 2005; 48: 451-8 63. Tsujinaka S, Ruiz D, Wexner SD, et al. Surgical management of pouch-vaginal stula after restorative proctocolectomy. J Am Coll Surg g 2006; 202: 912-8 64. Prudhomme M, Dozois RR, Godlewski G, et al. Anal canal strictures after ileal pouch-anal anastomosis. Dis Colon Rectum 2003; 46: 20-2 65. Fazio VW, Ziv y, Church JM, et al. Ileal pouch-anal anastomosis complications and functions in 1005 patients. Ann Surg g 1995; 222: 120-7 66. Farouk R, Pemberton JH, Wolff B, et al. Functional outcomes after ileal pouch-anal anastomosis for chronic ulcerative colitis. Ann Surg g 2000; 231:919-26 67. Gorgun E, Remzi FH, Montague DK, et al. Male sexual function improves after ileal pouch anal anastomosis. Colorectal Dis 2005; 7: 545-50 68. Lindsey I, George BD, Kettlewell MG, et al. Impotence after mesorectal and close rectal dissection for inammatory bowel disease. Dis Colon Rectum 2001; 44: 831-5 69. Carmon E, Keidar A, Ravid A, et al. The correlation between quality of life and functional outcome in ulcerative colitis patients after proctocolectomy ileal pouch anal anastomosis. Colorectal Dis 2003; 5: 228–32 70. Ko CY, Rusin LC, Schoetz DJ, et al. Using quality of life scores to help determine treatment: is restoring bowel continuity better than ostomy? Colorectal Dis 2002; 4: 41-7 71. Strong SA, Fazio VW. Surgical treatment of inammatory bowel disease. Curr Opin Gastroenteroll 1999; 15: 326 72. Johnson P, Richard C, Ravid A, et al. Female infertility after ileal pouch anal anastomosis for ulcerative colitis. Dis Colon Rectum 2004; 47: 1119-26 73. Ravid A, Richard CS, Spencer LM, et al. Pregnancy, delivery, and pouch function after ileal pouch-anal anastomosis for ulcerative colitis. Dis Colon Rectum 2002; 45: 1283-8 74. Hahnloser D, Pemberton JH, Wolff BG, et al. Pregnancy and delivery before and after ileal pouch-anal anastomosis for inammatory bowel disease: immediate and long-term consequences and outcomes. Dis Colon Rectum 2004; 47: 1127-35 75. Ramalingam T, Box B, Mortenson N. Pregnancy, delivery and pouch function after ileal pouch-anal anastomosis for ulcerative colitis. Dis Colon Rectum 2003; 46: 1292
Royal College of Surgeons in Ireland The Royal College of Surgeons in Ireland and the Section of Coloproctology, the Royal Society of Medicine Irish Travelling Fellowship The Council of Coloproctology has made available a Travelling Fellowship to enable a nonconsultant hospital doctor who is a Fellow or Member of the Royal College of Surgeons in Ireland to attend the annual (overseas) meeting of the Section. The Fellowship will be administered by the Royal College of Surgeons in Ireland. For the 2007/2008 season the meeting will be held in New York, on 3–6 June 2008. There will also be an opportunity to then travel to the Tripartite meeting in Boston on 7–11 June 2008. The Travelling Fellowship will be awarded on the basis of the applicant’s curriculum vitae and abstract(s) submitted for the meeting. Applicants do not have to be members of the Royal Society of Medicine. Closing date: Completed applications, together with curriculum vitae and abstract(s), one hard copy and one electronic copy of each, should be submitted to the Of fce of the Director of Surgical Affairs, for the attention of Ms G. Conroy, at the address below on or before Friday 8 February 2008. Application form and further particulars are available from: Ms G. Conroy Of fce of the Director of Surgical Affairs, Royal College of Surgeons in Ireland, St Stephen’s Green, Dublin 2 Ireland Tel: +353 (0)1 4022187 Email: [email protected] www.rcsi.ie/postgraduatesurgery
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Surgery for ulcerative colitis
Department of Surgery, Stirling Royal Inrmary Correspondence to: Wilson S. Hendry, 15 Randolph Road, Stirling, FK8 2AW Tel: +44 (0)1786 434438 Fax: +44 (0)1786 450588 Email: [email protected]
Ulcerative colitis is an in ammatory condition of unknown aetiology affecting all or part of the rectum and colon. The mainstay of treatment is medical but there are speci c indications for surgical intervention. This article reviews the evolution of surgical management and in particular compares outcome from proctocolectomy and pouch surgery. A number of factors determining choice of procedure are examined, including elective or emergency presentation, patient selection, technical issues, morbidity and quality of life. Emphasis is made regarding a full explanation of these factors so that the patient is fully involved in the nal decision regarding choice of procedure. Keywords: Ulcerative colitis, proctocolectomy, ileoanal pouch, patient selection, quality of life Surgeon, 1 December 356-62
INTRODUCTION Ulcerative colitis is a disease of unknown aetiology affecting all or part of the large bowel. The mainstay of treatment is medical. However, it is estimated that 20–30% of patients will ultimately require surgery. The criteria for surgical intervention are well established (Table 1). Deciding what constitutes failure to improve with maximum medical treatment is more subjective. Various predictive indices have been proposed; examples include >eight stools a day and C-reactive protein >45mg/L on day three of admission.1 Regular review by experienced physicians and surgeons is essential. The patient should be involved and understand the expected bene ts and potential side effects of any proposed treatment. Unlike Crohn’s disease, ulcerative colitis is surgically curable; this must be remembered when considering long-term major immunosuppression. Patients who are properly counselled about the balance of risks might opt for an early colectomy. Little has been published regarding surgery for patients with distal colitis causing debilitating symptoms unresponsive to, or intolerant of, medical treatment. The available data suggest that these patients are likely to do as well in terms of function and quality of life improvement as patients with extensive colitis.2,3
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EVOLUTION OF SURGICAL PROCEDURES The rst attempts at surgical management of colitis were based on the premise that colonic irrigation might allow mucosal healing. Fulton Weir described appendicostomy, and later Brown described caecostomy as a means of irrigating the colon. Irrigation remained the basis of surgical management for decades.4,5 Hurst in 1935 was sceptical and suggested that faecal diversion might be a better option.6 He described a split ileostomy, a sophisticated procedure at the time. McKittrick in 1949 reported a series of patients who had undergone ileostomy.7 Although a number of remissions occurred, patients with severe disease rarely responded and relapses were frequent. It became clear that morbidity and mortality were largely due to the presence of diseased colon and that resection was necessary. However, the lack of a satisfactory method of controlling the ef fuent from a ush ileostomy was a major deterrent. In 1944, Strauss enlisted the help of a patient to design a leak proof appliance.8 This revolutionised the means of collecting ileostomy ef fuent but problems with skin excoriation remained. The all-important step of eversion was undertaken by Brooke in 1949.9 These developments allowed resection of the diseased large bowel, initially as staged procedures.
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TABLE 1. INDICATIONS FOR SURGERY Frequent relapse Intolerance of medical treatment Intestinal dysplasia/mass lesion Malignancy Acute attack not settling with medical treatment Toxic megacolon Perforation Haemorrhage
Developments continued throughout the 1950s and a one stage proctocolectomy became standard, with acceptable morbidity and mortality. By the early 1960s the procedure had largely evolved to that practised today. Some patients were unhappy with a permanent stoma. Kock developed an intra-abdominal reservoir in the late 1960s.10 He later introduced a leak-proof one way nipple valve. Revision was required in up to 50%. Recent improvements have reduced this, but the procedure is technically demanding and carried out in few centres. Avoidance of a permanent appliance remained attractive and led to the evolution of restorative proctocolectomy. Total colectomy and ileorectal anastomosis was rst described in 1957.11 The main problems were that the procedure is only suited to patients with rectal sparing, and the cancer risk in the remaining mucosa requires follow-up. The aim therefore was to develop a procedure which would remove all affected mucosa but maintain continence. Attempts to carry out an ileoanal anastomosis were complicated by excessive stool frequency.12,13 Kock’s work conrmed that a small bowel reservoir functioned satisfactorily.10 Amalgamating the concepts of an ileal reservoir with ileoanal pull-through led to pouch surgery. Total colectomy, proximal proctectomy, distal mucosal proctectomy and ileoanal anastomosis were rst described by Parks and Nicholls in 1978.14 The reservoir was initially an ‘S’ pouch with three 10cm long limbs of ileum. Utsonomiya described the ‘J’ pouch in 1980.15 The absence of an efferent limb eliminated the evacuation problems experienced with some ‘S’ pouches. One of the most popular procedures currently is a totally stapled ‘J’ pouch-anal anastomosis just above the anal transitional zone (ATZ), without mucosal stripping.16 The ‘W’ pouch was described by Nicholls in 1987.17 This has the largest capacity but is complex to fashion, uses more small bowel and is dif fcult to place in a narrow pelvis. The other development was a progressive reduction in the length of the rectal muscular cuff.
CHOICE OF PROCEDURE The choice of procedure depends on indication, comorbidity, patient preference, local expertise and referral patterns. Satisfactory quality of life and function also depend on patient expectations and understanding of expected outcomes. Audit of personal results helps provide realistic expectations. Subtotal colectomy and end ileostomy remains the procedure © 2007 Surgeon 5; 6: 356-62
t patients of choice in patients with acute complications, in un and in suspected but unproven Crohn’s colitis. This procedure leaves all options open, provides the ultimate pathology specimen, and allows optimisation of the patient’s condition and discontinuation of immunomodulatory medication. Most surgeons leave a long rectal stump, avoiding pelvic dissection in the unt patient, allowing easier identication at subsequent surgery and leaving a virgin pelvic plane.18 The stump may be exteriorised or sealed and left intraperitoneally. Our preference is to incorporate the stump in the fascial closure, allowing easier subsequent identication and resulting in wound infection or a mucous stula, rather than pelvic sepsis, in the event of stump dehiscence.19 Most patients eventually come to completion proctectomy, with or without pouch-anal anastomosis. In a recent small study, most (>85%) patients having subtotal colectomy underwent a further procedure.20 For elective surgery, the choice lies between proctocolectomy with end ileostomy or restorative proctocolectomy with ileal pouch-anal anastomosis. Proctocolectomy and permanent end ileostomy is a relatively safe one stage option for the denitive management of ulcerative colitis. Some choose this option to avoid potential pouch complications, the potential for multiple procedures and potential problems with stool frequency. Patients with clinical impairment of sphincter function, un t patients and those with a failed pouch are good candidates for this procedure. The risk of an unhealed perineal wound is smaller with ulcerative colitis than with Crohn’s disease.21 There is potential for ileostomy related complications, the incidence of which varies widely between studies.22 Restorative proctocolectomy is a well accepted treatment option in the surgical management of ulcerative colitis. Indeed, its proponents consider it to represent the gold standard. It aims to avoid a permanent ileostomy while providing reasonable function. Success depends on patient selection, patient commitment, careful counselling, support and expedient management of complications. Although widely accepted, there remain areas of controversy.
PATIENT SELECTION Following the introduction of the double stapled technique, more elderly patients have undergone restorative proctocolectomy. Some studies suggest that stool frequency and episodes of incontinence increase with age.23-26 Complications, pouch The Royal Colleges of Surgeons of Edinburgh and Ireland
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longevity, quality of life and satisfaction with the procedure are age independent.26 Good outcomes have been reported in septuagenarians.27 The current consensus is that age should not be the sole exclusion criterion. Decisions should be based on tness, pre-operative continence, motivation and understanding of expected outcomes. Obese patients present technical issues that make surgery, particularly restorative proctocolectomy, more challenging. They are at risk of increased complications, including a higher risk of inability to achieve adequate length for anastomosis and a higher risk of ileostomy related complications.28 Long-term function is unaffected. Obesity is considered a relative contraindication to restorative proctocolectomy. Many surgeons would consider multifocal dysplasia, or lower rectal dysplasia or malignancy to be indications for mucosectomy.29 5-Fluorouracil based chemotherapy appears to be well tolerated following restorative proctocolectomy irrespective of whether a diverting ileostomy is fashioned.30 Low rectal cancers requiring an abdominoperineal approach for adequate clearance obviously preclude a restorative procedure. As the effect of radiotherapy on pouch function is unknown, low or bulky rectal cancers are relative contraindications to a restorative procedure. Patients on high dose steroids or immunomodulators could be more prone to complications, although this nding has not been universal.31 If in doubt, patients should be offered subtotal colectomy to optimise their condition before proceeding with proctectomy, with or without an ileal pouch. Even after repeated clinical, endoscopic, histological and radiological assessment, 1–15% of patients with in ammatory bowel disease cannot be classi ed as having ulcerative colitis or Crohn’s disease and are considered to have indeterminate colitis. Whilst Crohn’s remains a contraindication to restorative proctocolectomy in most centres due to the high rate of pouch failure and pelvic/perineal sepsis, indeterminate colitis is no longer a contraindication.32-36 Prior subtotal colectomy may help exclude Crohn’s disease; indeed many pathologists argue that the term indeterminate colitis should only be applied after histological evaluation of the colectomy specimen. Functional outcomes and complication rates are similar if this de nition is applied. Patients should be counselled about the risk of pouch failure from poor function or sepsis if Crohn’s is diagnosed subsequently.
TECHNICAL ISSUES Laparoscopic procedures are feasible and advances have been made in the available instrumentation.37,38 The learning curve is steep and operative times prolonged. Obesity, previous surgery and thickening of the mesentery add to the complexity. Function and quality of life are no different compared to open surgery, though recovery and hospital stay may be shorter.37 Patients appreciate the improved cosmesis. The potential long-term reduction in risk of small bowel obstruction remains unproven. Some technical issues are common to both elective procedures, including the need to avoid damage to the pelvic autonomic nerves during rectal dissection. Perimuscular dissection, common practice of which prior to total mesorectal excision being widely accepted, is time consuming and associated with increased blood loss, and has been largely replaced by close mesorectal dissection. Other technical issues are procedure speci c. 358
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Proctocolectomy, end ileostomy In the absence of low rectal cancer, the surgeons perform intersphincteric dissection of the anal canal. The plane is relatively bloodless, and perineal wound closure less likely to be under tension and consequently more likely to heal.39 Restorative proctocolectomy Most centres now employ a 20cm ‘J’ pouch.16 This is relatively easy to fashion, empties spontaneously and utilises 40cm of terminal ileum, minimising the length of small bowel lost in the event of pouch failure. Complications are more likely earlier in a surgeon’s learning curve. A halving of pouch failure rates after 10 years’ experience has been reported.40 Structured training is essential to minimise this effect. Case load may be important with a trend to higher leak rates reported in smaller series.41 The rate of intra-operative inability to perform the procedure is rarely reported, but it is at least 4%, almost half for technical reasons, the remainder due to unexpected pathology.42 There has been considerable debate since the introduction of the double stapled technique as to whether mucosectomy is essential. The double stapled technique creates an anastomosis 2–3cm from the anal verge, leaving a 1.5–2.0cm cuff of columnar mucosa as well as the ATZ (around 0.5cm) above the dentate line.43 This cuff is at risk of ongoing inammation (cuf ftis), dysplasia and malignant transformation. On the other hand, the ATZ is thought to play a part in continence. Mucosectomy necessitates prolonged sphincter dilatation, raising concerns of long-term functional decits. It increases duration and complexity, and requires more length for tensionfree anastomosis. The debate centres around function, risk of malignant transformation and the clinical signicance of cuf ftis. Many retrospective series and two small randomised studies report an increased incidence of incontinence after mucosectomy.44,45 Leak and pouch failure rates are comparable. The relative impact on function of ATZ removal and sphincter dilatation is unknown. Cuf ftis was present in 94% of cuff biopsies taken on a surveillance programme following a double stapled procedure, but was the cause of symptoms in only 7% of 61 patients with post-operative pouch symptoms.46,47 It responds well to topical mesalazine or steroids.48 The incidence of cuff dysplasia is unknown but probably very low, although it is more common if dysplasia or cancer was present in the initial specimen. In fact, dysplasia or cancer was present in the initial specimen in most reported cases following restorative proctocolectomy.49 In the aforementioned cuff surveillance study, no cuff dysplasia or cancer was detected at a median 56 month follow-up.46 The natural history of cuff dysplasia has not been determined, although regression has been reported. Cuff surveillance remains controversial. Biopsies may be unrepresentative, and the frequency and method of sampling, as well as what to do if dysplasia is detected, has not been standardised. Inter-pathologist variation in diagnosing dysplasia is an issue. Most authors would advocate mucosectomy and pouch advancement if high grade dysplasia is detected. However, mucosectomy has been shown to leave islands of rectal mucosa inaccessible to sampling between the rectal muscularis and the pouch serosa.50 Most cancers following ileal pouch-anal anastomosis have been reported following © 2007 Surgeon 5; 6: 356-62
mucosectomy.49 This may be explained in part by the greater likelihood of patients with rectal dysplasia or malignancy having mucosectomy. Current knowledge suggests a putative role for mucosectomy in select patients, such as those with high grade dysplasia or cancer pre-operatively. The double stapled technique is likely to be employed in most technicallt demanding patients, particularly in the obese, technically demanding operations and in the elderly when concerns regarding continence are likely to outweigh concerns of dysplasia. Patients undergoing proctocolectomy and end ileostomy should be aware of the small risk of malignant change in their ileostomy in the long-term; 31 ileostomy cancers, mostly adenocarcinomas, have been reported.51 When considering a one-stage procedure, avoiding a defunctioning loop ileostomy, the patient must be aware that leak rates may be as high as 10%, and relaparotomy and pouch failure rates may be higher than for a two-stage procedure.52-54 This is offset by the morbidity associated with ileostomy formation and closure, and the need for a further hospital admission. In a study from Toronto, 20% of cases of late small bowel obstruction requiring relaparotomy were due to adhesions to the ileostomy closure site.22,55 Given the lack of randomised studies, a one-stage procedure may be considered in a t, well counselled patient, if the procedure is straightforward and the anastomosis well perfused and tension free. Close observation post-operatively is mandatory, with a low threshold for imaging or relaparotomy. Although this approach has been shown to be safe, long-term function and quality of life after a leak remain a concern.56 Ten per cent of pouches fail long-term, most after the rst year. Pouch salvage has good results when performed by experienced surgeons, with more than 75% retaining a functioning pouch.57,58 Functional outcomes are worse than for primary reconstructive proctocolectomy, but most patients are satis ed. Associated morbidity is high. Salvage is more successful when performed for functional problems than for sepsis.57
OUTCOME Mortality from both restorative proctocolectomy and proctocolectomy with end ileostomy is consistently below 1%.40 Reported morbidity varies, but it is more common after restorative proctocolectomy, and more likely to require surgery. After proctocolectomy and end ileostomy, most early morbidity relates to the perineal wound. Late morbidity is generally ileostomy related. The range of potential morbidity after a restorative procedure is daunting, affecting around 50% in many series, but most patients keep a functioning pouch in the long-term and are satis ed with its function. Function A good functional result comprises six semi-formed stools per day, none at night, no urgency, no episodes of incontinence and no need to wear pads. A proportion of patients require lifelong antidiarrhoeals to achieve this. Concerns have been raised about the longevity of good pouch function as capacity and compliance change, and deterioration of sphincter function may occur in the long-term. Function and quality of life appeared to be well preserved in 409 patients followed-up for 15 years, and, given the comparable functional results in elderly patients, the expectation is that good function will be maintained in the longer term.59
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Early complications The risk of anastomotic leak and pelvic sepsis has decreased to 3–7% since the nineties.60 Early treatment is essential to minimise the impact on long-term function. Many require laparotomy, others can be drained per anus or radiologically. Patients having had a one-stage procedure are diverted. Patients who have an anastomotic leak are often relegated to worse function, higher stula rates and poorer quality of life.56 Early pouch failure , pouch excision or long-term diversion within a year, occurs in up to 3%. Late complications More than 75% of pouch failures occur after the rst year, with failure rates of 9–13% at 10 years being reported.40,60 Late pouch failures continue to occur with increasing time from surgery. Pelvic sepsis and poor function account for up to 80%; pouchitis accounts for a further 10%.40 Pouch-vaginal stulae, pouch-perineal stulae and pouchabdominal wall stulae have been reported in 5%, 3.6% and 1.5% of patients respectively at four years median follow-up.61 Fistulae are more likely after pelvic sepsis, when technical problems are encountered, or if Crohn’s is subsequently diagnosed.61 An asymptomatic stula may be observed and managed with a seton or brin glue. Diversion decreases symptoms, and there have been reports of spontaneous closure. Results of surgery are variable, with better results reported for early stulae, probably as fewer are Crohn’s-related. Most patients require an advancement ap or a transvaginal repair.62,63 Fistulae above the anastomosis usually require an abdominal approach, but pouch advancement is only feasible after stapled anastomosis. Anastomotic strictures occur in 4–18%, more commonly following hand sewn than stapled anastomosis. Although most respond to dilatation, with 40% requiring one dilatation only, a small group with brotic strictures require a mucosal advancement ap, and 0.5–4% eventually require pouch excision.64 Pouchitis affects up to 60% after restorative proctocolectomy depending on the criteria used.65 It is less common in familial adenomatous polyposis, suggesting a genetic predisposition. It does not occur in diverted pouches, implicating a bacterial aetiology. Clinical symptoms include increased frequency, urgency, rectal bleeding and pain. The diagnosis should be veri ed by endoscopy and histology. Small bowel obstruction occurs in up to 30% at 10 years. Most settle with conservative treatment; 7% require surgery, with the risk of requiring further resection.55 Sexual function Thirty-six per cent of patients reported reduced sexual activity or abstinence pre-operatively compared with 19% post-operatively.66 Dyspareunia and seepage during intercourse were experienced by 11% and 3% respectively of women with pouches. Male sexual function is preserved or improved in most.67 Erectile dysfunction affects 4% post-operatively; most respond to sildena l. Retrograde or no ejaculation was reported by 3% of men after 10 years.68 Quality of life Quality of life is impaired in even mild ulcerative colitis, but improves to approximately that of the general population post-operatively. This improvement is maintained long-term and is related to the functional outcome.59,69 Better body image The Royal Colleges of Surgeons of Edinburgh and Ireland
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but worse function results in similar scores in patients with a pouch as in those with a stoma.70 In the event of pouch failure, quality of life similar to that after one stage proctocolectomy is achieved.71 Fertility Many female ulcerative colitis patients are in their reproductive years. Fertility is unaffected by ulcerative colitis, or non-operative treatment. Studies on post-operative fertility are mainly retrospective. However, female infertility rates are consistently increased by restorative proctocolectomy; this should be discussed pre-operatively. No comparisons of fertility after proctocolectomy and end ileostomy to that after restorative proctocolectomy are available.72 Pregnancy and delivery During pregnancy, many pouch patients experience worsening continence and frequency from the mechanical and hormonal effects of pregnancy, particularly in the third trimester. These changes usually normalise promptly post-partum. A study of 29 pouch patients having 49 deliveries concluded that vaginal delivery was safe, but numbers were small and follow-up short.73 Similar results were observed in a study from the Mayo Clinic, with pouch function maintained, although they were slightly worse after complicated vaginal delivery.74 Follow-up was long, but numbers small and the patients still relatively young. The high risk of occult sphincter damage, the dif fculty of predicting complicated vaginal delivery and the unknown effects of ageing makes many surgeons reluctant to encourage vaginal delivery.75 The potential complications of Caesarean section should be borne in mind. Informed patients should be involved in decision making with their surgeon and obstetrician.
SUMMARY Proctocolectomy and end ileostomy remains a relatively safe and reliable option for the surgical cure of ulcerative colitis in one procedure. Restorative proctocolectomy has stood the test of time as an attractive option for elective surgical treatment of ulcerative colitis. Despite the high morbidity and the fact that often multiple procedures are required, most patients are satis ed and have a good quality of life. Patients should be well informed of the objectives of each procedure and the range of expected outcomes, and be involved in the decision making process. Copyright © 11 April 2007
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REFERENCES 1. Travis S. Review article: saving the colon in severe colitis – the case for medical therapy. Aliment Pharmacol Therr 2006; 24: 68-73 2. Samarasekera DN, Stebbing JF, Kettlewell MGW, et al. Outcome of restorative proctocolectomy with ileal reservoir for ulcerative colitis: comparison of distal colitis with more proximal disease. Gutt 1996; 38: 574-7 3. Brunel M, Penna C, Tiret E, et al. Restorative proctocolectomy for distal ulcerative colitis. Gutt 1999; 45: 542-5 4. Fulton Weir R. A new use for the useless appendix in surgical treatment of obstructive colitis. Medical Record d 1902; 62: 201-2 5. Brown JY. Value of complete physiological rest of large bowel in treatment of certain ulcerations and obstetrical lesions of this organ. Surg Gynaecol Obstett 1913; 16: 610-16 6. Hurst AF. Ulcerative colitis. Guys Hospital Report. 1935; 15: 317-55 7. McKittrick LS, Moore FD. Ulcerative colitis. Ileostomy: problem or solution? JAMA 1949; 139: 201-6 8. Strauss AA, Strauss FF. Surgical treatment of ulcerative colitis. Surg Clin North Am 1944; 24: 211-24 9. Brooke BN. The management of an ileostomy including its complications. Lancett 1952; II: 102-4 10. Kock NG. Intra-abdominal “reservoir” in patients with permanent ileostomy; preliminary observations on a procedure resulting in fecal “continence” in ve ileostomy patients. Arch Surg g 1969; 99: 223-31 11. Devine H, Devine J. Subtotal colectomy and colectomy in ulcerative colitis. BMJJ 1957; 1: 489-92 12. Ravitch MM. Anal ileostomy with sphincter preservation in patients requiring total colectomy for benign conditions. Surgery 1948; 24: 170-87 13. Martin LW, LeCoultre C, Schubert WK. Total colectomy and mucosal proctectomy with preservation of continence in ulcerative colitis. Ann Surg g 1977; 186: 477-80 14. Parks AG, Nicholls RJ. Proctocolectomy without ileostomy for ulcerative colitis. BMJJ 1978; 2: 85-8 15. Utsunomiya J, Iwana T, Imajo M, et al. Total colectomy, proctocolectomy and ileoanal anastomosis. Dis Colon Rectum 1980; 23: 459-66 16. McCourtney JS, Finlay IG. Totally stapled restorative proctocolectomy. Br J Surg g 1997; 84: 808-12 17. Nicholls RJ, Lubowski DZ. Restorative proctocolectomy: the g 1987; 4: 564-6 four loop (W) reservoir. Br J Surg 18. McKee RF, Keenan RA, Munro A. Colectomy for acute colitis: is it safe to close the rectal stump? Int J Colorect Dis 1995; 10: 222-4 19. Trickett JP, Tilney HS, Gudgeon AM, et al. Management of the rectal stump after emergency sub-total colectomy: which surgical option is associated with the lowest morbidity? Colorect Dis 2005; 7: 519-22 20. Bohm G, O’Dwyer ST. The fate of the rectal stump after subtotal colectomy for ulcerative colitis. Int J Colorect Dis 2007; 22(3):277-82 21. Prudhomme M, Dehni N, Dozois RR, et al. Causes and outcomes of pouch excision after restorative proctocolectomy. Br J Surg 2006; 93:82-6 22. Kaidar-Person O, Person B,Wexner SD. Complications of construction and closure of temporary loop ileostomy. J Am Coll Surg g 2005 201; 5: 759-73
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23. Dayton MT, Larsen KR. Should older patients undergo ileal pouch-anal anastomosis? Am J Surg g 1996; 172: 444-7 24. Delaney CP, Fazio VW, Remzi FH, et al. Prospective, agerelated analysis of surgical results, functional outcome, and quality of life after ileal pouch-anal anastomosis. Ann Surg 2003; 238: 221-8 25. Ho KS, Chang CC, Baig MK et al. Ileal pouch anal anastomosis for ulcerative colitis is feasible for septugenarians. Colorect Dis 2006 ; 8: 235-8 26. Chapman JR, Larson DW, Wolff BG, et al. Ileal pouch-anal anastomosis: does age at the time of surgery affect outcome? Arch Surg g 2005; 140: 534-9 27. Delaney CP, Dadvand B, Remzi FH, et al. Functional outcome, quality of life, and complications after ileal pouch-anal anastomosis in selected septuagenarians. Dis Colon Rectum 2002; 45: 890-4 28. Efron JE, Uriburu JP, Wexner SD, et al. Restorative proctocolectomy with ileal pouch-anal anastomosis in obese patients. Obes Surg g 2001; 11: 246-51 29. Remzi FH, Preen M. Rectal cancer and ulcerative colitis: does it change the therapeutic approach? Colorect Dis 2003; 5:483-5 30. Gor ne SR, Harris MT, Bub DS, et al. Restorative proctocolectomy for ulcerative colitis complicated by colorectal cancer. Dis Colon Rectum 2004; 47: 1377-85 31. Heuschen UA, Hinz U, Allemeyer EH, et al. Risk factors for ileoanal J pouch-related septic complications in ulcerative colitis and familial adenomatous polyposis. Ann Surg g 2002; 235: 207-16 32. Yu CS, Pemberton JH, Larson D. Ileal pouch-anal anastmosis in patients with indeterminate colitis: long-term results. Dis Colon Rectum 2000; 43: 1487-96 33. Dayton MT, Larsen KR, Christiansen DD. Similar functional results and complications after ileal pouch-anal anastmosis in patients with indeterminate colitis vs ulcerative colitis. Arch Surg g 2002; 137: 690-4 34. Delaney CP, Remzi FH, Gramlich T, et al. Equivalent function, quality of life and pouch survival rates after ileal pouch-anal anastomosis for indeterminate and ulcerative colitis. Ann Surg 2002; 236: 43-8 35. Brown CJ, Maclean AR, Cohen Z, et al. Crohn’s disease and indeterminate colitis and the ileal pouch-anal anastomosis: outcome and patterns of failure. Dis Colon Rectum 2005; 48: 1542-9 36. Tekkis PP, Heriot AG, Smith O, et al. Long-term outcomes of restorative proctocolectomy for Crohn’s disease and indeterminate colitis. Colorectal Dis 2005; 7: 218-23 37. Larson DW, Cima RR, Dozois EJ, et al. Safety, feasibility, and short-term outcomes of laparoscopic ileal pouch-anal anastomosis. A single institutional case-matched experience. Ann Surg g 2006; 243: 667-72 38. Kienle P, Z’graggen K, Schmidt J, et al. Laparoscopic restorative proctocolectomy. Br J Surg g 2005; 92: 88-93 39. Whitlow CB, Opelka FG, Hicks TC, et al. Perineal wound complications following proctectomy. Perspect Colon Rect Surg 2000; 13: 69-77 40. Tulchinsky H, Hawley PR, Nicholls J. Long-term failure after restorative proctocolectomy for ulcerative colitis. Ann Surg 2003; 238: 229-34 41. Tekkis PP, Fazio VW, Lavery IC, et al. Evaluation of the learning curve in ileal pouch-anal anastomosis surgery. Ann Surg g 2005; 241: 262-8
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Royal College of Surgeons in Ireland The Royal College of Surgeons in Ireland and the Section of Coloproctology, the Royal Society of Medicine Irish Travelling Fellowship The Council of Coloproctology has made available a Travelling Fellowship to enable a nonconsultant hospital doctor who is a Fellow or Member of the Royal College of Surgeons in Ireland to attend the annual (overseas) meeting of the Section. The Fellowship will be administered by the Royal College of Surgeons in Ireland. For the 2007/2008 season the meeting will be held in New York, on 3–6 June 2008. There will also be an opportunity to then travel to the Tripartite meeting in Boston on 7–11 June 2008. The Travelling Fellowship will be awarded on the basis of the applicant’s curriculum vitae and abstract(s) submitted for the meeting. Applicants do not have to be members of the Royal Society of Medicine. Closing date: Completed applications, together with curriculum vitae and abstract(s), one hard copy and one electronic copy of each, should be submitted to the Of fce of the Director of Surgical Affairs, for the attention of Ms G. Conroy, at the address below on or before Friday 8 February 2008. Application form and further particulars are available from: Ms G. Conroy Of fce of the Director of Surgical Affairs, Royal College of Surgeons in Ireland, St Stephen’s Green, Dublin 2 Ireland Tel: +353 (0)1 4022187 Email: [email protected] www.rcsi.ie/postgraduatesurgery
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