The Surgical Management of Ulcerative Colitis

The Surgical Management of Ulcerative Colitis LEO M. ZIMMERMAN, M.D. * JEROME M. SILVER, M.D.**

THE management of ulcerative colitis has, in the past, been largely unsatisfactory. The disease is essentially a chronic one with periods of acute exacerbation which may attain fulminant and even fatal intensity. These acute episodes may initiate the disease, or they may occur at intervals at any stage during its course. In addition, there are, characteristically, remissions and exacerbations which may continue over long periods of time with often extended intervals between the successive flare-ups of the disease. Numerous complications may occur at any stage of the course which may immediately threaten the life of the patient or lead to chronic and disabling sequelae. Such complications include acute and subacute perforations, hemorrhage, stricture formation, multiple fistulas, arthropathies, cutaneous ulcers and sinuses, and pseudopolypoid degeneration of the colonic mucosa which carries a serious predisposition to the development of carcinoma. The over-all mortality from ulcerative colitis is high and only a small percentage of its sufferers are completely restored and rehabilitated to a normal and useful life. Changes in the management which would alter this discouraging prospect have long been sought. Therapeutically, the disease lies between the domains of the internist and the surgeon. In general, most of the patients with ulcerative colitis have been treated by medical means alone. Over the course of many years, not more than 15 to 20 per cent of such patients have received surgical treatment. A review of the material of Michael Reese Hospital reveals that in the past five years 49 patients have been treated for ulcerative colitis, and surgical procedures have been employed in 11 (23 per cent). The results of operative management have left much to be

* Professor of Surgery and Co-Chairman, Department of Surgery, Chicago Medical School; Attending Surgeon, Michael Reese, Cook County and Chicago Memorial Hospitals. ** Resident in Surgery, Michael Reese Hospital. 1B9

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desired. Very often, the surgeon was summoned in desperation to rescue a moribund patient suffering from the acute phase of the disease, or in the throes of a life-threatening complication, and a last-minute ileostomy was done. Even this simple operative procedure, under such circumstances, has carried with it an almost prohibitive mortality. In the chronic forms of the disease, the physician has been loath to inflict upon his patient the distressing and disabling status of ileostomy life, particularly since the hope of ultimately closing the ileostomy has always been dim. As a result, patients have been carried along for as many years as was compatible with simple survival but in stages of chronic invalidism, with periodic episodes of exacerbation which required more intensive treatment. The accepted form bf surgery, for a long period of time, was simple ileostomy. This operation proved inadequate to cure the disease in many instances and was insufficient to prevent many of the disabling and complicating sequelae which follow in its train. Furthermore, the management of the ileostomy has been a distressing thing, with frequent complications such as prolapse or retraction of the ileostomy, and severe excoriation of the skin as a result of the digestive discharges extruded upon it. In more recent times, both the techniques of the operation and the management of the ileostomy have been vastly improved, so that life is no longer intolerable nor activity materially restricted to the ileostomy patient. Several distinct trends are discernible in the management of idiopathic ulcerative colitis. These include earlier operation, more frequent utilization of surgical therapy, and more radical types of intervention. The timing of the operation is most important. Surgeons have long felt that the primary mortality, as well as the salvage rate, could be greatly improved if the operation were done before the patient's state deteriorated to the point of impending death. The adoption of radical extirpative procedures, including subtotal and total colectomy, in both acute and chronic stages, has resulted in rapid clinical recovery, the avoidance of complications, a high rate of rehabilitation and a lowering of the over-all death rate. Prompted by the improving outlook, surgical operation is being invoked in an increasing percentage of cases of ulcerative colitis. Several recent reports indicate the employment of operative measures in 40 to 50 per cent of the cases treated. ACUTE FULMINANT ULCERATIVE COLITIS

The acute, fulminant stages of ulcerative colitis are characterized by severe and exhausting diarrhea with the passage of mucus, blood and pus; severe intoxication with high fever, prostration and malaise, and severe anemia, dehydration and general depletion. Too often, as has been stated, surgical intervention has been invoked in the terminal

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phases of acute ulcerative colitis with the patient frequently in a moribund condition. The impending death has been due to the severe dehydration and loss of blood and electrolytes and to actual or impending perforation of the colon. In this critical stage, even minimal surgery carries with it a very high mortality rate. The tendency of the internist to postpone operation in the hope that it may be avoided is understandable. On the other hand, to delay too long is to invite failure from the operation and death of the patient. No precise rules can be laid down

Fig. 53. Acute ulcerative-pseudomembranous colitis.

as to exactly when operation shall be done in the fulminant phases of ulcerative colitis. Intensive medical management including hospital care, blood transfusions, fluid and electrolyte replacement, antibiotics and cortisone, and all additional aids should be utilized. If, after a reasonable attempt, the patient fails to respond, timely operation should be performed. Early consultation should be held between. the internist and the surgeon, and joint observation and discussion should favor the selection of the optimal time for operation. The choice of operation, when an operation is performed during the acute stage of ulcerative colitis, depends in part upon the condition of the patient. In most instances, because of the extremely poor general

Leo M. Zimmerman, Jerome M. Silver 202 state, only minimal intervention is feasible. Under these circumstances a simple loop colostomy, under local anesthesia, is often the procedure of choice. Any exploration or handling of the bowel may result in peritonitis from actual perforation, or from the penetration of pathogenic organisms through the diseased intestinal wall. If the condition is somewhat less critical, a permanent type of ileostomy can be performed. This consists of division of the ileum far enough from the ileocecal junction to make certain that the disease has not involved that portion of the small bowel. The distal end of the divided ileum may then be inverted and closed, or it may be implanted in the abdominal wall as a mucous fistula. The proximal end of the severed bowel is brought out through a short incision just below and to the right of the umbilicus. Suture of the mesentery of the ileum to the parietal peritoneum for 2 or 3 inches will serve to fix the small bowel and prevent prolapse. No sutures should be placed in the ileum itself because of the danger of fistula formation. The further management of the patient depends, of course, upon the postoperative course. In most instances, the patient can be brought into a remission but is not definitively cured. Ultimately, subtotal or total colectomy will be done as the second and third stages of the operative procedure. In the last few years, there has been a noticeable trend toward radical and definitive surgery, particularly in the presence of the acute and fulminant manifestations. It has been reasonably pointed out that the acute symptoms are due to the presence of the infection within the colon, and leaving behind a defunctionalized bowel does not prevent the continuation of these intensely toxic manifestations. Furthermore, the creation of the ileostomy further increases the difficulties of restoring and maintaining fluid and electrolyte balance. The one stage removal of the entire diseased colon can be carried out with a reasonably low mortality rate and with prompt amelioration of the symptoms. The rate of recovery is rapid and the severe complications are avoided. The technique of the operation is similar to that employed in chronic ulcerative colitis. There is a natural hesitancy on the. part. of .both. physicians. a,ncl surgeons to invoke soradicalari operative procedure.inso.depleted and toxic a group of patients. Nevertheless, in tho~e ~eties whlchhave been reported, the bold attack has been justified bythel()w irl()rtality and the rapid recovery of the patients. Thefuture will deterIiiine whether this will become· the accepted management·· ()f acute fulmhlarit ulcerative colitis. CHRONIC ULCERATIVE COLITIS

It is customary to list as indications for operation in the chronic form of ulcerative colitis the various complications, including perforation,

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actual and impending, hemorrhage, obstruction, fistula formation, joint and skin disease, pseudopolypoid transformation of the mucosa, and carcinoma. In addition, intractability to medical management is usually appended. A word should be said as to the concept of intractability. In the past it has been considered sufficient if the patient has responded to medical management to the point of entering into a remission of the disease. During the remission, there has rarely been complete rehabilitation of the patient. A stage of chronic invalidism, with underweight, frequent diarrheas, successive exacerbations and ultimate complications has been the rule.

B A Fig. 54. A, Chronic ulcerative colitis, B, Ulcerative colitis.

In view of the attainments of early and radical surgery, the concept of intractability should be revised. If, clinically, the patient cannot~be completely rehabilitated to a state of normal well-being with the ability to carryon a useful vocation, surgery should be invoked. From the anatomical standpoint, if the bowel has been transformed into a rigid fibrous structure, restoration to normal is no longer possible. The presence of pseudopolypi is an ominous sign. Growing emphasis has been placed on the danger of carcinoma in the later stages of ulcerative colitis. It is now reported from many of the leading clinics that carcinoma of the colon is very much higher in ulcerative colitis than in comparable numbers of patients of the same age group without the disease. In all series so studied, the longer the duration of the disease, the higher is the incidence

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of carcinoma. In ulcerative colitis under five years' duration, carcinoma is no more frequent than in patients without this disease. After eight years, the frequency of carcinoma rapidly mounts and in disease of longer standing as many as 30 per cent have been found to harbor carcinoma. Carcinoma of the colon is always a serious complication, but in the presence of ulcerative colitis it is more deadly than when it occurs independently of the disease. Because of the presence of symptoms due to the colitis, the early detection of carcinoma is very difficult. When it becomes evident that some new factor has been added and operation is done, almost invariably the carcinoma has advanced beyond the stage

Fig. 55

Fig. 56

Fig. 55. Chronic ulcerative colitis with perforation. Fig. 56. Ulcerative colitis with minute infarcts.

of cure. There have been virtually no cures of carcinoma by operation in cases in which the malignancy is a complication of chronic ulcerative colitis. This threat of malignant degeneration must compel the use of definitive surgery in chronic ulcerative colitis, particularly when the disease has been present, albeit in a relatively quiescent form, for periods extending from five to eight or more years. Furthermore, in all forms of chronic ulcerative colitis in which colectomy is done, the abdominoperineal excision of the sigmoid and rectum becomes mandatory. Ileostomy

For many years, ileostomy has been considered the definitive operation for ulcerative colitis. Its limitations are well known. Most im-

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portant of these is the leaving behind of a chronically and irreparably diseased colon which causes continued invalidism, frequent recurrences and exacerbations, ultimate complications, and serious predisposition to the development of carcinoma. Because of these inadequacies, there is a notable trend in surgical centers toward radical surgery, comprising total colectomy plus removal of the rectum, if operation is at all necessary for chronic ulcerative colitis. With this regimen, the total operative mortality has been lowered, the late complications have been avoided, and the rehabilitation of patients to a normal and productive condition has been attained in the overwhelming majority of cases. If ileostomy is done, either alone or in conjunction with total colectomy, attention to the technique of the operation will greatly minimize the complications which follow in its train. Among these complications must be listed prolapse of the colostomy, retraction of the stoma into the abdominal cavity, extension of the disease into the small bowel, excoriation of the skin and difficulties in the application of a satisfactory prosthesis. The proper placing of the ileostomy is important. From the standpoint of a well-fitting prosthesis, the optimal place is on the right side of the abdomen just below and lateral to the umbilicus. In order to avoid the danger of leaving behind a portion of the terminal ileum which is already involved by the disease process, it is well to establish the ileostomy some little distance proximal to the ileocecal junction. Dennis has followed the practice of making fro zen sections of the ileum at the time of operation, at successively higher levels until microscopic proof of freedom from involvement has been attained. To prevent prolapse of the ileostomy, the mesentery of the terminal ileum should be sutured to the parietal peritoneum for 3 or 4 inches. An incision into the mesentery at right angles to its edge, that is, parallel with the bowel, will facilitate delivery of the stump of the ileum. The mesentery should be sutured to the parietal peritoneum, but no sutures should be placed in the bowel itself. Sutures uniting the bowel to the abdominal wall carry with them the probability of fistula formation, and should be rigidly avoided. The management of ileostomy has progressively improved in recent years. Immediately after the operation, a large tube is placed into the stoma to carry the intestinal contents away from the area of the wound . When healing is complete, the application of a prosthesis which is firmly attached by water-tight seal to the skin permits comfortable function of the ileostomy. The Koenig-Rutzen type of ileostomy appliance has greatly ameliorated many of the difficulties of ileostomy, and patients are now enabled to lead a much more nearly normal and useful life. Colectom.y

As has been intimated above, the role of ileoston;ty as the definitive operation has waned definitively in recent years. The conviction is

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growing that the cure of ulcerative colitis depends upon the removal of the diseased bowel. The operation of colectomy may be done in stages consisting of initial ileostomy, followed after an interval of some weeks by removal of the colon to the level of the sigmoid and finally by abdominoperineal extirpation of the sigmoid and rectum. More and more, primary colectomy, usually to the sigmoid level, is being carried out at the time of the initial operation. While colectomy impresses one as being a formidable procedure, it must be pointed out that the operation when done for ulcerative colitis is much less extensive than when performed for malignant disease of the colon. In the first place, the very nature of the disease causes a shortening and shrinking of the entire colon, so that the flexures do not extend as high into the right and left upper quadrants as they do in the normal. Furthermore, it is not necessary to resect the mesentery widely. Because of these facts, one-stage ileostomy and colectomy is a safe and recommended procedure. In performing colectomy for ulcerative colitis, a left rectus incision is used. This permits the dissection to be carried out on the left side of the abdomen and leaves the right side for the establishment of the permanent ileostomy. The dissection begins by mobilizing both the ascending and descending colons. The peritoneal reflections on either side are incised and the colon together with the hepatic and splenic flexures is mobilized. The greater omentum is freed from the transverse colon. The mesentery is clamped and divided and the entire colon, cecum and terminal ileum removed en bloc. The stump of the ileum is brought out as a permanent ileostomy at the optimal position, about 2 inches below and to the right of the umbilicus, through a short stab-wound. The sigmoid stump is fixed into the lower end of the operative incision as mucous fistula. Abdolllinoperineal ProctosigllloidectolllY

The earliest manifestations of ulcerative colitis usually arise in the lower reaches of the colon; and the sigmoid and rectum are involved in fully three-fourths of the cases. For this reason, ultimate anastomosis of the ileum to the sigmoid is rarely successful, and should not enter into the planning of the operation. Because of the almost invariable presence of disease in the terminal colon and rectum, persistence of symptoms must be expected if this portion of the bowel is left in situ. Furthermore, the ever present danger of carcinomatous degeneration of the remaining portion of the bowel is a source of constant apprehension. For this reason, completion of the operation by removal of the rectum and the sigmoid by an abdominoperineal approach is desirable. The removal of the rectum is a separate stage of the surgical management of ulcerative colitis and is carried out with minimal mortality. The mobilization and extirpation of the rectum require no wide dissection of lymph-bearing tissues, such as is necessary when operating for

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malignant disease. The presence of multiple fistulas involving the perineum may add somewhat to the difficulty of removal of the rectum. Nevertheless, the entire removal of the rectum should be performed. SUMMARY

There have been recent changes in the management of ulcerative colitis which promise permanent control of the disease with a high rate of rehabilitation and a manner of life that is compatible with a material degree of well-being and an economic usefulness. Among these recent trends are, notably, the earlier use of surgery, the more frequent resort to surgical intervention and more radical types of operative intervention. In the acute fulminant stages of the disease, timely operation alone will reduce the distressingly high mortality that has been experienced in the past. One-stage definitive subtotal colectomy in acute ulcerative colitis is being carried out in a number of centers with remarkably low mortality rates and early relief from the symptoms and complications of ulcerative colitis. In the chronic forms of the disease, the recommended operation is total colectomy, either in stages or as a one-stage procedure. Improvement in the management of the ileostomy has greatly reduced the terrors of permanent ileostomy existence. Further developments in these directions promise a brighter future for patients with ulcerative colitis. 55 E. Washington Street Chicago 2, Illinois