Ulcerative colitis surgery

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Tarek Nafee, M.D. [2]

## Overview

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Surgical intervention (colectomy) in ulcerative colitis is reserved for management of severe or fulminant cases that are non-responsive to maximal medical therapy. Additionally, surgery is indicated for patients who develop complications such as colorectal carcinoma or toxic megacolon that does not resolve within 24 to 72 hours despite maximal medical therapy and intestinal decompression.[1]

## Surgery

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Unlike Crohn's disease, ulcerative colitis can generally be cured by surgical removal of the large intestine. However, surgery may not be necessary for patients with mild or moderate disease. Colectomy is necessary in patients with the following conditions:[1]

* Exsanguinating hemorrhage
* Frank perforation
* Documented or strongly suspected carcinoma
* Patients with severe colitis that fails to show significant symptomatic improvement despite maximal medical therapy within 3 to 5 days
* Patients who develop toxic megacolon that does not resolve within 24 to 72 hours. *Patients with strongly suspected colorectal carcinoma
* Patients with symptoms that are disabling and do not respond to drugs
* Patients who have intolerable adverse effects to medication may wish to consider whether surgery would improve the quality of life

Ulcerative colitis is a disease that affects many parts of the body outside the intestinal tract. In rare cases the extra-intestinal manifestations of the disease may require removal of the colon. Examples of this include severe progressive pyoderma gangrenosum which does not respond to infliximab. Conversely, primary sclerosing cholangitis is an extra-intestinal condition associated with ulcerative colitis that is not affected by colectomy. [2][1]

Surgical options in ulcerative colitis include:[1]

* Subtotal colectomy: subtotal colectomy with an ileorectal anastomosis is rarely advisable as it leaves the potential for disease recurrence and / or cancer risk in the retained rectal segment.

* Total proctocolectomy with permanent ileostomy: is rarely used because of the frequency of pouch outlet obstruction over time.

* Ileal pouch-anal anastomosis (IPAA): IPAA has become the most commonly performed operation for UC, and is performed in 1, 2, or 3 stages, depending on the patient’ s clinical status at the time of surgery and the judgment and experience of the surgeon.

The first step involves the removal of the large bowel is removed, except for the rectal stump and anus, and a temporary ileostomy is made. The next part of the surgery can be done in one or two steps and is usually done at six to twelve month intervals from each prior surgery.

In the next steps of the surgery an internal pouch is made of the patients' own small bowel and this pouch is then hooked back up internally to the rectal stump so that patient can once again have a reasonably functioning bowel system, all internal. The temporary ileostomy can be reversed at this time so that the patient is now internalized for bowel functions, or in another step to the procedure, the pouch and rectal stump anastamosis can be left inside the patient to heal for some time, while the patient still uses the ileostomy for bowel function. Then on a subsequent surgery the ileostomy is reversed and the patient has internalized bowel function again.

### Management of IPAA complications

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* Management of Pouchitis (complication of IPAA surgery)
* Preferred Regimen (1): Metronidazole 400mg q8h OR 20mg/kg daily
* Preferred Regimen (2): Ciprofloxacin 500mg bid
* Note: Other etiologies mimicking pouchitis include irritable pouch syndrome, cuffitis, CD of the pouch, and postoperative complications such as anastomotic leak or stricture.

## References

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1. ↑ 1.0 1.1 1.2 1.3 Kornbluth A, Sachar DB, Practice Parameters Committee of the American College of Gastroenterology (2010). "Ulcerative colitis practice guidelines in adults: American College Of Gastroenterology, Practice Parameters Committee". Am J Gastroenterol. 105 (3): 501–23, quiz 524. doi:10.1038/ajg.2009.727. PMID 20068560.CS1 maint: Multiple names: authors list (link)
2. ↑ Ulcerative Colitis Practice Guidelines in Adults, Am. Coll. Gastroenterology, 2004. PDF

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