Editing Ulcerative colitis (section)

== '''Elective surgical management''' ==

=== '''Indications for surgery''' ===

** Failure to respond to maximal medical therapy (severe disease)
** Patient preference
** Dysplasia/malignancy
*** Colectomy indicated if multiple areas of low-grade dysplasia or areas of high-grade dysplasia are found
*** Especially difficult to identify suspicious areas with active colitis
*** If high-grade dysplasia is found on random biopsy, 42% chance of finding cancer after proctocolectomy
*** Cancer can develop in areas of low-grade dysplasia without necessarily 
*** Close surveillance an alternative if patient willing
** Failure to grow/thrive (children)
** Severe extra-intestinal disease which may respond to surgery

=== '''Surgical options:''' ===

** Total proctocolectomy with either end ileostomy or IPAA
*** No difference in overall quality of life
** End ileostomy
*** Be wary of patients with PSC - risk factor for both chronic pouchitis and peristomal varices - preference for IPAA given life-threatening nature of varices
** IPAA (ileal pouch-anal anastomosis)
*** Patient selection
**** UC not responding to medical therapy
**** Dysplasia/malignancy
*** Construction process:
**** Three-stage:  (preferred for patients who are hospitalised with refractory disease, or are on biologics/steroids, obese, young women wishing to preserve fertility)

****# Subtotal colectomy with end ileostomy and rectal stump
****# Proctectomy with IPAA and loop ileostomy
****# Ileostomy takedown

**** Two-stage: (favoured in well patients with malignancy)

****# Total proctocolectomy with IPAA and loop ileostomy
****# Ileostomy takedown

**** One-stage:

****# Total proctocolectomy with IPAA and no diversion

***** Appropriate if no immunosuppression, good nutritional state, and no tension on IPAA

*** Often difficult to get enough length for a tension-free ileal anastomosis
**** Check whether you have enough length before you form a pouch! Can leave as end ileostomy. If the apex of the pouch can reach 6cm below the inferior margin of symphysis pubis, then a tension-free anastomosis can usually be constructed.
**** Completely mobilise small bowel to root of mesentery, but preserve ileocolic vessels
**** Transverse incisions on visceral peritoneum of the mesentery - 'mesenteric releases'
**** Careful division of select vascular arcades in small bowel mesentery - can divide terminal branches of SMA, because they are likely to be the thing creating most tension. Jamieson's says ileocolic itself can be divided if necessary for an S pouch, and the major continuation of SMA for a J pouch. Put a bulldog clamp on before division to test if it leads to ischaemia.
*** Pouch configuration
**** Stapled anastomosis requires a short cuff of rectum, which is a potential source of symptoms - 'cuffitis' and cancer.
**** Hand-sewn anastomosis can be done with a mucusectomy - remove all rectal mucosa down to anorectal junction, so might have a lower rate of cancers. Maybe worse continence. Usually done from outside with an anal retractor (lone star). Note that this might make it harder for the pouch to reach down.
**** Preference for stapled J-pouch - simplest and easiest, least complications
**** Or, 'double-stapled' if you are also talking about the staple for the pouch-anal anastomosis (using the circular staple for that one)
**** W-pouch below - uncommonly done
**** S-pouch - can provide a bit more reach and larger reservoir
****

*
*

* Outcomes:
** Expect to have up to 6 loose bowel motions per day - need good anal sphincter control
** Function often improves over the first 6 months
* Ileostomy closure
** Anastomosis should be thoroughly investigated prior to closure
** DRE, endoscopy, gastrografin
* Complications
** SBO (20%)
** Sexual dysfunction
** Ileostomy complications
** Leak
*** Sepsis
*** Fistula
** Anastomotic stricture
*** Often a reflection of tension
** Pouchitis
*** Medical management - abx, probiotics, budesonide enemas. Consider immunosuppressive therapy
*** Surgical therapy if refractive - diversion or pouch excision

* Uncommon procedures
** Total proctocolectomy with continent ileostomy ('Kock's Pouch')
*** Continence maintained by an intussuscepted segment of ileum positioned between the ileal reservoir and the end ileostomy
*** Very prone to dessusception, which requires revision
*** Not done much any more
*** Works best in thin patients
** Subtotal colectomy with ileorectal anastomosis
*** Avoids complications of pelvic dissection - sexual function for both men and women
*** Still need rectal surveillance
*** Suitable for patients with limited rectal involvement, but that is rare with UC