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 Table of Contents  
REVIEW ARTICLE
Year : 2016  |  Volume : 2  |  Issue : 2  |  Page : 8-15

Surgical Management of Ulcerative Colitis: A Descriptive Mini Review


Department of GI surgery and liver transplant, AIIMS, New Delhi, India

Date of Web Publication15-Dec-2020

Correspondence Address:
Nihar Ranjan Dash
Department of GI Surgery and Liver Transplant, AIIMS, New Delhi
India
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Source of Support: None, Conflict of Interest: None


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How to cite this article:
Dash NR, Jain H. Surgical Management of Ulcerative Colitis: A Descriptive Mini Review. J Indira Gandhi Inst Med Sci 2016;2:8-15

How to cite this URL:
Dash NR, Jain H. Surgical Management of Ulcerative Colitis: A Descriptive Mini Review. J Indira Gandhi Inst Med Sci [serial online] 2016 [cited 2021 Dec 7];2:8-15. Available from: http://www.jigims.co.in/text.asp?2016/2/2/8/303394




  Introduction: Top


Ulcerative colitis is a colonic mucosal inflammatory pathology characterized by bloody diarrhea. The disease usually starts in colon and gradually extends upwards to involve various extent of colon. The clinical course varies from case to case with a characteristic periods of exacerbation and remission. In India it is more prevalent than it's counterpart crohn's disease and commonly differs from it with respect to etiology, clinical, endoscopy and histopathology. It usually is seen to start in 2nd and 6th decade of life with no striking prepondorence to any sex.

The exact etiology is not known. But factors strongly and positively associated are the family history, environment and recurrent infections. Appendectomy, breast feeding and smoking can be protective in selected patients.

Pathology seems to occur because of a disturbance of balance between the gut immunity and the intestinal flora. This leads to an immunological reaction mediated by the dendritic cells and macrophages in the mucosa further leading to breach in mucosal barrier and infiltration with inflammatory cells from the blood. There is mucous depletion, crypt problems, erosions and ulceration which in late stages may lead to loss of haustration with a pipe like deformity.

The common symptoms apart from bloody diarrhea are abdominal pain, tenesmus and fever in acute severe cases.

Diagnosis is established by colonoscopy and biopsy. Endoscopic features include mucosal erythema, loss of vascularity, granularity, friability, ulcerations and pseudopolyps. Identification of the extent of disease; particularly the involvement of whole colon, left colon or only rectum; are of help for deciding local therapy. Involvment of few inches of terminal ileum (back wash ileitis) has also a bearing in the surgical therapy. Before initiation of any therapy chronic infective conditions should be excluded.

There are various classifications, scores and criteria describes for the extent and severity of the disease (viz. Mayo clinic endoscopy score, Montreal classification and Truelove’s criteria).

If untreated the disease has a very unpredictable course. Majority (90%) of the patients present with mild disease. Disease extends with time involving rectum (40%), left colon (40%) or the whole colon (20%). The extent of disease is directly proportional to the severity.

There are a number of extra-colonic manifestations present independent of the extent, severity or treatment of the disease. The history and clinical examination of an ulcerative colitis patient includes identification and documentation of these manifestations (skin, bone, joint, biliary etc.)

Imaging usually is not a part of diagnosis unless there are findings or suspicion for the extracolonic manifestations or malignancy.

In general, irrespective of the extent, severity and course, the over all mortality is similar to the general population. However the debilitating symptoms, poor quality of life, exacerbations, repeated admissions and complications of disease and the therapy are main dictators for treatment.

Medical therapy is the main stay of management. It revolves around the anti-inflammatory and immunosupressants. These include mesalazine, corticosteroids (hydrocortisone and prednisolone) and more recently the monoclonal antibodies. Medical therapy is planned according to the severity and extent of disease and whether the physician is inducing or maintaining the treatment.

A conventional induction starts with mesalazine local therapy (1 gm) of left sided mild to moderate colitis. Depending on the response the oral therapy (2.4 gm or double of it) is instituted. Depending on the response or the lack of it, corticosteroids are added. If the patient becomes steroid resistant or dependent, Azathioprine or mercaptopurine can replace it. In case of a further poor response, infliximab or adalimumab can be instituted alone or in tandem. For a mild to moderate pancolitis topical as well as systemic therapy is recommended.

The disease in acute and severe form indicates parenteral administration of steroid in an hospital setting after ruling out associated infections. Two third of total admissions cases respond to steroid therapy. Certain factors can predict steroid response or the lack of it. Lack of response to steroid therapy leads to so called ‘rescue therapy’ with monoclonal antibodies or other immunosupressants including calcineurine inhibitors in various permutations and combinations.

Those patients who show remission need to be maintained with maintenance therapy mainly with local and or oral mesalazine with or without steroid. Monoclonal antibodies are not preferred by many for maintenance therapy.

The above introduction brings us to the fact that Ulcerative colitis is mostly a medical disease. However the limitations of the medical therapy have been the small population suffering from the dependency or refractoriness and/or the complications to the therapy. Moreover certain disease complications can contraindicate the medical therapy. Cost factor remains as another hurdle. About one fourth of patients need surgery.


  Surgical Management of Ulcerative Colitis: Top


Surgery is required either in emergency for life threatening complications or in elective setting in patients becoming depended on, resistant to, or non compliance to medical therapy. Some authors mention a third scenario named as ‘urgent setting’ wherein surgery is instituted as a consequence to non-responsiveness to medical therapy for acute severe ulcerative colitis admitted to the hospital.


  Emergency Surgery: Top


A sizable percent of patients present to emergency with acute exacerbations. Often they are nutritionally depleted with poor general condition. The absolute emergency indications for surgery include exsanguinating hemorrhage and perforation[1]. Robert et al defined severe bleed way back in 1990 as acute bleeding from colon requiring at least 4 units of blood transfusion over a period not exceeding 3 weeks[2].

Massive hemorrhage causing hemodynamic instability warrants surgery. Patients with acute severe colitis can develop a toxic megacolon with resultant perforation as disease progresses, or they may develop perforation spontaneously. Frequent clinical examination of the inpatient undergoing intensive medical therapy allows early detection and timely intervention.

Surgery is also indicated on an urgent basis in patients with severe acute disease not responding to medical management. Disease severity is based on number of stools and systemic signs of inflammation. Severe disease with advanced signs and symptoms is variably labelled as severe, toxic or fulminant. In 1955 Truelove and Witt classified the disease into mild, moderate and severe. It is the most widely followed clinical classification system. Six or more bloody stools in a day with systemic signs of inflammation (tachycardia > 90 bpm, fever > 37.8 °C, Hb < 10.5 gm/dL, and/or ESR > 30 mm/h) indicated severe disease. Montreal classification considers six or more bloody stools per day, pulse rate of ≥90 beats per min, temperature ≥37.5°C, haemoglobin concentration <105 g/L, erythrocyte sedimentation rate ≥30 mm/h as severe ulcerative colitis[3],[4],[5].

The assessment of response to medical therapy and the timing of surgery in unresponsive patients is important. Undue delay increases the morbidity and mortality of the procedure. Patients with severe disease should be admitted, resuscitated, intravenous steroids (Inj hydrocortisone 100 mg QID) and antibiotics with gram negative and anaerobic coverage started, fluid and electrolytes corrected and monitored. Patients should be under close monitoring with regular bedside clinical examination and X-rays to look for toxic megacolon (transverse colon diameter > 5.5 cms) and also free air.

Frank deterioration at any point of time is treated with urgent colectomy. On day 3, response is assessed. If the stool frequency is > 8 stools/day or is 3-8 stools/day with CRP>45mg/L, either rescue therapy (cyclosporine or infliximab) or surgery is considered. In case of good response to steroids (Stool frequency < 3 stools/day with improvement in clinical profile) oral steroids are started by 5-7 days of intensive therapy. Patients with partial response (Stool frequency < 8 stools/day with CRP<45 mg/L) are continued on intensive regimen till day 5-7, and in case of persistent incomplete response, are offered rescue therapy or surgery[6]. If the rescue therapy fails, colectomy should be done. There is no role of a second rescue therapy.


  Elective Surgery: Top


Patients diagnosed with ulcerative colitis were previously treated with improvement in clinical symptomatology being the goal. Today the therapy is directed towards improving the patient’s quality of life, decreasing the need for colectomy and trying to induce and maintain the remissions. Proctitis alone (Montreal E1)is treated with sulfasalazine (Mesacol) enemas (topical therapy). Mild and moderate disease is often controlled with enemas alone, if required tablets can be added. Left sided colitis (Montreal E2) and Pancolitis (Montreal E3) is managed with systemic plus topical therapy. Mesalamine, steroids, Azathioprine are used as required. An attempt is made to keep the duration and dose of steroids to minimum possible.

Surgery is often considered in patients on an elective basis. While emergency colectomies can be lifesaving, elective colectomy often improves the patient’s quality of life. Detection of malignancy is an absolute indication for colectomy. Management of dysplasia is controversial. Colectomy is also indicated in patients with steroid refractory or steroid dependent disease and in those who are unable to tolerate the side effects of medical therapy. In developing countries like India, a substantial number of patients are unable to bear the costs of long term medications. Surgery being a one-time therapy is preferred by these.


  Technical Details: Top


Though associated with changes in body image and perioperative morbidity and mortality, surgery is curative in ulcerative colitis.

In an emergency setting the surgery of choice is subtotal colectomy (total abdominal colectomy) with hartmann pouch and an end ileostomy. Removal of most of the diseased colon reduces the disease burden, allows immunosuppression to be tapered off and gives time for the general condition of the patient to improve. Diseased rectum left behind can be managed with medications and is not much of a problem clinically. Proctectomy in an emergency setting does more harm than good. Violation of pelvic planes makes subsequent pouch surgery technically difficult. In presence of severely inflamed rectum, proctectomy is technically challenging and the risk of bleed and injury to autonomic nerves is also higher. Laparotomy is done with a midline incision. Colon is mobilized off the retroperitoneum. Mechanical retractors help in splenic and hepatic flexure mobilization. Ideally a core colectomy is done and pedicles ligated close to colon. Minimizing the exposed raw surface decreases the incidence of adhesions and makes second stage simpler. Silk or vicryl ties can be used for ligation of pedicles. Vicryl being absorbable is supposed to decrease adhesions. Lower sigmoid colon at the level of sacral promontory is divided with a stapler. Rectal stump is usually oversewn with 3-0 or 4-0 prolene continuous seromuscular suture. Interrupted sutures are used if the rectal stump is very thick and friable. At both ends sutures are left long to facilitate identification of stump at the second stage. If the sutures don’t hold, serious consideration should be given to exteriorizing the stump as a mucous fistula either through a separate opening lateral to incision (preferred) or through the lower end of midline incision. Providing drainage to rectal stump by a wide bore per rectally placed catheter (Foleys or malecots) also helps. Stump blowout is not prevented but peritoneal contamination is reduced. Small volume saline washes can also be given through it and the stump cleared off faeces.

End ileostomy is fashioned through rectus abdominis. A good pouting stoma is constructed by standard technique. Care should be taken to have adequate opening in the sheath (to prevent stoma site obstruction) and to prevent a twist in bowel while delivering it for stoma. If the patient has very poor nutrition with hypoalbuminemia there is a risk of sutures cutting through. In these selected cases it is better to avoid taking a 3 point fixation suture for this temporary ileostomy. It is easier to manage a peristomal leak emanating from mucocutaneous seperation at surface than to manage a leak from the site of 3 point fixation suture deep inside with risk of intraperitoneal contamination.

After the patient recovers and his/her general condition improves, second stage surgery is planned 3-6 months later. Rectal inflammation if any is managed with sulfasalazine (Mesacol) suppositories. A J pouch is fashioned and anastomosed to anal canal with a covering ileostomy. Ileostomy is usually closed 6 weeks later. A contrast study (pouchogram) is done to evaluate integrity of pouch before ileostomy closure.


  Elective Surgery: Top


In a well preserved patient who is not on high doses of immunosuppression serious consideration may be given to one stage or two stage surgery.


  One Versus Two Versus Three Stage: Top


Hicks et al from John Hopkins compared outcomes of 116 patients undergoing 2 stage surgery with 28 patients undergoing classical 3 stage surgery during 2000 to 2011[8]. Three stage procedure was more commonly done for emergency surgery. The incidence of perioperative complications was higher for 2 stage surgery, but when surgeon experience was accounted for, the multivariate analysis showed that the difference was due to surgeon experience. They concluded that if an experienced surgeon is available a 2 stage surgery can be performed even in an emergency setting.

Bikhchandani from Mayo clinic reviewed the ACS- NSQIP database and evaluated 2002 patients who underwent pouch surgery from 2005 to 2011 in USA. All emergency cases were excluded. 1452(72.5%) patients had a 2-stage surgery. 550 (27.5%) had a 3 stage procedure. Though not statistically significant, the overall complication rate was higher with 2 stage procedure[9].

In elective setting if the patient is in good health, is not on high dose steroid therapy and has a tension free uneventful IPAA surgery, a diversion ileostomy may be omitted with equivalent results. However this is applicable only to a select group of patients and not as a norm. Should anastomotic leak and pelvic sepsis occur, proximal diversion helps. It is much easier to manage loop ileostomy associated complications than manage florid pelvic sepsis[10].


  Proctectomy: Top


Both closed rectal dissection and mesorectal dissection have been described for pelvic dissection. Closed rectal dissection is advocated to avoid injury to autonomic nerves. However it is more demanding and not bloodless. Moreover the mesorectal plane is bloodless and more familiar to most colorectal surgeons. Few available comparative studies do not shown significant difference in impotence rates between the two techniques[11],[13].

Lindsey et al[11] compared the rates of impotence in 156 patients at a median of 74.5 months after surgery. A total of 111 patients underwent mesorectal dissection and 45 underwent closed rectal dissection. The rates of complete or partial impotence were 4.5% vs 2.2% (p=0.76) and 13.5% vs 13.3% (p=0.99) respectively. The authors proposed that nerve injury leading to impotence occurred during anterolateral dissection which is similar in both techniques.

With improved energy sources like Harmonic scalpel, Ligasure closed rectal dissection is relatively straightforward[12]. With closed rectal dissection nerves are easily safeguarded, but an experienced surgeon doing a good dissection in proper mesorectal plane is not doing a disservice to his patient as rates of nerve damage are similar in both the techniques.


  Stapled vs Handsewn: Top


In patients with proven mucosal malignancy a formal mucosectomy with hand sewn anastomosis of the ileal pouch to dentate line is done. The rectal mucosa and anal transition zone are thus completely removed and chances of subsequent tumorigenesis reduced.

The functional outcomes of mucosectomy are inferior to double staple anastomosis. In upto 7% residual islands of rectal mucosa remain. Post IPAA cancers have been reported both after double stapled and hand sewn anastomosis. The cuff of anal transition zone left behind in double staple anastomosis can be monitored clinically and endoscopically. If dysplasia is detected, the cuff is excised and pouch advanced[10].

But for proven malignancy, we routinely use double staple anastomosis during IPAA surgery.


  Laparoscopic Versus Open: Top


In elective setting colectomy can be safely performed laparoscopically. Via a pfannensteil incision the specimen is removed, J pouch created and anastomosis fashioned. In emergency setting minimally invasive surgery has been used in cases otherthan frank perforation and massive bleed[14].

Singh et al[15] systematically reviewed and analysed 27 comparative studies encompassing 2428 patients. 45.1% patients had a laparoscopic procedure done. Pouch failure rates were comparable. Laparoscopic group had significantly longer operating time, shorter hospital stay, reduced intraoperative blood loss and a lower wound infection rate. Long term outcomes were comparable.
Table l: Relation between timing (Admission to colectomy) and postoperative mortality

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Table 2: Two stage versus Three stage procedure

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In order to evaluate the success of an operation, Quality of Life (QoL) measurements are becoming increasingly popular.[9] This reflects a paradigm shift, as purely medical outcome parameters such as morbidity and mortality often do not adequately reflect the subjective perception and expectation of affected patients.[10],[11] Therefore, it is of paramount importance to investigate QoL after such complex surgical procedures, especially when an alternative procedure like ileostomy is available.

Nearly all the reports on quality of life after IPAA operations have been from Western countries. Studies on Indian patients are also very few. Indian patients with ulcerative colitis have very different dietary habits and live in a different socio-cultural milieu. The presence of a stoma is sometimes a social stigma here and patients are barred from going to places of worship and doing rituals. Furthermore, ileostomy appliances are costly and not available everywhere and few patients have access to an enterostomal therapist. In such a situation, it is important to preserve the normal anal passage for defaecation and to assess the effects of such procedures.

In an unpublished study in AIIMS, New Delhi, all the patients of ulcerative colitis who underwent 3-stage ileal pouch surgery were prospectively assessed preoperatively as well as at different time points after surgery for quality of life using a generic instrument, WHOQoL-BREF (Hindi Version) which is validated in our country. WHOQoL-BREF had easy to fill questionnaire which took an average of 15 minutes to complete. There was statistically significant improvement in all the four domains after 12 months of ileostomy closure. Colectomy increased the physical domain score significantly and decreased the psychological domain score significantly whereas there were no change in social and environmental domain scores. Ileostomy closure increased the psychological domain score significantly. Social and environmental domain scores increased significantly 6 and 12 months after ileostomy closure respectively. Sex, indication of operation and occurrence of complications did not influence the QoL score significantly.

There were several limitations of this study:

First, they used generic instrument (WHO QoL- BREF) instead of disease specific instrument. Though generic instrument allows comparisons with other disease states and the general population, it is the disease specific instrument which is more responsive to small changes and better discriminates between individuals in the population[41].

Second, the sample size is small. Due to lack of time period many of the proposed parameters could not be assessed in this study.

Third, the duration of follow up after ileostomy closure is for one year only. As many of the complications can occur after this time period, the long term quality of life could not be assessed in this study.

Fourth, a possible drawback of the surgical team administering the questionnaire could be of patients trying to please their surgeon, i.e. an ‘expectation bias’. Though it has also been shown that functional outcome as assessed by surgeons correlate with QOL assessment done by independent evaluators[42].
Table 3: Comparison of QoL after restorative proctocolectomy

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Table 4: Comparision of outcome after restorative proctocolectomy

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  Summary and Conclusion: Top


Surgical management in ulcerative colitis has the potential to remedy a cure and restore the patient back to health. The aim of management is to save the life of patient and not the colon. Timing of therapy is very important. Various surgical technical options are available and the treating surgeon should choose one best suitable for the patient keeping the patient profile and locally available expertise in mind.

Historically, the standard surgical procedure for patients with ulcerative colitis was proctocolectomy with a Brooke Ileostomy. However, in the 1980s, restorative proctocolectomy with ileal pouch anal anastomosis (IPAA) was popularized. This approach maintained gut continuity and allowed patients to avoid an ileostomy. Restorative proctocolectomy is now considered the standard treatment for patients with ulcerative colitis requiring surgery. Several studies have shown that quality of life after the operation is comparable or not significantly inferior to that of healthy controls[2].

In conclusion, ileal pouch anal anastomosis improves the quality of life in Indian patients with ulcerative colitis and may be the most appropriate procedure for such patients in developing countries. For a firm conclusion regarding quality of life after IPAA in Indian patients a validated disease specific questionnaire and larger sample size with long term follow up is needed.



 
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Introduction:
Surgical Managem...
Emergency Surgery:
Elective Surgery:
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Elective Surgery:
One Versus Two V...
Proctectomy:
Stapled vs Handsewn:
Laparoscopic Ver...
Summary and Conc...
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