Safety of urgent restorative proctocolectomy with ileal pouch-anal anastomosis for fulminant colitis

Initial surgical management of ulcerative colitis in the biologic era

BACKGROUND

The initial minimum operation for ulcerative colitis is a total abdominal colectomy. Healthy patients may undergo proctectomy at the same time; however, for ill patients, proctectomy is delayed. Since the introduction of biologic medications in 2005, ulcerative colitis medical management has changed dramatically.

OBJECTIVE

We examined how operative management for ulcerative colitis has changed from the prebiologic to biologic eras.

DESIGN

We conducted a retrospective review of data on patients with ulcerative colitis who were included in the Nationwide Inpatient Sample database.

SETTINGS

This study was conducted at a single university.

PATIENTS

A total of 1,547,852 patients with ulcerative colitis who were admitted to a US hospital from 1991 to 2011 were included in the study.

MAIN OUTCOME MEASURES

We examined patients whose initial operation consisted of total abdominal colectomy without proctectomy versus a total proctocolectomy with or without a pouch. We also examined which operation was done at the time of the construction of an ileoanal pouch. Patients who underwent colectomy and pouch construction in the same hospitalization were compared with those who received pouch formation at a subsequent hospitalization.

RESULTS

Ulcerative colitis-related admissions rose by 170% during the years examined, and the number of patients who required total abdominal colectomy increased by 44%. Total abdominal colectomy increased by 15%, as opposed to total proctocolectomy (p < 0.001). Pouch construction at a subsequent operation increased by 16% (p = 0.002). Since 2008, total abdominal colectomy has surpassed total proctocolectomy as the most common initial surgical intervention for ulcerative colitis.

LIMITATIONS

The Nationwide Inpatient Sample is a retrospective database, and we were limited to examining the variables within it.

CONCLUSIONS

Total abdominal colectomy is currently the most common initial operation for patients with ulcerative colitis, and an ileoanal pouch is more frequently constructed at a subsequent hospitalization. These trends coincide with the initiation of biologic treatments and may imply that patients are acutely ill at the time of initial operation. Alternately, there may be surgeon-perceived bias of increased surgical risk or a shift in care to specialized surgeons for pouch construction.

Primary ileo-anal pouch anastomosis in patients with acute ulcerative colitis

INTRODUCTION

Proctocolectomy with ileal pouch-anal anastomosis (IPAA) was performed in ulcerative colitis (UC) for emergent or urgent indications in three stages. Since the three-step procedure imposes enormous demands on a patient, there was an attempt to introduce primary IPAA for urgent indications. The aim of this study was to compare early complications after Hartmann's colectomy (HC) and IPAA in a selected group of patients.

MATERIAL AND METHODS

Medical records of 274 patients who underwent surgery for UC between 1996 and 2010 were retrospectively evaluated. Finally, a group of 77 patients with acute form of UC entered this study.

RESULTS

All patients were divided into two groups. Group 1 consisted of 32 (42%) patients who underwent HC, whereas group 2 comprised 45 (58%) patients after IPAA. There was no postoperative mortality. Respiratory failure occurred in 8 (24%) patients after HC and in 6 (14%) patients who underwent IPAA. Intra-abdominal sepsis developed in 4 (12%) patients after HC and in 8 (17%) undergoing IPAA. Fascia dehiscence was present in 3 (8%) patients after HC and in 4 (9%) with IPAA. Bowel obstruction occurred in 1 (4%) patient after the former operation and in 3 (6%) patients after the latter one. Wound infection was diagnosed in 6 (20%) patients after HC and in 9 (20%) after IPAA. The differences between the investigated groups of patients were not statistically significant.

CONCLUSIONS

The IPAA could be performed for urgent indications only in the patients with no critical dilatation of the colon or with active UC but without signs of severe malnutrition.

Management of acute colitis and toxic megacolon

Severe colitis is a well-defined condition that can develop in patients afflicted with ulcerative colitis, but typically responds to a variety of medical therapies. Operative intervention is warranted when massive hemorrhage, perforation, or peritonitis complicates the clinical scenario or medical therapy fails to control the disease. Of the operative options, total/subtotal colectomy and end ileostomy is the usual procedure of choice especially if the operation can be performed through a laparoscopic approach.

Effect of corticosteroid dose and duration of administration on colonic anastomosis

BACKGROUND

Surgical intervention under concomitant steroid therapy can be complicated by impaired anastomotic healing. The aim of this experimental study was to investigate the effects of a corticosteroid (methylprednisolone) on healing colonic anastomoses in relation to the dose and duration of administration.

METHODS

Fifty male Spraque-Dawley rats weighing 200-220 g were divided into five groups each containing 10 rats. No treatment was given in the control group. Group HDST: high-dose methylprednisolone (1 mg/kg/day, intramuscular) treatment for a short term of 2 days; group HDLT: high-dose methylprednisolone treatment for a long term of 60 days; group LDST: low-dose methylprednisolone (0.28 mg/kg/day) treatment for a short term of 2 days; and group LDLT: low-dose methylprednisolone treatment for a long term of 60 days. Standard left colonic anastomosis was performed in all rats. Anastomotic bursting pressure, hydroxyproline measurement, and histopathological data were evaluated in all groups on postoperative day 4.

RESULTS

The mean anastomotic bursting pressure value was significantly lower in the HDLT group (P < 0.05). The mean hydroxyproline levels were significantly lower in all groups (P < 0.05). Histopathological results demonstrated significant changes according to neutrophil infiltration, granulation tissue formation, presence of vascularization, and peritonitis in the HDLT, LDST, and LDLT groups (P < 0.05).

CONCLUSIONS

High and low doses of the corticosteroid produced adverse effects on the healing of colon anastomosis in rats regardless of whether it was administered over a long or short preoperative period. However, the most prominent negative effect was associated with high-dose, long-term corticosteroid administration.

Surgical management of acute colitis and toxic megacolon

Toxic colitis, also known as fulminant colitis, or toxic megacolon when associated with bowel dilation, remains a significant emergent problem in patients with ulcerative colitis. The surgical options differ when compared with the patient undergoing elective resection for this disease and are influenced by the patients' overall medical status. Generally the options are total abdominal colectomy with ileostomy, and proctocolectomy with ileostomy or pouch reconstruction. In few circumstances, a decompressing colostomy and loop ileostomy may be performed. More recently, laparoscopy has been employed. The general surgical recommendations, indications, and techniques will be discussed.

Minimally invasive subtotal colectomy and ileal pouch-anal anastomosis for fulminant ulcerative colitis: a reasonable approach?

PURPOSE

This study was designed to evaluate the safety, feasibility, and short-term outcomes of three-stage minimally invasive surgery for fulminant ulcerative colitis.

METHODS

Using a prospective database, we identified all patients with ulcerative colitis who underwent minimally invasive surgery for both subtotal colectomy and subsequent ileal pouch-anal anastomosis at our institution from 2000 to 2007. Demographics and short-term outcomes were retrospectively evaluated.

RESULTS

During seven years, 50 patients underwent minimally invasive subtotal colectomy for fulminant ulcerative colitis; 50 percent were male, with a median age of 34 years. All patients had refractory colitis: 96 percent were taking steroids, 76 percent were recently hospitalized, 59 percent had >/=5 kg weight loss, 57 percent had anemia that required transfusions, 30 percent were on biologic-based therapy, and 96 percent had >/=1 severe Truelove & Witts' criteria. Of these 50 procedures, 72 percent were performed by using laparoscopic-assisted and 28 percent with hand-assisted techniques. The conversion rate was 6 percent. Subsequently, minimally invasive completion proctectomy with ileal pouch-anal anastomosis was performed in 42 patients with a 2.3 percent conversion rate. Median length of stay after each procedure was four days. There was one anastomotic leak and no mortality.

CONCLUSIONS

A staged, minimally invasive approach for patients with fulminant ulcerative colitis is technically feasible, safe, and reasonable operative strategy, which yields short postoperative length of stay.

Outcomes of the rectal remnant following colectomy for ulcerative colitis

OBJECTIVE

Controversy surrounds the optimal surgical management of the distal rectal remnant during colectomy for ulcerative colitis (UC) and the potential benefit from the placement of a rectal catheter for remnant drainage. This study reviews the clinical outcomes of patients who have undergone colectomy for UC with intra-peritoneal closure of the rectal remnant.

METHOD

Analysis of prospective data lodged on Lothian Surgical Audit databases from patients treated in a tertiary coloproctology unit over 11 years.

RESULTS

One hundred and fifty-nine patients were identified, the mean age was 41.9 years, 63% were men. Failure of maximal medical therapy necessitated surgery for 78.1% patients, while 12.6% had acute perforation and 11.9% had toxic megacolon. Complications included five (3.1%) stump dehiscences, eight (5.0%) intra-abdominal/pelvic collections, four (2.5%) significant wound infections, three (1.9%) small bowel obstructions and three (1.9%) deaths. Within the follow-up period, 62.3% patients had an ileo-pouch anal anastomosis (IPAA), 7.5% patients had a completion proctectomy, 10.1% patients within the series had a retained rectal remnant after 1 year follow up, the remaining patients had less than 1 year follow up.

CONCLUSION

The intra-peritoneal rectal stump following colectomy for UC is associated with low rates of pelvic sepsis and a high proportion of patients successfully proceeding to IPAA.

Should ileoanal pouch surgery be staged for patients with mucosal ulcerative colitis on immunosuppressives?

INTRODUCTION AND OBJECTIVE

Much debate has revolved around whether patients with mucosal ulcerative colitis (MUC) receiving immunosuppression should be weaned off immunosuppressives before undergoing ileal pouch surgery. Therefore, the aim of this study was to assess the affect of immunosuppressive drugs on postoperative complications after ileoanal pouch surgery.

MATERIALS AND METHODS

A retrospective medical record review of patients with MUC who underwent ileal pouch surgery while taking immunosuppressive drugs such as azathioprine, 6-mercaptopurine (6-MP), methotrexate, and cyclosporin A was performed. Postoperative complications in the study group were compared to three matched groups: patients with MUC who had ileoanal pouch surgery while taking systemic steroids, patients with MUC not receiving any immunosuppressive drugs, and patients with familial adenomatous polyposis.

RESULTS

Twenty-two patients with MUC who underwent ileoanal pouch surgery while taking immunosuppressive drugs were identified from a prospectively entered database of patients who had this surgery between 1988 and 2005. All but two patients underwent temporary fecal diversion. Fifteen patients were taking 6-MP or azathioprine; six were on cyclosporine A, and one both on azathioprine and cyclosporine A. Fifteen patients were also taking steroids at the time of ileoanal pouch surgery. Early (within 30 days of surgery) and late complications occurred in 36 and 50% of the study group patients, respectively, but did not significantly differ from a matched group of patients with MUC who did not take immunosuppressive drugs. Patients with familial adenomatous polyposis had a significantly lower long-term complication rate.

CONCLUSION

This retrospective case-matched study suggests that the use of immunosuppressive drugs and cyclosporine A may not be associated with an increased rate of complications after ileoanal pouch surgery.

Alternative approach to massive gastrointestinal bleeding in ulcerative colitis: highly selective transcatheter embolization

Massive haemorrhage in ulcerative colitis mainly occurs as a result of exacerbated disease, usually acute or even fulminant colitis. Emergency proctocolectomy is currently advocated as the only reliable treatment of this patient group. However, this type of surgical intervention has a high rate of morbidity and mortality. Recently, several promising studies have been published that describe transcatheter embolization for the treatment of massive lower gastrointestinal bleeding in cases of bleeding colonic diverticular disease and angiodysplasia. Success rates of 48-88% have been reported. To avoid the high risk associated with emergency colectomy, this modern procedure was performed in an ulcerative colitis patient with intractable lower gastrointestinal bleeding. To our knowledge, this is the first patient with ulcerative colitis presenting with massive lower gastrointestinal blood loss to be successfully treated by highly selective transcatheter embolization. This interventional procedure is suggested as an alternative therapeutic approach to haematochezia in selected ulcerative colitis patients.

Laparoscopic total colectomy for acute colitis: a case-control study

INTRODUCTION

There are no previous comparative studies of total abdominal colectomy by laparoscopic methods in ulcerative colitis and Crohn's disease patients requiring urgent colectomy. This study aimed to determine the safety and efficacy of laparoscopic colectomy in these patients compared with those undergoing conventional urgent colectomy.

METHODS

Patients undergoing laparoscopic total colectomy for acute colitis were identified in a prospective registry. All patients underwent a total colectomy with creation of an end ileostomy and buried mucous fistula. No patient had fulminant disease (tachycardia, fever, marked leukocytosis, peritonitis), but all were failing to respond to medical treatment. Patients undergoing conventional total colectomy were matched for age, gender, body mass index, diagnosis, disease severity, and operative period. Median values (range) are listed.

RESULTS

From 1997 to 1999, there were 19 laparoscopic and 29 matched conventional patients. There were no inadvertent colotomies or conversions in the laparoscopic group. Although there was no difference in operative blood loss in the laparoscopic group (100 (range, 50-700) ml) when compared with the conventional group (150 (range, 50-500) ml), the operative times were significantly longer in the laparoscopic group (210 (range, 150-270) vs. 120 (range, 60-180) minutes, P < 0.001). Bowel function returned more quickly in the laparoscopic group (1 (range, 1-3) vs. 2 (range, 1-4) days; P = 0.003) and the length of stay was shorter (4 (range, 3-13) vs. 6 (range, 4-24) days; P = 0.04). Complications occurred in three (16 percent) laparoscopic patients (2 wound infection and 1 ileus) and in seven (24 percent) conventional patients (3 wound infection, 3 deep venous thrombosis, 1 upper gastrointestinal bleed).

CONCLUSIONS

Laparoscopic total colectomy is feasible and safe in patients with acute nonfulminant colitis and may lead to a faster recovery than conventional resection.

The incidence and outcome of pelvic sepsis following handsewn and stapled ileal pouch anal anastomoses

The incidence and outcome of pelvic sepsis was analyzed in 210 patients who underwent restorative proctocolectomy for ulcerative colitis (UC) in 197 patients, and for familial adenomatous polyposis (FAP) in 13 patients. Pelvic sepsis developed in 18 patients (8.6%) and a significantly higher incidence was seen in men than in women, at 13.6% vs 3.7%, respectively (P < 0.05). The incidence of pelvic sepsis in patients with UC complicated by toxic megacolon and/or fulminant colitis was significantly higher that in those without any preoperative complications, at 36.4% vs 7.4% (P < 0.05). The incidence of pelvic sepsis following handsewn anastomosis was significantly higher than that following stapled anastomosis, at 15.6% vs 5.5% (P < 0.05). The outcome of pelvic sepsis in patients with a stapled anastomosis was better than that in those with a handsewn anastomosis. The prognosis of women who developed pelvic sepsis was better than that of men who developed pelvic sepsis. The risk factors predisposing to pelvic sepsis were UC, especially when complicated by toxic megacolon and/or fulminant colitis, and male sex, while a handsewn anastomosis was more vulnerable than a stapled anastomosis.

Ileal pouch anal anastomosis without ileal diversion

OBJECTIVE

To evaluate continued experience with a one-stage stapled ileoanal pouch procedure without temporary ileostomy diversion.

SUMMARY BACKGROUND DATA

Most centers perform colectomy, proctectomy, and ileal pouch anal anastomoses (IPAA) with a protective ileostomy. Following a previous report, the authors performed 126 additional stapled IPAA procedures for ulcerative colitis and familial adenomatous polyposis, of which all but 2 were without an ileostomy. Outcomes in these patients question the need for temporary ileal diversion, with its complications and need for subsequent surgical closure.

METHODS

Two hundred one patients underwent a stapled IPAA since May 1989, 192 as a one-stage procedure without ileostomy, and 1 with a concurrent Whipple procedure for duodenal adenocarcinoma. Patient charts were reviewed or patients were contacted by phone to evaluate their clinical status at least 1 year after their surgery.

RESULTS

Among the patients who underwent the one-stage procedure, 178 had ulcerative colitis (38 fulminant), 5 had Crohn's disease (diagnosed after IPAA), 1 had indeterminate colitis, and 8 had familial adenomatous polyposis. The mean age was 38 +/- 7 (range 7--70) years; there were 98 male patients and 94 female patients. The average amount of diseased tissue between the dentate line and the anastomosis was 0.9 +/- 0.1 cm, with 35% of the anastomoses at the dentate line. With 89% follow-up at 1 year or more (mean 5.1 +/- 2.4 years) after surgery, the average 24-hour stool frequency was 7.1 +/- 3.3, of which 0.9 +/- 1.4 were at night. Daytime stool control was 95% and night-time control was 90%. Only 2.3% needed to wear a perineal pad. Average length of hospital stay was 10 +/- 0.3 days, with 1.5 +/- 0.5 days readmission for complications. Abscesses or enteric leaks occurred in 23 patients; IPAA function was excellent in 19 of these patients (2 have permanent ileostomies). In patients taking steroids, there was no significant difference in leak rate with duration of use (29 +/- 8 with vs. 22 +/- 2 months without leak) or dose (32 +/- 13 mg with vs. 35 +/- 3 mg without leak). Two (1%) patients died (myocardial infarction, mesenteric infarction).

CONCLUSIONS

The triple-stapled IPAA without temporary ileal diversion has a relatively low complication rate and a low rate of small bowel obstruction, provides excellent fecal control, permits an early return to a functional life, and can be performed in morbidly obese and older patients.

Severe steroid-unresponsive ulcerative colitis: outcomes of restorative proctocolectomy in patients undergoing cyclosporin treatment

PURPOSE

The recent introduction of the immune suppressor cyclosporin for treatment of steroid-refractory ulcerative colitis has required surgeons to perform a colectomy in those patients who eventually fail this rescue treatment, thus raising questions as to the safety of surgery as performed in patients with a heavily manipulated immune system. To assess the rates of mortality and morbidity in this setting, we studied a cohort of consecutive patients who had surgery after failing cyclosporin for refractory ulcerative colitis at our center.

METHODS

Between January 1991 and December 1996, 25 patients with ulcerative colitis underwent restorative proctocolectomy performed in three steps (21 patients) and in two steps (4 patients). Seventeen of the 25 patients (68 percent) were initial nonresponders to a dose of 2 mg/kg/day of intravenous cyclosporin and underwent surgery immediately, the remaining 8 (32 percent) relapsed as outpatients on oral cyclosporin and were readmitted for surgery.

RESULTS

There was no operative mortality. Nine patients of the 25 developed postoperative (early) complications (36 percent). The three-step operation subset had a 28 percent complication rate, the two-step 75 percent. Three patients needed reoperation. A total of 11 patients (44 percent) reported with late complications: two patients required surgical treatment, one for obstruction and one for pouch-perianal fistula. Three cases of pouchitis were recorded. No patient required pouch removal.

CONCLUSION

Given the absence of postoperative mortality and a low overall complication rate, restorative proctocolectomy can safely be performed in patients who fail rescue treatment with a dose of 2 mg/kg of cyclosporin for steroid-refractory ulcerative colitis. Corollary evidence in this article hints but does not prove that the three-step procedure is safer than the two-step operation.