Surgery

Introduction

Pharmacotherapy is successful at relieving intestinal symptoms in many ulcerative colitis (UC) patients. However, some patients will experience medically refractory disease and may opt for elective proctocolectomy, removing the source of the disease and in many cases, their symptoms. Other patients will develop life-threatening complications that necessitate urgent or emergent surgical intervention. Within the first year of diagnosis, between 4% and 9% of UC patients will require proctocolectomy, with the risk of surgical intervention increasing by about 1% each subsequent year. After 30 years of diagnosis, approximately one-third of UC patients will require surgery, compared with about 70% of patients with Crohn’s disease (CD).

Total proctocolectomy with ileal-pouch anal anastomosis (IPAA) is the most common operation for UC. Proctocolectomy is often described to patients as being “curative,” but postoperative complications, including pouchitis, are common. These risks should be adequately discussed with patients. Given that surgery for UC affects patient quality of life, close interaction between colorectal surgeons and gastroenterologists is necessary to optimize patient outcomes.

Trends in Surgery Rates

Disease requiring colectomy is more likely to develop in UC patients with more severe disease, disease extending proximal to the splenic flexure, in male patients, in patients with corticosteroid resistance and in patients who develop complications related to corticosteroid administration.

The risk of surgery in both UC and CD patients has decreased over the past several decades. In UC patients, the 10-year risk of colectomy has decreased from 13.5% during the 1970s to 7.6% during the 2000s (P <0.05). In a more recent study of 481 patients with UC who underwent elective or urgent colectomy for medically refractory UC between 1998 and 2011, the total incidence rate of surgery declined by 16% every year from 2005 onward. In an Italian cohort study of 159 patients with severe UC from referral centers, short-term colectomy rates decreased from 64.7% during the 1976 to 1980 period to 9.8% during the 2006 to 2010 period (P <0.0001). These reductions in colectomy rates parallel the approval of anti-tumor necrosis factor (TNF) agents for UC, the first of which (infliximab) was approved in 1998. Indeed, significant short-term reductions in colectomy rates have been reported following treatment with infliximab. Thus, reductions in colectomy rates have been in part attributed to more aggressive medical therapy, including approval and use of biologics for UC. However, long-term effects of biologics in preventing colectomy are still unclear.

Indications for Surgery

Indications for surgery in UC patients are categorized into urgent, emergent and elective (Table 12-1). The most common indication for urgent surgery is acute, severe UC refractory to intravenous (IV) steroids with failed response to rescue therapy (infliximab or cyclosporine), where severe UC is defined by passage of more than six bloody stools per day with associated fever, tachycardia, hemoglobin <75% of normal and an increased sedimentation rate. Additionally, not only are laboratory and clinical parameters important in deciding whether colectomy is appropriate, the severity of the colonic inflammation is also an important predictor of future prognosis.

Toxic megacolon, another indication for urgent surgery, is defined as the presence of transverse colon dilatation >6 cm in the presence of severe colitis. Since megacolon can progress to colonic perforation, which is associated with a mortality rate of between 27% and 57%, patients should undergo surgery if it does not improve with medical treatment.

Emergency surgery is required for life-threatening complications, such as severe uncontrolled hemorrhage, perforation, or multiple organ dysfunction syndrome.

The most common indication for elective surgery in UC patients is refractory disease, where optimal medical therapy fails to control disease symptoms or extraintestinal manifestations, when adverse effects from medications negatively affect quality of life or compliance, or when prolonged medication use results in unacceptable risks. Colorectal cancer (CRC) is another important indication for elective surgery. In a systematic review and meta-analysis of 81 studies that enrolled a total of 181,923 patients, the incidence rate of CRC in UC patients was found to be 1.58 per 1,000 patient-years and 1.24 per 1,000 patient-years when only population-based studies were considered. In studies that included only patients with extensive colitis, the incidence rate increased to 4.02 per 1,000 patient-years.

Incidence rates also increased with duration of disease, from 0.91 per 1000 patient-years during the first decade of disease, to 4.07 and 4.55 per 1000 patient-years during the second and third decades of disease, respectively. Incidence rate was also found to decrease from 4.29 per 1000 patient-years in studies published in the 1950s to 1.21 per 1000 patient-years in studies published within the preceding decade. Since colorectal cancer is one of the most common causes of mortality in UC patients, proctocolectomy is recommended in all UC patients with colorectal carcinoma or dysplastic lesions not amenable to endoscopic removal. Lastly, stricture formation is another indication for elective surgery.

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Proctocolectomy

The standard surgical procedure for UC patients is restorative proctocolectomy with IPAA. In this procedure, the entire colon and rectum are removed. The distal 30 cm of the ileum is then folded back on itself, creating a 15 cm J-shaped pouch to store stool. The ileum is then attached to the anus, allowing patients to pass stool. IPAA therefore does not require a permanent stoma and is favored by patients.

In urgent or emergent situations, proctocolectomy with IPAA is typically done in three stages (Figure 12-1) to reduce the risk of postoperative complications, such as pelvis sepsis or anastomotic leak. The first stage consists of a subtotal colectomy and creation of a temporary ileostomy. In the second stage, after improvement of clinical status, the ileal pouch is created and anastomosed to the anal canal with a diverting ileostomy. Lastly, intestinal continuity is restored in the third stage by taking down the diverting ileostomy.

Patients with an IPAA will typically have four to six bowel movements during the day in addition to one to two overnight. Frequency of bowel movements can be reduced with use of loperamide and fiber supplementation.

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Complications of Surgery

Postoperative complications are relatively common following IPAA, with up to 33% of patients experiencing early complications, up to 30% of patients experiencing late complications (excluding pouchitis) and up to 5% of patients experiencing pouch failure. Infertility is a common concern related to IPAA in women and is perceived to be a consequence of tubal adhesions from pelvic surgery. Infertility rate is approximately 25% in women following open surgery, however, laparoscopic restorative proctocolectomy with IPAA has been shown to form less adhesions, demonstrating a lower infertility rate compared with open IPAA and with similar rates compared with controls who had an appendectomy. Increased sexual dysfunction is another concern, with up to 25% of male patients experiencing erectile dysfunction or retrograde ejaculation following IPAA. Other complications of IPAA include stricture and development of Crohn’s disease. While TPC-IPAA greatly reduces the risk of CRC, surveillance of the remaining rectal mucosa and pouch is recommended.

Pouchitis is the most common postoperative complication following IPAA, with at least one episode occurring in up to 46% of patients. Pouchitis is a non-specific inflammatory condition of the ileal pouch, presenting with increased frequency, urgency, incontinence and abdominal discomfort. Two to 4 weeks of ciprofloxacin (1,000 mg daily) or metronidazole (20 mg/kg daily) is sufficient to treat most episodes; however, 10% to 15% of patients can develop chronic pouchitis, with frequent relapses or symptoms persisting beyond 4 weeks of treatment. Other agents have been used to treat pouchitis, including rifaximin, amoxicillin with clavulanic acid, topical mesalamine and other agents, including immune modulators and biologic agents. In a more recent phase 4 trial, the integrin inhibitor vedolizumab has demonstrated efficacy in the treatment of pouchitis, with 31% of vedolizumab-treated patients achieving modified Pouchitis Disease Activity Index (mPDAI) remission (an mPDAI score of ≤4 and a reduction from baseline of ≥2 points), compared to 10% of patients who received placebo (P=0.01). Patients who undergo ileal pouch anal anastomosis have rectal tissue at the anastomosis between the ileum and anal canal. This area can become inflamed (known at cuffitis), but typically responds to treatment with aminosalicylate (5-ASA) suppositories.