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Emergency

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  • Total abdominal colectomy with end ileostomy is the only operation typically performed in the emergent setting for the following indications:
    • Ulcerative colitis: toxic megacolon, perforation, fulminant colitis, hemorrhage.
    • Crohn's disease: same indications, plus obstruction.

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Elective

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Ulcerative Colitis (Curative)

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  • Either total proctocolectomy with end ileostomy or ileal pouch anal anastomosis (IPAA) may be selected, depending on patient factors.
  • Indications for proctocolectomy include:
    • Dysplasia or malignancy.
    • Condition refractory to medical management; intractability.
    • Growth retardation in children.
    • Complications secondary to adverse effects of medical treatment.

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Crohn's Disease (Palliative)

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  • Total proctocolectomy with end ileostomy only; IPAA is not an option (see Contraindications later).
  • Indications for proctocolectomy include:
    • Internal fistula.
    • Abscess.
    • Malignancy.
    • Intractability.

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Ileal Pouch Anal Anastomosis

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Absolute

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  • Crohn's disease.
  • Emergency procedure.
  • Low rectal neoplasia.
  • Disseminated carcinoma.
  • Incontinence (fecal).
  • Inability to tolerate a long period of general anesthesia (4–6 hours) due to comorbidities.

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Relative

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  • Indeterminant colitis.
  • Obesity (thick mesentery precludes adequate mobilization).
  • Ongoing high-dose steroid therapy (eg, prednisone, 50–60 mg/day); a staged approach may be preferable.
  • Malnutrition (serum albumin < 2 g/dL).

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Total Proctocolectomy with End Ileostomy

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  • If a patient is extremely ill, as in the emergent setting, total abdominal colectomy with end ileostomy should be performed, leaving the rectum intact at that operative setting.

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Expected Benefits

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Total Abdominal Colectomy with End Ileostomy (Emergent Surgery)

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  • Removal of the bulk of the diseased colon, allowing the patient to improve from a medical standpoint while enabling a restorative procedure to be performed at a later date.

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Ileal Pouch Anal Anastomosis

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  • Restoration of gastrointestinal continuity precluding the need for permanent ostomy.
  • Significantly reduces risk of developing colorectal malignancy secondary to chronic inflammatory bowel disease.

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Total Proctocolectomy with End Ileostomy

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  • Prevents the development of colorectal malignancy secondary to chronic inflammatory bowel disease.
  • Provides effective treatment for fistulous perineal disease.

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Potential Risks

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Men (All Procedures)

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  • Urinary retention.
  • Erectile dysfunction.
  • Retrograde ejaculation.

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Women (All Procedures)

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  • Dyspareunia.
  • Decreased fertility.
  • Urinary dysfunction.
  • Enlarged uterus may necessitate hysterectomy at the time of operation.

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Both Men and Women

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  • Need for diverting ileostomy (IPAA).
  • Anastomotic leak → abscess or sepsis → poor pouch function (IPAA).
  • Anastomotic stricture (IPAA).
  • Bowel obstruction (all procedures).
  • Anal leakage (IPAA).
  • Pouch failure requiring revision to end ileostomy (IPAA).
  • Pouchitis (IPAA).

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  • Lone-Star retractor (useful for exposure during the perineal dissection).
  • Self-retaining retractor (helpful for the abdominal portions of the procedure to facilitate exposure of the operative field).
  • Gastrointestinal anastomosis (GIA) stapler.
  • End-to-end anastomosis (EEA) stapler (optional).

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  • Anesthesia consultation, ...

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