Ulcerative colitis and Crohn’s disease are gastrointestinal disorders of modern society, and their frequency has increased in developed countries since the mid-20th century. The highest incidence and prevalence of inflammatory bowel disease are seen in North America and Northern Europe, whereas the lowest rates are seen in continental Asia.1 Despite the use of biologics and other advances in medical treatment, up to 15% to 30% of patients with ulcerative colitis and up to 70% of patients with Crohn’s disease will require surgery during the course of their disease. Recent trends in inflammatory bowel disease have included the increased adoption of a laparoscopic or minimally invasive approach to surgery with the advantages of a faster recovery, fewer complications, less intra-abdominal adhesions, better cosmesis, and a shorter hospital stay. Biologics have changed the medical approach to inflammatory bowel disease, particularly in patients with Crohn’s disease, with an increasing usage of a “top down” approach to treatment in an attempt to rapidly induce remission in patients. With increasing usage of biologics for treatment of inflammatory bowel disease, there is increasing concern about the risk of infectious complications and other complications in patients on biologics who require surgery and the optimal perioperative management of these agents.
This perspective reviews trends in surgery for ulcerative colitis, the role and results of ileal pouch anal anastomosis surgery, the use of biologics around the time of surgery, and the management of dysplasia and cancer.
Since its introduction by Parks and Nicholls in 1978, restorative proctocolectomy with ileal pouch anal anastomosis has become the standard operative approach for the majority of patients who require surgery for ulcerative colitis. Despite over 35 years of experience, the procedure remains technically demanding and is associated with a number of potential complications that are balanced by the patient’s desire to avoid a permanent ileostomy. With appropriate expertise, outcomes are excellent and associated with improved quality of life and high patient satisfaction.
The ileoanal pouch procedure is performed in a staged approach, rarely in a single stage without an ileostomy and most commonly as a 2- or 3-stage procedure (Table 47-1). Indications for surgery for patients with ulcerative colitis include failure of medical therapy, intractable fulminant colitis, toxic colitis, perforation, uncontrolled bleeding, intolerable side effects of medications, strictures, growth retardation in children, high-grade or multifocal dysplasia and dysplasia-associated lesions or masses, and cancer. Patients with acute colitis or fulminant colitis and those who require emergency surgery are generally initially treated with total abdominal colectomy, ileostomy, and Hartmann closure of the rectum. In these nonelective situations, pouch construction is generally felt to be contraindicated.
TABLE 47-1RESTORATIVE PROCTOCOLECTOMY: 1-, 2-, AND 3-STAGE PROCEDURES