Chapter 22. Operative Management of Inflammatory Bowel Disease

Emergency

• 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.

Elective

Ulcerative Colitis (Curative)

• 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.

Crohn's Disease (Palliative)

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

Ileal Pouch Anal Anastomosis

Absolute

• 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.

Relative

• 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).

Total Proctocolectomy with End Ileostomy

• 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.

Expected Benefits

Total Abdominal Colectomy with End Ileostomy (Emergent Surgery)

• 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.

Ileal Pouch Anal Anastomosis

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

Total Proctocolectomy with End Ileostomy

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

Potential Risks

Men (All Procedures)

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

Women (All Procedures)

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

Both Men and Women

• 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).

• Lone-Star retractor (useful for exposure during the perineal dissection).
• Self-retaining retractor (helpful for the abdominal portions of the procedure to facilitate ...