Wayne B. Tuckson, M.D.
Associate Professor of Surgery
Department of Surgery
University of Louisville
Thirty-eight percent of patients with ulcerative colitis require surgery within 13 years of diagnosis (1). The percentage requiring surgery varies with the extent of disease. Sixty-one percent of patients with pancolitis require surgery, compared to 52% for left sided colitis and 14% for proctosigmoiditis (1).
Ulcerative colitis is a disease of the mucosa of the colon. Since it does not directly affect the small intestines or anus, removal of the colon effectively treats the intestinal manifestations.
Fifteen to 20% of patients presumed to have ulcerative colitis instead have either indeterminate colitis or Crohn's disease. This misdiagnosis may lead to inappropriate surgical treatment and possible otherwise avoidable complications. Clinical features that facilitate differentiating ulcerative colitis from Crohn's colitis include a history of anal disease predating the onset of diarrhea, abdominal masses, and evidence of small bowel disease, stricture formation, rectal sparing, cobblestoning of the mucosa, and serpiginous ulcers (2). If the diagnosis is uncertain either a total abdominal colectomy with ileostomy and Hartmann's pouch, or an ileorectal anastomosis are viable options. The resected colon provides a larger specimen for the pathologist to clarify the diagnosis, and does not obviate later reconstruction if needed (3).
Surgical Indications and Goals
Indications for surgery for UC include 1) intractability, 2) hemorrhage, 3) extraintestinal manifestations, 4) fulminating disease, 5) perforation, 6) toxic colitis, and 7) cancer or the risk of cancer (4). In particular, patients with either a dysplasia-associated lesion or mass (DALM), or dysplasia (low or high grade) should be considered for proctocolectomy (5)
The ideal operation for UC would 1) remove the diseased bowel, 2) return the patient to health, 3) lessen the risk of developing cancer, 4) obviate the need for permanent ileostomy, 5) preserve the anus for defecation, 6) maintain continence, 7) have few complications, and 8) be done in one stage (4).
The four current surgical options for treating ulcerative colitis are total proctocolectomy with Brooke ileostomy (TPC, ileostomy), total abdominal colectomy with ileorectal anastomosis (TAC, IRA), total proctocolectomy, continent ileostomy (Barnett or Kock pouch) (TPC, KP), and total proctocolectomy, ileal pouch anal anastomosis (TPC, IPAA). To date, none of the 4 options completely satisfies all of the ideals.
As has been previously discussed in this forum, proctectomy and segmental colectomy are inadequate for the surgical treatment of ulcerative colitis (6). Diseased bowel is left behind and often the disease progresses necessitating completion colectomy at a later date. This option will not be discussed further except to say that it is not an appropriate alternative.
Subtotal Colectomy with Ileostomy and Hartmann's Pouch
Patients with mild to moderate fulminant colitis may undergo definitive surgical treatment, as an emergency with few complications. However, patients with fulminant colitis and toxic colitis are often more debilitated and a staged procedure with a subtotal colectomy and ileostomy with either a Hartmann's pouch or mucus fistula (STC, ileostomy) may lessen the morbidity and mortality in urgent and emergency settings. Using STC, ileostomy, the bulk of the disease is removed and the complications associated with an anastomosis are avoided. Of particular note is the avoidance of pelvic dissection in this acute setting which alone is associated with a significant morbidity.
Following colectomy, as the patient improves the need for medical support diminishes definitive elective treatment may be safely completed. Several options are then available including an ileal pouch-anal anastomosis if the final diagnosis is ulcerative colitis.
Complications of Pelvic Nerve Injury
The mean age of diagnosis of UC is 32 years and the mean age at surgery 35 years (1). At these ages patients are very much concerned with their reproductive capabilities. The pelvic nerves injury occurs during rectal mobilization. This may complicate all of the procedures except for TAC, IRA. Dissection close to the rectal wall within identifiable planes can prevent most of these complications.
Though 10 to 25% of male patients may be impotent following surgery, this often resolves during the first year after surgery (7). Between 5 and 33% of women experience sexual dysfunction, including dyspareunia (7).
Bladder dysfunction, hesitancy and dribbling, is usually self-limiting and resolves without treatment within 1 to 2 weeks. However, 21% of patients may continue to have problems up to 5 years later (8).
Total Proctocolectomy with Ileostomy
TPC with ileostomy remains the benchmark procedure for the treatment of UC. The advantages are that 1) the diseased colon is removed, 2) UC medications can be stopped, 3) patients are able to return to normal health and activities, 4) the risk of cancer is obviated, and 5) the procedure is done in one stage. All UC patients are candidates for this operation irrespective of age, sex, and body habitus (9).
The disadvantages of TPC, ileostomy include 1) the need for a permanent ileostomy and stoma appliance, 2) a lack of control over stool evacuation, 3) the complications associated with pelvic dissection, and 4) the potential for a perineal wound. After 20 years, 76% of patients with an ileostomy have experienced complications such as skin irritation, intestinal obstruction, stoma retraction, or parastomal herniation (10).
Patients on average empty their appliances 6 times over 24 hours with total volumes between 600 - 800 ml. The stoma effluent varies from pasty to watery depending upon absorption and transit. Many patients use antidiarrheal medications either regularly or intermittently, adjusting for stool frequency.
In spite of the need to wear an appliance, ileostomates are generally very satisfied with their quality of life after surgery. (11,12). Though happy, ileostomates report more restrictions on daily activities compared to patients with either an IPAA or a KP (13).
Total Abdominal Colectomy with Ileal Rectal Anastomosis
TAC, IRA removes the abdominal colon, but leaves the rectum intact. The advantages are that 1) there is an improvement in health, 2) there is no pelvic dissection, 3) the operation is done in one stage, 4) patients have 3 stools on average per 24 hours, 5) continence is preserved, and 6) patients do not have a stoma. TAC, IRA was an alternative to TPC and ileostomy for younger patients in an effort to delay an ileostomy until a more acceptable time. Now, it is used in those few patients who have rectal sparing, or are not suitable candidates for an IPAA (14), or in those with a picture suggestive of indeterminate colitis.
The disadvantages of this procedure are that 1) all of the diseased bowel is not removed, and 2) the risk of cancer, though decreased is not eliminated. After 25 years of follow up 13% of patients with an IRA for UC developed cancer in the rectal remnant (15). Since these patients will need routine surveillance for both cancer and persistence of UC, it is imperative that they be reliable and able to return for examinations on a regular basis.
Of patients with an IRA over 90% resume normal activities and have an improved quality of life ( ). Overall, patients are very satisfied following surgery, but because of the need for regular surveillance patients do not always feel cured (9).
Total Proctocolectomy with Continent (Kock) Pouch
Prior to 1983 TPC, KP was a popular alternative to TPC with Brooke ileostomy. Though several centers continue to promote its advantages as a treatment for UC, the popularity of KP has waned. Currently KP is limited to those patients who are 1) not candidates for an IPAA, 2) as a modification for patients who currently have a Brooke ileostomy, and 3) as an alternative to Brooke ileostomy for those patients requiring ileal pouch excision (17).
The advantages of this operation are that 1) all of the diseased bowel is removed, 2) patients are off of medications, 3) patients return to health and normal activities, 4) the risk of cancer is obviated and 5) patients are continent and don't have to wear a stoma appliance.
The disadvantages are 1) that this is a 2 to 3 stage operation, 2) the risk of pouchitis, 3) complications of pelvic dissection, 4) patients must catherize the pouch to evacuate the contents and 5) an almost 50% reoperation rate because of nipple valve slippage (18).
Continence is maintained by the creation of a nipple valve fashioned by intussuscepting a portion of the ileum into the pouch. Several techniques have been employed to prevent nipple valve slippage including the use of fascia, mesh and intestines in the Barnett modification (19). Nipple valve slippage results in either incontinence of the pouch or the more urgent problem an inability to catherize and empty the pouch. Other valve specific complications include bleeding, ischemia, and valve necrosis (16).
Compared to patients with a Brooke ileostomy, patients with a KP are more active, less restricted, and have a better self-image (13,16). In spite of the high reoperation rate, 97% of patients with a KP said that they would rather have KP revision rather than have the pouch removed if it failed (16).
Total Proctocolectomy with Ileal Pouch Anal Anastomosis
Early attempts at preserving bowel continuity after TPC in a patients with UC resulted in failure because of high stool frequency and incontinence. Modifications by Parks, Utsunomiya, and Martin in the late 70's resulted in a low-pressure reservoir and improved continence. As a result of these and other modifications, TPC, IPAA has supplanted all other operations as the preferred surgical option for patients with UC.
The advantages of TPC, IPAA are that 1) all of the diseased bowel is removed, 2) patients may stop UC medications, 3) patients return to health and normal activity, 4) the cancer risk is obviated, 5) stool is passed through the anus, and 6) continence is preserved.
The disadvantages are that 1) it requires 2 or 3 stages, 2) complications associated with pelvic dissection, 3) patients have a mean stool frequency of 6 per day one of which is nocturnal, 4) incontinence rates vary from 5 to 20%, 5) many patients must take antidiarrheal preparations, and 6) pouchitis.
Patients with an IPAA report the highest levels of satisfaction compared to patients with either a Brooke or continent ileostomy (13). However, complications such as stool frequency, urgency and incontinence can detract from the quality of life.
Stool frequency is affected by stool volume, pouch compliance, pouch capacity, and the patient's response to distention (20). Pouches may be constructed from either 2 limbs ("J" pouch), 3 limbs ("S" pouch), or 4 limbs ("W" pouch). Though J pouches are the easiest to construct, they have the lowest capacitance and compliance. S pouches have a longer reach into the pelvis than J pouches, but the efferent limb must be less than 2 cm in length to prevent outlet obstruction. W pouches have a greater capacitance and compliance than either J or S pouches, but this does not translate into a functional advantage (9).
Anal Transition Zone Preservation
Continence is dependent upon stool characteristics, pouch compliance and contraction, and anal sphincter tone. Eighty-five percent of the resting tone of the anal canal is derived from the internal anal sphincter (IAS). Attempts at minimizing IAS injury result in improved continence. IAS tone may be decreased directly as a consequence of anal dilation to facilitate mucosectomy and hand sewn anastomosis, or indirectly as a consequence of ischemia or disruption of autonomic innervation to the anal sphincter after rectal resection (9,21).
The double stapled technique in which the rectum is transected 1 to 2 cm proximal to the dentate line and a second stapler is introduced through the anus to complete the pouch-anal anastomosis avoids IAS damage from dilation. As a consequence of this procedure the transitional mucosa between the dentate line and the rectum, the anal transition zone (ATZ), is preserved. Though theorized, it is not clear that this area actually affects continence.
Concern has arisen over the potential of leaving mucosa that may persistent in producing symptoms of UC, or more importantly develop a cancer. In long term follow up, the risk of dysplasia remaining in the ATZ is low (3.1%) (22). Still, because of concerns, it may be prudent to biopsy this area yearly. If persistent dysplasia or cancer is found then a trans anal mucosectomy to remove the involved segment is possible without jeopardizing pouch integrity (23). ATZ preservation is not recommended if a patient preoperatively is known to have either high-grade dysplasia or a cancer in the rectum. In these cases a mucosectomy is recommended.
Diverting loop ileostomy has been an integral part of TPC, IPAA. It protects the anastomosis and has decreased the incidence of pelvic sepsis. However, closure of an ileostomy is not without complications, not to mention the added cost of a second surgery and hospitalization. TPC, IPAA can be performed without an ileostomy, particularly in those patients in good nutritional condition, and not on steroids or 6 MP. Not withstanding, pelvic sepsis following IPAA has such grave consequences to both the patient and the pouch that it seems prudent to protect the IPAA with fecal diversion (24).
Pouchitis is the most common complication of TPC, IPAA. Patients with pouchitis present with an increased stool frequency, urgency, incontinence, cramping abdominal pain, and a flu like generalized malaise. On pouchoscopy the mucosa is inflamed and may be ulcerated. Other conditions to be considered include 1) idiopathic pouchitis, 2) anastomotic stricture with bacterial overgrowth, 3) pouch anal abscess or fistula, 4) ischemia, 5) cytomegalovirus infection, 6) recurrent UC in retained rectal mucosa, 7) Crohn's disease, and 8) irritable bowel syndrome (25).
Up to 30 percent of patients with an IPAA have one episode of pouchitis and 10% have severe chronic pouchitis (25,26) exacerbation. Pouchitis is also seen in patients with a KP. The fast response to Metronidazole supports the role of anaerobic bacteria overgrowth as a cause or significant factor in the etiology. Fortunately few patients' symptoms are severe enough to require pouch excision.
Following TPC, IPAA some women experience dyspareunia, but fertility rates are unaffected in the absence of pelvic sepsis. While pregnant, stool frequency is increased, but returns to normal post partum. Patients may be delivered vaginally or by cesarean section without disrupting the pouch or the pouch-anal anastomosis (9).
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- Bodzin JH, Klein SN, Priest. Ileoproctostomy is preferred over ileoanal pull-through in patients with indeterminate colitis. Am Surg 1995;61:590
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- Ziv Y, Fazio VW, Sirimarco MT, et al. Incidence, risk factors, and treatment of dysplasia in the anal transition zone after ileal pouch-anal anastomosis. Dis Colon Rectum 1994;37:1281
- Fazio VW, Tjandra. Transanal mucosectomy. Ileal pouch advancement for Anorectal dysplasia or inflammation after restorative proctocolectomy. Dis Colon Rectum 1994;37:1008
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