Therapy of IBD in 1994: a surgeon’s perspective

Abstract

The options of surgical therapy for ulcerative colitis patients include total proctocolectomy and Brooke ileostomy, total proctocolectomy and the continent ileostomy, subtotal colectomy and ileorectal anastomosis, as well as the pelvic pouch procedure. A stoma is required for the first two mentioned procedures, and no stoma is required for subtotal colectomy and ileorectal anastomosis and the pelvic pouch procedure. In our experience, as well as others, there are very few candidates that are now acceptable for a colectomy and ileorectal anastomosis alone. All of the above procedures achieve continence except for the conventional ileostomy, but the reoperation rates for all of the procedures vary from 25–50% with the continent ileostomy to ~ 10–12% following the pelvic pouch procedure. With all types of surgeries there may be failures of therapy. As will be discussed below, the morbidity following a pelvic pouch procedure is considerable, and must be weighed against doing this procedure versus a total proctocolectomy and Brooke ileostomy. However, it must be stated that surgery is curative for ulcerative colitis, and ‘avoidance of colectomy’ should not be the major outcome measure when one is assessing a patient for either medical or surgery therapy. The disease is completely removed with any form of total proctocolectomy and in most cases with the pelvic pouch procedure, although recently the transitional zone as well as 1–2 cm of anal mucosa may be left behind using a stapled technique for the pelvic pouch procedure.