Surgical Management Of Ulcerative Colitis Research Articles

Update on the Surgical Management of Ulcerative Colitis and Ulcerative Proctitis: Current Controversies and Problems

: The surgical management of ulcerative colitis has been revolutionized in recent years by the development of the ileal pouch-anal procedure. Although it is now the operation of choice for most patients, there remain several controversies. A variety of designs of ileal pouch are available each with advantages and disadvantages. The technique used to anastomose the pouch to the anal canal is also open to debate with some surgeons favoring distal mucosectomy with eradication of all disease and others choosing to perform a stapled anastomosis to achieve better functional results. The main concern for gastroenterologists, however, is the risk of development of pouchitis. The etiology, diagnosis, and treatment of this condition will also be discussed in this review as well as the more classical options for the surgical treatment of ulcerative colitis.

Chronic inflammatory bowel disease.

To be consigned to a life spent searching for the aetiology of inflammatory bowel disease remains as much a cause for supplication to St Jude as it ever did. Over the last decade new forms of inflammatory bowel disease have been described, the surgical management of ulcerative colitis has seen the impact of restorative proctocolectomy, and major changes have taken place in the medical management of Crohn's disease in childhood and adolescence. It is therefore appropriate to review some of these developments.

Restorative proctocolectomy with an ileal reservoir

Panproctocolectomy with a permanent incontinent ileostomy has become the gold standard in the surgical management of ulcerative colitis, and is often necessary in the treatment of polyposis coli. The advantage of this technique is that it completely removes all intestinal disease in one stage, with a low operative mortality, and eliminates the possibility of malignant change. Many patients, however, regard the acquisition of a stoma for the remainder of their lives as a major disadvantage. This latter factor may cause patients to delay surgery beyond the optimum time, and dissuade polyposis families from undergoing screening evaluation.

Harry E. Bacon oration. Evolution of surgical management of ulcerative colitis.

Harry E. Bacon oration. Evolution of surgical management of ulcerative colitis.

Alan Guyatt Parks 1920-1982

Alan Parks was born December 19, 1920. After attending Epsom College, he proceeded to Brasenose, Oxford, receiving his B. A. in 1943. That same year he was awarded a Rockefeller Fellowship to attend Johns Hopkins University to complete his medical training, and took a medical internship there. He returned to Guy's Hospital, London, and in 1949 he passed the examination for F.R.C.S. Following a period in the National Service in the Far East, Parks came back to Guy's to continue his research on anatomy of the anal canal. There followed numerous publications that provide an extraordinary testament to his dedication as a scientist and to his creative thinking. Parks was appointed Consultant Surgeon to the staff of St. Mark's Hospital in 1959 and to the London Hospital in the same year. His practice attracted many surgeons from throughout the world who came to train and to observe. He was regarded as a brilliant surgical technician, a compassionate humanitarian, an indefatigable worker, and a revered teacher. In 1954, Parks obtained a Master of Surgery for his work leading to his special operation for hemorrhoids. Through the years the name Alan Parks has been associated with innovation in the field of colon and rectal surgery. His contributions included the development of a number of surgical instruments, the etiology and classification of fistula-in-ano, physiology and anatomy of the pelvic floor, the treatment of anal incontinence, and the application of ileal reservoir with ileoanal anastomosis for the surgical management of ulcerative colitis and familial polyposis. It is this last subject, written with his colleague R. J. Nicholls, that has been chosen to be reproduced here as a classic article in colon and rectal surgery. Parks' honors were numerous, and included Presidency of the Section of Proctology of the Royal Society of Medicine, Fellowship of the Royal College of Physicians, and honorary fellowships from the American, Australasian, Canadian, Edinburgh, and Glasgow Colleges of Surgeons. A few days before his death he was admitted to honorary fellowship of the Italian Surgical Society. His contributions were further recognized when he was awarded a knighthood. Sir Alan Parks died after emergency cardiac surgery November 3, 1982.

Procedures conserving continence in the surgical management of ulcerative colitis: J. C. Goligher. Surg Clin North Am 63:49–60, (February), 1983

Procedures conserving continence in the surgical management of ulcerative colitis: J. C. Goligher. Surg Clin North Am 63:49–60, (February), 1983

Procedures Conserving Continence in the Surgical Management of Ulcerative Colitis

In managing ulcerative colitis, surgeons have relied on the one-stage ileostomy and complete proctocolectomy. The author cites four alternatives to this surgical treatment, alternatives that would avoid a permanent stoma, conserve continence, and preclude the use of an external appliance. The reservoir or continent ileostomy, artificial occlusive devices used with conventional ileostomy, colectomy and ileorectal anastomosis, and total colectomy, full-thickness proximal proctectomy, mucosal distal proctectomy, and ileoanal anastomosis with or without valveless ileal reservoir are the procedures in question.

Preservation of anorectal continence following total colectomy.

The search for continence in the surgical management of ulcerative colitis has resulted in the evolution of a method that has yielded gratifying results in the last 18 patients. The disease process is removed; all patients are continent; they have no postoperative perineal excoriation; the frequency of stools is not excessive and the patients are returning to work or to school within three weeks following ileostomy closure. Their ages were eight to 52 years. The procedure consists of a total of colectomy with mucosal proctectomy, ileoanal anastomosis and construction of a terminal ileal, pelvic reservoir. A proximal ileostomy diverts the fecal stream until healing is complete. The authors are now recommending the operation be considered for patients of all ages who require surgery for chronic ulcerative colitis as well as polyposis.

Cancer in the excluded rectum following surgery for inflammatory bowel disease.

The procedure of choice in the emergency surgical management of ulcerative colitis and Crohn's colitis is often subtotal colectomy and ileostomy. Further surgery of the retained rectum may be delayed, sometimes for many years. The risk of malignant change in ulcerative colitis is well documented; the cancer risk seems to be much less in Crohn's disease. Five cases are reported where carcinoma developed in the out-of-circuit rectal stump after subtotal colectomy, three cases of ulcerative colitis, and two of Crohn's disease. The importance of regular surveillance or removal of an excluded rectum is emphasized.

Surgical management of ulcerative colitis in childhood

Forty-seven children with ulcerative colitis (UC) have been treated by colectomy at the UCLA Hospital in the two decades since 1956. An intensive course of medical therapy including a short course of steroid treatment in an attempt to obtain clinical remission is recommended before proceeding with colectomy. Thirty-four children underwent elective colectomy, indicated by intractability of symptoms and a year of growth failure. Postoperative complication rates were higher after emergency colectomy (77 per cent) than after elective operation (50 per cent). The only deaths (3) occurred subsequent to emergency colectomy. Judicious use of preoperative steroids did not increase the incidence of postoperative complications. Thirteen of twenty-four children who underwent initial subtotal colectomy had the remaining rectum removed because of progression of disease within an average period of twenty-eight months. No child underwent successful ileorectal anastomosis after initial subtotal colectomy. Inasmuch as UC usually begins in the rectum, most children with this condition during the past ten years have been treated by total colectomy. Postoperative weight gain and improvement in quality of life were strikingly evident in almost all children who underwent total coloproctectomy. Colectomy is recommended particularly for children who do not experience remission from acute disease after steroid therapy and for those who have chronic disease during the growth period of adolescent years.

The Surgical Management of Ulcerative Colitis

As long as our understanding of ulcerative colitis is too limited to allow a more specific, disease-targeted treatment, surgery will play an important role in the management of these patients. Careful interdisciplinary evaluation and counselling of patients with ulcerative colitis will permit to achieve the goals on an individual basis with maximum safety. Restorative proctocolectomy with an IPAA has evolved as the procedure of choice among four basic surgical options because it appears to be safe and carries a low mortality. Although the associated morbidity is not negligible, functional results are generally good and patient satisfaction is high.

The Surgical Management of Ulcerative Colitis

In this small book, the author reviews his personal experience with some 400 ulcerative colitis patients. He covers the field broadly, from etiology through differential diagnosis, associated extra abdominal features, preoperative complications, surgery, postoperative complications, to results including physiological as well as psychological effects. It is almost a truism to many young people today that specialists, particularly surgeons, are devoid of personal feelings for the patient and the effects of his disease. Nothing in Mr. Walker's case could be further from the truth. The minutiae necessarily associated with conscientious care are well set out and exemplify in the best sense the involvement of the physician with the patient. For the most part, the book is clearly and interestingly written. There is a feeling of personal recounting of experiences. It is, however, somewhat repetitious in certain areas; but perhaps the author felt that there are aspects which bear repeating for emphasis.

Early pathologic changes in ulcerative colitis: Their relation to surgical complications

Study of colonic biopsy specimens in early ulcerative colitis has revealed a constant pattern of change in the involved mucosa. Degeneration occurs in the thickened layer of collagen fibrils which lies under the surface epithelium and often progresses to involve the entire pericellular collagen stroma of the lamina propria. The fibroblasts are granular and vacuolated. The small vessels of the mucosa contain reduced numbers of red blood cells, and signs of cellular anoxia appear in the surface epithelium. Early stromal edema gives way to round cell infiltration of the lamina propria. Later in the course of the disease, platelet agglutination occurs in the small mucosal vessels, and the surface capillaries are obliterated. The resulting mucosal infarctions are associated with the accumulation of polymorphonuclear leukocytes, apparently in response to ordinary bacterial invasion of the devitalized mucosa. The agglutination of the intact platelets is usually reversible, but occasionally the platelets break down, with the release of thromboactive materials. This may lead lead to true thrombosis, with enlargement of the areas of mucosal ulceration and the occurrence of pulmonary emboli from areas of pelvic venous thrombosis. The significance of these observations in the surgical management of ulcerative colitis is discussed.

ADJUSTMENT TO SURGERY OF CHILDREN WITH ULCERATIVE COLITIS.

Surgeons are generally optimistic about achieving good results in appropriate cases with the surgical management of ulcerative colitis in children. Individual contact with surgeons as well as their reports in the literature substantiate these results. Presumably this includes an improvement in the child's emotional state and ability to function as a result of removing his diseased organ and his no longer being chronically sick. If the surgeons' clinical experience and judgment is valid, it would seem of interest to examine more carefully the psychological basis for these good results. This has not been reported on previously in the literature to our knowledge. An opportunity presented itself to study this question when two boys with ulcerative colitis, who were being seen in psychiatric treatment by the psychiatrist (L. C.), required surgical treatment. Both boys underwent the standard two-stage operation: stage 1: ileostomy and subtotal colectomy; stage 2: abdominoperineal resection. Both boys

Surgical Management of Ulcerative Colitis

Surgical Management of Ulcerative Colitis

The Surgical Management of Ulcerative Colitis

The Surgical Management of Ulcerative Colitis

The Surgical Management of Ulcerative Colitis

The Surgical Management of Ulcerative Colitis