From the Guidelines
Surgical options for ulcerative colitis include total proctocolectomy with ileal pouch-anal anastomosis (IPAA), total proctocolectomy with permanent ileostomy, and subtotal colectomy with ileorectal anastomosis, with IPAA being the gold standard procedure as it preserves bowel continuity and eliminates diseased tissue 1. The choice of surgical procedure depends on various factors, including the patient's overall health, disease severity, and personal preferences.
- Total proctocolectomy with IPAA is commonly called a J-pouch and is the most frequently performed procedure for ulcerative colitis, as it allows patients to avoid a permanent ostomy while eliminating diseased tissue 1.
- Total proctocolectomy with permanent ileostomy may be recommended for patients with poor sphincter function, advanced age, or those who cannot undergo multiple surgeries 1.
- Subtotal colectomy with ileorectal anastomosis preserves the rectum but carries a risk of ongoing disease and is rarely performed 1. Surgery is typically considered when medical therapy fails, complications like toxic megacolon occur, or when there's concern for dysplasia or cancer 1. Recovery involves multiple stages for IPAA, with temporary ileostomy for 2-3 months between stages, and patients should expect 4-6 bowel movements daily after full recovery, with potential complications including pouchitis, small bowel obstruction, and sexual dysfunction 1. It is essential to involve a multidisciplinary team, including a gastroenterologist, colorectal surgeon, and stoma therapist, to ensure better management and patient outcomes 1. The British Society of Gastroenterology recommends that patients with acute severe ulcerative colitis who have not responded to rescue therapy within 7 days should undergo subtotal colectomy and ileostomy, with preservation of the rectum 1.
From the Research
Surgical Options for Ulcerative Colitis
The primary surgical option for ulcerative colitis is restorative proctocolectomy with ileal pouch-anal anastomosis (RP/IPAA) 2, 3, 4, 5, 6. This procedure involves the removal of the colon and rectum, and the creation of a pouch from the ileum to store feces.
Types of RP/IPAA
There are different types of RP/IPAA, including:
- J pouch: a J-shaped pouch created from the ileum 2
- S pouch: an S-shaped pouch created from the ileum 2
- H pouch: an H-shaped pouch created from the ileum, mainly used in redo pouches 2
Approaches to RP/IPAA
RP/IPAA can be performed using different approaches, including:
- Laparoscopic approach: a minimally invasive approach using a laparoscope 3
- Robotic approach: a minimally invasive approach using a robotic system 2
- Open approach: a traditional open surgery approach 2
- Single incision laparoscopic (SILS) approach: a minimally invasive approach using a single incision 3
Staged Approach
A staged approach is often used for RP/IPAA, which can be performed in 2 or 3 stages 2. This approach allows for a more gradual recovery and reduces the risk of complications.
Complications of RP/IPAA
Common complications of RP/IPAA include:
- Pouchitis: inflammation of the pouch 4, 6
- Pelvic sepsis: infection of the pelvic area 2
- Pouch failure: failure of the pouch to function properly 2
- Anastomotic stricture: narrowing of the anastomosis 2
Success Rate of RP/IPAA
The success rate of RP/IPAA is high, with over 95% of patients becoming stoma-free in 10 years 2. However, the procedure is complex and requires experienced professionals to perform.