Emergency surgery in ulcerative colitis

1
Emergency surgery in ulcerative colitis
Background and evolution Before 1950 Mortality
40-50 Steroid therapy (1960s) Mortality
8-10 Emergency colectomy (1970s-1980s)
Mortality 1-2
Truelove and Witts, 1952 Brooke Sampson,
1964 Goligher 1970, Truelove 1978
2
Emergency surgery in ulcerative colitis
Why surgery is required Intensive medical therapy
fails in a third of patients with severe acute
ulcerative colitis Additional immunosuppressive
agents are toxic and controversial Those who do
respond eventually, upto 50 require colectomy at
a later date (within a year) In the presence of
complications such as toxic megacolon, impending
perforation and bleeding, surgery is the best
option
3
Emergency surgery in ulcerative colitis
Indications for emergency surgery Refractory
severe acute ulcerative colitis Toxic
megacolon Perforation spontaneous iatrogenic Mas
sive lower GI bleeding Large bowel obstruction
4
Emergency surgery in ulcerative colitis
Clinical laboratory parameters predicting
failure of medical therapy Stool frequency gt
9 33 Pulse gt 100 36 Temperature gt
38ºC 56 Serum albumin lt 3 g/dl 42 Day 3 CRP
level gt 45 mg/L 85 Radiological signs
predicting failure of medical therapy Mucosal
islands 75 Colonic dilatation 75 Small
intestinal dilatation 73
Lennard-Jones, 1975 Travis, 1996
5
Emergency surgery in ulcerative colitis
Timing of surgery Non-controversial
Perforation spontaneous or iatrogenic Toxic
megacolon 24-48 hours Massive bleeding gt 6
units over 24 hours Large bowel obstruction
Resuscitate operate Controversial Refractory
severe acute ulcerative colitis Timing 3-5
days Add Cyclosporine/Azathioprine ? The more
the delay, higher the surgical mortality and
morbidity
Goligher 1970, Ritchie 1984, Hyde 1997
6
Emergency surgery in ulcerative colitis
Timing of emergency surgery Severity of episode/
predicted outcome Presence of complications Patien
ts general condition Nutritional
status Patients consent acceptance Physicians
consent and acceptance Past history Duration and
course of ulcerative colitis Extent of colonic
involvement Compliance with drug
therapy Complications of drug therapy
7
Emergency surgery in ulcerative colitis
Choice of emergency procedure Accepted and
recommended Subtotal colectomy with
ileostomy long rectal stump short rectal
stump Total proctocolectomy with
ileostomy Controversial Diverting ileostomy
alone Subtotal colectomy with IRA (one
stage) Total proctocolectomy with restorative
proctocolectomy (one stage)
8
(No Transcript)
9
Emergency surgery in ulcerative colitis
Choice of surgical procedure Subtotal colectomy
with ileostomy with a long rectal stump with
Hartmanns closure or mucus fistula Keighley et
al, Nicholls RJ, 2002 Special situations Total
proctocolectomy with permanent ileostomy One
stage subtotal colectomy with Ileo-rectal
anastomosis
10
Emergency surgery in ulcerative colitis
Subtotal colectomy with ileostomy Advantages
Suitable for most indications Safest option
(mortality 6 morbidity 30-40) Avoids
anastomoses and leaks Allows staged restorative
proctocolectomy Allows accurate pathological
diagnosis Aids in patients psychological
adjustment Disadvantages Requires staged
re-operation Not appropriate for patients with
low rectal cancer Rectal stump related problems
10-15 continued bleeding stump leaks with
pelvic sepsis (rare) symptomatic proctitis
11
Emergency surgery in ulcerative colitis
Subtotal colectomy with ileostomy management of
the rectal stump Long vs. short Preference Long
rectal stump reaching sacral promontory/ lower
abdominal wall Short stump severe rectal
bleeding/rectal cancer Keighley et al, Karch et
al, 1995 Hartmanns closure vs mucus
fistula Guided by personal preference Mucus
fistula unhealthy stump severe proctitis with
bleeding The middle path Stump closed but
tacked to the rectus sheath in the lower part of
the midline incision Motson Menche, 1985 Ng RL
et al, 1992
12
Emergency surgery in ulcerative colitis
Total proctocolectomy with ileostomy Rare
situations UC with low rectal growth Profuse
rectal bleeding Short rectal stump? High
morbidity (50-60) mortality (10-14), nerve
injury, disallows subsequent restorative
proctocolectomy
13
Emergency surgery in ulcerative colitis
Outcomes of surgery Indication Incidence Mortalit
y Perforation 10-15 40 Toxic
megacolon 6-13 11-16 Haemorrhage 1-2
4-5 Obstruction 5-10 -
Treatment related outcome Medical treatment
alone 18 Surgery (overall) 8-10 STC
3-6 TPC 7-15
Becker JM, GCNA 1999
14
Emergency surgery in ulcerative colitis
Controversial procedures Ileostomy alone
Anecdotal experience Sub total colectomy with
ileorectal anastomosis Highly selected young
patients with rectal sparing. Contraindicated in
Crohns, anal dysfunction, severe proctitis,
dysplasia Subsequent proctectomy 20, life-long
surveillance for cancer, anastomotic leaks,
intestinal obstruction One stage total
proctocolectomy with ileal pouch-anal
anastomosis Highly selected patients Limited
experience (Harms 1994, Fazio 1995) Increased
morbidity Higher leak rates, obstruction, pelvic
sepsis
15
Emergency surgery in ulcerative colitis
The AIIMS experience 1987-2003 Patients 157
patients (88 M), Age 35 years (14-72y) Emergency
operations 69 patients (43) Proportion of
patients with severe ulcerative colitis requiring
surgery 31 Indications Refractory severe
acute ulcerative colitis 53 (77) Others 16
(23) Perforation 8 (Spontaneous 5, iatrogenic
3), Toxic megacolon 3, Severe LGIH 4,
Obstruction 1
16
Emergency surgery in ulcerative colitis
The AIIMS experience Subtotal colectomy with
ileostomy 65 Ileostomy alone 4 (2) Timing of
the procedure Mean 8.8 days (Range 1-30
days) Group I (lt 5 days) 29 42 Group II
(6-10 days) 20 29 Group III (gt 11 days) 20 29
17
Emergency surgery in ulcerative colitis
Timing and indication Indication GroupI Group
II Group III number 29 20 20 Refractory 72 80 80
Other 28 20 20
Indications and surgical outcome Indication
n Died gt 5 d Refractory severe
UC 53 8 15 8 Severe LGIH 4 1 25 0 Toxic
megacolon 3 2 66 1
18
Emergency surgery in ulcerative colitis
Timing and surgical outcome Timing n Deaths
Mortality Group I 29 2 6.8 Group
II 20 3 15.0 Group III 20 6 30.0 Overall 69 11 1
5.9
Cause of death Septicaemia 6 Respiratory failure
2 ARDS, DIC 1 Ketoacidosis 1 UGI bleeding 1
19
Emergency surgery in ulcerative colitis
Conclusions Joint management is the first
step Timing of surgical intervention
crucial Severe acute ulcerative colitis 3-5
days Perforations ASAP Toxic megacolon 24-48
hrs Lower GI hemorrhage 48-72 hrs Obstruction
48-72 hrs Procedure of choice subtotal
colectomy with Hartmanns/ mucus fistula