Operative options

1
Results of surgery in ulcerative colitis

• Operative options
• Ileo-anal pouch anastomosis (IAPA)
• Proctocolectomy ileostomy
• Ileo rectal anastomosis
• Continent ileostomy

2
Results of surgery in ulcerative colitis

• Subjective outcomes of ileoanal pouch anastmosis
• Continence
• Frequency
• Deferment
• Medication
• Diet
• Activities
• Objective outcomes of ileoanal pouch anastomosis
• Anal function MRP, MSP
• Pouch compliance and capacity
• Pouch emptying

3
Results of surgery in ulcerative colitis

• Good pouch function
• 4-8 stools per day
• No urgency, deferment gt 30 minutes
• No daytime incontinence, minor nocturnal leakage
• Painless spontaneous defecation
• Factors influencing functional outcome
• Pre operative factors Age, No. of stools
• Operative factors Pouch design
• Mucosectomy
• Surgeons experience
• Post operative factors Complications

4
Results of surgery in ulcerative colitis

• Early complications of ileoanal pouch anastomosis
• Intestinal obstruction
• Septic complications anastomotic leaks, pelvic
  abscesses, pouch-related fistulae
• Rarely resolve with conservative measures
• May need multiple procedures
• Sepsis from pouch anal anastomosis site is the
  most difficult to treat

5
Results of surgery in ulcerative colitis

• Late complications of ileoanal pouch anastomosis
• Stricture
• Pouch dysfunction
• Risk factors for pouch dysfunction
• Septic complications
• Experience of the surgeon
• Long term steroid use ?
• Hand sewn rather than stapled pouch ?
• One stage rather than three stage surgery ?
• Management of pouch dysfunction
• Rediversion
• Pouch excision
• Redo pouch

6
Results of surgery in ulcerative colitis

• Pouchitis
• Diagnosis Clinical examination
• Endoscopic findings
• Histological evidence
• Pathogenesis Stasis and bacterial overgrowth
• Mucosal ischemia
• SCFA deficiency
• Glutamine deficiency
• Crohns disease
• Recurrence of ulcerative colitis
• Treatment Antibiotics
• Immunosuppressive therapy
• Novel therapies
• Consider Crohns disease
• Pouch excision

7
Results of surgery in ulcerative colitis

• GB Pant Hospital data
• Jan 1990 to Dec 2002, 150 patients
• Intestinal obstruction 11
• Septic complications 9
• Pouch excision 4
• Pouchitis 7/54