Ulcerative Colitis: Surgical Management
Management of patients with ulcerative colitis remains challenging despite advances in the medical and surgical fields. These patients are usually diagnosed at a young age and face the risk of a life-altering operation or lifelong risk of cancer degenerat
- PDF / 2,233,001 Bytes
- 26 Pages / 595.28 x 790.87 pts Page_size
- 98 Downloads / 207 Views
Key Concepts • Patients with ulcerative colitis should be managed by a multidisciplinary team of gastroenterologists, surgeons, pathologists, enterostomal therapists, and nutritionists. • Preoperative weight management, improvement of nutrition, and optimization of medical therapy before proceeding with construction of the ileal pouch anal anastomosis are critical steps to achieve optimal long-term functional results. • Laparoscopy should be considered the standard of care for elective surgery for ulcerative colitis • While ileal pouch anal anastomosis should be considered the standard of care in the surgical treatment of ulcerative colitis patients, the surgical plan should be individualized both in terms of staged approach and restoration of intestinal continuity. • Long-term follow-up of patients with an ileal pouch anal anastomosis is mandatory, even though the risk of malignant degeneration remains quite low.
Introduction Ulcerative colitis (UC) is an inflammatory intestinal condition characterized by continuous colonic inflammation extending from the rectum proximally. Patients generally present in the second or third decade of life with manifestations of the disease including abdominal pain, diarrhea, rectal bleeding, and weight loss. While medical therapy is often first-line treatment, proctocolectomy is curative and therefore surgery has a pivotal role in the therapeutic armamentarium of UC. The aim of this chapter is to highlight the indications for surgery, principles of surgical decision-making, operative techniques, and special considerations.
Indications for Surgery Approximately 25–30 % of patients with UC will undergo surgical intervention in their lifetime, with up to 10 % of patients requiring surgery within the first year of diagnosis due to a variety of elective and emergent causes (Table 50-1) [1]. The timing of surgery depends on the indication and severity of disease.
Elective Surgery Elective indications for surgery include failure of medical management, complications or side effects associated with medications, dysplasia or invasive cancer, extraintestinal manifestations, and growth retardation in children and adolescents. Patients with active disease despite optimization of maintenance therapy are often in better general health than patients with fulminant colitis, but may undergo surgery in order to avoid corticosteroid dependency. A diagnosis of high-grade dysplasia (HGD), dysplasiaassociated lesion or mass (DALM), or invasive carcinoma in a patient with UC is an absolute indication for surgery. The diagnosis of dysplasia or cancer can be challenging in the setting of UC; therefore, it is imperative to obtain confirmation from two experienced GI pathologists [2]. The overall rate of colorectal cancer in patients with UC is 3.7 % with a risk of 2 % at 10 years, 8 % at 20 years, and 18 % at 30 years [3]. Synchronous and metachronous dysplasia and carcinoma are more common in patients with UC than in the sporadic colorectal cancer population. Kiran et al. recently reported a 14 % synchro
Data Loading...
