- Total abdominal colectomy with end ileostomy is the only operation typically performed in the emergent setting for the following indications:
- Ulcerative colitis: toxic megacolon, perforation, fulminant colitis, hemorrhage.
- Crohn's disease: same indications, plus obstruction.
Ulcerative Colitis (Curative)
- Either total proctocolectomy with end ileostomy or ileal pouch anal anastomosis (IPAA) may be selected, depending on patient factors.
- Indications for proctocolectomy include:
- Dysplasia or malignancy.
- Condition refractory to medical management; intractability.
- Growth retardation in children.
- Complications secondary to adverse effects of medical treatment.
Crohn's Disease (Palliative)
- Total proctocolectomy with end ileostomy only; IPAA is not an option (see Contraindications later).
- Indications for proctocolectomy include:
- Internal fistula.
Ileal Pouch Anal Anastomosis
- Crohn's disease.
- Emergency procedure.
- Low rectal neoplasia.
- Disseminated carcinoma.
- Incontinence (fecal).
- Inability to tolerate a long period of general anesthesia (4–6 hours) due to comorbidities.
- Indeterminant colitis.
- Obesity (thick mesentery precludes adequate mobilization).
- Ongoing high-dose steroid therapy (eg, prednisone, 50–60 mg/day); a staged approach may be preferable.
- Malnutrition (serum albumin < 2 g/dL).
Total Proctocolectomy with End Ileostomy
- If a patient is extremely ill, as in the emergent setting, total abdominal colectomy with end ileostomy should be performed, leaving the rectum intact at that operative setting.
- The patient should be in modified lithotomy position, with the legs supported in noncompressing stirrups.
- This position allows easy access to both the abdomen and the perineum.
- Arms may be tucked at the sides or extended on arm boards.
- During the operation, steep Trendelenburg position is helpful for obtaining access and exposure to the pelvis and perineum.
- Await resolution of ileus.
- For total proctocolectomy, vigilant care of the perineal wound and avoidance of pressure or weight bearing on the perineum.
- Close monitoring for signs and symptoms of anastomotic leak and pelvic sepsis.
- Tapering of stress-dose steroids, if appropriate.
- Patient education regarding dehydration, including information on:
- Signs and symptoms of dehydration.
- Recognition of risk factors for becoming dehydrated.
- Proper maintenance of appropriate oral fluid intake.
- Recognition of and treatment for high ostomy output.
- Enterostomal therapist education of patient and family regarding ostomy care.
- Nutritional counseling.
- Dehydration and electrolyte abnormalities.
- Although a diverting ostomy is in place, patients may require readmission to the hospital for hydration and correction of electrolyte derangements.
- If this problem is recurring or severe, it may necessitate early reversal of ostomy.
- Small bowel obstruction occurs in 15% of patients (half require operative intervention).
- Common causes include adhesions, internal hernia, and volvulus.
- Pelvic abscess.
- Anastomotic leak.
- Potentially indicative of Crohn's disease if it occurs after IPAA.
- Anastomotic stricture.
- Usually resolves with digital or balloon dilation.
- May require pouch revision.
- Poorly understood entity, occurring in 30–50% of pouch ...
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