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Emergency

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  • 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.

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Elective

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Ulcerative Colitis (Curative)

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  • 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.

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Crohn's Disease (Palliative)

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  • Total proctocolectomy with end ileostomy only; IPAA is not an option (see Contraindications later).
  • Indications for proctocolectomy include:
    • Internal fistula.
    • Abscess.
    • Malignancy.
    • Intractability.

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Ileal Pouch Anal Anastomosis

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Absolute

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  • 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.

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Relative

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  • 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).

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Total Proctocolectomy with End Ileostomy

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  • 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.

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  • 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.

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  • 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.

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  • 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.
  • Sepsis.
    • Pelvic abscess.
    • Anastomotic leak.
  • Fistula.
    • Pouch-vagina.
    • Perineal.
    • Potentially indicative of Crohn's disease if it occurs after IPAA.
  • Anastomotic stricture.
    • Usually resolves with digital or balloon dilation.
    • May require pouch revision.
  • Pouchitis.
    • Poorly understood entity, occurring in 30–50% of pouch ...

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