Chapter 22. Operative Management of Inflammatory Bowel Disease

Emergency

• 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.

Elective

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.
  • Abscess.
  • Malignancy.
  • Intractability.

Ileal Pouch Anal Anastomosis

Absolute

• 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.

Relative

• 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.
• 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 ...