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General Surgery
Ulcerative Colitis
Built from Maingot's Abdominal Operations
What’s inside
12 sections · 187 slides
Overview
- What this deck covers
Understanding the disease
What it is, and why surgeons meet it
- Definition of ulcerative colitis
- Clinical importance and the place of surgery
- Early descriptions of the disease
- Separation of the two inflammatory bowel diseases
Epidemiology
Who gets ulcerative colitis, and where
- Counting the disease, and how common it is
- Global trends and populations at risk
- Age at onset
Pathophysiology
Genes, environment and an immune response that will not switch off
- The central mechanism
- Sequence from susceptibility to tissue damage
- Genetic basis and the loci identified
- Environmental triggers
- Innate and adaptive immunity in the gut
- The immune response in ulcerative colitis
Pathology
What the colon looks like, to the eye and down the microscope
- Distribution and depth of inflammation
- Mucosal changes at endoscopy
- Colectomy specimen in ulcerative colitis
- Pseudopolyps, the burnt-out colon and strictures
- Backwash ileitis
- Microscopic hallmarks of active disease
- Features not seen, and the quiescent biopsy
Clinical features
How patients present, and how a flare is graded
- Range of first presentations
- Symptoms and sequelae as the disease worsens
- Patterns of disease over time
- Truelove and Witts criteria for a severe attack
- Disease activity in ulcerative colitis
- Extraintestinal manifestations
- Organs affected outside the bowel
- Primary sclerosing cholangitis
- Skin and biliary manifestations of ulcerative colitis
- Pyoderma gangrenosum of the lower limb
- Cholangiographic appearance of primary sclerosing cholangitis
Diagnosis
Endoscopy, surveillance and the markers that separate the two diseases
- Making the diagnosis
- Endoscopic appearance by severity and in chronic disease
- Differentiation of ulcerative colitis and Crohn's disease
- Endoscopy in severe acute colitis
- Surveillance colonoscopy for cancer
- Dysplasia and DALM
- Managing a raised lesion found at surveillance
- Deciding treatment for a raised lesion
- Serologic markers: pANCA and ASCA
- Value, limits and newer markers
Medical management
Inducing remission, and keeping it
- Principles of medical therapy
- Mild to moderate distal colitis
- Extent of disease and oral therapy
- Severe colitis: intravenous corticosteroids
- Rescue therapy
- Supportive care in severe colitis
- Other essential measures in severe colitis
- Remission and first-line maintenance
- Thiopurines for steroid-dependent disease
- Infliximab and other maintenance options
Indications for surgery and preoperative care
When to operate, and what must be done first
- How the indications are grouped
- Grouping the indications for operation
- Acute severe colitis and toxic megacolon
- Toxic megacolon on abdominal radiographs
- Dilated transverse colon in toxic megacolon
- Timing surgery when the response is incomplete
- Outcome after medical control of toxic colitis
- Perforation and massive haemorrhage
- Intractability and steroid dependence
- 2%
- Colectomy when cancer is not confirmed
- Dysplasia grades and why the whole colon goes
- Systemic complications and growth retardation
- Goals before surgery
- Thromboembolic prophylaxis and bowel preparation
- Perioperative steroids and nutrition
- Marking the stoma site
- Incisions and preserving future options
Surgical options
From the first colostomy to the pelvic pouch
- Evolution of surgery and the Brooke ileostomy
- Ileorectal anastomosis and the continent ileostomy
- Why the Kock pouch fell out of favour
- Birth of the ileal-pouch anal anastomosis
- Operations available today
- Subtotal colectomy and ileostomy: indications
- Further indications and the caveat
- Subtotal colectomy: opening steps
- Mobilising the colon
- Dividing the bowel
- The rectal stump problem
- Three ways to handle the rectal stump
- Trade-offs of each rectal stump option
- Laparoscopic subtotal colectomy: technique and extraction
- Evidence for the laparoscopic approach and its limits
- Colectomy and ileorectal anastomosis
- Ileorectal anastomosis: technique
- Proctocolectomy and ileostomy: rationale
- Living with a stoma, and who has this operation
- Proctocolectomy: positioning and preparation
- Positioning hazards and abdominal access
- Mobilising the rectum
- Differences from a cancer operation
- Bleeding and injury during pelvic dissection
- The perineal dissection
- Completing the operation, closure and drainage
- Constructing and maturing the end ileostomy
- Kock pouch: what it offers and who gets one
- Building the Kock reservoir
- Making and stabilising the nipple valve
- Bringing out the Kock stoma
- Ileal-pouch anal anastomosis: why it is preferred
- Relative contraindications to IPAA
- Perianal disease and cancer as contraindications
- One, two or three stages
- What each staged plan looks like
- The authors' staging preference
- Pouch configurations
- Hand-sewn versus stapled anastomosis
- Living with the retained cuff
- Open IPAA: the extirpative phase
- Gaining mesenteric length
- Reconstructive phase: mobilisation
- Building the J-pouch
- Making the ileoanal anastomosis
- Securing the anvil and stapling the rectum
- Completing the pouch-anal anastomosis
- Hand-sewn anastomosis: mucosectomy
- Delivering and sewing the pouch
- Laparoscopic IPAA: the evidence
- Laparoscopic IPAA: technique
- Extraction and pouch construction laparoscopically
- Hand-assisted laparoscopy
- Selecting between the laparoscopic techniques
Complications of surgery
Obstruction, the stoma, the perineum, the pelvis and each procedure's own troubles
- Small bowel obstruction: why it happens
- How often obstruction occurs after IPAA
- Adhesion barriers and laparoscopy
- Ileostomy complications: overview
- Early and late ileostomy complications
- Loop ileostomy: high output and closure
- Problems with permanent ileostomies
- Managing a parastomal hernia
- Peristomal ulcers, fistulas and pyoderma
- Perineal wound complications and chronic sinus
- Genitourinary dysfunction and nerve protection
- Sexual function after IPAA
- Infertility after surgery
- Why fertility falls, and how to counsel
- Pregnancy and delivery after IPAA
- Anastomotic leak after ileorectal anastomosis
- Cancer in the rectal remnant after IRA
- Nipple valve slippage
- How valve slippage presents and is managed
- Nipple valve prolapse
- Fistulas after a Kock pouch, and why the fundus fails
- Recognising and treating a valve fistula
- Cancer, volvulus and valve ischaemia
- Leaks after IPAA: where and when
- Why leaks matter, and how often they occur
- Detecting a leak
- Salvaging the pouch
- Pouch-vaginal fistula
- Repairing a pouch-vaginal fistula
- Anal stenosis after IPAA
- Late anal fistulas, setons and skin tags
- Cuffitis
- Pouchitis
- Diagnosing pouchitis, and how common it is
- Causes and risk factors for pouchitis
- Treating pouchitis
- Dysplasia in the pouch
- Which pouches are at risk, and how to follow them
- Cancer risk in the rectal outlet
- Dysplasia in the anal transition zone
- Surveillance strategy after IPAA
Outcome, quality of life and summary
What happens to patients in the long run
- Mortality and morbidity after surgery
- Long-term outcome after IRA and the Kock pouch
- Failure rates and causes after IPAA
- Experience and hospital volume
- Quality of life before and after surgery
- Quality of life does not depend on the operation
- Why patients still choose a pelvic pouch
- Functional results after IPAA
- Key points: the disease
- Key points: when and how to operate
- Key points: what goes wrong, and how it ends
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- Maingot's Abdominal Operations, 12th Edition