Special Surgery 21. Surgical Aspects of Ulcerative Colitis

I. Ulcerative Colitis Overview Relevant to Surgery

Definition

• Chronic inflammatory bowel disease affecting colon and rectum
• Always starts in rectum and extends proximally in continuous pattern
• Inflammation is mainly mucosal and submucosal
• No skip lesions in typical UC
• Surgery can be curative for colonic/rectal disease because disease is limited to colon and rectum

Morphology

• Location:

• Rectum always involved in classic UC
• May extend to left colon or entire colon
• Backwash ileitis can occur in severe pancolitis but is not Crohn-type skip ileitis

• Macroscopic:

• Diffuse erythema
• Loss of vascular pattern
• Friability and bleeding
• Ulceration in severe disease
• Pseudopolyps

• Microscopic:

• Mucosal/submucosal inflammation
• Cryptitis and crypt abscesses
• Crypt architectural distortion in chronic disease

Clinical Features

Intestinal Manifestations

• Onset often teenage/young adult
• Bloody diarrhea with mucus
• Tenesmus and urgency
• Left lower quadrant abdominal pain
• Weight loss, fever, fatigue in active/severe disease
• Nocturnal stooling in active colitis

Extraintestinal Manifestations

• Joints: arthritis, ankylosing spondylitis, sacroiliitis
• Skin: erythema nodosum, pyoderma gangrenosum
• Eyes: uveitis, episcleritis
• Hepatobiliary: primary sclerosing cholangitis, more common association than in Crohn disease
• VTE risk increased during active severe colitis and hospitalization

• Perianal fistula/abscess/fissure is not typical UC; prominent perianal fistulizing disease should raise suspicion for Crohn disease or alternative diagnosis

Diagnosis

• Labs:

• Increased CRP/ESR/WBC
• Anemia, often iron-deficiency from chronic bleeding
• Fecal calprotectin increased
• Albumin low in severe disease/malnutrition
• Stool tests to exclude infection, especially C. difficile in severe flare

• Colonoscopy/sigmoidoscopy:

• Ulceration, erythema, friability
• Loss of vascular pattern
• Continuous inflammation from rectum proximally
• Biopsy: crypt abscesses, mucosal inflammation, chronic architectural distortion, pseudopolyps

• In acute severe colitis, perform limited flexible sigmoidoscopy carefully; avoid full colonoscopy because perforation risk

II. Surgical Indications

Emergency / Urgent Indications

1. Toxic megacolon
2. Perforation
3. Acute severe colitis refractory to maximal medical therapy
4. Severe bleeding

Toxic Megacolon

• Toxic colonic dilatation due to severe inflammation extending into deeper layers and neuromuscular dysfunction
• Systemic toxicity:

• Fever
• Tachycardia
• Leukocytosis
• Anemia
• Dehydration/electrolyte disorder

• Risk: perforation → fecal peritonitis and sepsis
• Initial treatment: bowel rest, IV steroids, broad-spectrum antibiotics if toxicity/perforation concern, correction of electrolytes, stop antimotility/opioid drugs
• Surgery if perforation, worsening toxicity, increasing dilation or no rapid response

Acute Severe / Fulminant Colitis

• Severe sudden flare with frequent bloody stools and systemic toxicity
• Complications:

• Dehydration
• Sepsis-like physiology
• Toxic megacolon
• Perforation

• Medical treatment:

• Hospitalization
• IV corticosteroids first-line
• Rescue infliximab or cyclosporine in selected steroid-refractory cases if no immediate surgical emergency

• Surgical consultation early
• If no improvement after about 3 days of IV steroids/rescue assessment, avoid prolonged delay; colectomy becomes safer than continuing failed therapy

Perforation and Severe Bleeding

• Perforation = absolute emergency indication
• Signs:

• Sudden severe pain
• Peritonitis
• Free air
• Sepsis/shock

• Massive lower GI bleeding from UC is rare but can require urgent colectomy if uncontrolled

Elective Indications

• Medically refractory disease:

• Persistent symptoms despite optimized medical therapy
• Poor quality of life

• Steroid dependence or steroid toxicity
• Medication intolerance/contraindication
• Dysplasia or colorectal cancer suspicion/diagnosis
• Long-standing disease with high cancer-risk lesion not manageable endoscopically
• Growth failure or delayed puberty in children
• Extraintestinal manifestations that improve with colectomy, selected cases

Colorectal Cancer Risk and Surveillance

• CRC risk increases with:

• Disease duration, especially after 8-10 years
• Extent: pancolitis > left-sided colitis
• Persistent inflammation
• PSC
• Family history
• Previous dysplasia

• Surveillance colonoscopy with biopsies/chromoendoscopy depending on protocol
• High-grade dysplasia, multifocal dysplasia or unresectable visible dysplasia → proctocolectomy usually recommended

III. Surgical Options

Emergency Operation: Subtotal Colectomy with End Ileostomy

• Preferred urgent operation for acute severe UC, toxic megacolon, perforation or severe refractory colitis
• Procedure:

• Remove colon
• Create end ileostomy
• Leave rectal stump or mucous fistula

• Why not immediate pouch in acute severe colitis:

• Patient is septic/malnourished/steroid-exposed
• Pelvic dissection risk high
• Diagnosis can be confirmed before definitive reconstruction
• Allows recovery before completion proctectomy/IPAA

• Rectal stump needs monitoring; retained rectum can still bleed/inflame and has cancer risk if left long-term

Total Proctocolectomy with Ileal Pouch-Anal Anastomosis (IPAA)

• Most common restorative curative operation for suitable UC patients
• Removes colon and rectum
• Preserves anal sphincter
• Creates neorectum from terminal ileum, usually J-pouch
• Pouch is anastomosed to anal canal
• Usually includes temporary diverting loop ileostomy depending on stage/risk

Staging Options

• One-stage:

• Proctocolectomy + IPAA without diverting ileostomy
• Rare, highly selected elective low-risk patients

• Classical two-stage:

• Proctocolectomy + IPAA + diverting loop ileostomy
• Later ileostomy closure

• Modified two-stage:

• Subtotal colectomy + end ileostomy first
• Later completion proctectomy + IPAA without diverting ileostomy in selected patients

• Three-stage:

• Subtotal colectomy + end ileostomy
• Completion proctectomy + IPAA + diverting loop ileostomy
• Ileostomy closure
• Preferred in acute severe colitis, high-dose steroids, biologic exposure, malnutrition or uncertain diagnosis

Total Proctocolectomy with Permanent End Ileostomy

• Definitive and curative for colonic/rectal UC
• No pouch
• Indications/preferred when:

• Weak sphincter or fecal incontinence
• Low rectal cancer or anal sphincter problem
• High surgical risk / older patient
• Patient preference to avoid pouch risks
• Suspicion of Crohn disease or severe perianal disease

Ileorectal Anastomosis (IRA)

• Colectomy with ileorectal anastomosis, rectum preserved
• Not standard gold option because rectum remains diseased and cancer-risk tissue remains
• Can be considered in highly selected patients with minimally affected rectum, good compliance with surveillance and strong preference to avoid pouch/pelvic dissection
• Requires lifelong rectal surveillance and medical treatment of residual proctitis

Technical Principles

• Minimally invasive laparoscopic/robotic approach preferred when feasible
• Protect pelvic autonomic nerves to preserve urinary/sexual function
• Assess sphincter function before IPAA
• Confirm diagnosis: Crohn disease or indeterminate colitis increases pouch failure risk
• Preoperative stoma marking and patient education
• Optimize nutrition, anemia and steroid dose before elective surgery

IV. Postoperative Considerations and Complications

IPAA Functional Expectations

• Typical bowel function after pouch:

• Several bowel movements per day
• Possible nocturnal stooling
• Urgency usually improves over time
• Continence depends on sphincter function and pouch health

• Quality of life is often good, but not identical to normal rectum

Early Complications

• Anastomotic leak
• Pelvic sepsis/abscess
• Small bowel obstruction
• Bleeding
• Wound infection
• Ileus
• High-output ileostomy → dehydration/electrolyte disorder
• Stoma complications: retraction, prolapse, skin irritation

Late Complications

• Pouchitis:

• Common after IPAA
• Symptoms: increased stool frequency, urgency, cramps, pelvic discomfort, fever, malaise
• Treatment: antibiotics for infrequent acute pouchitis, usually ciprofloxacin or metronidazole depending on protocol
• Chronic/recurrent pouchitis may need endoscopy, cultures, biologics/small molecules or specialist care

• Cuffitis: inflammation of retained rectal cuff
• Pouch failure:

• Persistent sepsis, poor function, Crohn-like disease of pouch or refractory pouchitis
• May require diversion or pouch excision

• Fertility issues in women after pelvic surgery, especially open pelvic dissection
• Sexual/urinary dysfunction from pelvic nerve injury, uncommon but important
• Incontinence or urgency
• Stricture at pouch-anal anastomosis
• Vitamin B12/bile salt issues are less common than after extensive ileal resection but nutrition still needs monitoring

Cancer Surveillance After Surgery

• Permanent end ileostomy after complete proctocolectomy: no colorectal mucosa remains, so CRC risk from UC is removed
• Rectal stump left after subtotal colectomy:

• Requires endoscopic surveillance
• Can develop proctitis, dysplasia or cancer

• IPAA:

• Pouch/cuff surveillance in high-risk patients: previous dysplasia/cancer, PSC, chronic pouchitis/cuffitis, retained rectal cuff

Exam Pearls

• UC surgery is curative for colonic/rectal disease; Crohn surgery is not curative
• Emergency UC operation = subtotal colectomy + end ileostomy, not immediate pouch
• IPAA/J-pouch is restorative option for suitable patients with good sphincter function
• Permanent ileostomy is a valid definitive curative option
• Toxic megacolon, perforation, refractory acute severe colitis and severe bleeding are emergency indications
• Dysplasia/cancer, refractory disease and steroid dependence are key elective indications
• Prominent perianal fistulas/abscesses suggest Crohn disease rather than typical UC