Surgical Strategies Choice of Procedure

Operative strategies for treating severe ulcerative colitis are controversial. Nonresponder patients healthy enough to undergo full procedure at once can be submitted to restorative proctocolectomy. Conversely, patients with perforation, peritonitis, sepsis or massive bleeding should be submitted to a staged procedure: subtotal or total colectomy and ileostomy, followed later by ileorectal anastomosis (IRA) or by proctectomy with ileal pouch/anal anastomosis or by proctectomy with definitive ileostomy. In patients without perforation, peritonitis, sepsis or severe bleeding but not healthy enough to undergo full procedure at once, operative options include subtotal colectomy or rectum sparing total colectomy with ileostomy. Rarely, a blowhole colostomy with ileosto-my may be performed. Colectomy with IRA is rarely performed in a select group of patients, namely, those who have a contraindication to a stomy (e.g., portal hypertension or ascites). In most instances, a staged approach, with subtotal colectomy or rectum sparing total colectomy with an end ileostomy, is probably the best treatment because it safely removes the majority of the diseased organ, allowing the patient to recover from the toxic disease state for a future elective full procedure (Fig. 2). Diverting loop ileostomy or segmental colectomy are unusually performed in seriously ill patients. Specific criteria to assume the decision whether to perform an extensive resection or a staged approach are not defined. It is general experience, however, that a staged procedure is mandatory in patients with perforation, peritonitis or sepsis or in patients who do not respond to best medical treatment. Although a few studies report low morbidity and mortality in patients undergoing immediate restorative proctocolectomy [21, 22],

Acute Severe Colitis
Fig. 2. Acute severe colitis in pediatric age: gross appearance

most authors noted higher incidence of anastomotic leakage (30-40%) in patients undergoing immediate reconstruction [23, 24]. Currently, the choice of surgical procedure must be individualised on the basis of underlying physical, medical, sexual, social and psychological situation [25]. Special consideration in patient selection and in operative planning must be given to age, fertility and fecundity. Advanced age is not an absolute contraindication for ileal pouch-anal anastomosis (IPAA). According to some authors [26], there are no significant functional differences between young or healthy older patients with good sphincter tone. However, a few institutions have reported poorer functional outcomes in elderly patients (>45 years) submitted to IPAA [27]. Given the deep impact of surgery on fertility and fecundity, women should be informed of the possibility of decreased fertility after IPAA. Fecundity is significantly lower in young patients submitted to IPAA than those who undergo to IRA [28-30], probably due to anatomic changes in the pelvic configuration. Patients submitted to ileorectostomy or coloproctec-tomy with an end ileostomy usually have a normal pregnancy and delivery. Higher rate of caesarean sections are noted in IPAA patients. Both groups often experience temporary stoma or pouch dysfunction with increase in stool frequency, incontinence and pad usage during pregnancy [29, 31, 32].

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