Chronic Ulcerative Colitis

Question 1

surgery does not improve outcomes in

Answer 1

PSC, ankylosing spondylitis, or sacroiliitis.

Question 2

When will UC Patients require to do annual colonoscopic surveillance

Answer 2

Patients with UC and PSC are at higher risk for dysplasia and colorectal cancer and should undergo annual colonoscopic surveillance beginning when PSC is diagnosed

Question 3

Smoking in IBD

Answer 3

Cigarette smoking > protective against UC
and > risk factor for Crohn’s disease.

Question 4

presence of strictures or fibrotic disease

Answer 4

should raise suspicion for Crohn’s colitis or malignancy.

Question 5

endoscopist should grade the mucosa using the Mayo endoscopic subscore

Answer 5

see

Question 6

Diagnosis

Answer 6

• Endoscopy (sigmoidoscopy and/ or colonoscopy) with biopsy is the gold standard
• Examination of the terminal ileum can help avoid misdiagnosis of Crohn’s disease
• ESR, CRP
• Stool Test, C.Diff
• Fecal Calprotectin differentiate between inflammatory versus noninflammatory diarrhea and correlates well with disease activity
• CT Scan > Acute Setting Rule out Perf or Toxic mega
• CTE or MRE > identify Small Bowel Disease

Question 7

mild to moderate UC Tx

Answer 7

• Aminosalicylates
  (mesalamine or diazo-bonded 5-ASA)
  given orally and/ or topically by suppository or enema.
• Oral prednisone, rectal steroids, or oral or rectal budesonide multimatrix (MMX) can also be used to aid in achieving remission.

Question 8

moderate to severe disease

Answer 8

• Biologics (monoclonal antibodies) with or without an immunomodulator (e.g., azathioprine) or small molecules.
• Except for steroids, medications used for induction of remission for moderate to severe UC are continued for maintenance.

Question 9

patients with Acute Severe UC Tx

Answer 9

• bowel rest
• intravenous hydration
• venous thromboembolism prophylaxis
• minimizing narcotics
• cessation of antidiarrheal agents to avoid toxic megacolon.
• C. diff should be rule out
• flexible sigmoidoscopy > risk-stratification and to rule out superimposed CMV colitis.
• intravenous steroids and biologic agents.
• Surgical consultation > surgery results in an end ileostomy.

Question 10

surgery for three main reasons

Answer 10

(1) failure of medical management to control either the intestinal or extraintestinal manifestations of UC
( MC Indication )
(2) dysplasia and colorectal cancer
(3) toxic megacolon

Question 11

routine endoscopic surveillance, When ?

Answer 11

-beginning 8 to 10 years after disease onset or sometimes sooner.

-Colonoscopy should occur every 1 to 3 years depending on risk factors such as PSC, a family history of colorectal cancer, and whether active inflammation is present.

Question 12

Role of close colonoscopic surveillance ?

Answer 12

• patients with visible and resectable dysplasia can be safely followed with close colonoscopic surveillance
• using dye spray or virtual chromoendoscopy and high-definition endoscopes
• If persistent invisible multifocal or high-grade dysplasia, unresectable dysplasia, or colorectal cancer on biopsy
  > proctocolectomy

Question 13

Patients with advanced disease despite maximal medical therapy, Risk for ?

Answer 13

• may progress to toxic megacolon
• characterized by colonic dilation, fevers, tachycardia, leukocytosis, and abdominal distension
• requires urgent surgical Intervention

Question 14

Patients with (toxic megacolon, severe medically refractory disease, refractory ASUC, perforation) whats best done ?

Answer 14

total abdominal colectomy with end ileostomy

Question 15

Steps of Total Colectomy with loop ileostomy

Answer 15

1- Medial to lateral approach
2- dissection begins on the left by the sigmoid colon
3- retracted anteriorly > identify IMA.
4- identify and preserve the left ureter and gonadal vessels before ligation
5- Create window > isolate the pedicle > ligation
6- dissection then proceeds superiorly separating the colon from Gerota’s fascia up to the splenic flexure
7- Dissect lateral attachments > white line of Toldt
8- Division of the rectosigmoid junction with a stapler
9- ligation of mesenteric vessels.
10- then go to the right colon with identification and ligation of the ileocolic artery
11- medial dissection proceeds superiorly toward the hepatic flexure, followed by a lateral dissection releasing the peritoneal attachments.
12- all remaining attachments along the transverse colon are divided.
13- The colectomy is completed with division of the terminal ileum.

Question 16

If the rectosigmoid bowel is thick and edematous, What to do ? ‘‘challenging rectal stump ‘’

Answer 16

-the selected division point should allow for the rectosigmoid area to be matured to the skin as a mucous fistula.

-Other strategies include :
oversewing the staple line
decompressing the rectum with a rectal tube.

Delayed intraabdominal breakdown of the rectal stump results in sepsis and usually needs to be managed with reoperation.

Question 17

Where should be your proximal Division ?

Answer 17

The proximal division should be in the very distal terminal ileum so that sufficient small bowel remains for an ileal pouch if the patient desires.

Question 18

Why ileostomy should be above the skin

Answer 18

• will allow for a well-fitting ileostomy appliance and reduce risk of skin breakdown, pain, and discomfort.
• Also ensure that the mesentery of the small bowel is not twisted > can lead to obstruction and ischemia then reoperation

Question 19

Completion Proctectomy/ Total Proctocolectomy best offered for

Answer 19

dysplasia
cancer
chronic medically refractory disease
(not hospitalized, not on high dose steroids, and without signs of malnutrition)

either proceed with ileal pouch anal anastomosis (IPAA) with a temporary diverting loop ileostomy or simply remove the rectum and remain with a permanent end ileostomy.

Question 20

Proctectomy Steps

Answer 20

1- The rectum is identified
2- IMA > coursing along the retroperitoneum
3- peritoneum is incised
4- left ureter is identified
5- IMA and IMV are ligated.
6- dissection into the pelvis posteriorly > developing plane between the mesorectum and the fascia propria of the rectum.
7- The superior hypogastric plexus should be identified and preserved.
8- Once the pelvic floor is reached, the anterior dissection should be initiated
9- developing plane between the rectum and prostate or vagina.
10- avoid entering Denonvilliers’ fascia as nerves controlling sexual function course around the pelvic brim
11- lateral stalks of the rectum should be divided on the right and left
12- rectum should now be free circumferentially to the pelvic floor
13- confirmed by placing a finger in the anus.
14- rectum and anus will be completely removed > dissection from the anus.
15- Simple dissection conducted from the perineum in the intersphincteric (between the internal and external anal sphincter) groove.
16- This is usually bloodless and leaves the external sphincter in place to help with perineal wound healing and prevent herniation later
17- The perineum is closed in multiple layers approximating the muscle layers using Vicryl or other absorbable suture, followed by skin closure.
18- Surgical closed suction drains are typically left in the presacral space

Question 21

What should patients expect with IPAA

Answer 21

6 to 10 bowel movements per day
The stool will be looser
consistency may improve with time
urgency and even some fecal incontinence

Question 22

scenarios where IPAA is not appropriate

Answer 22

• history of fecal incontinence
• Hx of sphincter injury
• history of anorectal disease (anal fistula)
• uncertainty related to the diagnosis of UC versus Crohn’s disease (indeterminate colitis or IBD unclassified)
• and those who are frail and would not be able to tolerate the complications associated with IPAA (pelvic sepsis).

Question 23

How to do IPAA

Answer 23

• when the rectal dissection is at the level of the pelvic floor
• the rectum is transected with a stapler, approximately 1 cm above the anal sphincters
• ileal pouch is created
• the terminal ileum is freed up from the ileostomy site.
• distal terminal ileum is identified as is the superior mesenteric artery.
• The “tip” of the small bowel is located— the area of the small bowel that will reach the furthest into the pelvis.
• usually 10 to 15 cm proximal from the distal end.
• If this “tip” can touch the pubic bone, it will likely reach the anus.
• The two limbs of the ileal pouch are aligned, and a linear stapler is used to fashion the pouch
• two loads of the linear stapler are needed as the goal is to have the pouch 10 to 12 cm in length.
• The pouch to anus anastomosis is created with a circular stapler
• The anvil is placed in the pouch, secured with purse-string suture, and the handle is placed in the anus.
• The anastomosis is fashioned by firing the stapler.
• It is essential that there is excellent visibility in the pelvis when creating the anastomosis to ensure that the small bowel, bladder, vagina, etc. do not fall into the staple lines.
• There should be two complete “donuts” on the stapler, and the pouch should be inspected for bleeding by sigmoidoscopy and for air tightness by inflating air into the pouch and looking for air bubbles in the pelvis (saline irrigation is used to submerge the pouch from the abdominal side).

Question 24

Most surgeons, when creating an IPAA, Do what ?

Answer 24

protect the pouch with a diverting loop ileostomy, created using more proximal small bowel brought up as a loop in the right lower quadrant.

Although this does not prevent postoperative pelvic sepsis, it mitigates the severity as the fecal stream is diverted.

The diverting loop ileostomy is closed in a separate operation about 3 months later.

Question 25

Perioperative Management

Answer 25

• limit opioids and maximize nonopioid analgesia including regional analgesia
• patients on high-dose, long-term steroids, a short course of steroid taper should be used
• Surgical site infection prevention :
  presurgery bathing with chlorhexidine
  mechanical bowel preparation with oral antibiotics (elective surgery)
  preincisional prophylactic antibiotics (cefazolin and Flagyl,
  alcohol-based skin preparation
  sterile technique
• Early ambulation
• deep venous thrombosis prophylaxis
• Catheter-associated urinary tract infection
  early removal either at the end of the surgical case or the following morning

Question 26

How to divide Complications

Answer 26

• immediate perioperative complications associated with pelvic surgery
• longer-term complications more specific to the ileal pouch

Question 27

Surgical risks include

Answer 27

• injury to surrounding structures
  especially nerves associated with sexual and urinary function
• infection related to leaking at staple lines leading to pelvic abscess and sepsis
• bleeding and ileus
• early postoperative small bowel obstruction

Question 28

Postoperative management should also include

Answer 28

-monitoring for persistent frank blood in the stool consistent with intraluminal bleeding (although some bleeding is expected in the first few days), which may require endoscopy with inspection of the staple line.

-Hemodynamically unstable patients should be taken to the operating room.

Question 29

Early anastomotic leak will present with

Answer 29

fever, tachycardia, leukocytosis, and pelvic abscess on CT and is usually treated with a percutaneous drain

but sometimes it is very low in the pelvis and needs to be drained transanally in the operating room.

Question 30

Pouch-specific issues include

Answer 30

acute, recurrent, or chronic inflammation in the ileal pouch, termed pouchitis.

occur in about half of patients

treated with antibiotics, mesalamine, topical steroids, budesonide, or biologic agents.

Question 31

de novo Crohn’s disease after IPAA

Answer 31

Medically refractory pouchitis, especially secondary to de novo Crohn’s disease, may lead to pouch failure and necessitate end ileostomy and/ or pouchectomy.

Question 32

women should be counseled that IPAA has been reported to

Answer 32

increase the infertility rate compared with medically managed patients, although laparoscopic approaches may preserve fertility.