Abstract
Severe acute ulcerative colitis unresponsive to medical management is characterized by multiple associated risk factors including anemia, hypoproteinemia, and high steroid requirements when urgent surgery is required. Current surgical options include use of primary ileal pouch-anal anastomosis (IPAA) vs. historic trends favoring colectomy with ileostomy. PURPOSE: To evaluate the efficacy of primary IPAA in patients with severe colitis, we reviewed our own experience in 20 patients with this condition. METHODS: Patients undergoing primary restorative proctocolectomy included 13 males and 7 females (mean age, 30.5±2.4 years). Exclusion criteria for primary reconstruction included septic patients and patients with associated medical conditions such as pulmonary or cardiovascular disease. History of ulcerative colitis averaged 3.1±1.1 years (range, 1 month to 19 years). Preoperative mean total serum protein concentration was 5.0±0.2 g/dl, and mean albumin concentration was 2.1±0.2 g/dl, reflecting disease severity. The average daily steroid requirement at the time of urgent colectomy was 58.0±4.4 mg of prednisone (or intravenous equivalent). Primary IPAA included 18 “W” reservoirs, 1 “S” reservoir, and 1 “J” reservoir. RESULTS: Major surgical complications included mild pancreatitis (10 percent), anastomotic leak (5 percent), adrenal insufficiency (15 percent), an upper gastrointestinal bleed (5 percent), and small bowel obstruction (15 percent). There were no deaths, and no patients developed pelvic sepsis or required IPAA removal. At three and twelve months, 24-hr stool frequency averaged 7.3±0.4 and 4.9±0.3, respectively. Overall day and night continence was excellent and not different from patients who underwent elective IPAA procedures for ulcerative colitis. CONCLUSIONS: Improved options such as primary IPAA may be safely used in selected patients requiring urgent surgery for severe or fulminant ulcerative colitis. Medical management should be abbreviated when disease control cannot be promptly achieved.
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References
Danovitch SH. Fulminant colitis and toxic megacolon. Gastroenterol Clin North Am 1989;18:73–82.
Truelove SC, Lee EG, Willoughby CP, Kettlewell MG. Further experience in the treatment of severe attacks of ulcerative colitis. Lancet 1978;11:1086–8.
Truelove SC. Management of ulcerative colitis and indications for colectomy. World J Surg 1988;12:142–7.
Grant CS, Dozois RR. Toxic megacolon: ultimate fate of patients after successful medical management. Am J Surg 1984;147:106–10.
Anderson JB, Turner GM, Williamson RC. Fulminant ulcerative colitis in late pregnancy and the puerperium. J R Soc Med 1987;80:492–4.
Heppell J, Farkouh E, Dube S, Peloquin A, Morgan S, Bernard D. Toxic megacolon: an analysis of 70 cases. Dis Colon Rectum 1986;29:789–92.
Kambe H, Yoshida T, Haraguchi Y, Iwashita T, Sakamoto A, Tanaka K. Quantification of disease activity in patients with ulcerative colitis. J Clin Gastroenterol 1986;8:651–4.
Goligher JC, Hoffman DC, deDombal FT. Surgical treatment of severe attacks of ulcerative colitis with special reference to the advantages of early operation. Br Med J 1970;4:703–6.
Caprilli R, Vernia P, Lantella G, Torsoli A. Early recognition of toxic megacolon. J Clin Gastroenterol 1987;9:160–4.
Sirenik KR, Tetrick CE, Thomford NR, Pace WG. Total proctocolectomy and ileostomy: procedure of choice for acute toxic megacolon. Arch Surg 1977;112:518–22.
Harms BA, Hamilton JW, Starling JR. Quadruple loop (W) ileal pouch reconstruction following proctocolectomy: analysis and functional results. Surgery 1987;102:561–7.
Harms BA, Pellett JR, Starling JR. Modified quadruple loop (W) ileal reservoir for restorative proctocolectomy. Surgery 1987;102:234–7.
McHugh SM, Diamant NE, McLeod R, Cohen Z. S-pouchesvs. J-pouches: a comparison of functional out-comes. Dis Colon Rectum 1987;30:671–7.
Hawley PR. Emergency surgery for ulcerative colitis. World J Surg 1988;12:169–73.
Pemberton JH, Phillips SF, Ready RR, Zinsmeister AR, Beahrs OH. Quality of life after Brooke ileostomy and ileal pouch-anal anastomosis: comparison of performance status. Ann Surg 1989;209:620–6.
Turnbull RB Jr, Hawk WA, Weakley FL. Surgical treatment of toxic megacolon: ileostomy and colostomy to prepare patients for a colectomy. Am J Surg 1971;122:325–31.
Zenilman ME, Super NJ, Dunnegan O, Becker JM. Previous abdominal colectomy affects functional results after ileal pouch-anal anastomosis. World J Surg 1990;14:594–9.
Nicholls RJ, Holt SD, Lubowski DZ. Restorative procto-colectomy with ileal reservoir: comparison of two-stagevs. three-stage procedures and analysis of factors that might affect outcome. Dis Colon Rectum 1989;32:323–6.
Wexner SD, Wong WD, Rothenberger DA, Goldberg SM. The ileoanal reservoir. Am J Surg 1990;159:178–85.
Harms BA, Andersen AB, Starling JR. The Wileal reservoir: long-term assessment after proctocolectomy for ulcerative colitis and familial polyposis. Surgery 1992;112:638–48.
Williams NS. Restorative proctocolectomy is the first choice elective surgical treatment for ulcerative colitis. Br J Surg 1989;11:1109–10.
Pemberton JH, Kelly KA, Beart RW Jr, Dozois RR, Wolff BG, Ilstrup DM. Ileal pouch-anal anastomosis for chronic ulcerative colitis: long term results. Ann Surg 1987;206:504–13.
Buckell NA, Lennard-Jones JE, Hernandez MA, Kohn J, Riches PG, Wadsworth J. Measurement of serum proteins during attacks of ulcerative colitis as a guide to patient management. Gut 1979;20:22–7.
Phillips JD, Kim CS, Fonkalsrud EW, Zeng H, Dindar H. Effects of chronic corticosteroids and vitamin A on the healing of intestinal anastomoses. Am J Surg 1992;163:71–7.
Stelzner M, Phillips JD, Fonkalsrud EW. Acute ileus from steroid withdrawal simulating intestinal obstruction after surgery for ulcerative colitis. Arch Surg 1990;125:914–7.
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Harms, B.A., Myers, G.A., Rosenfeld, D.J. et al. Management of fulminant ulcerative colitis by primary restorative proctocolectomy. Dis Colon Rectum 37, 971–978 (1994). https://doi.org/10.1007/BF02049307
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DOI: https://doi.org/10.1007/BF02049307