Extracolonic Manifestations

3 Proctocolectomy can help with some of the extracolonic manifestations, though PSC, pyoderma

gangrenosum, and ankylosing spondylitis specifically do not respond to surgery. Proctocolectomy has

shown to help with erythema nodosum, and small/large joints arthralgia, though the role of colectomy

is not completely defined in the treatment of extraintestinal manifestations of UC.85

Figure 66-6. Brooking ileostomy.

Surgical Management

Unlike CD, proctocolectomy is curative for gastrointestinal UC. As the disease begins in the rectum and

involves the colon proximally for a variable distance, ultimately proctectomy should be performed for

definitive treatment of UC.

Multiple surgical options are available, with treatment dependent on the urgency of presentation, and

general condition of the patient. Currently, in emergency conditions, the operation of choice is a

subtotal colectomy with preservation of the rectum, and a Brooke ileostomy (Fig. 66-6). Resection of

the rectum in the emergent setting should be avoided if possible, to both to allow continent

reconstruction at a later time and to avoid a perineal dissection in suboptimal conditions. Mobilizing the

rectum unnecessarily in emergent conditions disrupts the presacral planes, and will make later

reconstruction more difficult. In addition, the ureters and pelvic nerves are put at risk. Additional

consideration should be given to the level of ileal transection proximally, keeping in mind that a later

ileal pouch reconstruction is dependent on the ileocolic arterial arcade, and thus all efforts should be

made to keep this vascular network intact.

Abdominal Colectomy with a Brooke Ileostomy

The location of stoma should be marked preoperatively with the help of an enterostomal therapist if at

all possible. Managing a poorly placed stoma is a major source of frustration for the patient

postoperatively. Additionally, appropriately training and educating the patient preoperatively with

regard to the care of their stoma is critical to their postoperative progress.

4 A minimally invasive approach should be attempted if the patient is stable and the surgeon is

sufficiently comfortable with the operation.86,87 A systematic technique should be employed, and with

sufficient training and experience excellent outcomes can be achieved.88

The operation is started in the lithotomy position. If there is a concern regarding visualization of the

ureters, it is recommended that ureteral stents be placed. Though they do not reduce the rate of ureter

injury, they do help identify an injury immediately, and facilitate prompt repair.89 The colon is

mobilized in a lateral to medial fashion most commonly (Figs. 66-7 and 66-8), and unless there is

concern of dysplasia/neoplasia, the vessels (ileocolic, middle colic, and inferior mesenteric artery

branches) can be transected distally, facilitating safer mobilization. Particular attention should be paid

to the splenic flexure, as a splenic tear will unnecessarily complicate the operation.

Once the colon has been completely mobilized and the vessels have been divided, the distal ileum can

be transected. Particular attention must be paid to the integrity of the ileocolic vessel arcade, as the

subsequent ileal pouch construction is largely dependent on these vessels. The colon can then be

extracted through the ileostomy site, or through either a low vertical midline or a Pfannenstiel incision.

The terminal ileum can then be extracorporialized and a Brooke ileostomy can be constructed (Fig. 66-

6). It is critical to make sure that the small bowel mesentery is not twisted before “brooking” the

ileostomy.

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Figure 66-7. Colon mobilization. A: right colon. B: transverse colon. C: left colon.

Figure 66-8. Mobilized colon with vessels divided, and stapled at the rectum. This specimen is ready for extraction; the ileum can

be transected intracorporeally, or after specimen is extracorporealized.

Proctocolectomy with Brooke Ileostomy

Abdominal colectomy is performed as above. In cases of rectal dysplasia or cancer, a total mesorectal

excision is necessary. Patient is placed in Trendelenburg position and all bowel is displaced in the upper

abdomen. The sigmoid and rectum are placed on tension, and any adhesions are freed. If the uterus and

ovaries prevent visualization or adequate dissection, they are affixed in place by passing a 0-Prolene

stitch through the abdominal wall, through the uterus, and back through the abdominal wall. Retracting

the uterus anteriorly will help with visualization and dissection in the plane posterior to the vagina. The

rectal mobilization is commenced by placing the rectum on cephalad and anterior traction. The

peritoneum on the right of the rectum, medial to the ureters and the pelvic nerves is incised. This

embryologic plane is followed cephalad just posterior to superior rectal artery along its course, tracing

it proximally to the inferior mesenteric artery (IMA). Careful dissection just posterior to the IMA

pedicle toward the left pelvic sidewall will reveal the left ureter; its location is almost always higher

than expected. Lateral (on the left) to the ureter, the gonadal vessels are found. The ureter is

retroperitoneal, and as such all efforts should be made to avoid incising the retroperitoneum, and

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instead, it is safer if this embryologic layer is left undisturbed. Following this shiny layer superiorly,

one can easily carry the dissection cephalad until the IMA is identified and skeletonized. In the absence

of neoplasia, it is unnecessary to perform a high (proximal) ligation of the IMA, though by doing so,

one simplifies the dissection. Once the IMA (or the left colic artery) is identified and skeletonized, it can

be divided with the appropriate instrument, after making sure that both ureters are well out of the field.

Carrying the pelvic dissection distally, the pelvic nerves and the ureters should be clearly identified

and protected. Meticulous dissection can be done relatively bloodlessly. During anterior dissection of

the rectum, all effort should be made to continue the dissection posterior (on the rectum side) of the

Denovilliers fascia, specifically in men, to avoid sexual dysfunction. Similarly, during posterior

mobilization of the rectum particular attention should be given to identifying the presacral fascia, as

dissection posterior to this layer puts at risk the presacral vessels which can result in troublesome and

sometimes life-threatening bleeding. Once the dissection is carried out to the pelvic floor

circumferentially, a clamp can be placed on the proposed transection site, and the distance from the anal

verge can be assessed by a simple digital rectal examination. If the distance is appropriate then the

perineal dissection can follow. The patient is placed in Trendelenburg position, with both feet raised to

afford exposure to the perineum. The dissection plane starts in the intersphincteric plane. This dissection

leaves the external sphincter in situ, and can be incorporated in closing the perineal incision, which

decreases the complication rate. This intersphincteric plane is followed proximally and circumferentially

with particular attention anteriorly, to avoid injury to the vagina in women and urethra in men. Once

the intra-abdominal plane is reached, this part of the dissection is done.

Figure 66-9. Distal rectal transection, (A) stapled above the dentate line, or (B) a mucosectomy in preparation for a hand-sewn

anastomosis.

Proctocolectomy with Ileal Pouch-Anal Anastomosis (IPAA)

5 The colectomy and rectal mobilization are performed as above, however, once one reaches the pelvic

floor the rectum is transected approximately 1 cm above the anorectal ring with the stapler (Fig. 66-

9A). This rectal cuff will allow for better function, but will require surveillance as it is at risk for

cuffitis, and neoplasia. Alternatively, a mucosectomy can be done (Fig. 66-9B) with a subsequent handsewn IPAA anastomosis, though this is mostly done in cases of distal neoplasia, and poorer function is

observed.

Once the proctectomy is finished, a pouch is fashioned from the terminal ileum. Multiple

configurations are possible; the J-pouch configuration is the most popular in the United States (Fig. 66-

10). This is constructed by first aligning the terminal ileum into a J-configuration. It is necessary for the

apex of the pouch (the end connection of the pouch to the anus) to reach the rectal cuff or anus.

Usually, if the apex can be stretched without tension beyond the symphysis pubis, the pouch should

reach the anastomosis site without undue tension. Multiple maneuvers can be done to “lengthen” the

reach of the pouch, and are beyond the scope of this discussion. The pouch is usually between 10 and 20

cm in length, and ultimately optimizing reach has some effect on how long the pouch is. Once the apex

location is decided on, the two limbs of the ileum are aligned with interrupted suture. An enterotomy is

made at the apex of the pouch, and a stapler is used to fashion a common channel between the two

limbs of ileum. The pouch can then be attached by using an EEA stapler device (placing the anvil in the

J-pouch, and firing pin through the rectal pouch), or by performing a hand-sewn anastomosis (Fig. 66-

11).

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Figure 66-10. IPAA construction and anastomosis. (A) terminal ileum alignment for (B) common channel creation. C: EEA anvil

attachment at the apex of the pouch.

Figure 66-11. Anastomosis of the J-Pouch with (A) stapled anastomosis and (B) hand-sewn anastomosis.

IPAA-Postoperative Complications

6 The majority of patients who have an IPAA report high quality of life. Small bowel obstruction occur

in up to 20% of patients, most commonly managed nonoperatively.90 The J-pouch is at risk for

postoperative abscess, fistula, and pelvic sepsis, which can occur anytime after the pouch formation.

Immediate intervention with drainage and antibiotic treatment to control the infection is key, as

prolonged infection puts the pouch at risk.91,92

Pouchitis is a nonspecific inflammation of the pouch that occurs in up to 40% of the patients.93 This is

the most common complication after IPAA. Pouchitis is treated initially with oral antibiotics. If

pouchitis does not resolve, pouch evaluation using endoscopy is undertaken, with pouch mucosa biopsy,

and further evaluations can include testing for infections, such as C. difficile. Other medications that

have shown to help treat pouchitis are corticosteroids, budesonide, 5-aminosalicylic acid, and

allopurinol.94

Corticosteroid use does not preclude IPAA construction, though a slightly higher rate of anastomotic

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leaks is observed, thus, usage of a diverting ileostomy should be considered in this patient population.95

The effect of preoperative use of anti-TNF agents is not clear and limited to nonrandomized studies.

Routine surveillance of the pouch for dysplasia is not essential, however, surveillance of the rectal

cuff or transitional zone is necessary (both stapled and hand-sewn anastomoses). The incidence of

carcinoma in the rectal remnant/anal transition zone is rare but reported.96

Proctocolectomy with Koch Pouch

This is the second continent option (in addition to IPAA). Only a few centers worldwide perform this

procedure, and the technique is beyond the scope of this chapter.

In summary, UC is an inflammatory bowel condition influenced by both genetic and environmental

factors. Its treatment includes increasingly sophisticated medical and surgical treatment regimens. An

individualized, multidisciplinary treatment approach should be employed for each patient, at an

institution that has the experience and volume to provide the most current and appropriate treatment.

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