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Ulcerative Colitis

Ulcerative colitis. Ileoanal anastomosis has replaced the Brooke ileostomy as the operation of choice in most institutions for ulcerative colitis, because of the following factors: the disease is removed, the malignant potential largely eliminated, fecal continence is preserved, there is no stoma and we have fairly good data that the quality of life is improved.

The next two slides are my surgical experience with this problem over a five week period in January. Here are four patients who underwent this operation and look at the interesting mix of patients; polyposis, refractory, bad bleeding. This patient was stage II of a III stage disease. He had toxic megacolon. This patient was refractory to medical management and another four - again, this is only a five week period - this one had cancer. He’s a little older. We did a Brooke ileostomy.

As I said, the operation has evolved from a simple, straight connection of the ileum to the anus with all sorts of problems, all they way down to a double-stapled ileoanal anastomosis. A small data set, which I’ll share with you in a minute, is based on 1,847 patients undergoing the operation, until 2006. Almost all of which had two stages of the procedure done, and I can perhaps talk to that later. Most of these were for ulcerative colitis and the follow-up was six years on mean.

This shows fecal incontinence over a ten-year period of time, and importantly, in the same 300 patients. In other words, patients surveyed - same group - at 1,5 and 10 years. Not different patients at different years. So daytime perfect fecal incontinence is shown here at about 75%. Imperfect, meaning once or twice a week - or perhaps slightly more frequently - shown here at 

The mortality - for this usually, completely elective procedure - is very low. Morbidity is also not bad. Pelvic sepsis being a particularly difficult problem in 5% of patients. Wound infections are good at Mayo in general.

The problem of pouchitis. About 40%-50% of our patients will experience an episode of pouchitis in the postoperative period. What does that mean? Well, let’s take a flow diagram of pouchitis in our patients. So of 100 patients after ileoanal anastomosis, 50 will never have the problem. So let’s go to the 50 that do. Twenty-five of the 50 will have one episode leaving 25 with more than one episode. Of that 25 patients, only four will have something called chronic, unremitting, long term problems with pouchitis, of whom three of the four will be managed. We can talk about the management perhaps later.

For gastroduodenal Crohn’s disease, which is indeed quite rare, the symptoms of pain, nausea, vomiting and weight loss with studies to confirm upper GI Crohn’s disease with complications, as you see here, in obstruction, fistula and hemorrhage. The surgery for gastroduodenal Crohn’s disease is fortunately rare but consists really of only bypass and strictureplasty. Resection is reserved for only the worst situations.

What about disease-free margins in small-bowel Crohn’s disease? Just briefly, there are studies that show with normal and disease margins no difference in the rate of cumulative recurrence rate over an eight year period of time. This was published many years ago now, in 1983. In work from our own institution we would say that gross residual disease, in the orange line, has a much higher rate of recurrence than in the overall group of patients without gross residual disease. So what our practice is - at least mine is - is to approach the patient with small-bowel Crohn’s disease, resect that to non-diseased margins.