Surgeries for Ulcerative Colitis

What is ulcerative colitis?

Ulcerative colitis is an inflammatory bowel disease involving only the large intestine. The cause is not exactly known. It manifests itself with bloody diarrhea, abdominal pain, weight loss, and anemia. The definitive diagnosis can be made with pathological examination of the sample taken during colonoscopy.

What is the treatment of ulcerative colitis?

The treatment of ulcerative colitis is the use of other immunosuppressive drugs as in Crohn’s disease which is another inflammatory bowel disease. These drugs should be used under the supervision and follow-up of a gastroenterologist. Although the initial treatment of ulcerative colitis is drugs, approximately 40% of patients need surgical treatment at some point in their lives.

When does an ulcerative colitis patient require surgery?

  1. Patients who cannot achieve complete recovery despite adequate drug therapy
  2. In cases where colon cancer is suspected of developing
  3. The occurrence of severe intestinal bleeding
  4. Development of a life-threatening emergency situation such as intestinal perforation or infection
  5. Growth retardation in pediatric patients

Which surgery is carried out?

In non-emergency surgeries

Ileal pouch-anal anastomosis: Since ulcerative colitis is limited to the large intestine, the standard surgery is total proctocolectomy surgery in which the large intestine is totally removed. After this point, the small intestine is given a J shape (J pouch) and connected to the rectal region in patients whose rectal regions are not affected by the disease. The goal of creating a pouch is to allow the intestinal content to wait here for a while, providing the patient to go to the toilet less frequently. This operation is called J pouch-anal anastomosis. This is the most commonly used ulcerative colitis surgery in the world. This anastomosis performed at the very low level poses a high risk in terms of the leak (the risk of a leak is about 10%). During the healing period, we do not want stool to pass through this region, so an opening (stoma) that connects a little more upper part of the small intestine to the abdomen is created.

Ileorectal anastomosis: Although the disease almost always begins from the last part of the large intestine, in some cases, the last 15cm of the large intestine, called the rectum, can be intact. In such a case, other parts of the large intestine are removed without removing the last 15 cm part and the small intestine is connected to this remaining part.

Advantage

  • • This connection poses a relatively low risk in terms of a leak.
  • Since the surgery is not performed adjacently to the urinary and reproductive tracts, the complications associated with these organs almost never arise.
  • No complication associated with pouch arises since ileal pouch is not required.

Disadvantage

  • Since the entire large intestine is not removed, the disease may recur in this region in the later periods.
  • Within 10 years, 50% of the patients require a second surgery in which the remaining large intestine is removed.
  • End ileostomy: In some cases, the muscles that allow us to control bowel movements become dysfunctional by being affected by the disease. In such a case, connecting the small intestine to the rectum leads to a very uncomfortable situation for the patient. Therefore, ileostomy procedure (small intestine is diverted through an opening in the abdomen) is performed. Although it is a very low-risk surgery compared to other surgeries, ileostomy is permanent for life.

In emergency surgeriesIn cases where the general condition of the patient is very poor and posing a high threat to life, performing the above-mentioned surgeries has very high risk. Since these patients usually use high-dose ulcerative colitis drugs, the healing functions are impaired, resulting in increased susceptibility to infections. At this point, the shortest and the most risk-free surgeries that will save the patient’s life are performed. The above-mentioned surgeries can be performed in a second session after the patient overcomes the life-threatening situation.

What is experience in ulcerative colitis surgery?

The European Crohn´s and Colitis Organisation (ECCO) classified ulcerative colitis surgeries as featured surgeries and prohibited them to be performed by non-experienced surgeons. The centers carrying out at least 10 ulcerative colitis surgeries per year have been accepted as the reference centers, and it has been recommended that these surgeries performed by surgeons working at these centers. Since Assoc. Prof. Samet Yardimci, MD has become a general surgeon, he worked at Turkish High Specialty Training and Research Hospital as well as Marmara University, which are accepted to be reference centers for ulcerative colitis, and was involved in the surgical treatment of numerous patients with ulcerative colitis.

What are the risks of the surgery?

  1. Leak: Leak is the occurrence of discharge from the anastomosed intestines. It may lead to intraabdominal infections, repetitive surgeries, and prolonged hospital stays. It is life-threatening.
  2. Bleeding: There is a risk of bleeding as in any intra-abdominal surgery.
  3. Urinary tract injuries: It may lead to repetitive surgeries and intraabdominal infections, and is life-threatening.
  4. Infections: In patients whose immune system is suppressed due to the drugs used, the risk of developing infections both in the surgical site and in distant organs (such as lungs, urinary tract) increases.
  5. Pouchitis: It may develop a month or two after the surgery, as well as after years. It is an undesirable condition which is specific to patients who undergo ileal pouch-anal anastomosis from the abovementioned surgeries. It means the inflammation of the pouch created from the small intestine due to excessive proliferation of bacteria. This problem can be solved with antibiotherapies and local therapies in the majority of patients, while severe complications that may require surgical removal of the pouch may also develop.
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