B) Surgery in ulcerative colitis:
Surgery is curative in ulcerative colitis, but the extraintestinal symptoms may persist after surgery. About 25% of patients with ulcerative colitis need surgical intervention. The doctors keep this surgical intervention to specific circumstances.
Indications of surgery include:
- Failure of medical treatment to control the symptoms and frequent flares-up that impair the quality of life
- Severe bleeding that may lead to death
- Toxic megacolon and colon perforation require immediate surgery
- Strong suspicion of colon carcinoma
- Any severe complications or symptoms that threats the patient’s life or disable him
Although surgery is curative, doctors don’t prefer them in early and mild cases that can be controlled by medical treatment because surgical procedures may lead to impacts on the patient life and may carry risks.
The standard surgical procedure in ulcerative colitis is proctocolectomy. It means the total removal of the large intestine (rectum and colon). The surgeon can perform proctocolectomy by two procedures:
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- Proctocolectomy with ileal pouch-anal anastomosis
- Proctocolectomy with end ileostomy.
Let’s discuss each of them in some detail.
1) Proctocolectomy with ileal pouch-anal anastomosis (J-pouch surgery):
It is the most performed surgery in ulcerative colitis. In this procedure, the surgeon removes the colon and rectum, then creates a pouch (J-pouch) by the small intestine. Then, the surgeon connects this pouch to the anus, which allows the stool to pass through its normal pathway from the anus.
The surgeon may perform this procedure in one, two, or three stages, as follow:
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- The first stage involves subtotal colectomy, which means the removal of the colon only without the rectum. In this stage, the surgeon creates a temporary ileostomy.
- The second stage involves proctectomy (removal of the rectum) and the creation of the pouch. But, the surgeon will create a new ileostomy to allow the pouch to heal with the small intestine and anus. During this period, the intestinal wastes will pass into a removable ostomy bag.
The surgeon will determine the way of the procedure based on your general health and the severity of the disease. This procedure doesn’t restore the normal bowel function immediately. You may have up to 15 bowel movements daily, and your stools may be liquid or soft in the following months after the procedure. The bowel status will improve gradually, as the pouch increase in size, and the anal muscles strengthen. Most patients have six bowel movements daily after one year.
This surgery cures ulcerative colitis, but some complications may occur, such as pouchitis. Pouchitis means inflammation of the pouch, which leads to symptoms, such as diarrhea, abdominal cramps, fever, and joint pain. Pouchitis need antibiotic treatment. Pouchitis is the most common complication, but there are other rare complications, such as fistulas and pouch failure. According to the severity of the condition, your doctor may need revision surgery to decide the need to repeat the surgery.
2) Proctocolectomy with end ileostomy:
In this procedure, the surgeon will remove the entire large intestine (colon, rectum, and anus). After that, he will create a new pathway for the stools. The surgeon will create a stoma (small hole in the abdominal wall) and connect the terminal ileum (the terminal part of the small intestine) to this stoma. Thus, the intestinal contents will pass through this stoma to the external ostomy pouch (or bag) that you should evacuate several times daily.
Some complications may occur, such as infection, prolapse (bulging), or retraction of the stoma. These complications require immediate seeing of your doctor.
You may need an adaptation period for about one year to adapt to the changes in your body. Follow your doctor’s instructions about diet and physical activity after surgery. In the first days after surgery, you should be on liquids and soft foods. Gradually, you will return to solid foods, but you should avoid foods that cause irritation and diarrhea. Also, it is useful to drink a lot of water. Also, your doctor may recommend the limitation of physical activity for a period.
After surgery, you can return to your active life with an ileostomy. See your doctor or a mental health professional if you felt depression or anxiety because your mental health is important as your physical health.
Cancer surgery and screening:
Patients with ulcerative colitis have a high risk of colorectal cancer. Thus, they should undergo screening by colonoscopies every one or two years. The doctor takes biopsies with the colonoscope to send it for pathological examination. If the doctor found any precancerous tissue, such as dysplasia or polyps, he should recommend the surgical removal of the colon and the rectum. This surgery eliminates the risk of colorectal cancer.
