Ileal pouch-anal anastomosis for ulcerative colitis--the Rhode Island experience.

Victor E. Pricolo, MD INDICATIONS AND RATIONALE FOR SURGERY IN ULCERATIVE COLITIS Despite significant progress in the medical management of ulcerative colitis (UC), over 20% of patients affected by this chronic and medically incurable disease still require surgical intervention. There are three main groups of indications for an operation in UC: acute lifethreatening complications, medical intractability or side effects, and cancer risk. 1 Severe complications include massive hemorrhage, obstructing stricture, toxic colitis or megacolon, and perforation with sepsis. UC patients often require emergency surgical care while debilitated by anemia, malnutrition and immunocompromised from their chronic disease or from medications (e.g. azathioprine, 6-mercaptopurine, corticosteroids, infliximab, etc.). Timing of surgery in patients hospitalized for severe UC is best determined by a coordinated effort between gastroenterology and colorectal surgery staff. Patients may become unresponsive to medications, or dependent on them, or develop severe side-effects from chronic use. Particular care and precautions have to be considered in these patients who are at higher risk of surgical infections, poor wound healing and venous thrombo-embolic events from their hypercoagulable state. Growth failure in children is also a recognized indication for colectomy.2 In patients with early onset and long-standing ( > 10 years), extensive disease (pancolitis), there is also a progressive increase in the dysplasia-carcinoma sequence over time. The cumulative cancer risk has been estimated at 2% at 10 years, 8% at 20 years, and 18% after 25 years of colitis. 3 Such risk is quadrupled in patients with primary sclerosing cholangitis as one of the extra-intestinal manifestations associated with UC. Since UC is limited to the large intestine, removal of the target organ will achieve definitive cure. The colon and rectum are not essential for nutrition and/ or survival and their removal does not require any nutritional supplementation. Small bowel adaptation over several months allows it to assume some colonlike absorptive functions, a startling example of the adaptability of our gastrointestinal tract to anatomical and environmental changes (e.g. stasis, pH, bacterial flora).