Inflammatory Bowel Disease. Controversies
CONTROVERSIES
17. Should all patients with enteroenteral fistulas secondary to Crohn’s disease have surgery when the fistula is discovered?
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For: Such patients ultimately do poorly, develop further intraperitoneal septic complications, and almost always require surgery.
Against: Many of these patients do well without operative treatment until they develop symptoms. It is fine to wait for symptoms.
18. Should all patients with ulcerative colitis that is documented for 10 years, whether the disease is active or not, undergo a colectomy to avoid the risk of carcinoma of the colon?
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For: The risk of colon cancer in ulcerative colitis increases by approximately 1% per year 10 years after the diagnosis.
Against: Using surveillance colonoscopy and biopsy, only patients whose colons show dysplastic changes need a colectomy.
19. Is ileorectal anastomosis an acceptable operation after colectomy for ulcerative colitis?
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For: The patients have reasonably normal bowel habits and avoid the complications associated with anal reconstructive procedures.
Against: At least 50% of patients eventually require reoperation for recurrence of disease. The remaining rectum also may be a site for the development of cancer.
20. Is standard (Brooke) ileostomy a good way to handle the terminal ileum after total colectomy for chronic ulcerative colitis?
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For: The complication rate is very low. More than 90% of patients lead satisfactory lives.
Against: Psychosocial and sexual problems are associated with the use of external appliances, particularly in the teenage group, among whom chronic ulcerative colitis is quite common.
21. Is the continent Kock pouch a good procedure after colectomy for chronic ulcerative colitis?
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For: It avoids use of an external appliance and is quite easy to manage.
Against: Approximately 25% of all patients who have a Kock pouch require a revision due to slippage of the valve mechanism, thus rendering the pouch incontinent.
22. Is an ileoanal anastomosis with a surgically constructed ileoanal reservoir a good operation after colectomy for chronic ulcerative colitis?
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For: It avoids external appliances or ostomies, so it is well accepted by patients. Currently, this is the most commonly performed operation after colectomy.
Against: It is more difficult technically to construct; thus, the complication rate is higher. The average number of bowel movements is five per day, and there may be soilage at night. Pouchitis remains a problem.
23. Do all ileal pouch anal anastomoses require a temporary diverting ileostomy?
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For: The diverting ileostomy protects the reservoir and its suture lines by diverting the fecal stream until it is healed, thus lowering the complication rate.
Against: The triple-stapled ileal pouch anal anastomosis has a low complication rate and low rate of small bowel obstruction. Thus, avoidance of the diverting ileostomy returns the patient to a functional life sooner.
References
BIBLIOGRAPHY
1. Duerr RH: The genetics of inflammatory bowel disease. Gastroenterol Clin North Am 31:63-76, 2002. Medline Similar articles
2. Farouk R: Functional outcomes after ileal pouch-anal anastomosis for chronic ulcerative colitis. Ann Surg 231:919-926, 2000. Medline Similar articles Full article
3. Fazio V: Current status of surgery for inflammatory bowel disease. Digestion 59:470-480, 1998. Medline
4. Heuschen UA, Hinz U, Allemeyer EH, et al: One- or two-state procedure for restorative protocolectomy: Rationale for a surgical strategy in ulcerative colitis. Ann Surg 234:788-794, 2001. Medline Similar articles Full article
5. Hurst RD, Michelassi F: Strictureplasty for Crohn’s disease: Techniques and long term results. World J Surg 22:359-363, 1998.
6. Present DH, Rutgeerts P Targan S, et al: Infliximab for the treatment of fistulas in patients with Crohn’s disease. N Engl J Med 340:1398-1405, 1999. Similar articles Full article
7. Solomon MJ, Schmitz M: Cancer and inflammatory bowel disease: Bias, epidemiology, surveillance, and treatment. World Surg 22:352-358, 1998. Full article
8. Stocchi L, Pemberton JH: Pouch and pouchitis. Gastroenterol Clin North Am 30:223-241, 2001. Medline Similar articles
9. Sugerman HJ: Ileal pouch anal anastomosis without ileal diverson. Ann Surg 232:530-541, 2000. Medline
10. Wolff BG: Factors determining recurrence following surgery for Crohn’s disease. World J Surg 22:364-369, 1998. Medline Similar articles Full article
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Abernathy’s Surgical Secrets, Updated Edition (Book w / Student Consult)
Author / s: Harken Alden H., Abernathy Charles, Moore Ernest Eugene
Year: 2004
Pages: 473
Publishers: Elsevier Mosby; 5th Bk & Acc edition
ISBN: 0323034160
