IPPA must be performed in 90% of patients with ulcerative colitis-Prof. Panis


Surgical Management of Ulcerative Colitis
IPPA must be performed in 90% of
patients with ulcerative colitis-Prof. Panis
Segmental colectomy is an alternative to IPAA in
Elderly UC patients with colorectal cancer
Pouch surgery should only be done in specialist
centers-Prof. Ronan O’Connell

KARACHI: On second day of the Surgical Week for Colorectal Diseases organized by JPMC from 14-17 October 2019, Prof. Yves Panis the visiting colorectal surgeon and Master Trainer from France made two presentations. The first one was on Surgical Management of Ulcerative Colitis. He was of the view that IPPA must be performed in 90% of patients with ulcerative colitis. However, segmental colectomy is an alternative to IPPA in elderly ulcerative colitis patients suffering from colorectal cancer.

Continuing Prof. Panis said that it is only 10-15% of ulcerative colitis patients with short history of disease, no proctitis and no micro rectum and no colonic cancer wherein IPPA or IRA can be an alternative. Speaking about the indications of surgery in ulcerative colitis, he mentioned acute colitis i.e. complicated forms with perforation, toxic mega colon, hemorrhage, sepsis and failure of medical treatment. Chronic refractory form of UC includes long standing ulcerative colitis with chronic symptoms, micro rectum, dysplasia or cancer. He then discussed in detail the algorithm of management of acute colitis. Laparoscopic approach for inflammatory bowel diseases he said, is a real alternative to open surgery. In one of the studies he quoted, there were just one death after subtotal colectomy for acute colitis among one hundred five patients. He then referred to indications of total coloproctectomy in patients with flat low grade dysplasia.

Photographed during the surgical course for colorectal diseases held at JPMC recently shows
Prof. Tariq Mahmood photographed alongwith Prof. John Nicholls and Prof. Yves Panis the
visiting colorectal surgeons from UK and France. Photo Courtesy Shams Qureshi.

Ileal pouch-anal anastomosis is recommended in 80-90% of ulcerative colitis patients. However, ileo rectal anastomosis is suggested for highly selected patients which comprise of just 10% of the patients. These include patients with short history of ulcerative colitis, no refractory proctitis, naïve to biologics, no dysplasia or cancer and no cholangitis.

Speaking about the surgical options, Prof. Panis said that there are three new operations for ulcerative colitis patients. It includes ileostomy in refractory acute colitis, appendectomy and segmental colectomy. Responding to questions during the discussion, he said that quality of life is much better after six months with surgery. However, surgery should be done in an environment where everybody knows his responsibilities and works.

Laparoscopic Pouch Surgery

His next presentation was on Tips and Tricks in laparoscopic Pouch Surgery. In this he discussed in detail the five trocars technique with lateral approach for subtotal colectomy with double end ileostomy and sigmoidoscopy for acute colitis. His advice was to remain away from the nerves during surgery. He also discussed the double end ileostomy and sigmoidostomy at the same place. He was of the view that the second step of IPAA is easier.

During the first step of laparoscopic IPAA the surgeon should be on the right side of the patient while in the second step the surgeon should stand on the left side of the patient. In the third step, the surgeon should be between the legs and afterwards on the left side of the patient. He also referred to the stapled or manual IPAA and pointed out that incase of stapled it is easier, offers better continence but manual is more difficult and there is also risk of incomplete mucosectomy. He also discussed how to avoid a too long rectal cuff in stapled anastomosis. He concluded his presentation by stating that even after forty years, IPAA remains a very good operation for many reasons. It cures ulcerative colitis, prevents colorectal cancer and the mortality rate is almost zero percent. Only those should be doing these surgery who have a high volume of work and their surgical technique is more standardized. Laparoscopic surgery offers 80-90% fertility rate and there are lower postoperative morbidity as well.

Prof. John Nicholls, Prof. Yves Panis, Prof. Ronan O’Connell and Prof. Mumtaz Maher
speaking at the Surgical Course for Colorectal Diseases held at JPMC recently.
Photo Courtesy Shams Qureshi.

During discussion Prof. John Nicholls suggested that the patient should be involved in his possible treatment, discuss the long term complications and the outcome. The patient is in a much better position to come to a decision.

Prof. Ronan O’Connell from UK the course coordinator discussed Ileal pouch anal anastomosis, management and complications. He also referred to the long term IPAA success and stated that pouch success is good. In Crohn’s disease, pouch failed in long term in my hands. If you end up in colon perforation by laparoscope, you will be in trouble. Aging pouch results in gradual degradation of functions. Elderly patients have more acceptance as they have more co-morbidities and they also have a longer disease duration. The complications rate is the same as in open surgery. However, elderly patients have more serious complications, they have longer length of stay in hospital. With laparoscope it ensures short duration of procedure and short hospital stay. Pouchitis, he further stated, is most common complication of IPAA.

Continuing Prof. Ronan O’Connell said that majority of patients with pouch will have minimum pouchitis in their life. Failing pouch or struggling pouch could result in sepsis in 50%, poor function in 30%, mucosal inflammation in 15% while dysplasia will account for less than 5%. Failure of sepsis is a progressive overtime sepsis. IPAA abdominal salvage surgery, he said, is a major operation. It has potential morbidity and it can have late failure. He emphasized the point that pouch surgery should only be done in specialist centers. There are twenty four surgeons in UK and they do three to eight cases in a year. In Ireland, only eight units are allowed to do rectal surgery. We get the most complex tumours as we get all these cases which are referred to us. High volume surgeons, he further stated, have low failure rate and low volume surgeons have high failure rate. It conveys the message that it is the experience which matters a lot. An institution must be doing at least ten or more cases in a year and if not, they should refer these cases to other centers.

IPAA Prof. Ronan O’Connell remarked has stood the test of time. Laparoscopic approach has some advantages. Fertility is an issue. It is a sub-specialty operation. Participating in the discussion Prof. Asghar Channa remarked that most pouch cases will go into complications. He wondered whether it was the disease or the surgical work which results in complications.

A few cases were also presented by the residents. During discussion it was pointed out that one should never leave the patients in the hands of juniors. It is essential to stay around if you wish to teach and train these juniors.

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