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home - IBD - Surgery - UC Surgery Written by Dr Sebastian Zeki
Knowledge

Knows the criteria for assessing the severity and extent of IBD, in
particular recognition of acute severe colitis. Knows treatment options
including aminosalicylates, corticosteroids, and steroid sparing
therapies.

Knows differing methods of delivery for therapy.
Skills
Selects of appropriate treatment for extent and severity of disease,
including timing of immunomodulator therapy and referral for surgery.

Behaviours
Recognises the urgency of treating acutely sick patients, including
multidisciplinary team early, particularly surgeons. Clearly explains
the clinical situation and treatment options to patient and family.
Involves patient and family in decision making about treatment
options.

also....
Knows the complications of IBD including stricturing, fistulae,
extraintestinal manifestations, colon cancer and special situations
such as pregnancy.

Skills
Able to recognise potential complications and take appropriate action
to investigate and alter treatment as necessary including referral for
surgery and involvement of other healthcare professionals

Behaviours
Works with patient to explain complications and options for treatment
Involves the multidisciplinary team especially IBD nurse and surgeon
in management, and tailors treatment to the needs of the patient.
Discusses with colleagues early and appropriately

Also...

Knowledge


Understands the indications for surgery in active disease and for
complications including structuring and fistulising disease

Understands different surgical approaches in particular methods of
bowel-preserving surgery in Crohn’s disease and long term options
for surgery in UC

Recognises that early liaison with surgeons is important in high
quality patient management

Skills
Has appropriate discussions with surgeons when patients are
admitted with active disease

Involves surgeons early in patients with difficult chronically active
disease or with complications

Is able to explain clearly to patients and relatives the role of the
surgeon and possible surgical approaches to treatment
PS
Behaviours
Shows willingness to liaise appropriately with surgical teams
Explains clearly to patients and relatives the involvement of the
surgical teams and their importance and possible outcomes

Also...

Knowledge


Knows the pathogenesis and complications of fistulising Crohn’s
disease including perianal enteroenteric enterocutaneous
colovesical and rectovaginal fistulae

Understands the different treatment modalities available for treatment
of fistulae including antibiotics immune modulators biologics
surgical drainage and the possible combinations that may be
required

Is aware of the importance of joint medical-surgical management of
complex fistulae and of nutritional support for high output fistulae

Skills
Able to detect the possibility of fistulising disease and to perform
appropriate investigations

Can liaise with surgical colleagues to define the most appropriate
management plan

Behaviours
Can make an appropriate of fistulae including deciding a
long term management strategy

Can provide an appropriate explanation of the problem to the patient PS
Involves all relevant health professionals and patient in deciding the
appropriate treatment strategy

UC Surgery

Early Complications Bowel obstruction, pouch bleeding, pelvic and wound sepsis, transient urinary dysfunction, and dehydration from temporary loop ileos - tomy with high output Late complications Stricture of the anastomosis, anal fistula and abscess, poor postoperative anorectal function, reduced fertility and pouchitis Divide to leave distal descending or At rectosigmoid junction Allows anchoring to anterior abdominal wall or as a mucous fistula (safer as allows drainage ). If divided at promontory, need rectal drainage to prevent blow-out Stage 1= A subtotal colectomy Stage 2= Restorative Proctocolectomy (ie formation of a pouch) Anastomostic technique for restorative proctocolectomy If the stapling technique cant be done then hand sew anastomosis Site of anastomosis for neoplasia compli - cating colitis Mucosectomy from the dentate line to remove all of the potentially diseased mucosa Site of anastomosis for restorative poctocolectomy Remnant of anorectal mucosa above the dentate line usually left- can cause cuffitis or dysplasia But a v. short length of mucosa (<1 cm) above dentate line would exclude most maless from stapling technique, due to probs getting low anastomosis in narrow pelvis Stapling gives better nocturnal continence Role of covering ileostomy for restorative procto - colectomy Sometimes a covering ileostomy may be useful to prevent puch leakage. Pouch Surveillance Unknown if this needs to be done If mucosectomy very little chance of getting dysplasia Choice of operation for ulcerative colitis 1)Proctocolectomy with permanent ileostomy (Brooke ileostomy)gold standard until 80’s 2)Proctocolectomy with continent ileostomy (Kock pouch)- not good 3)Abdominal colectomy with ileorectal anastomosis (IRA)- 50% stil have IRA after 10 years 4)Colectomy, mucosal proctectomy, and ileal pouch-anal canal anastomosis (IPAA)- gold standard 5)Colectomy and stapled ileal pouch distal rectal anastomosis (IPDRA)Nevertheless, bowel function is not restored to normal and both functional outcome and quality of life after IPAA have still to be compared to living with an ileostomy. Pouch surgery not good for indeterminate IBD- many turn out to have Crohn’s with high complication rate Surgery and medication >20mg prednisolone for >6 wks have an inc.risk of surgical complications. If on corticosteroids for <1 month, steroids can usually be stopped abruptly after surgery without ill effect. If the patient has had 1–3m of steroids,reduce by 5mg/ week from 20mg. If the patient has had 3-6 m of steroids, reduce by 2.5mg/ week. If the patient has had >6m of steroids, reduce by 1 mg/week (or even more slowly) is advisable. Azathioprine does not appear to increase the risk of surgical complications. Elective surgery +anti-TNF may not cause high sepsis rates. Emergency + anti-TNF may cause high sepsis rates and leaks. Even higher if ciclosporin and anti-TNF. Colectomy then restorative procto - colectomy 5% need revision to prevent ileos - tomy If older - ileostomy (15% dysfunc - tion) Emergency - subtotal colectomy then ileoanal pouch Perioperative anti-TNF therapy Perioperative azathioprine Perioperative prednisolone Written by Dr Sebastian Zeki The timing of colectomy A stool frequency >12/day on day 2 assoc. with 55% colectomy.The Oxford Index: frequency >8/day on day 3 of intensive treatment predicted colectomy in 85% on that admis-sion.Sweden index: CRP is >8 on day 3: predicted colectomy in 75%.Paediatric Index: CRP+stool frequency on day 3 + temp. in kids with acute severe colitis predicts need for colec-tomy.ESR >75 or a pyrexia >38 °C on admission is assoc. with a x9 increase in need for colectomy.A lack of response to steroids predicted by <40% reduction in stool frequency within 5 days.Colonic dilatation >5 cm (75% need for colectomy), or mucosal islands on a plain abdominal radiograph (75% colectomy).Ileus (indicated by >3 small bowel loops of gas) is assoc with colectomy in 73%.Colectomy rate of around 30% overall (higher if extensive, 2% if proctitis only).

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