Ulcerative colitis (UC) is an inflammatory disease of the rectum and colon of unknown etiology, also known as non-specific colitis. The disease is characterized by vague pain and discomfort in the lower abdomen, increased frequency of stools with mucus and blood in the stool. The lesion is characterized by continuous diffuse chronic exudative and hemorrhagic inflammatory and ulcerative lesions of the colonic mucosa and submucosa, rarely involving the muscularis and mucosa.
The incidence of the disease is high in Northern Europe and America, and in recent years, the incidence in China has been increasing, with a 3.08-fold increase in the number of cases in the last decade or so. The age of prevalence is reported to be around 30 years abroad, and the peak age of incidence is 40.7 years in China, with a similar proportion of men and women. The cause of the disease is not very clear, mainly bacterial, viral infection theory, genetic theory, etc. There is also evidence that the disease may belong to autoimmune diseases, and may be related to race, psychological factors, smoking and diet.
Currently, the treatment of UC is mainly pharmacological, but there are still a considerable number of patients who need surgical treatment when medical treatment is ineffective or when serious complications arise. With the further improvement of the understanding of the disease and the continuous improvement of diagnosis and treatment methods, surgical treatment plays an increasingly important role in the treatment of the disease, so that the quality of life of more patients can be improved.
1, the history of the development of surgical treatment of UC
In 1893 Mayo first used colostomy to treat UC, in 1909 Keele and Weir through the cecum stoma or appendiceal stoma drug irrigation of the diseased intestinal segment. brown reported ileostomy to make a complete diversion of feces is more helpful to the recovery of intestinal inflammation. In 1944, Alfreed and Siegfried reported a patient-created stoma bag.
This pouch was made of rubber and had a metal rubber panel that anastomosed with the stoma end. The invention of the pouch and the ileostomy were epoch-making for the surgical treatment of UC. 1952, Brooke exenterated the ileocecal end of the stoma and overcame the two major complications of ileostomy: high drainage and salt loss. 1903, Lilienthal attempted ileosigmoid anastomosis. 1943, Staley Aulett reported ileorectal anastomosis and demonstrated the retention of partial sigmoid anastomosis. In 1943, Staley Aulett reported the ileorectal anastomosis and confirmed that preserving part of the sigmoid colon was detrimental to the recovery of bowel function.
In 1933, Rudolph first tried ileoanal anastomosis, and in 1947, Ravitch and Sabson successfully applied it to the surgical treatment of UC. in 1977, Matin et al. achieved great success in this procedure, which promoted the surgical treatment of UC. in 1972, Kock designed the famous restraining ileostomy with effective restraining power . He designed a double U-shaped reservoir pouch inside the terminal ileum and connected the abdominal wall stoma with a catheter to control defecation with a biological flap.
In 1978, Parks and Nicholls reported the ileal pouch-anal anastomosis (IPAA), which has become the standard procedure for the treatment of UC after continuous development and improvement, and is accepted by more and more doctors and patients.
2.Surgical indications and procedures
The prognosis of UC has improved significantly in recent years, mainly due to the comprehensive medical treatment and timely surgical treatment. At present, medical treatment is still the main focus, about 10% to 50% of patients eventually need surgery. The main surgical indications are.
(1) Extensive lesions that have failed to respond to medical treatment;
(2) Severe bleeding;
(3) toxic megacolon;
(4) perforation
(5) Fulminant acute UC;
(6) Stenosis causing intestinal obstruction;
(7) Suspected or confirmed cancer;
(8) Children should also be treated surgically if growth and development are significantly affected.
There are currently five basic surgical procedures for the surgical treatment of UC.
(1) colorectal resection ileostomy;
(2) total or subtotal colectomy rectal preservation (ileorectal anastomosis or ascending colorectal anastomosis);
(3) Total colon and rectal resection with ileo-anal anastomosis;
(4) Total colectomy and rectal resection with ileal pouch stoma (Kock stoma);
(5) total colon and rectal resection ileal pouch anastomosis (IPAA).
3.Evaluation of surgical methods
3.1 Colorectal resection ileostomy
This procedure is used for patients with total colonic type UC or long-term hormone use and more severe disease. Although colorectal resection is a complete treatment, the permanent postoperative ileostomy is not easy to manage and difficult for patients to accept. kock stoma is less used in China, most patients can fully control gas and stool after surgery, no skin irritation or bad odor around the stoma, but patients feel inconvenienced because there is still a stoma in the abdomen and a catheter needs to be inserted several times a day to guide defecation and exhaust. Complications such as bleeding, inflammation, and hernias next to the stoma can also occur in 30% of patients.
3.2 Total or subtotal resection ileorectal anastomosis or ascending colorectal anastomosis
This procedure is simple and easy to operate, but the residual rectum and colon still have the possibility of recurrence and the risk of cancer, so this procedure is only suitable for ascending colon or rectum lesions are not serious, and the patient has the condition of regular close follow-up, this procedure is now rarely used. The biggest disadvantage of ileoanal anastomosis is the increase in the number of stools, which is difficult for patients to accept.
3.3 Total colon and rectal resection ileal pouch anastomosis (IPAA)
This procedure is a more ideal procedure, since 1978, the clinical application of the majority of patients to get rid of the stoma pain. This procedure can not only cure UC, but also preserve the self-control of defecation and the function of defecation through the anus in the long term. The quality of life is much better than that of ileostomy patients. Because of the high level of skill in making the bag, it needs to be done by experienced doctors. The specific type of pouch should be chosen according to the degree of ileocecal freeing, the width of the patient’s pelvis, and the surgeon’s experience and habits.
The size of the pouch volume has a strong relationship with postoperative function. The types of ileal pouch are J and H type for 2-tab, S type for 3-tab, and W type for 4-tab. If the tether is long enough, J-type can be used, and vice versa, S-type. J-type and H-type pouch operation is relatively simple, but its volume is small, and the number of stools after surgery is more. S-type pouch volume is larger, and the number of stools after surgery is less, but the operation is relatively complex, and the incidence of pouchitis is high. W-type pouch volume is the largest, and the postoperative function is the best, but the operation is also the most complex. At present, the most used is the J-type storage bag, and has rarely retained the rectum.
The incidence of IPAA complications is 13% to 59% (10-12). The different incidence rates are related to the surgical technique, the type of reservoir pouch, and the technique of reservoir pouch anal canal anastomosis. The use of the anastomotic technique has fewer complications and has better postoperative function (13).
Griffin (14) investigated the quality of life of 585 UC patients treated with IPAA over a 10-year period and found that male and younger patients were superior to other patients. Keighley reported on 154 UC patients with long-term follow-up who underwent IPAA, with a 5-year success rate of 82% and a 10-year success rate of 72% for the reservoir pouch, with the main failure being chronic infection in 29% and a satisfactory quality of life in 81% of patients. Rintala followed up 29 pediatric UC patients treated with IPAA, suggesting that IPAA complications are higher, so it should be carefully selected for pediatric UC patients.
3. 4 Treatment of toxic megacolon
In the management of patients with toxic megacolon, although ileal collar diversion stoma with colonic abdominal wall stoma (colonic opening) decompression surgery can make the procedure easy and shorten the operative time, it is difficult to sew the dilated thin intestinal wall in layers to the abdominal wall stoma, while performing total colectomy to preserve the rectum does not increase mortality. Intraoperative contamination of the abdominal cavity by intestinal perforation should be prevented.
The mortality rate of emergency surgery for toxic megacolon is generally reported to be 8.7%, including 6.1% for total colectomy and 14.7% for total colectomy and rectal resection, which indicates that in emergency cases, the surgery should be relatively conservative, and the rectum should be preserved and ileoanal anastomosis should be performed in the second stage of surgery.
Evaluation of the procedure in recent years.
(1) Although the shape of the storage pouch is different, there is no difference in function in general, and the surgical complications are similar. In the long term, the number of bowel movements has little to do with the volume and shape of the bag. Therefore, the simple operation of the J-shaped reservoir bag and the application of the anastomosis seems to be more preferable.
(2) Early on, too much emphasis was placed on preserving about 1 cm of mucosa above the dentate line to facilitate the control of bowel function, which seems to be unfounded at present, and there is a potential risk of cancer in this section of mucosa.