eMedicine Specialties > Pediatrics: Surgery > General Surgery
Ulcerative Colitis: Surgical Perspective: Treatment
Updated: Dec 4, 2008
Treatment
Medical Therapy
Medical treatment of ulcerative colitis (UC) varies depending on the severity of the disease and the portion of the colon involved. It consists of induction treatment followed by maintenance therapy.46 In mild disease confined to the rectum, topical mesalazine (Asacol) given by suppository is the preferred therapy. Enemas or foam are less effective because their concentration in the rectum rapidly diminishes. Left-sided colonic disease is best treated with a combination of mesalazine suppository and an oral aminosalicylate. Combined oral and topical therapy is better than either route alone. Of the oral amino salicylates, sulfasalazine has the longest history. Sulfasalazine is 5-aminosalicylate (5-ASA) coupled to a sulfapyridine. It is poorly absorbed in the proximal bowel, and the bacteria in the colon uncouple the 5-ASA from the sulfa moiety, allowing 5-ASA to exert its anti-inflammatory effect on the colonic mucosa by inhibiting prostaglandin synthesis.
Mesalazine, another 5-ASA containing molecule, is better tolerated orally than sulfasalazine and has become the preferred medication. Systemic steroids are indicated when disease fails to quickly respond to aminosalicylates.
Acute, severe ulcerative colitis (ie, >6 bloody bowel movements/d, with one of the following: fever >38ºC, hemoglobin level <10.5 g/dL, heart rate >90 beats per minute [bpm], erythrocyte sedimentation rate >30 mm/h, or C-reactive protein level >30) requires hospitalization with intravenous high-dose corticosteroids (hydrocortisone 400 mg/d or methylprednisolone 60 mg/d). Alternative induction medications have been evaluated. Cyclosporine, tacrolimus, and infliximab are often effective in bringing steroid resistant disease under control. They have not been compared in a randomized controlled fashion; thus, one cannot be recommended above the others. They have all been associated with overwhelming sepsis. Cyclosporine and tacrolimus are both nephrotoxic and should not be used for long-term therapy. Infliximab requires the coadministration of an antimetabolite to limit the development of human anti-mouse antibody (HAMA).
For induction, other treatments have been proposed but are not standard therapy. Antibiotics have been used as an adjunct to steroid therapy but have not altered outcomes. Helminth ova have not been shown to be superior to placebo. Heparin may promote epithelial repair but is not effective given current delivery systems. Leukocytapheresis has some promise and is quite popular in Japan, where it has been used to induce remission47 and prevent postoperative septic complications.48 Confirmatory studies in adults49 and pediatric patients50 are very promising. However, it remains a resource intensive treatment.
Once remission has been achieved, maintenance therapy is recommended for all patients to prevent relapse. Oral aminosalicylates are indicated for disease that responded to ASA or steroids. Failure to continue with suppressive therapy is associated with high rates of relapse. Some patients are unable to maintain remission or are intolerant of 5-ASA. Azathioprine or 6-mercaptopurine are alternatives that have proven effectiveness. For patients who were induced with infliximab, maintenance therapy should continue with infliximab or azathioprine.
Probiotics also appear to be effective at maintaining remission. Escherichia coli strain Nissle 1917 has been compared with mesalazine and proved to be similarly effective.51 Bio-Three, a commercially available probiotic supplement (Enterococcus T-110, C butyricum TO-A, B mesentericus TO-A) produced remission in 45% of patients tested with mild-to-moderate ulcerative colitis.52 Trials of fish oil to produce or maintain remission have shown no benefit over placebo.
Surgical Therapy
The underlying principle to the surgical management of ulcerative colitis is total removal of the colon and rectal mucosa. This is achieved by performing a total proctocolectomy. However, ulcerative colitis tends to occur in young individuals in whom the implications of permanent ileostomy may be psychologically damaging; therefore, over the past 20 years, numerous continence-restoring procedures have evolved.
The creation of an ileal pouch–anal anastomosis involves total proctocolectomy, with folding of the distal ileum into a J, S, or W formation to create a fecal reservoir. The anastomosis to the anus preserves continence function involving the internal and external anal sphincters. The S and W configurations have been associated with a failure rate as high as 66% and a need for revision. Conversely, the J configuration is associated with a need for revision in only 1-2% of cases.
Reasons for failure with S and W pouches include dilation of the reservoir that leads to stasis and elongation of the spout at the anal anastomosis that leads to stenosis.53 These technical points are all but alleviated with the current technique of J pouch construction. Transanal defecation is restored in 88% of children with J pouches, whereas 32% of those with S pouches and 32% of those undergoing straight ileoanal pull-through procedures require revision.54 Although most surgeons do not use the S pouch as the first option (because of its pouchitis rate), the spout created in its construction provide an additional 3-5 cm in length in the entire ileal reservoir, compared with the length of a J pouch.
Some still advocate straight ileoanal pull-through anastomosis without reservoir construction. Straight endorectal pull-through causes dilatation and compensation over time so that the pouch develops a reservoir function. In addition, length is generally not a problem with a straight pull-through. Thus, many pediatric surgeons perform this as their primary procedure. Good long-term outcomes and patient satisfaction are reported.55 However, others have noted a need for revision of the straight pull-through configuration in 70% of the cases.53 Construction of the ileal J pouch-anal anastomosis is described below. However, one should keep in mind that the straight ileoanal pull-through is performed in essentially the same manner and uses less total length of small bowel.
In summary, the choice of pouch size and type is a balance between increasing reservoir function to decrease stool frequency and the risk of developing pouchitis. All reservoirs have a tendency to enlarge over time. Consequently, most surgeons have opted for a smaller initial reservoir that depends on reservoir enlargement to gradually decrease stooling frequency while avoiding pouchitis.
Preoperative Details
Timing of the surgical intervention is the major preoperative concern in ulcerative colitis. If possible, emergency surgery should be avoided because of the considerations mentioned above. If emergency surgery is indicated, most advocate use of a staged procedure. Initially, emergency total colectomy with end ileostomy is performed to alleviate the major symptoms of the disease, including bleeding and pain, and allows the patient to be weaned from steroids. Later, an ileal pouch–anal anastomosis is created, if the patient desires it, with removal of the remaining rectum. Most advocate leaving the rectum in place during the initial emergency operation to prevent disrupting the pelvic tissue planes to make the subsequent pelvic dissection safer. If the patient has mild disease or disease in remission, total proctocolectomy with the creation of an ileal pouch–anal anastomosis may be performed as the initial definitive procedure.
Intraoperative Details
A total proctocolectomy is performed through a midline abdominal section. The ileum is divided close to the ileocecal valve with a stapler to save maximal ileal length. The ileal branch of the ileocolic artery is preserved, if possible, to provide optimal blood supply to the distal ileum. The rectum is stapled and divided, within 1 cm proximal to the dentate line. This procedure theoretically preserves the sensory nerve fibers in the anal transition zone that contribute to discrimination between gas and stool. Some refute the importance of retaining this zone, reporting no change in functional outcome when the anal transition zone is removed.56 However, rectal mucosectomy may be performed and the ileum brought through a short seromuscular sleeve of rectum.
The dimensions of the pouch depend on the size of the patent. In adolescents, as in adults, a 9-cm to 12-cm pouch is created by folding the distal ileum on itself in a J configuration and by using a linear cutting stapler to place staples longitudinally along the antimesenteric border between the two limbs of the J to create a reservoir (see Media file 2). Limb lengths of 8-10 cm are used in small children. The bowel at the lower end (ie, curve) of the J is then used to create an anastomosis to the anus with a circular stapling device or sutures. Because of the increased incidence of cancer in patients with ulcerative colitis and primary sclerosing cholangitis (PSC), complete mucosectomy to the dentate line and creation of a hand-sewn pouch-anal anastomosis has been recommended in these patients.30
To ensure a tension-free anastomosis at the anus, numerous techniques may be used to gain length in the small bowel. First, the ligament of Treitz may be mobilized to allow the proximal jejunum to turn toward the pelvis is a more gradual manner. The peritoneum overlying the small bowel mesentery may be sequentially opened in an orientation perpendicular to the superior mesenteric artery ("stair stepping") to release tension and provide length. The superior mesenteric artery may be divided just distal to the origin of the first or second arterial arcade. This proximal division preserves distal collateral flow and provides length. Finally, vein interposition grafts may be used as a last resort in the most extreme cases in which length is prohibitively short.57
The need for fecal diversion after ileal pouch–anal anastomosis is controversial in the adult patients. Usually, the need to operate on young patients is due to the severity of illness. Thus, most surgeons prefer to proximally divert the fecal stream in young patients. During the procedure, the distal vascular arcades of the ileum are often divided to gain length to reach the pelvis; this division predisposes the patient to ischemia. Therefore, many surgeons opt for an end ileostomy or loop ileostomy as the means of diversion. Many use loop ileostomy because of the widely held belief that takedown of a loop ileostomy is technically easier.
Recent data refute this assumption. On average, the operating time with loop ileostomy takedown is 54 minutes less than that of end ileostomy. However, loop ileostomy takedown lengthens the hospital stay, increases the time to oral feeding, and has a 2-fold higher wound infection rate compared with that of end-ileostomy takedown. In addition, loop ileostomy requires significantly more outpatient stoma care and is associated with more frequent anal complications.58
Finally, minimally invasive surgical technique has been used in total colectomy. Over the past 10 years, several centers have reported success with using laparoscopy to perform the total colectomy combined with transanal mucosectomy to completely remove the diseased colon and rectal mucosa. An ileo-anal anastomosis (with or without J Pouch) can be successfully performed, as described above. The main disadvantage of the laparoscopic approach is the increase in total operating time compared with open surgery. However, preliminary data suggest decreased length of hospital stay, shorter time to return to normal activities and school, and improved cosmetic results. This technically demanding laparoscopic operation has also been successfully performed using robotic-assisted technology.
Postoperative Details
After ileal pouch–anal anastomosis procedures, patients are treated as with any bowel procedure. Their diet is changed as bowel function returns. They are weaned from steroid use. At 6-12 weeks, diverting ileostomies are evaluated for closure. This evaluation usually involves contrast-enhanced imaging of the pouch to assess healing. Once the ostomy is taken down, stool frequency is evaluated, and the need for bulk-forming agents or motility agents determined.
Follow-up
Although the incidence of colon adenocarcinoma is greatly reduced with total proctocolectomy and ileal pouch–anal anastomosis, it is not zero. The residual colonic mucosa is at risk for dysplasia and neoplastic transformation.59 Moreover, in patients with chronic pouch inflammation, villous hypertrophy and dysplasia may occur. Although dysplasia has never been found within the pouch of a pediatric patient, chronic inflammatory changes have been found, leading to the supposition that dysplasia may develop. Yearly screening endoscopy has been recommended for the 5 years after the procedure. In children who have chronic inflammatory changes in the pouch reservoir, annual screening endoscopy should be performed. If no inflammation is present, screening endoscopy may be performed every 2 years.60
Complications
Several complications have been reported after ileal pouch–anal anastomosis procedures. The anastomotic leak rate is 7-9%.54,61 If this leak occurs, fecal diversion, percutaneous drain placement, or repeat surgery with removal or revision of the reservoir is required. Pelvic abscess, which frequently accompanies an anastomotic leak, occurs in about 5% of cases (reports vary from 0-25%). Among patients with a pelvic abscess, 26% require excision of the pouch. Only 5.9% of patients without an abscess have pouch failure that requires removal. If the abscess is managed with diversion and drainage, the pouch may be spared. However, these patients have higher rates of long-term incontinence and pain compared with those without abscesses.62 In patients who require pouch excision due to abscess, a gracilis muscle interposition flap has been used to maintain the anal canal and allow future attempts at pouch procedures.63
Pouch-vesicle, pouch-vaginal, pouch-anal, and enterocutaneous fistulas occur with a frequency of about 1% each.
Pouchitis is defined as a clinical syndrome in which the patient has increased stool frequency, malaise, fever, or incontinence that usually responds to antibiotic therapy. The most frequently used antibiotics are ciprofloxacin or metronidazole.61 The incidence is reported to be 40-60%. Risk increases with time; 18% have pouchitis at 1 year, and 48% have pouchitis at 10 years.54,61,64 Pouch dilatation and pouch-anal anastomotic stricture may lead to fecal stasis and predispose the patient to pouchitis. Patients without a pouch rarely develop pouchitis and have comparable stool frequency with time. Clostridium difficile and Clostridium perfringens have been disproportionately found in patients with ulcerative colitis after ileal pouch–anal anastomosis. Treatment of these infections has led to decreases in inflammation.65,66
More on Ulcerative Colitis: Surgical Perspective |
| Overview: Ulcerative Colitis: Surgical Perspective |
| Workup: Ulcerative Colitis: Surgical Perspective |
 Treatment: Ulcerative Colitis: Surgical Perspective |
| Follow-up: Ulcerative Colitis: Surgical Perspective |
| Multimedia: Ulcerative Colitis: Surgical Perspective |
| References |
| « Previous Page | Next Page » |
References
Parks AG, Nicholls RJ. Proctocolectomy without ileostomy for ulcerative colitis. Br Med J. Jul 8 1978;2(6130):85-8. [Medline].
Hunt LE, Eichenberger MR, Petras R, Galandiuk S. Use of a microsatellite marker in predicting dysplasia in ulcerative colitis. Arch Surg. May 2000;135(5):582-5. [Medline].
Garland CF, Lilienfeld AM, Mendeloff AI, Markowitz JA, Terrell KB, Garland FC. Incidence rates of ulcerative colitis and Crohn's disease in fifteen areas of the United States. Gastroenterology. Dec 1981;81(6):1115-24. [Medline].
Cotran RS, Collins T, Robbins SL, Kumar V. Pathologic Basis of Disease. Philadelphia, PA: WB Saunders; 1998.
Lindberg E, Magnusson KE, Tysk C, Jarnerot G. Antibody (IgG, IgA, and IgM) to baker's yeast (Saccharomyces cerevisiae), yeast mannan, gliadin, ovalbumin and betalactoglobulin in monozygotic twins with inflammatory bowel disease. Gut. Jul 1992;33(7):909-13. [Medline].
Levine J, Ellis CJ, Furne JK, et al. Fecal hydrogen sulfide production in ulcerative colitis. Am J Gastroenterol. Jan 1998;93(1):83-7. [Medline].
Almeida MG, Kiss DR, Zilberstein B, Quintanilha AG, Teixeira MG, Habr-Gama A. Intestinal mucosa-associated microflora in ulcerative colitis patients before and after restorative proctocolectomy with an ileoanal pouch. Dis Colon Rectum. Jul 2008;51(7):1113-9. [Medline].
Felder JB, Korelitz BI, Rajapakse R, et al. Effects of nonsteroidal antiinflammatory drugs on inflammatory bowel disease: a case-control study. Am J Gastroenterol. Aug 2000;95(8):1949-54. [Medline].
Bousvaros A, Zurakowski D, Duggan C, et al. Vitamins A and E serum levels in children and young adults with inflammatory bowel disease: effect of disease activity. J Pediatr Gastroenterol Nutr. Feb 1998;26(2):129-35. [Medline].
Cottliar A, Fundia A, Boerr L, et al. High frequencies of telomeric associations, chromosome aberrations, and sister chromatid exchanges in ulcerative colitis. Am J Gastroenterol. Sep 2000;95(9):2301-7. [Medline].
Vasiliauskas E. Serum immune markers in inflammatory bowel disease. Gastroenterology and Endoscopy News. Available at http://www.gastroendonews.com.
Peeters M, Joossens S, Vermeire S, et al. Diagnostic value of anti-Saccharomyces cerevisiae and antineutrophil cytoplasmic autoantibodies in inflammatory bowel disease. Am J Gastroenterol. Mar 2001;96(3):730-4. [Medline].
Dubinsky MC, Ofman JJ, Urman M, et al. Clinical utility of serodiagnostic testing in suspected pediatric inflammatory bowel disease. Am J Gastroenterol. Mar 2001;96(3):758-65. [Medline].
Hoffenberg EJ, Fidanza S, Sauaia A. Serologic testing for inflammatory bowel disease. J Pediatr. Apr 1999;134(4):447-52. [Medline].
Kaditis AG, Perrault J, Sandborn WJ, et al. Antineutrophil cytoplasmic antibody subtypes in children and adolescents after ileal pouch-anal anastomosis for ulcerative colitis. J Pediatr Gastroenterol Nutr. Apr 1998;26(4):386-92. [Medline].
Duggan AE, Usmani I, Neal KR, Logan RF. Appendicectomy, childhood hygiene, Helicobacter pylori status, and risk of inflammatory bowel disease: a case control study. Gut. Oct 1998;43(4):494-8. [Medline]. [Full Text].
Andersson RE, Olaison G, Tysk C, Ekbom A. Appendectomy and protection against ulcerative colitis. N Engl J Med. Mar 15 2001;344(11):808-14. [Medline]. [Full Text].
Levenstein S, Prantera C, Varvo V, et al. Stress and exacerbation in ulcerative colitis: a prospective study of patients enrolled in remission. Am J Gastroenterol. May 2000;95(5):1213-20. [Medline].
Heuschen UA, Hinz U, Allemeyer EH, et al. Backwash ileitis is strongly associated with colorectal carcinoma in ulcerative colitis. Gastroenterology. Mar 2001;120(4):841-7. [Medline].
Kaufman SS, Vanderhoof JA, Young R, et al. Gastroenteric inflammation in children with ulcerative colitis. Am J Gastroenterol. Jul 1997;92(7):1209-12. [Medline].
Gooding IR, Springall R, Talbot IC, Silk DB. Idiopathic small-intestinal inflammation after colectomy for ulcerative colitis. Clin Gastroenterol Hepatol. Jun 2008;6(6):707-9. [Medline].
Slatter C, Girgis S, Huynh H, El-Matary W. Pre-pouch ileitis after colectomy in paediatric ulcerative colitis. Acta Paediatr. Mar 2008;97(3):381-3. [Medline].
Cucchiara S, Celentano L, de Magistris TM, et al. Colonoscopy and technetium-99m white cell scan in children with suspected inflammatory bowel disease. J Pediatr. Dec 1999;135(6):727-32. [Medline].
Kim B, Barnett JL, Kleer CG, Appelman HD. Endoscopic and histological patchiness in treated ulcerative colitis. Am J Gastroenterol. Nov 1999;94(11):3258-62. [Medline].
Calabrese C, Fabbri A, Gionchetti P, et al. Controlled study using wireless capsule endoscopy for the evaluation of the small intestine in chronic refractory pouchitis. Aliment Pharmacol Ther. Jun 1 2007;25(11):1311-6. [Medline].
Falcone RA Jr, Lewis LG, Warner BW. Predicting the need for colectomy in pediatric patients with ulcerative colitis. J Gastrointest Surg. Mar-Apr 2000;4(2):201-6. [Medline].
Lichtiger S, Present DH, Kornbluth A, et al. Cyclosporine in severe ulcerative colitis refractory to steroid therapy. N Engl J Med. Jun 30 1994;330(26):1841-5. [Medline]. [Full Text].
Rowe FA, Walker JH, Karp LC, et al. Factors predictive of response to cyclosporin treatment for severe, steroid-resistant ulcerative colitis. Am J Gastroenterol. Aug 2000;95(8):2000-8. [Medline].
Cox KL, Cox KM. Oral vancomycin: treatment of primary sclerosing cholangitis in children with inflammatory bowel disease. J Pediatr Gastroenterol Nutr. Nov 1998;27(5):580-3. [Medline].
Marchesa P, Lashner BA, Lavery IC, et al. The risk of cancer and dysplasia among ulcerative colitis patients with primary sclerosing cholangitis. Am J Gastroenterol. Aug 1997;92(8):1285-8. [Medline].
Bernstein CN, Blanchard JF, Rawsthorne P, Yu N. The prevalence of extraintestinal diseases in inflammatory bowel disease: a population-based study. Am J Gastroenterol. Apr 2001;96(4):1116-22. [Medline].
de Vlam K, Mielants H, Cuvelier C, et al. Spondyloarthropathy is underestimated in inflammatory bowel disease: prevalence and HLA association. J Rheumatol. Dec 2000;27(12):2860-5. [Medline].
Murata I, Satoh K, Yoshikawa I, et al. Recurrent subcutaneous abscess of the sternal region in ulcerative colitis. Am J Gastroenterol. Mar 1999;94(3):844-5. [Medline].
Kimura K, Hunter SF, Thollander MS, et al. Concurrence of inflammatory bowel disease and multiple sclerosis. Mayo Clin Proc. Aug 2000;75(8):802-6. [Medline].
Egan CA, Meadows KP, Zone JJ. Ulcerative colitis and immunobullous disease cured by colectomy. Arch Dermatol. Feb 1999;135(2):214-5. [Medline].
Treem WR, Cohen J, Davis PM, et al. Cyclosporine for the treatment of fulminant ulcerative colitis in children. Immediate response, long-term results, and impact on surgery. Dis Colon Rectum. May 1995;38(5):474-9. [Medline].
Gorfine SR, Bauer JJ, Harris MT, Kreel I. Dysplasia complicating chronic ulcerative colitis: is immediate colectomy warranted?. Dis Colon Rectum. Nov 2000;43(11):1575-81. [Medline].
Ekbom A, Helmick C, Zack M, Adami HO. Ulcerative colitis and colorectal cancer. A population-based study. N Engl J Med. Nov 1 1990;323(18):1228-33. [Medline].
Rutter MD, Saunders BP, Wilkinson KH, et al. Thirty-year analysis of a colonoscopic surveillance program for neoplasia in ulcerative colitis. Gastroenterology. Apr 2006;130(4):1030-8. [Medline].
Kapsoritakis AN, Koukourakis MI, Sfiridaki A, et al. Mean platelet volume: a useful marker of inflammatory bowel disease activity. Am J Gastroenterol. Mar 2001;96(3):776-81. [Medline].
Durno CA, Sherman P, Williams T, et al. Magnetic resonance imaging to distinguish the type and severity of pediatric inflammatory bowel diseases. J Pediatr Gastroenterol Nutr. Feb 2000;30(2):170-4. [Medline].
Charron M, del Rosario JF, Kocoshis S. Use of technetium-tagged white blood cells in patients with Crohn's disease and ulcerative colitis: is differential diagnosis possible?. Pediatr Radiol. Nov 1998;28(11):871-7. [Medline].
Ludwig D, Wiener S, Bruning A, et al. Mesenteric blood flow is related to disease activity and risk of relapse in ulcerative colitis: a prospective follow up study. Gut. Oct 1999;45(4):546-52. [Medline]. [Full Text].
Deutsch DE, Olson AD. Colonoscopy or sigmoidoscopy as the initial evaluation of pediatric patients with colitis: a survey of physician behavior and a cost analysis. J Pediatr Gastroenterol Nutr. Jul 1997;25(1):26-31. [Medline].
Matsumoto T, Nakamura S, Jin-No Y, et al. Role of granuloma in the immunopathogenesis of Crohn's disease. Digestion. 2001;63 Suppl 1:43-7. [Medline].
Travis SPL, Stange EF, Lemann M, et al. European Consensus on the diagnosis and management of ulcerative colitis: current management. J Crohn's & Colitis. 2008;2:24–62.
Sakuraba A, Sato T, Naganuma M, et al. A pilot open-labeled prospective randomized study between weekly and intensive treatment of granulocyte and monocyte adsorption apheresis for active ulcerative colitis. J Gastroenterol. 2008;43(1):51-6. [Medline].
Miki C, Okita Y, Yoshiyama S, Araki T, Uchida K, Kusunoki M. Early postoperative application of extracorporeal leukocyte apheresis in ulcerative colitis patients: results of a pilot trial to prevent postoperative septic complications. J Gastroenterol. Jun 2007;42(6):508-9. [Medline].
Emmrich J, Petermann S, Nowak D, et al. Leukocytapheresis (LCAP) in the management of chronic active ulcerative colitis--results of a randomized pilot trial. Dig Dis Sci. Sep 2007;52(9):2044-53. [Medline].
Ruuska T, Lahdeaho ML, Sutas Y, Ashorn M, Gronlund J. Leucocyte apheresis in the treatment of paediatric ulcerative colitis. Scand J Gastroenterol. Nov 2007;42(11):1390-1. [Medline].
Rembacken BJ, Snelling AM, Hawkey PM, Chalmers DM, Axon AT. Non-pathogenic Escherichia coli versus mesalazine for the treatment of ulcerative colitis: a randomised trial. Lancet. Aug 21 1999;354(9179):635-9. [Medline].
Tsuda Y, Yoshimatsu Y, Aoki H, et al. Clinical effectiveness of probiotics therapy (BIO-THREE) in patients with ulcerative colitis refractory to conventional therapy. Scand J Gastroenterol. Nov 2007;42(11):1306-11. [Medline].
Fonkalsrud EW, Bustorff-Silva J. Reconstruction for chronic dysfunction of ileoanal pouches. Ann Surg. Feb 1999;229(2):197-204. [Medline].
Durno C, Sherman P, Harris K, et al. Outcome after ileoanal anastomosis in pediatric patients with ulcerative colitis. J Pediatr Gastroenterol Nutr. Nov 1998;27(5):501-7. [Medline].
Shamberger RC, Masek BJ, Leichtner AM, et al. Quality-of-life assessment after ileoanal pull-through for ulcerative colitis and familial adenomatous polyposis. J Pediatr Surg. Jan 1999;34(1):163-6. [Medline].
Choi JS, Potenti F, Wexner SD, et al. Functional outcomes in patients with mucosal ulcerative colitis after ileal pouch-anal anastomosis by the double stapling technique: is there a relation to tissue type?. Dis Colon Rectum. Oct 2000;43(10):1398-404. [Medline].
Metcalf DR, Nivatvongs S, Sullivan TM, Suwanthanma W. A technique of extending small-bowel mesentery for ileal pouch-anal anastomosis: report of a case. Dis Colon Rectum. Mar 2008;51(3):363-4. [Medline].
Fonkalsrud EW, Thakur A, Roof L. Comparison of loop versus end ileostomy for fecal diversion after restorative proctocolectomy for ulcerative colitis. J Am Coll Surg. Apr 2000;190(4):418-22. [Medline].
Chia CS, Chew MH, Chau YP, Eu KW, Ho KS. Adenocarcinoma of the anal transitional zone after double stapled ileal pouch-anal anastomosis for ulcerative colitis. Colorectal Dis. Jul 2008;10(6):621-3. [Medline].
Sarigol S, Wyllie R, Gramlich T, et al. Incidence of dysplasia in pelvic pouches in pediatric patients after ileal pouch-anal anastomosis for ulcerative colitis. J Pediatr Gastroenterol Nutr. Apr 1999;28(4):429-34. [Medline].
Simchuk EJ, Thirlby RC. Risk factors and true incidence of pouchitis in patients after ileal pouch-anal anastomoses. World J Surg. Jul 2000;24(7):851-6. [Medline].
Farouk R, Dozois RR, Pemberton JH, Larson D. Incidence and subsequent impact of pelvic abscess after ileal pouch- anal anastomosis for chronic ulcerative colitis. Dis Colon Rectum. Oct 1998;41(10):1239-43. [Medline].
Shamberger RC, Hergrueter CA, Lillehei CW. Use of a gracilis muscle flap to facilitate delayed ileal pouch-anal anastomosis. Dis Colon Rectum. Nov 2000;43(11):1628-31. [Medline].
Meagher AP, Farouk R, Dozois RR, et al. J ileal pouch-anal anastomosis for chronic ulcerative colitis: complications and long-term outcome in 1310 patients. Br J Surg. Jun 1998;85(6):800-3. [Medline].
Shen BO, Jiang ZD, Fazio VW, et al. Clostridium difficile infection in patients with ileal pouch-anal anastomosis. Clin Gastroenterol Hepatol. Jul 2008;6(7):782-8. [Medline].
Falk A, Olsson C, Ahrné S, Molin G, Adawi D, Jeppsson B. Ileal pelvic pouch microbiota from two former ulcerative colitis patients, analysed by DNA-based methods, were unstable over time and showed the presence of Clostridium perfringens. Scand J Gastroenterol. Aug 2007;42(8):973-85. [Medline].
Karlbom U, Raab Y, Ejerblad S, et al. Factors influencing the functional outcome of restorative proctocolectomy in ulcerative colitis. Br J Surg. Oct 2000;87(10):1401-8. [Medline].
Ogilvie JW Jr, Goetz L, Baxter NN, Park J, Minami S, Madoff RD. Female sexual dysfunction after ileal pouch-anal anastomosis. Br J Surg. Jul 2008;95(7):887-92. [Medline].
Cornish JA, Tan E, Teare J, et al. The effect of restorative proctocolectomy on sexual function, urinary function, fertility, pregnancy and delivery: a systematic review. Dis Colon Rectum. Aug 2007;50(8):1128-38. [Medline].
Cohen RD, Stein R, Hanauer SB. Intravenous cyclosporin in ulcerative colitis: a five-year experience. Am J Gastroenterol. Jun 1999;94(6):1587-92. [Medline].
Garcea A, Fazi M, Ficari F, Valanzano R, Tonelli F. Are the preoperative histological findings accurate for the choice of the surgical approach in ulcerative colitis associated with colorectal cancer/dysplasia?. Suppl Tumori. May-Jun 2005;4(3):S3. [Medline].
Martin de Carpi J, Vilar P, Prieto G, Garcia Novo MD, Ribes C, Varea V. Safety and efficacy of granulocyte and monocyte adsorption apheresis in paediatric inflammatory bowel disease: a prospective pilot study. J Pediatr Gastroenterol Nutr. Apr 2008;46(4):386-91. [Medline].
Mor IJ, Vogel JD, Moreira Ada L, Shen B, Hammel J, Remzi FH. Infliximab in ulcerative colitis is associated with an increased risk of postoperative complications after restorative proctocolectomy. Dis Colon Rectum. Aug 2008;51(8):1202-7; discussion 1207-10. [Medline].
Sako M, Kimura H, Arai K, et al. Restorative proctocolectomy for pediatric patients with ulcerative colitis. Surg Today. 2006;36(2):162-5. [Medline].
Velayos FS, Sandborn WJ. Positioning biologic therapy for Crohn's disease and ulcerative colitis. Curr Gastroenterol Rep. Dec 2007;9(6):521-7. [Medline].
Further Reading
Keywords
ulcerative colitis, UC, inflammatory bowel disease, colonic adenocarcinoma, Crohn disease, CD, pancolitis, proctocolectomy, biliary disease, Klebsiella species, nonsteroidal anti-inflammatory drug, NSAID, appendectomy, appendicitis, small intestinal inflammation, colonic dysmotility, colonic gangrene, toxic megacolon, abdominal pain, bloody diarrhea, tenesmus, Primary sclerosing cholangitis, PSC, uveitis, pyoderma gangrenosum, pleuritis, erythema nodosum, ankylosing spondylitis, spondyloarthropathies, multiple sclerosis, colon cancer
