Stefan Holubar, MD, on Surgical Options for Ulcerative Colitis

In this video Dr Holubar talks about the types of surgical procedures available for treating ulcerative colitis.

Stefan Holubar, MD, is director of research and of the Inflammatory Bowel Disease Surgery section at the Cleveland Clinic in Cleveland, Ohio. 

TRANSCRIPT:

Hello, I'm Stefan Holubar. I'm the IBD surgery section chief here at Cleveland Clinic and also the director of research for the department. Today we're going to talk about surgery for ulcerative colitis. In general, there are two approaches. There is nonrestorative and there is restorative approach.

The majority of people, about 9%, will choose to have a restorative approach, which is most commonly called the J-pouch, while 10%, of people don't want to go through the J-pouch and they undergo a nonrestorative approach, which consists of a total abdominal colectomy with a prostatectomy, total proctocolectomy with end ileostomy.

What that means is the diseased large and small bowel is removed. The anus is sewed up and then a permanent end ileostomy is made. Again, that's about 10% of people overall. Much more commonly people decide to go with a restorative approach.

These days, we talk about the 3-stage approach to J-pouch surgery, because the majority of people are ill at the time that they need their colon taken out. We usually start out with a laparoscopic total abdominal colectomy with an end ileostomy.

Then we leave the rectal stump usually implanted in a small bikini line incision outside of the body so that if it leaks, the patient doesn't get sick and need to go back to the operating room. That's step 1 of the 3-stage approach.

After that, we do something called the laparoscopic completion prostatectomy, which means removing the rectum and construction of an ileal pouch-anal anastomosis. That's where we take the end ileostomy, we pull it into a J, and anastomose to the anus.

This is typically protected by temporary diverting loop ileostomy. The third stage of the 3-stage approach is the diverting loop ileostomy closure.

A modification of the 3-stage is called the modified 2-stage. That begins when we first do the total abdominal colectomy with end ileostomy, but then for the second stage, when we make the J-pouch and remove the rectum, we don't need to cover that with an ileostomy. This is something that's popular in Europe these days. It's unclear whether or not it's safe to do it. It's done less frequently in the United States because what we do know is that if you have a leak from the J-pouch, which happens in about 5% to 10% of cases, that can ruin the function of the pouch long-term, so a minority of surgeons are willing to perform the modified 2-stage and typically only if it goes perfectly.

That's the approach that we use for people who most commonly have medically refractory disease. That's when they've gotten lots of medications and they're quite ill, malnourished, on steroids, and anemic. That's about 80% of the people who need surgery for ulcerative colitis.

However, about 20% of them have neoplasia as the indication, which includes multifocal low-grade dysplasia, high-grade dysplasia, or colorectal cancer.

In these patients often we can do the 2-stage approach, which is a total proctocolectomy with a J-pouch and diverting loop ileostomy all at the first stage, and then the second stage is diverting loop ileostomy closure.

In summary, the majority of patients in the 21st century will have a 3-stage J-pouch surgery for medically refractory disease. Less commonly, they'll have a 2-stage total proctocolectomy with J-pouch. That's typically for someone who has neoplasia, not medically refractory disease.

For both, overall, about 10% of patients will choose not to have a J-pouch, but go with other 1-stage or 2-stage total proctocolectomy with end ileostomy. Thank you.