Inflammatory Bowel Disease — Surgical Management — SAQ

Stem

A 30-year-old woman with a 12-year history of extensive ulcerative colitis has confirmed high-grade dysplasia on surveillance colonoscopy. She is otherwise well and wishes to avoid a permanent stoma.

Questions

a) What is the recommended definitive surgical procedure? (3 marks)

Total proctocolectomy with ileal pouch-anal anastomosis (IPAA/J-pouch):

1. Removes all colonic and rectal mucosa (eliminates cancer risk)
2. Preserves anal sphincter function (maintains continence)
3. Ileal reservoir (J-pouch) created from terminal ileum
4. Anastomosed to anal canal (double-stapled technique)
5. Defunctioning loop ileostomy (closed at 8-12 weeks)

b) What are the main alternatives? (2 marks)

1. Proctocolectomy with end ileostomy (Brooke) — permanent stoma; for patients not suitable for pouch
2. Continent ileostomy (Kock pouch) — internal reservoir with nipple valve; rarely performed now

c) What are the main complications of IPAA? (3 marks)

1. Pouchitis (40-50% lifetime): increased stool frequency, urgency — treated with ciprofloxacin + metronidazole
2. Small bowel obstruction (15-20%): adhesions
3. Anastomotic leak (5-10%): may require temporary diversion
4. Pouch failure (5-10%): requiring pouch excision and end ileostomy
5. Cuffitis: inflammation of retained rectal cuff mucosa
6. Reduced fertility in women (3x increased infertility after pelvic surgery)

d) What pre-operative optimisation is important? (2 marks)

1. Correct anaemia and malnutrition
2. Taper steroids if possible
3. Hold biologics 4-8 weeks before surgery
4. VTE prophylaxis
5. Stoma site marking by stoma nurse
6. MDT discussion