Ulcerative Colitis Surgery
What is ulcerative colitis surgery?
Ulcerative colitis—or UC—is a form of inflammatory bowel disease (IBD). The other type of IBD is Crohn’s disease. While Crohn’s can affect any part of the digestive tract, UC only occurs in the colon and rectum. As a result, surgery is a curative ulcerative colitis treatment.
There are four ulcerative colitis surgery options:
Proctocolectomy and Brooke ileostomy: This surgery removes the entire colon, rectum and anus and creates an ileostomy. An ostomy—or stoma—is an opening from the intestines to the abdominal wall. It allows fecal matter to pass from the intestines into a collection bag. An ileostomy is a connection between the small intestine and the abdominal wall. This option will work for almost anyone, especially those with poor sphincter function.
Abdominal colectomy and ileorectal anastomosis: This involves removing the entire colon but leaving the rectum in place. The small intestine connects directly to the rectum, allowing normal passage of fecal material. A temporary ostomy is necessary while the connection heals. It is the simplest sphincter-saving surgery. However, it is not completely curative because the rectum remains.
Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA): IPAA is the procedure of choice for UC and is the most common. It removes the colon and rectum, but leaves the sphincter muscles in place. It creates a pouch with the end of the small intestine and connects the pouch to the anus. A temporary ostomy allows the connection to heal. Afterwards, stool will pass normally through the anus. J-pouch is another name for this surgery.
Proctocolectomy and Kock pouch: This surgery removes the entire colon and rectum, but creates a reservoir pouch with the small intestine instead of connecting it to the anus. The pouch has a valve that exits through the skin of the lower abdomen. You empty the pouch through the valve 2 to 4 times a day. It may be an option if you want to avoid an ostomy bag or have a Brooke ileostomy and want to convert it. It is also an option if IPAA fails.
Each procedure has advantages and disadvantages. Talk with your doctor to find the option that best suits you.
Why is ulcerative colitis surgery performed?
Ulcerative colitis surgery is curative because it removes the source of the problem. Curing the disease may not be necessary for people with mild ulcerative colitis symptoms. Medication is often enough to keep mild cases of the disease under control. However, there are times when your doctor may recommend curative surgery including:
Growth problems in children due to malnutrition or long-term corticosteroid use
Medications are no longer effective at relieving inflammation and symptoms
Symptoms outside the intestines develop, such as skin or eye problems—this happens to about 30% of people and is related to disease activity
Surgery may also be necessary to treat emergency situations including:
Perforated bowel, which is a hole in the intestine
Toxic megacolon, which is rapid and extreme widening or dilation of the colon
In emergency situations, surgery can be lifesaving. If you are considering elective surgery, talk with your doctor about all risks and benefits of the procedure.
Who performs ulcerative colitis surgery?
Colon and rectal surgeons perform ulcerative colitis surgery. Colorectal surgeons specialize in treating diseases and conditions of the colon, rectum and anus. They use both surgical and nonsurgical treatments to manage these diseases and conditions. If you are facing UC surgery, experience is important when choosing a surgeon. Look for a colorectal surgeon who has treated plenty of UC patients like you.
How is ulcerative colitis surgery performed?
Ulcerative colitis surgery takes place in a hospital using general anesthesia. The details of the surgery will vary depending on the specific procedure you need. Usually, emergency surgeries are traditional open procedures.
Elective surgeries can be either open surgery or minimally invasive. In general, minimally invasive surgery involves less pain, fewer complications, and a faster recovery. However, there are times when open surgery may be the safest or most effective choice. Talk with your doctor to find out if you are a candidate for minimally invasive surgery.
Some surgeries only involve one procedure. This includes the Brooke ileostomy and the Kock pouch. The other options require two procedures. The first procedure connects the small intestine to either the rectum or anus and creates a temporary ostomy. After the connection heals, a second surgery closes the ostomy.
In emergency situations, three procedures may be necessary. The first removes the colon and creates an ostomy. After recovery, a second procedure removes the rectum and connects the small intestine to the anus. After the connection heals, a third surgery closes the ostomy.
What are the risks and potential complications of ulcerative colitis surgery?
Surgery of any kind involves risk and potential complications. Complications can occur during surgery or may develop throughout your recovery or even afterwards.
General risks of surgery
The general risks of any surgery include:
Anesthesia reaction, such as an allergic reaction and problems with breathing
Potential complications of ulcerative colitis surgery
The risks and complications of UC surgery will vary with the specific procedure. Each type of procedure has some unique complications, such as reoperation rates and surgical failure rates. Ask your doctor to review the possible outcomes with the surgery you are considering.
Some potential complications common to all UC surgeries include:
Damage to other abdominal organs
Intestinal scarring, or adhesions that can block the intestine
Leakage through the incisions or tears in the connections
Nerve, muscle, or blood vessel damage
Reducing your risk of complications
You can reduce your risk of certain complications by openly communicating with your doctor and surgical staff, including the anesthesiologist. Information to share with them includes:
How do I prepare for ulcerative colitis surgery?
Taking steps to prepare before surgery can improve your comfort and outcome. You can prepare for ulcerative colitis surgery by:
Completing bowel preparation regimen as directed
Ensuring all your healthcare providers have your complete medical history. This includes chronic conditions, allergies and medications. When listing medications, include prescriptions, over-the-counter drugs, herbal treatments, and vitamin supplements.
Getting preoperative testing if your doctor orders it. This will vary depending on the procedure and your medical history.
Losing excess weight before surgery
Not eating or drinking before surgery as directed
Stopping smoking as soon as possible to help the healing process. Smoking is a risk factor for problems with the small intestine pouch (J-pouch) following IPAA.
Taking or stopping medications as directed
Questions to ask your doctor
Making a list of questions you want to ask can help you remember everything you want to know during your appointments. Questions you may want to ask include:
Why are you recommending ulcerative colitis surgery for me?
Which procedure is best for me and why?
How long will the surgery take? When can I go home?
What restrictions will I have after surgery? What kind of assistance will this require at home?
When can I return to work and other activities?
How will you manage my pain?
What changes, if any, to my medication plan do I need to make?
When should I follow up with you?
How should I contact you after hours if I have a problem?
What can I expect after ulcerative colitis surgery?
It is easier to plan and prepare for a successful recovery when you know what to expect. Here are a few things to go over with your surgeon.
How long will it take to recover?
Recovery is a gradual process after UC surgery. You will stay in the hospital until your bowel function returns. This can take up to a week. During this time, you will not be able to eat solid foods. It’s common to have IV nutrition for a short time after surgery. You will transition to clear liquids, soft foods, and finally solid foods as your intestines heal.
If you have an ostomy, you will meet with an ostomy nurse to learn how to care for your stoma. The ostomy is temporary if you had a sphincter-saving surgery. Full recovery can take 6 to 12 weeks. At that time, your doctor will decide if the ostomy is ready for closure.
Will I feel pain?
You will have some pain and discomfort after UC surgery. Managing your pain is important for a smooth recovery. It allows you to comfortably walk and complete other activities necessary for healing. Tell your doctor if your pain worsens or changes, as this can be a sign of a complication.
When should I call my doctor?
If you have questions between follow up appointments, contact your doctor’s office during normal business hours. However, call doctor right away or seek immediate medical care if you have:
Breathing problems or shortness of breath
Chest pain, pressure or tightness
Confusion or changes in alertness
Drainage of pus, redness or swelling around your incision
Fever. It’s common to have a fever right after surgery. Your doctor will give you instructions about when to call for a fever.
Inability to urinate or move your bowels
Leg pain, redness or swelling, which could mean you have a blood clot
How might ulcerative colitis surgery affect my everyday life?
With an experienced surgeon, outcomes are usually good after UC surgery. For IPAA, you can expect up to seven bowel movements per day. Typically, this includes at least one at night. It’s possible to have problems being able to tell the difference between gas and stool before you pass it. And some people find they need to use incontinence pants or pads at night. Daytime incontinence is usually minor.
During the first year, it may help to take antidiarrheal medicines. Gradually, both daytime and nighttime bowel control and function will improve after a year. About 10% of IPAA pouches will fail due to complications, such as pouchitis—inflammation of the small intestine pouch. An ileostomy will be necessary if this occurs.
In general, quality of life after IPAA is better than with the other procedures. It avoids skin problems, as well as the psychosocial, physical and sexual problems that are common in people with ostomies. This is one of the main reasons IPAA is the procedure of choice for UC surgery. However, overall satisfaction with a Kock pouch is also very good. It too helps avoid some of the issues with an ostomy and improves body image over an ostomy. Unfortunately, there is a higher complication rate with a Kock pouch. About 35% of people need another revision surgery within the first two years.