Surgical management of ulcerative colitis

quote from "Pediatric Surgery (Springer Surgery Atlas)" by Prem Puri, Michael E. Höllwarth -

"Between 25% and 40% of children with ulcerative colitis undergo surgical treatment. As most patients today can be stabilised by medical treatment, emergency operations for toxic megacolon, unremitting bleeding, or refractory fulminant colitis are not common. The typical indications for surgery of ulcerative colitis are poor response to optimal medical treatment, dependence on high-dose corticosteroids with significant side effects, delay in growth and maturation, and severe extraintestinal manifestations of the disease. Surgery should not be considered as a primary or early treatment of ulcerative colitis. A significant proportion of patients achieve long-term symptom relief with conservative treatment and may remain in remission with minimal or no medication. Moreover, the functional outcome following restorative proctocolectomy is not comparable to normal bowel function. When patients go through several exacerbation phases of the disease, they gradually learn to accept that their bowel will function from a few t0imes to several times a day. Before proctocolectomy is undertaken, Crohn’s disease should be ruled out with every possible measure, as Crohn’s disease patients should not undergo restorative proctocolectomy."

Quote from "Pediatric Surgery (Springer Surgery Atlas)" by Prem Puri, Michael E. Höllwarth -

"The gold standard of surgery for ulcerative colitis has been proctocolectomy and permanent ileostomy. Limited colonic resections, as well as colectomy and ileorectal anastomosis, have been abandoned, as these procedures have been associated with a high incidence of complications and recurrence of the disease. Proctocolectomy and permanent ileostomy gives excellent control of ulcerative colitis and related symptoms, but it is not very well tolerated by children and adolescents because of the significant social restrictions and permanently altered body image that are related to this operation. Since late 1970s, restorative proctocolectomy with ileoanal anastomosis has gained overall acceptance as the standard operative procedure for both adult and paediatric ulcerative colitis. Many paediatric surgeons advocate the use of an ileal reservoir; the most popular and easiest to construct is the J-pouch. Some paediatric surgeons still use a straight ileoanal anastomosis without a reservoir. A two-stage operation (colectomy and pouch formation with ileostomy in the first stage and stoma closure in the second stage) is the most common elective approach for ulcerative colitis. A three-stage operation (first colectomy, then pouch formation, and finally stoma closure) should be considered in patients with high-dose steroid use or severe malnutrition, and when Crohn’s disease has not been completely excluded. Restorative proctocolectomy without ileostomy may be considered in patients without any risk factors (steroids, anastomotic tension). The laparoscopic approach can be used safely in children. The rate of complications may be less than for open surgery, and the cosmetic results are definitely superior."