Early and Late Results of Total Colectomy with Simultaneous Ileorectostomy due to Non-Specific Ulcerative Colitis

The dissertation is devoted to the investigation of early and late outcomes of total colectomy with simultaneous ileorectostomy for non-specific ulcerative colitis. The research encompasses early and late postoperative outcomes in 110 patients, including a comparative analysis of various one-stage surgical interventions, morphofunctional assessment of the ileorectal anastomosis, ileum, and rectum, and medical and social rehabilitation of patients. The technique of "transrectal ileostomy on stretch" proposed by Prof. N.N. Kanshin was employed to reduce the risk of complications during ileorectal anastomosis formation against the background of an inflamed rectal segment.

Relevance of the problem. Non-specific ulcerative colitis (NUC) is an autoimmune lesion of the colon of undetermined etiology, known since the mid-19th century. Since the mid-20th century, a fairly rapid increase in morbidity has been noted, predominantly among residents of the most developed countries [1, 19, 30, 34, 60, 71, 134, 184, 206].

In relatively mild forms of NUC (typically with distal and left-sided involvement of the colon), satisfactory results can be achieved with modern conservative treatment [32, 75, 83, 91, 112, 123]. At the same time, severe forms of the disease are highly resistant to conservative therapy and in most cases lead either to severe complications requiring emergency surgical intervention or to forced elective surgery due to the development of "colitic carcinoma." The risk of malignancy in NUC sharply increases with disease duration exceeding 10 years, especially if the disease onset occurred before the age of 18 [20, 37, 71, 78, 109].

Frequent and prolonged exacerbations of severe NUC, accompanied by pronounced intoxication and blood loss, lead to patient exhaustion, deep metabolic disturbances, anemia, and hormonal dependence due to the inevitable transition to steroid therapy with all its negative consequences. Ultimately, severe NUC leads either to disability or to death from arising grave complications [34, 47, 74, 84, 87, 90, 100].

The radical operation for severe non-specific ulcerative colitis is panproctocolectomy, in which cure is achieved at the cost of a permanent ileostomy. Taking into account the mutilating nature of this surgical intervention, indications for it in the past were set quite cautiously. However, refinement of the operative technique through formation of an ileoanal anastomosis with a reservoir from the ileum (pouch) led to a substantial expansion of indications for surgical treatment of NUC [61, 146, 171, 203].

At the same time, such an operation is frequently accompanied by complications and undesirable consequences (anastomotic insufficiency — 10–20% of cases, inflammation in the pouch area — up to 30%, fecal incontinence, disorders of sexual function and pelvic organ function — up to 30% of cases) [1, 186, 187, 190].

Domestic surgeons, like most foreign authors, more often perform subtotal colectomy with temporary placement of ileostomy and sigmoidostomy both in emergency and elective cases. The high risk of ileorectal anastomotic insufficiency associated with a pronounced destructive-inflammatory process in the rectum forces surgeons to perform the operation in two stages (with subsequent restorative intervention). Even during the restorative operation, the ileum must still be anastomosed to the colitis-affected stump of the sigmoid colon or rectum [65, 66, 71, 90, 99].

A number of surgeons consider total colectomy with simultaneous ileorectostomy the operation of choice in the surgical treatment of non-specific ulcerative colitis. With a favorable outcome, this operation eliminates the need for repeated intervention, accelerates recovery without a period during which the patient is obliged to have a functioning ileostomy [21, 33, 34, 36, 60, 69, 80, 90, 108, 117, 118].

To reduce the danger of a one-stage intervention in which the ileum is anastomosed to the inflamed rectum, Professor N.N. Kanshin proposed an original technique of anastomosis formation on a silicone tube of the "transrectal ileostomy on stretch" type (Author's Certificate No. 116191 with priority date of 11.05.1983), successfully used by him in the surgical treatment of severe non-specific ulcerative colitis in 72 patients.

The advantage of the developed ileorectostomy technique lies in the complete exclusion of passage of small intestinal chyme through the rectum, the absence of its contact with the suture zone of the anastomosis in the early postoperative period, which favors uncomplicated healing of the joined intestinal segments [34, 36].

However, to date, comparative results of one-stage operations, including those by Prof. N.N. Kanshin, are lacking. The late results of one-stage surgical treatment of non-specific ulcerative colitis in children and adults remain unstudied, and there are no data on the morphofunctional state of the ileorectal anastomosis, ileal and rectal mucosa after total colectomy.

The goal of the present investigation: study of early and late results of one-stage surgical interventions for severe NUC.

Tasks of the investigation:

1. To study the features of the operation and postoperative management of patients after total colectomy with "transrectal ileostomy on stretch."

2. To conduct a comparative evaluation of early results of various one-stage colectomy operations with ileorectostomy for severe NUC.

3. To study late results of one-stage surgical intervention for severe NUC.

4. To study morphofunctional features of the anastomosis, ileum, and rectum after colectomy in the late postoperative period.

Scientific novelty. Study of early and late results of one-stage total colectomy with ileorectostomy in 110 patients with NUC showed that in the overwhelming majority of patients, regression of systemic complications of NUC occurred in the first 1–2 years after the operation, and ulcerative proctitis tended toward subsidence and stable long-term remissions.

Total colectomy with simultaneous ileorectostomy by the method of "transrectal ileostomy on stretch" is characterized by a low rate of early postoperative intra-abdominal complications and mortality, good late results of surgical treatment of NUC and medical and social rehabilitation.

Conducted endoscopic, contrast-radiological, and histological investigations of the morphofunctional state of the rectum and ileum in the late period after colectomy showed that in the overwhelming majority of examined patients there was a low degree of activity of the inflammatory process in the mucosa and compensatory dilation of the rectum and terminal ileum.

Practical significance of the work. At total colectomy for NUC, fixation of a wide silicone tube ("ileostomy drain") in the ileum stump and its transrectal external output provides in the early postoperative period decompression and emptying of the small intestine without contact of intestinal chyme with the sutures of the ileorectal anastomosis, creating favorable conditions for intestinal suture healing.

One-stage colectomy with formation of ileorectal anastomosis for severe NUC eliminates the need for a restorative operation, allows avoidance of complications such as anastomotic insufficiency, reduces postoperative mortality, and expands indications for surgical treatment of this disease.

Implementation. The provisions of the dissertation were introduced into clinical practice in the following medical institutions: N.V. Sklifosovsky Research Institute of Emergency Medicine, Clinical Hospital of the Main Directorate of Internal Affairs, and City Clinical Hospital No. 3 of Moscow.

Presentation of the work. The main provisions of the dissertation were reported at the I Interregional Scientific-Practical Conference of Surgeons (Moscow, 2003); at the Conference of Surgeons of Russia dedicated to the 100th anniversary of Professor B.S. Semenov (Tver, 2004); at the II Interregional Scientific-Practical Conference of Surgeons (Moscow, 2005); at the International Surgical Congress (Rostov-on-Don, 2005). The work was discussed at the meeting of Problem-Planning Commission No. 2 of the N.V. Sklifosovsky Research Institute of Emergency Medicine (Moscow, December 2005).

Publications. Eleven scientific papers have been published on the dissertation topic.

Structure and volume of the work. The dissertation consists of an introduction, 4 chapters, conclusion, findings, practical recommendations, and a list of references. The work is presented on 104 pages of typed text (excluding the reference list), illustrated with 40 figures and 7 tables. The reference list includes 206 sources, of which 113 are in Russian and 93 are in foreign languages.