Ulcerative colitis is an inflammatory condition affecting the colon and rectum. It may only affect a limited part of the bowel, or it can affect the whole of the large bowel. The management of ulcerative colitis is usually with medication, such as steroids, to bring the inflammation under control, and then maintained with other drugs. Up to 40% of patients with ulcerative colitis will come to require surgery for their condition.
Surgery may become necessary during an acute flare of colitis, either because the patient is becoming increasingly unwell or because the colon is rapidly distending. Sometimes, colitis never fully settles with medication and it may become necessary to undergo surgery. For a small proportion of patients, surgery becomes necessary because of pre-cancerous or cancerous changes within the bowel. Unfortunately, colitis is associated with an increased risk of developing colorectal cancer.
Should surgery become necessary due to colitis that never fully settles, or during an acute flare, it is normally recommended to undergo a subtotal colectomy and have an ileostomy. This operation removes nearly all of the colon, but leaves the rectum and a short length of colon intact. This can normally be undertaken as a laparoscopic (keyhole) operation. Following surgery, you would normally be able to stop all of the medication for your colitis. If you are considering having an ileal pouch (see here), the operation is safer if you are not taking any colitis medication or steroids.
When there are pre-cancerous or cancerous changes within the bowel, we would normally aim to remove all of the colon and rectum in the one operation. If you want to have an ileal pouch this can normally be done at the same time. If you are certain you do not want to have a pouch, the anus is normally removed at the time of surgery. If there is cancer in the lower part of the rectum, it is not normally possible to have an ileal pouch procedure as it is important to obtain adequate clearance of the cancer.
Following a subtotal colectomy for colitis, there are a number of options in terms of what to do with the rectum. A lot of patients will want to have the rectum removed and have an ileal pouch formed in order to avoid having a permanent ileostomy. In some patients it may be possible to leave the rectum in place and join the small bowel on to the top of this – an ileorectal anastomosis. Sometimes, patients are coping well with their ileostomy and don’t want to accept the added risks of having an ileal pouch at the time of having their rectum removed. Under these circumstances we would normally remove the rectum and anus together. Finally, it is not uncommon for patients to want to have some time to get their life back on track, particularly if they have been unwell for some time with colitis, and use the time to consider their options. This is not unreasonable, and for women considering having a family it can be an ideal time to start before undergoing further surgery.
Ileal pouch surgery. Link
Colorectal cancer. Link
Crohn’s and Colitis UK. Link
The Ileostomy Association. Link