Surgery for Ulcerative Colitis (UC)

Abstract

The most common indication for emergency surgery is severe acute colitis not responding to medical treatment (70%).Indications for elective surgery include chronic ill health,repeated acute attacks and steroid dependence.Recent data from our unit show a high level of social disability among patients undergoing medical treatment for IBD. Surgery including conventional proctocolectomy, colectomy with ileorectal anastomosis and restorative proctocolectomy (RPC) has changed over the last thirty years.The indications for RPC will be presented with a discussion of Crohnʼs disease,sclerosing cholan-gitis and fertility.Failure is related to the duration of follow up being ５% at ５ years, 10% at 10 years and around 20% at 20 years.The reasons for failure include sepsis(50%),poor function (30%) and pouchitis(10%).Analysis of long term function from the UK Pouch Registry shows that defaecation frequency remains stable but minor incontinence increases with time.Technical aspects including the method of anastomosis,type of reservoir and the use of a defunctioning ileostomy will be discussed using the results of meta-analyses.Salvage surgery for threatened failure in selected cases results in success rates of 90% when the indication is non-septic.These patients usually have ileo-anal outlet obstruction due to stricture or a retained rectal stump.The success of salvage falls to 60-70% when the indication is for sepsis whether pelvic or fistulation . Published data on pouchitis are usually presented as cumulative incidence with rates of up to 50%.Prevalence analysis shows that clinically significant pouchitis is much less common being ５-10%.The aetiology and treatment of pouchitis will be discussed including DNA microbiology.Neoplastic transformation in the pouch or distal anorectal mucosa is rare.Risk factors include the presence of neoplasia in the original operative specimen,Type C changes and diagnosis of UC of more than 10 years.A strategy of surveillance will be presented. Introduction Skin and soft tissue infections (SSTIs) are among the most common sites of bacterial infection and a cause of considerable morbidity.They may be community or nosocomially acquired,and their severity ranges from minor pyodermas to severe necrotizing infections.SSTIs generally develop after the integrity of the skin has been breached by some type of trauma.Hospitalized patients face a particular risk for nosocomial SSTIs due to surgical procedures and frequently performed interventions such as venipuncture. Gram-positive bacteria are an important cause of SSTIs,with the most frequently isolated pathogen being Staphylococcus aureus (S. aureus). The precipitous rise of antibiotic resistant pathogens is a cause of great concern,and MRSA has become endemic in facilities across the world.MRSA strains continue to be a major problem in many healthcare institutions,and are reported in 30-70% of skin and soft tissue infections seen in emergency departments. The rates in the intensive care setting are even higher.Data from the National Nosocomial Infections Surveillance(NNIS) System Report,issued October 2004,show that MRSA account for 63% of the staph isolates from intensive care units (ICU) in the United States. MRSA is now a major nosocomial pathogen,responsible for up to 28% of surgical wound infections, 21% of skin infections,and 12% of all bacteremias.But while it first appeared as a hospital acquired infection (HA-MRSA),MRSA now has two faces： HA-MRSA and community ( CA - MRSA ). Risk factors are commonly identified with HA - MRSA infection and include a recent hospitalization or surgery,residence in a long-term?care facility,the use of injectable drugs, or the presence of an indwelling percutaneous medical device. No risk factors are usually identified with a CA-MRSA infection. HA-MRSA is commonly associated with nosocomial pneumonia and bacteremia while the majority of CA-MRSA infections are skin and soft tissue infections although necrotizing pneumonia and bacteremia are reported. The incidence of acute and chronic diseases is increasing worldwide and especially in some Asian countries.It is associated with significantly elevated and increasing morbidity in connection with surgery and trauma.The development is strongly associated with Western lifestyle:lack of physical exercise, mental stress, use of tobacco and alcohol and consumption of refined and calorie-condensed foods, a lifestyle,which all seem to generally increase the level of systemic inflammation in the body,”paralyze” the innate immune system and reduce resistance to disease. Patients who develop severe septic complication are known to respond to the stress induced by extensive surgery or trauma with an exuberant super-inflammation, accompanied by signs of exaggerated and prolonged release of proinflammatory cytokines such as interleukin (IL)-6,acute phase proteins such as C-reactive protein, and plasminogen activator inhibitor (PAI)-1. It is also strongly associated with a subsequent development of severe exacerbation of disease, including acute respiratory distress and multiple organ failure(MOF).Among the changes observed in the over-exuberant acute phase response, often called the nervous phase,are augmented endothelial adhesion of polymorphonuclear (PMN)cells, increased production of intercellular adhesion molecule(ICAM)-1,priming of the PMNs for an oxidative burst,release of proinflammatory platelet activating factor,and associated with this,a delay in PMN apoptosis.Common treatment options such as antibiotics and antagonists and inhibitors of individual proinflammatory cytokines have not met the high expectations. Instead, these treatments have often precipitated new complications and new morbidities. The majority of the immune system is in the gut,and consumed foods,especially antioxidants and plant fibres have in combination with flora and supplied lactic acid bacteria (LAB)a profound influence not only on the function of the GI tract but also the function of the immune system,particularly on what is called the innate immune functions.Both of antioxidants and plant fibres the size and