Conditions

Practice Parameters for the Surgical Treatment of Ulcerative Colitis

Prepared by
The Standards Practice Task Force
The American Society of Colon and Rectal Surgeons
Jeffrey L. Cohen, M.D., Scott A. Strong, M.D., Neil H. Hyman, M.D., W. Donald Buie, M.D., Gary D. Dunn, M.D., Clifford Y. Ko, M.D., Phillip R. Fleshner, M.D., Thomas J. Stahl, M.D., Donald G. Kim, M.D., Amir L. Bastawrous, M.D., W. Brian Perry, M.D., Peter A. Cataldo, M.D., Janice F. Rafferty, M.D., C. Neal Ellis, M.D., Jan Rakinic, M.D., Sharon Gregorcyk, M.D., Paul C. Shellito, M.D., John W. Kilkenny III, M.D., Charles A. Ternent, M.D., Walter Koltun, M.D., Joe J. Tjandra, M.D., Charles P. Orsay, M.D., Mark H. Whiteford, M.D., Jason R. Penzer, M.D.

The American Society of Colon and Rectal Surgeons is dedicated to assuring high-quality patient care by advancing the science, prevention, and management of disorders and diseases of the colon, rectum, and anus. The Standards Committee is composed of Society members who are chosen because they have demonstrated expertise in the specialty of colon and rectal surgery. This Committee was created to lead international efforts in defining quality care for conditions related to the colon, rectum, and anus. This is accompanied by developing Clinical Practice Guidelines based on the best available evidence. These guidelines are inclusive, and not prescriptive. Their purpose is to provide information on which decisions can be made, rather than dictate a specific form of treatment. These guidelines are intended for the use of all practitioners, health care workers, and patients who desire information about the management of the conditions addressed by the topics covered in these guidelines. It should be recognized that these guidelines should not be deemed inclusive of all proper methods of care or exclusive of methods of care reasonably directed to obtaining the same results. The ultimate judgment regarding the propriety of any specific procedure must be made by the physician in light of all of the circumstances presented by the individual patient.

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METHODOLOGY
An organized search of Medline, PubMed, and the Cochrane Database of Collected Reviews was performed through September 2004. Key-word combinations included ulcerative colitis, ileal pouch-anal anastomosis, ileostomy, colorectal neoplasm, surgery, ileoproctostomy, and related articles. Directed searches of the embedded references from the primary articles also were accomplished.

INDICATIONS FOR SURGERY
Acute Colitis

1. Patients with clinical evidence of actual or impending perforation should undergo urgent surgery. Level of Evidence: III; Grade of Recommendation: A.

Severe acute colitis affects between 5 to 15 percent of patients with ulcerative colitis. The diagnosis of severe colitis is based on the criteria of Truelove and Witts1 and is defined as colitis with more than six bloody stools per day, fever (temperature, >37.5°C), tachycardia (heart rate, >90 beats per minute), anemia (hemoglobin, <75 percent of normal), and elevated sedimentation rate (ESR, >30 mm per hour).2 Alternatively, toxic, or fulminant, colitis is characterized by more than ten bloody stools per day, fever (temperature, >37.5°C), tachycardia (heart rate, >90 beats per minute), anemia (transfusion required), elevated sedimentation rate (ESR, >30 mm per hour), colonic dilation on radiography, and abdominal distention with tenderness.2 When the colonic distention of the transverse colon exceeds 6 cm, the diagnosis becomes toxic megacolon.3,4 Surgery is required in 20 to 30 percent of patients with toxic colitis.5

Perforation in patients with toxic colitis has a high mortality rate, which ranges from 27 to 57 percent regardless of whether the perforation is contained or free.6,7 The mortality rate increases as the time interval between perforation and surgery increases.6,8 Patients with toxic colitis receiving surgical intervention before perforation have a significantly better outcome than those operated on after perforation.7,8 However, there are few “hard” signs of impending perforation in patients with toxic colitis. Perforation can occur without dilation and these patients often do not exhibit classic signs of peritonitis.6 Persistent or increasing colonic dilation, pneumatosis coli, worsening local peritonitis, and the development of multiple organ failure can be signs of impending or actual perforation. 7,9,10 Localized peritonitis may reflect only local inflammation or may be a sign of impending perforation. 11

The development of multisystem organ failure (MSOF) is an ominous sign. In a series of 180 patients with toxic colitis, 11 developed MSOF. The overall mortality in the entire group was 6.7 percent; however, of the 12 patient deaths, 8 occurred in patients with MSOF.12

2. Patients whose condition worsens on medical therapy or who fail to make significant improvement after a period of 48 to 96 hours of appropriate medical therapy should be considered for surgery. Level of Evidence: III; Grade of Recommendation: B.

Patients are judged to have failed medical therapy if their condition worsens while on medical therapy or their condition fails to improve after a period of initial stabilization. Limited evidence suggests that intravenous cyclosporine is more effective than standard steroid- based treatment for severe colitis13–15 and has been advocated as a second-line agent before colectomy. The need for and timing of surgery in patients whose condition seems to “plateau” after a period of initial improvement often is difficult to judge. However, patients with more than eight stools per day or three to eight stools and a C-reactive protein > 45 mg/ml after three days of therapy have an 85 percent chance of requiring colectomy during the same hospitalization, regardless of whether corticosteroid or cyclosporine treatment is used.16 Furthermore, persistent colonic distention seems to characterize a subgroup of patients who respond poorly to medical therapy and are at increased risk for the development of megacolon.17 Prolonged observation of these patients may risk exhaustion of their physiologic reserve but does not necessarily increase perioperative morbidity. 18 Most series define a period of 48 to 96 hours after which surgery is indicated if the patient fails to improve,5,8,9 although evidence specifying the most appropriate time period for a trial of medical therapy, especially with “second-line” agents, is lacking.

Intractability

1. Surgery is indicated in ulcerative colitis when medical therapy is ineffective. Level of Evidence: III; Grade of Recommendation: B.

Intractability is one of the most common surgical indications for ulcerative colitis. Medical therapy can fail for several reasons. Symptoms may be insufficiently controlled despite an intensive medical regimen and the patient is unable to achieve an acceptable quality of life. Alternatively, the response to treatment may be adequate, but the risks of chronic medical therapy (especially long-term corticosteroids) may be excessive. Patients also may be unable to tolerate the deleterious side effects of medical therapy. Patients who are noncompliant with treatment regimens might be candidates for surgical management. The postoperative quality of life for patients with ulcerative colitis is improved after colectomy.19–23

Growth failure in children is another form of intractability that may require colectomy. Surgery should be considered if growth failure persists despite maximal nutritional and medical therapy.24 Substantial disability from colectomy-responsive extraintestinal manifestations also may prompt resection.

Cancer Risk

1. Patients with long-standing ulcerative colitis should undergo endoscopic surveillance. Level of Evidence: IV; Grade of Recommendation: B.

Although it is clear that patients with longstanding ulcerative colitis have an increased risk of colorectal cancer, its magnitude has been difficult to estimate. A recent meta-analysis estimated the risk of colorectal cancer for a patient with colitis to be 2 percent at 10 years, 8 percent at 20 years, and 18 percent after 30 years of disease.25 Surveillance colonoscopy has been recommended in these patients despite a lack of clear evidence that shows surveillance prolongs survival in patients with ulcerative colitis. Carcinomas tend to be detected at an earlier stage in persons who are undergoing surveillance colonoscopy, and these patients have a better prognosis.26,27

Patients with extensive colitis (microscopic disease proximal to the splenic flexure) should be advised to undergo a screening endoscopy after eight years of disease symptoms and should have a surveillance colonoscopy performed every one to two years. If a person suffers from left-sided disease (i.e., microscopic disease distal to the splenic flexure yet proximal to the rectum), he or she may begin the same surveillance program after 15 years of disease symptoms despite a lack of direct supporting evidence for this duration-dependent stratification.28–30 Surveillance colonoscopies should be ideally performed when the disease is in remission to minimize confusion regarding neoplasia. Because it is necessary to take at least 33 biopsies from the colon and rectum to achieve 90 percent sensitivity,31 it is reasonable to obtain four quadrant random biopsies at 10-cm intervals along the large intestine, taking particular care to biopsy any strictures or mass-like lesions while avoiding any nonsuspicious pseudopolyps. Polyps that appear potentially dysplastic can be removed by polypectomy, and the adjacent flat mucosa also should be biopsied to exclude dysplasia. Recent enthusiasm has emerged for targeted biopsies with chromoendoscopy by using pancolonic indigo carmine dye spraying. 32,33

Several studies indicate patients with concomitant primary sclerosing cholangitis (PSC) are at a higher risk of colorectal neoplasia.34 The absolute cumulative risk of cancer or dysplasia in this subset of patients has been estimated to be 9 percent after 10 years, 31 percent after 20 years, and 50 percent after 25 years of colitis.34 Patients with PSC often have quiescent colitis, so it is difficult estimating the precise onset of disease in this subgroup. For the above reasons, it is recommended that such patients should undergo annual surveillance colonoscopy.

2. Total proctocolectomy is recommended for patients with carcinoma, nonadenoma-like dysplasia associated lesion or mass (DALM), high-grade dysplasia, and low-grade dysplasia in a stricture that is symptomatic or impassable during colonoscopy. The diagnosis of dysplasia should ideally be confirmed by two independent expert gastrointestinal histopathologists. Level of Evidence: Class III; Grade of Recommendation: C.

Dysplasia detection by conventional histopathologic assessment of colonoscopic biopsies remains the “gold standard” to identify patients at highest risk of developing cancer in ulcerative colitis.35 Ten prospective surveillance programs published before 1994 demonstrated that in patients diagnosed with a DALM, 43 percent had a synchronous cancer at immediate colectomy.36 The risk of cancer at immediate colectomy was 42 percent for high-grade dysplasia and 19 percent for low-grade dysplasia. The risk of developing high-grade dysplasia, DALM, or cancer was 2.4 percent in patients without dysplasia on initial screening, 18 percent for those with “indefinite dysplasia,” and 29 percent for those with low-grade dysplasia. In another review, 9 of 18 patients identified with ulcerative colitis and low-grade dysplasia developed advanced neoplastic lesions, which were defined as adenocarcinoma, raised dysplasia, or highgrade dysplasia, during follow-up.37 Moreover, a surveillance study indicated the five-year predictive value for cancer or high-grade dysplasia in patients with low-grade dysplasia was 54 percent.38

However, in a conflicting study, 60 patients with low-grade dysplasia in flat mucosa found during endoscopy were followed for an average of ten years; low-grade dysplasia was found at several locations and during repeated colonoscopies in 73 percent of cases, but progression to high-grade dysplasia or a dysplasia-associated lesion/mass occurred in only 11 patients (18 percent).39 The high rates of interobserver variation between histopathologists further confounds the management of low-grade dysplasia. 40–43

There also is controversy regarding the natural history of adenoma-like DALMs. Specifically, in the absence of dysplasia in neighboring flat mucosa, recent reports suggest that adenoma-like DALMs can be effectively removed by colonoscopic resection without placing the patient at increased risk of developing future dysplasia or carcinoma.44–46

Patients should be encouraged to take prescribed 5-aminosalicylate (ASA) medication, because recent literature suggests that regular consumption of 5-ASA compounds may reduce their colorectal cancer risk.47–49 In a case control study,49 regular 5-ASA therapy reduced cancer risk by 75 percent (odds ratio (OR), 0.25; 95 percent confidence interval (CI), 0.13– 0.48; P < 0.00001). Another study demonstrated that pharmacologic therapy, especially sulfasalazine, was associated with a significant protective effect (relative risk (RR), 0.38; 95 percent CI, 0.2–0.69) independent of disease activity.47 The risk of developing cancer was 5 of 152 (3 percent) in a group who took longterm 5-ASA and 5 of 16 (31 percent) in those who had had their treatment stopped or did not comply with therapy.48 3. Patients with ulcerative colitis who develop a stricture, especially with long-standing disease, should undergo resection. Level of Evidence: III, Grade of Recommendation: A. Strictures develop in 5 to 10 percent of patients with ulcerative colitis. Although the majority of strictures are benign, as many as 25 percent will be malignant, and malignant strictures account for up to 30 percent of cancers occurring in ulcerative colitis patients. Strictures that arise on a background of long-standing disease, originate proximal to the splenic flexure, or cause obstructive symptoms are more likely to be malignant. 50 Endoscopic biopsy of strictures can reveal dysplasia or malignancy51 but may be unreliable because of sampling error and the more infiltrating nature of colitis-associated malignancies.50,52 SURGICAL OPTIONS
Emergency
1. The most appropriate operative procedure for emergency surgery in ulcerative colitis is total or subtotal abdominal colectomy with end ileostomy. Level of Evidence: III, Grade of Recommendation: B.

The surgical alternatives in the acute setting are designed to restore patient health with the greatest reliability and minimal risk while preserving reconstructive options after the patient has recovered. Subtotal colectomy with end ileostomy and Hartmann’s closure of the distal bowel or creation of a mucous fistula is a safe and effective approach.18,53 This procedure removes the majority of the inflamed bowel with a comparatively straightforward operation and avoids pelvic dissection as well as an intestinal anastomosis. 54,55 Compared with intraperitoneal closure of the rectal stump, extrafascial placement of a closed rectosigmoid stump may be associated with fewer pelvic septic complications and facilitates subsequent pelvic dissection.56 Transanal drainage of the distal stump may further decrease the risk of pelvic sepsis.57

The resected colon specimen should be histopathologically examined for confirmation of ulcerative colitis or Crohn’s disease because the likelihood of an altered diagnosis is appreciable after colectomy.18,53 In patients with ulcerative colitis, a completion proctectomy and ileal pouch-anal anastomosis (IPAA) often can be safely performed at a later date to remove the remaining disease and restore intestinal continuity. If the diagnosis is Crohn’s disease and the rectum is reasonably compliant and distensible, consideration may be given to an ileorectal anastomosis.

Elective Surgery

1. Total proctocolectomy with ileostomy is an appropriate surgical alternative for patients with ulcerative colitis. Level of Evidence: III; Grade of Recommendation: B.

Proctocolectomy with ileostomy has been the conventional operative approach for patients with ulcerative colitis and may be considered a benchmark procedure to which all other operations are compared. 58,59 It has been established as a safe, curative operation that permits most patients to live a full, active lifestyle.20,60 Although restorative proctocolectomy with IPAA has become increasingly popular during the past two decades, proctocolectomy with ileostomy can still be considered the first-line procedure for patients who choose not to undergo a restorative proctocolectomy and for those at significant risk for pouch failure, such as patients with impaired anal sphincter muscles, previous anoperineal disease, or limited physiologic reserve secondary to comorbid conditions.61

The operation, however, does have recognized complications. Although stoma-associated problems, such as prolapse, are probably most frequent,62 other complications that are common to any abdominal/ pelvic procedure also have been recognized.62,63 These include small-bowel obstruction, infection/ fistula, persistent pain, unhealed perineal wound, sexual and bladder dysfunction, and infertility.64 In one recent study of 44 patients, the long-term complication rate of proctocolectomy with permanent ileostomy was significantly lower than restorative proctocolectomy (26 vs. 52 percent).63

2. Total proctocolectomy with ileal pouch-anal anastomosis is an appropriate operation for most patients with ulcerative colitis. Level of Evidence: III; Grade of Recommendation: A.

Total proctocolectomy with IPAA has become the most commonly performed procedure for patients with ulcerative colitis requiring elective surgery. The operation is relatively safe and durable,65,66 associated with an acceptable morbidity rate (19 to 27 percent), 67,68 an extremely low mortality rate (0.2–0.4 percent),67,68 and a quality of life that approaches that of the normal population.69–72 The complications of the procedure include those of any major abdominal operation: risks arising from the pelvic dissection, such as infertility or sexual dysfunction, and pouchspecific complications, such as pouchitis.73–81

a. Total proctocolectomy with IPAA may be appropriately offered to selected ulcerative colitis patients with concomitant colorectal cancer. Level of Evidence: IV; Grade of Recommendation: C.

Studies examining the use of IPAA in patients with invasive cancers of the colon or upper rectum without distant metastases have yielded somewhat conflicting findings. In several series, ulcerative colitis patients with a concomitant carcinoma had a rate of postoperative complications and functional results comparable to colitis patients without cancer; metastatic disease developed in a small number of patients.82–85 In contrast, a separate study revealed that nearly 20 percent of ulcerative colitis patients with cancer who underwent an IPAA subsequently died of metastatic disease. 86 A more conservative management approach has been advocated by some who recommend an abdominal colectomy with ileostomy followed by a restorative proctectomy after an observation period of at least 12 months to better assure that no recurrent disease develops.87

Metastatic disease is generally considered a contraindication to IPAA. These patients should usually be managed with segmental colectomy or abdominal colectomy with anastomosis to facilitate early discharge and allow them to spend the rest of their lives relatively free of complications. Another group of patients who may not be eligible for IPAA are those with invasive carcinomas of the mid or low rectum, because basic principles of cancer surgery may be compromised. Adjuvant radiotherapy, if indicated, should be performed preoperatively whenever possible, because postoperative radiotherapy is associated with a high incidence of pouch loss secondary to radiation enteritis and poor pouch function.83 Ulcerative colitis patients with cecal cancers represent another unique subgroup of patients. If a long segment of adjacent distal ileum with its mesenteric vessels must be sacrificed, difficulties with positioning of the reservoir into the pelvis may ensue, and an ileostomy may be necessary if a tension-free anastomosis cannot be attained.

b. Total proctocolectomy with IPAA may be appropriately offered to selected elderly patients with ul- Vol. 48, No. 11 PRACTICE PARAMETERS FOR ULCERATIVE COLITIS 2001 cerative colitis. Level of Evidence: III; Grade of Recommendation: C.

Many groups have demonstrated that IPAA in the elderly patient is safe and feasible.88–91 Chronologic age should not itself be used as an exclusion criterion. However, careful consideration should be given to other comorbidities, as well as the patient’s mental status and anal sphincter function. Pouch procedures are feasible in suitably motivated elderly individuals who understand the risks and potential function difficulties that often accompany this procedure. Although some series have found that bowel frequency remains constant in the first decade after the surgical procedure,92 others have found the number of daytime and nighttime stools increases as does the likelihood of fecal incontinence.65,93

c. Mucosectomy and double-stapled procedures are both appropriate techniques in most circumstances. Level of Evidence: II; Grade of Recommendation: A.

The potential advantages of the double-stapled approach include enhanced technical ease because it avoids mucosectomy and the perineal phase of the operation, there is less tension on the anastomotic suture line, and possibly improved functional results. Sphincter injury is minimized and the anal transition zone with its abundant supply of sensory nerve endings is preserved. Conversely, short segment inflammation94,95 and perianastomotic zone carcinoma96–98 are legitimate concerns, highlighting the importance of performing the anastomosis to the top of the anal canal. Three prospective, randomized trials have demonstrated no significant difference in perioperative complications or functional results for patients in whom a mucosectomy was performed vs. those patients in whom the proximal anal canal mucosa was preserved.99–101 It is important that the surgeon performing an IPAA be familiar with both techniques in the event of failure or inability to use a surgical stapler or when a handsewn anastomosis is contemplated but anastomotic tension is excessive. Patients should be followed in a surveillance program with biopsies of the retained columnar mucosa performed at least every two years beginning eight to ten years after the onset of their initial disease symptoms.102

d. Pouch configuration may be chosen based on individual preference. Level of Evidence: II; Grade of Recommendation: B.

Although the initial ileal reservoir created by Parks in the late 1970s was a triple-loop S-pouch,103 other pouch configurations have been described in an attempt to reduce pouch complications and improve functional outcome. These include the double-loop J-pouch, the lateral isoperistaltic H-pouch, and the quadruple-loop W-pouch.104–106 S-pouches were initially plagued with evacuation problems associated with a long (5 cm) exit conduit, frequently requiring pouch catheterization.103 With shortening of the exit conduit to 2 cm, mandatory catheterization has been substantially reduced.107 The long outlet tract formed in the H-pouch also was associated with pouch distention, stasis, and pouchitis.108 The Wpouch has been advocated because of a greater capacity. 106 However, two randomized trials comparing the J-pouch and W-pouch did not substantiate an improvement in functional outcomes.109,110 In one study,109 the median number of stools per day was the same in patients with a J-pouch or W-pouch, and there was no difference between the two reservoirs in the rates of incontinence, urgency, soiling, and the use of antidiarrheal agents. Another controlled study110 also demonstrated similar functional results between J-pouch and W-pouch one year after surgery. An S-pouch can provide additional length (2–4 cm) compared with the J-pouch and may help minimize anastomotic tension.111 However, the 2-cm exit conduit of the S-pouch may elongate with time, and obstructive defecation can develop.

e. A diverting loop ileostomy may be reasonably omitted in some patients. Level of Evidence: III; Grade of Recommendation: B.

Retrospective and prospective trials suggest that one-stage restorative proctocolectomy can be safely performed in selected patients by experienced surgeons. The one-stage procedure is associated with a more challenging early recovery,112 as well as a slightly increased rate of anastomotic disruption and pelvic sepsis.113–121 Although some disagree,122 these complications should usually be managed with fecal diversion118,119 because of concerns about compromised functional outcome and resultant pouch loss.123 Despite aggressive nonoperative and operative measures, the estimated cumulative three-, fiveand ten-year rate of pouch failure in all patients with septic complications is 20, 31, and 39 percent, respectively. 121 This highlights the need for great caution when considering pelvic pouch surgery without temporary diversion. Single-stage IPAA avoids the risks of ileostomy closure, which include anastomotic leaks from the closure site and an increased incidence of postoperative small-bowel obstruction that often mandates hospitalization or laparotomy.119,124–127 In 2002 COHEN ET AL Dis Colon Rectum, November 2005 general, selective omission of the ileostomy may be considered safe when the anastomosis appears intact, is under no tension, the procedure is not complicated by excessive bleeding or other technical difficulties, and the patient is not on high doses of corticosteroids before surgery.84,116,117,121–123,127,128

f. Routine surveillance of ileal pouches for dysplasia in the ileal mucosa is not warranted. Level of Evidence: III; Grade of Recommendation: B. A decrease in villous height and increase in concentration of crypts have been observed in most ileal pouches.129 These metaplastic changes of the ileal mucosa to a colonic type mucosa are considered adaptations to the reservoir function of the pouch. This transformation also may be driven by the chronic inflammation frequently observed in these pouches.130 Inflammatory changes could theoretically lead to dysplasia and cancer in the ileal mucosa. However, dysplastic and neoplastic transformation within the pouch seems to be extremely rare.131–133

g. Pouchitis is common after IPAA and readily managed with antibiotics in most circumstances. Level of Evidence: II; Grade of Recommendation: A.

The most frequent long-term complication after IPAA for ulcerative colitis is a nonspecific inflammation of the ileal pouch known as pouchitis.67,68,92,134 The presence of extraintestinal manifestations of ulcerative colitis before colectomy, especially primary sclerosing cholangitis, has been associated with an increased incidence of pouchitis.134,135 It is unclear whether the presence of backwash ileitis or extent of disease predict the likelihood of ultimately developing pouchitis.136–138 The etiology of this nonspecific inflammation is unclear but may be the result of an overgrowth of anaerobic bacteria.139,140 Presenting symptoms usually include abdominal cramps, fever, pelvic pain, and an increase in stool frequency. Clinical diagnosis may require confirmation by endoscopy and pouch mucosal biopsy, because clinical symptoms alone can be misleading.141 However, it seems that histologic evaluation may be omitted without compromising diagnostic accuracy.142 Treatment of pouchitis relies primarily on antibiotics, such as metronidazole and ciprofloxacin.143–145 Probiotics have been used successfully in pouch patients to provide prophylaxis against pouchitis and to maintain remission in chronic pouchitis.146,147 In antibiotic refractory cases, budesonide enemas or other medical treatments may be useful.148 Patients suffering with chronic pouchitis should be assessed for a diagnosis of Crohn’s disease. Uncommonly, an ileostomy with or without pouch excision is required for severe refractory pouchitis.145

3. Continent ileostomy is an alternative surgical option for patients with ulcerative colitis who are not eligible for or have had a failed restorative proctocolectomy. Level of Evidence: III; Grade of Recommendation: B.

The present role of the continent ileostomy is primarily confined to patients with poor sphincter function, a failed IPAA, or those who are dissatisfied with a conventional Brooke ileostomy.149,150 This reduced role is the result of the success of the IPAA and the high rate of early and late complications associated with the continent ileostomy.151

Early complications are seen in approximately onequarter of patients, most commonly sepsis (secondary to suture line leaks, fistulas, and stomal necrosis) and obstruction.152,153 Late complications occur in up to 50 percent of patients and include incontinence and obstruction secondary to disruption or dysfunction of the valve; valve revision is required in up to 60 percent of patients.151 Although valve prolapse has been reduced with stapling techniques,150,154 the overall pouch failure rate has not decreased.155

The cumulative success rate of the continent ileostomy in a recent study was 71 percent at 29 years.151 The failure rate is greater after secondary construction after a failed IPAA (46 percent) than after primary construction (23 percent).155 For the two-thirds of patients with a functional continent ileostomy, the reported quality of life is similar to that described for patients with IPAA.151,155,156

4. Total abdominal colectomy with ileoproctostomy is an acceptable surgical approach in a highly selected group of patients with ulcerative colitis. Level of Evidence: III; Grade of Recommendation: B.

Because the performance of a total abdominal colectomy with ileoproctostomy requires a relatively normal rectum to create a safe anastomosis, severe rectal inflammation or a marked decrease in rectal distensibility are contraindications to the procedure. 157,158 Severe anoperineal disease, although unusual in ulcerative colitis, also precludes an ileorectal anastomosis.159 Other contraindications to this operation are colonic dysplasia or carcinoma in a potentially curative situation.160

Whereas the benefits of total abdominal colectomy with ileoproctostomy are its relative simplicity and predictability compared with IPAA, the disadvantages are related to the long-term durability of the procedure. Studies demonstrate a 12 to 50 percent failure Vol. 48, No. 11 PRACTICE PARAMETERS FOR ULCERATIVE COLITIS 2003 rate with follow-up of more than six years.161–163 In addition, the theoretical risk of developing cancer in the remaining rectum should be considered when counseling the patient and other options discussed. Although the incidence of developing cancer seems to be low (0–6 percent with long-term followup), 155,163–165 patients undergoing total abdominal colectomy with ileorectal anastomosis must be willing to undergo annual endoscopic screening.158–163

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