Geetha (name changed) was suffering from ulcerative colitis for nearly eight years. She responded well to medical treatment for the initial five years but had frequent relapses of the disease since.
She had been on prolonged course of mesalamine, steroids, immune modulator drugs, Humira etc. Despite best efforts to control the disease with medications, she needed frequent hospital visits and her symptoms of loose stools with blood continued unabated. A senior medical gastroenterologist for surgery referred her after best efforts to treat her with all available medical options failed. Her quality of life was seriously compromised and she was in tears during her first out patient consultation for surgery. After two sessions of detailed counseling regarding surgery and preoperative evaluation she underwent a ‘restorative procto-colectomy’ a procedure wherein the entire large intestine was removed and a reservoir (pouch) for stool was constructed from the last one foot of small intestine and connected to the anal canal. The operation removed the entire diseased portion and the pouch performs the function of the large intestine. She made a smooth recovery from surgery and three months after surgery she is glad that her normal life is restored. The most satisfying part for her was that the operation was performed laparoscopically (key hole) and she made a much faster recovery than she expected.
Surgery is required in about ten percent of patients with Ulcerative colitis. The clear indications for surgery would be
- Non-responders to medical treatment
- Need for prolonged steroids and related complications
- Complications of disease – intestinal obstruction, perforation, development of cancer
- Precursor of cancer detected during long term screening (one out of ten patients with ulcerative colitis stands the risk of developing cancer in the large intestine)
Patients fear surgery for several reasons and the foremost concern with this operation is the perceived need to have a permanent stoma (motion outlet from abdomen wall). Current surgical treatment avoids need for a permanent stoma in nearly all patients. In the last decade I have been performing this entire operation laparoscopically giving the advantages of lesser pain and early recovery, and this has increased the acceptance of the operation by patients, Dr Srikanth said. A temporary stoma may be required for few weeks during recovery from surgery. Risks from surgery are comprehensively evaluated during preoperative workup of patients.
Ulcerative Colitis – At a glance
- Typical symptoms would be loose stools with mucus and blood. Fever, weakness, decreased appetite, joint pains, etc may be present in 15-20% patients
- Diagnosis is established by colonoscopy and biopsy
- Majority (90 %)of patients can be treated with medical therapy and avoid surgery
- Patients not responding to medical therapy or requiring steroids for longer than six months and/or complications of the disease and medications, must have an expert surgical consultation
- Surgical expertise is not available in many centres in the city under one roof. This may cause delay in referral with persistent medical treatment with steroids, immune modulators, the prolonged use of which can have serious side effects and drains the patient of their finances to the extent that they are left in a hopeless situation and in no position to explore the surgical option.