Surgical treatment of acute severe colitis: an interview with Yves Panis

Ahead of the first ESCP/ECCO regional masterclass in Moscow, Professor Yves Panis (Professor of Digestive Surgery at the Université Paris VII and Head of the Department of Colorectal Surgery at Beaujon Hospital, Clichy, France) discusses the surgical treatment of acute severe colitis.

Although there are no established national registries or surveys on the exact numbers regarding the prevalence of acute severe colitis, the current evidence suggests that around 10-15% of all the patients with ulcerative colitis will at some point develop acute severe colitis. Although which patients will develop the condition and why, is unknown.

The surgical benefits for treating acute severe colitis have been known for many years," explained Professor Panis. "Just after the Second World War, St Marks Hospital in London, UK, reported a mortality rate of over 50% for patients with acute severe colitis because they were treated with steroids without surgery. The surgeons proposed performing a subtotal colectomy on these patients and saved the lives of over 90% of patients."

Surgery

According to Professor Panis, the main decision within a multi-disciplinary team (MDT) of when deciding when to operate is the failure or interference of medical therapy. The first stage of treatment is corticosteroids and if this fails, it is followed by a second line of medical therapy such as Remicade (infliximab) or Cyclosporine.

If this second line fails then you propose surgery," he added. "This is usually the case in 70% of patients who have acute non-complicated colitis. The key to a successful surgical outcome is that we need to have a good window of opportunity, so if the patient is very sick, medical therapy is failing or it is a complicated case, then surgery needs to be undertaken as soon as possible."

Within three months, approximately 75-80% of patients who have a positive response to medical therapy will avoid surgery. However, there is a risk of recurrence or refractory disease within three years and a 50% chance that the patients will have surgery at some point. Nevertheless, medical therapy remains a very good option for most patients.

The only danger is one of delaying surgery. If the patient is not responding to medical treatment then treatment should cease and the patient should have surgery," he emphasised. "A paper from the USA (Gastroenterology 2008; 134: 680) clearly showed a correlation between the number of days a patient was hospitalised before surgery and an increase in the mortality rate after surgery. The conclusion is that the patients who died had surgery too late."

However, in patients who present with acute complicated colitis such as perforation or a large dilatation of the colon, then surgery is recommended before medical treatment.

Professor Panis explained that the options available to the surgeon depend on the acute process of the condition. For example, if the patient has acute colitis on the left colon and the transverse colon but the right colon is OK, then it is best to perform a subtotal colectomy with ileostomy with sigmoid-ostomy without any anastomosis in the abdomen.

There is a large consensus among surgeons that we need to perform procedures without the need for anastomosis and this would be a subtotal colectomy. In terms of low morbidity and mortality the operation with the best outcomes is subtotal colectomy."

The outcomes from subtotal colectomy without any anastomosis are very good with a mortality rate of less than 1% and the risk of post-operative complications such as sepsis very low. In addition, for postoperative problems that require a second procedure the operative risk is less than 5%.

The major change in the procedure occurred with the advent of laparoscopic surgery. There was some debate surrounding open vs. laparoscopic surgery when performing a subtotal colectomy, but the advantages of the laparoscopic approach was clearly shown by the publication of a meta-analysis in the British Journal Surgery (Bartels et al. Systematic review and meta-analysis of laparoscopic vs. open colectomy with end ileostomy for non-toxic colitis. May 2013: 100(6): 726-33). More recently, some surgeons who are highly experienced in laparoscopic surgery are performing single-port laparoscopic subtotal colectomy.

The current debate for experts performing a subtotal colectomy is whether to perform a ileostomy with sigmoidostomy or the Hartman’s procedure where a cut is made at the level of the rectum and it is closed keeping it within the abdomen.

Although the ESCP MasterClass is primarily aimed at surgeons, I think that gastroenterologists would also find it very interesting because they play a very important role in the decisions of the MDT when evaluating who are suitable or not suitable candidates for surgery," concluded Panis. "I think this kind of masterclass with be very good for outlining the risks of not operating on patients and showing that we need to work together when managing this group of patients."

This event is supported by an education grant from