MANAGEMENT OF FULMINANT ULCERATIVE-COLITIS BY PRIMARY RESTORATIVE PROCTOCOLECTOMY

Severe acute ulcerative colitis unresponsive to medical management is characterized by multiple associated risk factors including anemia, hy poproteinemia, and high steroid requirements when urgent surgery is re quired. Current surgical options include use of primary ileal pouch-an al anastomosis (IPAA) vs. historic trends favoring colectomy with ileo stomy. PURPOSE: To evaluate the efficacy of primary IPAA in patients w ith severe colitis, we reviewed our own experience in 20 patients with this condition. METHODS: Patients undergoing primary restorative proc tocolectomy included 13 males and 7 females (mean age, 30.5 +/- 2.4 ye ars). Exclusion criteria for primary reconstruction included septic pa tients and patients with associated medical conditions such as pulmona ry or cardiovascular disease. History of ulcerative colitis averaged 3 .1 +/- 1.1 years (range, 1 month to 19 years). Preoperative mean total serum protein concentration was 5.0 +/- 0.2 g/dl, and mean albumin co ncentration was 2.1 +/- 0.2 g/dl, reflecting disease severity. The ave rage daily steroid requirement at the time of urgent colectomy was 58. 0 +/- 4.4 mg of prednisone (or intravenous equivalent). Primary IPAA i ncluded 18 ''W'' reservoirs, 1 ''S'' reservoir, and 1 ''J'' reservoir. RESULTS: Major surgical complications included mild pancreatitis (10 percent), anastomotic leak (5 percent), adrenal insufficiency (15 perc ent), an upper gastrointestinal bleed (5 percent), and small bowel obs truction (15 percent). There were no deaths, and no patients developed pelvic sepsis or required IPAA removal. At three and twelve months, 2 4-hr stool frequency averaged 7.3 +/- 0.4 and 4.9 +/- 0.3, respectivel y. Overall day and night continence was excellent and not different fr om patients who underwent elective IPAA procedures for ulcerative coli tis. CONCLUSIONS: Improved options such as primary IPAA may be safely used in selected patients requiring urgent surgery for severe or fulmi nant ulcerative colitis. Medical management should be abbreviated when disease control cannot be promptly achieved.