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Surgical Interventions for Ulcerative Colitis

May 04 | 3:30 PM

The physical extent of mucosal involvement is the most important predictor of colectomy in Ulcerative Colitis. Surgery in UC is split into three types based on the stage of the disease and the patient's condition: urgent, emergent, and elective. Surgical management of UC remains a significant challenge despite many efforts. Join us live as Dr. Chetan Kantharia, HOD, Surgical Gastroenterology, KEM Hospital, Mumbai, explains when, why, and how a multidisciplinary approach to UC care is crucial in achieving the best possible outcome for the patient.

[Music] dr kandi and i welcome you all on the behalf of netflix today we are gathered here for a very interesting session on surgical interventions for ulcerative colitis by doctor jason dr jason pantaria is a renowned doctor in the field of surgical gastroenterology he will be charged of the liver transplant program he is a passionate teacher and has been awarded the distinguished amdai award for the stage dr today will be talking about the multi-disciplinary approach towards ulcerative colitis and its impact on the outcomes so good evening everybody uh today i'll be discussing on the surgical management of ulcerative colitis so we all know that surgical uh ulcerative colitis is a chronic inflammatory condition of the large vowel with the disease being limited essentially to the mucosal layer of the colon the characteristic of this disease is that it almost always involves the rectum and it extends proximally in a continuous fashion to involve the other portion of the collar this disease is characterized by excessivation and remission of active inflammation when we speak of management of ulcerative colitis it is essentially medical with surgery being indicated in a select subgroup of patients as far as surgical indications are concerned they can be broadly divided into emergency and elective the emergency indications for surgery are colonic perforation life-threatening gi hemorrhage toxic megacolon and acute fulminant colitis which is refractory to medical treatment while the first two indications are self-explanatory and needs no further discussion let us see in brief the later two indications toxic megacolon is a potentially lethal complication of ulcerative colitis in which there occurs total or segmented non-obstructive colonic dilatation of more than six centimeters and it is always associated with systemic toxicity and if the patient fails to respond to treatment in 48 hours then he becomes a candidate for emergency surgery next is acute feminine colitis which is characterized by more than 10 stools per day with continuous bleeding associated with abdominal pain and distension and acute severe toxic symptoms including fever and anorexia in these patients surgery is indicated if this condition is refractory to both steroids and biological namely infliximab now we come to elective indications for surgery they are chronic ulcerative colitis persistent symptoms increased risk of malignancy dysplastic or adenomatous colorectal polyps long-standing disease and extra intestinal manifestations so let us see in brief about each indications so chronic ulcerative colitis the treatment option is either surgery or a long-term medical therapy so basically you need to discuss with the patient and take into consideration his characteristics whether there are associated morbidities what is his socio-economic status and available resource in form of both money as well as the surgical expertise but being a surgeon i can safe with confidence that the surgery that is a ilo pouch anal anastomosis which is a continence preserving procedure is a one-time solution for this patients which is important to be taken into consideration next is persistent symptoms persistence of symptoms in spite of the best medical management including steroids biologicals are an indication for surgery besides if the patient is inability enabled to tolerate the medical therapy or there are severe side effects of these therapy then this forms an indication for elective surgery next is increased risk of malignancy now we all know that ulcerative colitis is associated with primary sclerosing cholangitis besides this in patients with strong family history of colorectal malignancy they become an indication also the extent of disease and duration of the disease plays a very important role the patients with pancolitis have 19 times higher risk of developing malignancy than a normal individual besides this a one it is important to note that the risk of malignancy in patients of pancolitis increases after eight years and is significantly high on the other hand patients with left side colon has risk of only four times than that of normal patient and it takes 12 to 15 years to develop malignancy after the onset of disease besides this the cumulative risk at the end of 10 years is 2 percent at the end of 20 years is 8 and at the end of 30 years is 18 but what is important here to be noted is that following surgery where you remove the entire colon and rectum the risk of developing malignancy reduces significantly now coming to this plastic or adenomatous colorectal polyps so patients with polyps have a high risk of developing malignancy patients with low grade dysplasia the risk is 10 to 30 percent with high grade dysplasia is 30 to 40 percent and this place there within a lesion that is what we call as dalm that is dysplasia associated lymphoid malignancy it is 80 so the risk is very high and hence these patients need to be offered surgery next is long-standing disease now patients with long-standing ulcerative colitis have a risk of developing malignancy though the risk is less in first eight to ten years thereafter the risk increases by 0.5 to 1 per year so if the surgery is offered in patients even after 10 years it reduces the risk of developing malignancy in these patients and hence it's an important indication now coming to extra intestinal manifestation here the indication is not definite it is a relative indication and why do i say that because the response to surgical management following uh following surgery in patients with extra intestinal manifestation is not very uh clear we don't know whether the patients get secured of extinction manifestations or not or whether it still persists and hence it's a relative indication and not a definitive indication for surgery now coming to what are the concerns prior to surgery as a surgeon what you should be worried of and what you should be discussing with the patient and his relatives and how do you counsel about so very important to take into consideration is the nutrition of the patient both the mob body the body mass index the albumin and hemoglobin it is very important that you optimize the patient prior to taking this patient surgery whether it is important to know whether the patient is on high dose steroids and biological therapy because that will alter your management and approach to surgery which we will be discussing later it is also important to assess the function of the sphincter prior to surgery because it helps to planning what type of surgical option you want to give important to counsel both the patient and family with regards to stoma care because in majority of this patient the stoma remains for a period of six to nine months because these surgeries are done in stages with stoma present and hence it's very important that they be counseled and they have to be mentally prepared for them you explain to in detail to both to the patients and their relatives with regards to the post-operative quality of life with regards to increased bowel frequency initially for about one to one and a half year nocturnal frequency and the need for anti-diuretics also it's important to take into consideration whether you are doing surgery in elective setting or in an emergency setting because the nature of surgery will change and most importantly you have to counsel and motivate the patient that for post surgery it's not the end of the story but they have to remain under constant surveillance for autoscopy because they may develop malignancy which we will see later on so now coming to these surgical options as far as surgical options in an emergency setting is concerned we have total colectomy with endyostomy or a protocolectomy with endyostomy or just doing a blowhole colostomy with and diagnostic so total colectomy with end dialystomy is done in a life-threatening emergencies where there is acute severe collate colitis patient is in high dose of steroids you would not do this when the patient has got massive hemorrhage from the lower rectum because in this surgery you leave the rectal stump behind so you have not addressed the issue because the bleeding is going to continue the advantage of this procedure is that you get enough time to optimize the patient and build him up and then take him up for a definitive surgery that is higher pouch in your anastomosis after the patient has been adequately optimized practically is done in very few sub select patients where is a life threatening malignancy and it's important that you remove the entire large bowel including the rectum you would not do this in a patient who is unstable because he is not going to tolerate this surgery and in patients with severe systemic toxicity so advantage of this procedure is that you are giving a definitive treatment we are reviewing the entire diseased colon as far as the disadvantage is concerned that the patient does not have the option of doing ipa at a later date because you are doing an end diagonally for this as far as blowhole colostomy is concerned it is very very rarely done nowadays it used to be done in past in very severe unstable patient where you just do a stoma and try to salvage him and the and build him up and take him up for surgery later on so now we come to uh the impo surgeries which are usually done in an emergency indications are total abdominal collective youth and diagnostomy or a de-functioning hydrostatic now what so usually we do a total colectomy leaving behind the sigmoid colon and a diverting stoma so the question arises that what happens to the rectal stump which is left behind well it is left behind so that you could go in at a later stage easily to do a completion protectomy and do an ileo pouch in a lot so it is just sutured and either kept inside as a heart as a heartman's procedure or you can bring it out as a mucus fistula or you can bring out the stump at the facial level what is known as subcutaneous stoma and if you suture it and just keep it like a heart means then you can drain that rectal stump by putting in a rectal drain so whatever secretion is there will keep on coming up now as far as elective uh uh surgery is concerned the options are restorative proctocolectomy with ielts pouch in an anastomosis this is considered to be the gold standard for surgery of ulcerative collectors besides this you also have the option of total abdominal colectomy with iliorectal anastomosis or you can do a total protectomy with a permanent broke sileostomy or a total colectomy with cox continent ios so let us see the later two first and then discuss in detail about the restorative proctolectomy with ideal power channel anaesthetis and hyaluronic cleaners now the later two are done very very rarely nobody ever does cox continent ileostomy it's an historical surgery where you uh create with some it's a permanent stoma which is not got out you create a pouch of the ielum just below the abdominal wall and create a valve which needs to be intubated every time you the patient has to be uh be compressed of his stools so uh the advantage of this is that you are completely removing the large vowel you are the patient is fecally continent because you have created a wildlife structure and there is no need of external appliance the disadvantage is that every time you have to empty the pouch you need to intubate this patient so you have it's a procedure thing which the patient has to be taught and learned and it can be quite cumbersome at times besides this there is a risk of that pouch getting inflamed and over a period of time this valve loses its control and it needs to be revised as i said previously that this surgery is no longer done it's of historical perspective now brook silas to me is where for some reason you don't do a reconstructive surgery you just do a total protocolectomy and do a permanent ideostomy so it's a one-time surgery thus you bring out the stoma invert it well so it functions well it and it has the risk of the ileostomy standardized to me that is a parastomal herniation or getting retracted the disadvantage other disadvantages that the patient is incontinent for faces so he has to be continuously moving around with the bag but that majority of does this because they have no other option now we come to uh uh this total colectomy with endeavors to me as i said that when it is done the usually the sigmoid colon and downwards is not resected and you can do enhartments procedure and if if the bleeding is occurs then from that segment then you can either do a transcendental suturing of the bleeding rectal ulcer or you further go down and resect the bleeding part so this is a very rare complication again now we come to the main surgery that is restorative protocolectomy with ideal pouch and human estrogens so this surgery is usually done in three stages at times in some patients in two stages and very rarely in single sleep so let us see what this three stage two stage and single stages so three stage when i say three stage the first stage involves doing a total abdominal colectomy with endyostomy followed by the second stage which is completion proptectomy with ielts pouch anal anastomosis with diversion do pileostomy and final stage is the closure of the ileostomy or eyelash from the reversal so each stage uh is done at the end of four to 12 weeks depending upon the patient's condition and how well he has recovered from each stage so basically it takes about a year or so by the time the patient completes his final surgical procedure now in two stage pro two-stage surgery in first stage you would do a re restorative proctolectomy and you do reconstruct as well with ielts pouch in lns mostly and you divert by doing a loop ileostomy and in second stage you close the uh you close the uh i lost me that is you do a reversal of financial so this this surgery is done in select group of patients where the patient's general condition is very good the patient is not on any steroids or anti metabolites like infliximab or methotrexate and you anticipate that the healing is not that bad it's going to be good so that is the time you can do reconstruction at first stage itself in one stage which is done in very very very uh sub select group of patients very rarely done if the surgeon is very very confident that his stoma his anastomosis is not going to leak then he can do one stage surgery where he doesn't divert the anastomosis doesn't do an eyelash to me and does this as i said the percentage of patients undergoing one stage surgery must be less than five percent so this particular study took into consideration the use of steroids and anti-metabolites in both the stages and whether the surgery was done at a high volume center uh by people who are used to doing ibd and they found that the the post-operative complications and perioperative complications in both two stage and the one stage were almost over almost equal as you see as i have marked and hence the they concluded that just because the patient is on high dose of steroids and anti-metabolites doesn't mean that always they should undergo a three-stage procedure and you could do a two-stage procedure as well so this is the conclusion which they made and yet another study by french group where they studied the both the three stage and two stage procedures in 185 consecutive patients they found that patients who had undergone a three-stage procedure as compared to a two-stage procedure both when these steroids and when both in home steroids and antimetabolites were used they found that the complications in patients undergoing three stage procedure was much less as compared to patients who were who had undergone two-state surgery and even including the uh though the surgical morbidity in this patients were high obviously because it's a three-stage procedure as compared to sleep two-stage procedure and then concluded that you should judiciously do a two-stage procedure in select group of patients and do for sure three-stage procedure in patients who are operated for acute colitis refractory to uh medical treatment and patients who are on high dose steroids and anti-metabolites yet another study which takes into consideration the national national trend of three stage versus two stage of restorative proctolectomy for chronic ulcerative colitis so they found uh had lesser use of means they were the patients in whom the steroids used were more than compared to patients in two-stage procedure and they found that the patients with three-stage procedure had less complications and less amount of septic shock as compared to two states with less amount of with less percentage of re-admission rates also so they are concluded by saying that uh the decision making process of which approach to be taken should be taken into cus consideration taking both the patient and the pre-operative therapy related factors and they said that it requires a much better trial in a prospective fashion before condemning one against the other now while this discussion was going on between three stage and two stage there came a proposal of doing a modified two-stage iel power channel anastomosis and what do you do in modified two stage is that in first stage you do uh you do a total proctolectomy with uh uh il uh uh allele and a ileostomy and in second stage you do the reconstructive reconstruction without ileostomy so you are obviating the third stage so that is the modified two-stage procedure which has been uh which has been advocated and they found that the complications rate and survival rate in modified two-stage procedure was almost the same as that of a three-stage procedure so uh if at all there is any doubt with regards to three-stage procedure then one should proceed now what are the alternatives to surgical options other than total proctocolectomy with ileostomy so we have seen the first that is the total proctolectomy with endigostomy and we have also seen the cochlear symmetry so what remains other option is total colectomy with iliorectal anesthesia that is you leave behind the rectal stump and you anesthetize the ielium to the so this is uh the advantage of this is that because you are leaving behind the rectum you are not not going to disturb the pelvic now so hence fertility is going to preserve and hence it becomes a important surgery in young patients who have yet to finish their child bearing however if the patient pre-operatively has a poor anal tone then this surgery is contraindicated because even if you do a reconstruction the patient will be incontinent besides this the advantage of this surgery is that it is a one stage surgery you preserve the continents because you have less nerve injury and because you are anesthetizing to the rectal stump there is no need of diverting this anastomosis so there is no need of stoma but the biggest disadvantage is that this patients if have a high chance of the disease recurring in the rectum as high as 30 percent and at the end of 10 years these patients develop a high risk of developing malignancy in directed stuff so these patients need to be really motivated to be constantly under surveillance so that you can if at all malignancy occurs you can pick it up early so this uh this discusses the uh uh uh alluric anastomosis as i said that you preserve the post-operative fertility and female patients it has better functional results the quality of life is obviously better than the total proctolectomy so indications are when there is some difficulty in doing technical difficulty in doing ideal power channel anastomosis or you many so what are the important prerequisites for doing this surgery the rectum should be disease free it should not be a fibrotic there should be no colorectal malignancy and the duration of the disease should be less than 10 years and most importantly the patient should be willing to remain under surveillance program for a long period of time now uh as i said that the biggest disadvantage of this patient is that these patients have a high risk of developing malignancy as shown in this study compared to patients who undergo ideal power channel anaesthesia so here they found that the risk of developing malignancy at the end of 10 15 and 20 years was as high as three or four percent nine percent and 22 which is very high percentage and hence it's very very important that these patients remain under surveillance uh for a long period of time now comes the question is is it very important to divert the these patients meaning do you require a diversion stoma that is ileostomy or can you do away with ileostomy so this particular study published in world journal of gastroenterology they they concluded that if you adopt a stringent criteria then only less than 10 percent of patients will qualify for an anastomosis without a diversion stoma that is majority of the patients will definitely require a diversion stream so this study uh again another study which was uh which studied whether to divert or not so they devised the scoring system and they found that patients who qualify for without diversion who can do away with stoma are patients with familial adenomatous polyposis and patients who pre-operatively were not on steroids and patients who undergo a stapled ileo pouch in an anastomosis by double stapling technique so these are the patients who qualify for doing uh undergoing a surgery without stoma okay so uh this is another study where uh they've studied whether de-functioning ileostomy is required or not and then this study interestingly showed that patients whether you divert or not will if it has to leak it will definitely leak so the question whether a stoma is required or not uh this is a a ideal trial which has been registered with the uh clinical trial registry undertaking in 2019 and this particular trial which is underway and is uh the results are yet to out have uh are analyzing in prospective fashion patients undergoing a surgery with stoma and without stomach and i am very very sure that the results of this will lead will lay the pathway for further uh uh for further uh uh decision making whether a stoma is required or not but as of now uh i would say that stoma is definitely must because you are doing a very low ilo power channel anastomosis and by uh doing a divergent stoma you are giving enough time for the anastomosis to heal and even if there is a small leak it will settle down its own so it's a small price the patient will have to pay but it is going to be ultimately in his benefit now we come to the question that can one do this surgery by minimal access or one has to do by an open approach as well so literature has enough evidence to show that this surgery can be done both by uh by minimal access with same results and the same with same results with improved quality of life as compared to the conventional open open method as shown in this study so this is another study where they concluded that by surgery by minimal excess is safe and b can be performed with low conversion rates and it definitely confers beneficial very operative outcomes this is a systematic review which has uh taken into consideration 11 trials including 607 patients uh undergoing laparoscopic ileal pouch in anastomosis and they concluded that the laparoscopic ideal pouch anastomosis is feasible and safe procedure it does have a short-term advantage over the open access however they say that with regards to post-operative complications and the quality of life and cause how far it is better than the open surgery one cannot say and they say that it requires more studies so as of now what we can conclude for the viewers is that you can do this surgery uh by and a minimal excess very safely and it is very feasible with good cosmetic results but as far as the complication rates are concerned the quality of life issues are concerned they are almost same as that of open and it has no advantage over it now we come to another issue is should you always do this anastomosis stapled or can you do it handsome so having said that let me confess that until 10 years or 12 years back we used to do this surgery by open technique we used to do it very well by open technique and since last 10 to 12 years we have started using doing this by double stapling technique where you use contour to disconnect the lower rectum and we do an ideal pouch and we create the pouch using stapler and you we do an ideal power channel anastomosis by anastomosing the uh with a circular stapler so uh what what does the literature say so this particular study has shown clearly show that when you do a stapled anastomosis the complications rate are much less than enhanced uh a handsome anaesthetist again this particular study uh conducted in as high as 3109 patients they found that patient undergoing a stapled il pouch in illinois has a better outcome and quality of life than those going a hand-sewing procedure now this study showed that clearly shows that both the septic complications the anaesthetic structure rate small bowel obstruction wound infection pouch failure is all very very low in stapled anastomosis as compared to the as compared to the open anaesthetist so this is another a meta analysis when meta analysis has lot of credence so what they concluded is that both techniques have similar early post-operative outcomes however stapled anastomosis offers improved nocturnal continence which is reflected in higher inorected physiological measurement so this is very important that the complication of nocturnal continents is also taken care of now next we come to the issue is should we do glucose ectomy in all patients or uh or in only select few patients so basically let me tell you when you do an open anastomosis open ilear power channel anastomosis you always do a mucosectomy the advantage of doing mucosectomy in open procedure is that you eliminate the risk of developing malignancy in the small ring of mucosa which is left behind however however having said this there is no evidence to suggest that the disease control per se is superior when mucosectomy is done as shown in this study so this study says that one that there is no superiority of mucosectomy in disease control however it says that it should be done when there is a high risk of dysplasia or there is a high risk of malignancy so this particular study compares the double staple technique and in patients with patients who have undergone mucosectomy and they found that patients in whom mucosectomy was not done and double stapling technique was done it is technically easy it preserves the sphincter it improves the function there is decreased septic complications there is no risk of dysplasia and no risk of malignancy as well so the message to be sent is that there is no need for doing mucosectomy in all patients you should do it only in very select sub subgroup of patients where there is high risk of dysplasia or if there is high risk of malignancy now we come to a very important technical question is what type of pouch because we have been saying that what surgery we do is an ideal power channel anaesthetist so which pouch should be done which is an ideal power so we know that there are three pouches which are standard this standard described one is the j pouch the next is the w pouch and the s part as i have shown in the diagram here so let us see into the characteristics of each so basically the limb length of all the three are almost the same as far as volume is concerned the w pouch has the maximum volume followed by a spout with j pouch being the least voluminous as far as the frequency of stool is concerned because the uh the because the volume of w w pouch is more the frequency is less in w pouch followed by that of s pouch and followed by j power but the nocturnal frequency is released in w pouch followed by s pouch and it is maximum of the three in j-power again anti-diarrheal requirement is same in s and j pouch and least because the volume is more in w power efficacy of evacuation is good in j and w powers the need for intubation is maximum in s pouch difficult to construct the most easiest to construct is j pouch w pouch will be definitely more complex and s pouch is easier than w but difficult than j so uh besides this the j pouch can be used can be done both by stapler and hence whereas the w and s power definitely cannot be done with stapler and you need to do it with handsome having said that what is going to be noted is that one routinely does a j pouch for of this reason that it is easy to construct can be done with stapler and it is with an acceptable uh pouch function so this study uh takes into consideration compares the j pouch with the blue pouch and what did they find they find they found that w pouch because its volume is large because its w shape so it has a advantage but this advantage is only for a short term for first six months after that after that the advantage of w pouch is loss and it functions as good as j-power so this advantage is attenuated as the pouch matures resulting in no disparity in the pouch besides this for obvious reason w pouch cannot be done in a patient with narrow or pelvis thin pelvis for that the patient has to have used to should have been having a large pelvis so that's why we commonly do a j pouch surgery now this is uh this study compares the quality of life issue and then they conclude that the j pouch configuration is technically less demanding and has similar quality of life as compared to w pouch now now we come to another technical question is many a times and especially for exam going students is it's a very favorite question to be asked in exam when you prepare a pouch and what what do you do if the pouch doesn't reach the pelvis so the maneuvers which are routinely described as first you ligate the iloco hylocolic medical ligation you follow follow it up by transverse anterior and posterior peritoneal incision over the sma pedicle you take a release incision over the meson tree then you selectively divide the secondary arcade of the mesenteric effects of the pouch if nothing works then you convert it to an spout or if still doesn't work the last resort is you leave the pouch suspended in the pelvis and you go in at a later stage after a period of three months or so when vascularity develops and you can lengthen it further and take it down now coming to the complications of surgery so the early complications are important complications are hemorrhage acute pelvic cells pelvic sepsis and portal vent thrombosis and late complications important ones are chronic pelvic sepsis small bowel dysfunction pouch dysfunction pouch failure dysplasia and malignancy and infertility in some patients so let us see the complications in uh brief so as far as early complication of hemorrhage is concerned it is mostly reactionary or delayed it occurs in four percent of patients and the commonest cause of bleeding is bleeding from the stapler line so what do you do in this patients if the bleeding is significant you take up the patient for examination under anesthesia if possible you do a pouch endoscopy if there is diffuse ooze you give an adrenal wash and if you can see a specific breeder then you can under run the spa under run the bleeder under vision now uh it can also occur if there is pouch stemia if there is intra from the raw surface of the intra-abdominal cavity or if there is a pouch hematoma and this pouch hematoma is a surrogate marker of a pouch leak smallly and this patients therefore needs to be treated with broad spectrum antibiotics and you need to decompress the pouch by incubating the pouch with a catheter now we come to acute pelvic sepsis we all know that pelvic sepsis is the commonest cause of leak so this sepsis can occur because of an infected hematoma and the patient clinically manifests as fever pain and purulent discharge per annum you need to confirm the diagnosis by either doing a ct scan or an mri which will show an abscess collection or edumatous tissue planes these patients need to be treated very aggressively with high antibiotics and if required you can do an image guided drainage either percutaneous or trance in it you also have an option of endocavitational vacuum therapy and removing the collection if untreated what happens is that this pouch becomes stiff non-compliant and ultimately it goes to pouch failure now we come to late complications late complications is chronic pelvic sepsis which you which can occur in about 20 percent of patients and these patients manifest as pouch fistulae either pouch anal or pouch vaginal in females or at times pouch perineum they or they can have an elastomeric structure and these patients their compliance is very poor and the pouch doesn't function very well so this is pouch vaginal fistula which is not very uncommon we see it in our practice with incidents being as high as around 10 percent these patients come with a vaginal dis passing of feces from vagina so treatment is you need to examine the patient under the anesthesia do a pauchogram and see whether the dye is coming out from the vagina and you quantify the uh the size of the fistula so if uh if if it is if it is a significant fistula then what requires to be done is a stoma so basically the treatment will depend upon the severity of the symptoms if the if it is a very minimal discharge you can pass on a sit-on and as the sit-on keeps on draining the fistula and cutting the track it will keep on healing but if it is significant making it become very embarrassing for the patients or cumbersome for the patient then what is required is doing a divergent stoma giving rest to the track control the sepsis and at a later stage take up the patient for a definitive treatment where you do an advancement flap which can be done either transcendental or trans vagina now we come to small bowel obstruction which is not very uncommon we see very uh very often patients with ideal power changing anastomosis presenting with small small vowel obstruction and it's important to note here that these patients can present even at the end of one year or five years and as late as 10 years so this usually occurs because of extensive abdominal and pelvic dissection the three state surgeries which the patient undergoes sepsis they all lead to fibrosis leading to small bowel obstruction and the cumulative risk is nine percent at the end of one month 18 percent at the end of one year 27 percent at the end of five years and 31 at the end of 10 years necessitating surgery in one person three percent seven percent and eight percent at the end of one month one year five years and 10 years respectively now we come to finally pouch this function so when a normal pouch function is usually defined as passage of 24 hours tools about four to eight times per day with one nocturnal motion so that is the norm initially and if the uh and the patient is able to control and pass tools when it is convenient so any deviation from this norm is called as pouch dysfunction and this is basically maybe due to sepsis for which we require to treat it with antibiotics as we have seen earlier and finally we come to pouch failure the incidence is as high as 5 to 10 percent it may necessitate excising the pouch permanently leading to a permanent stomach and because the redo pouch surgery is easier said than done it is very complex and it has a very poor functional outcome so once the patient develops pouch failure then he has no option but to have a permanent stomach and this is the final slide that how do you keep the patient who has undergone a ideal power channel anastomosis surveillance for malignancy so basically you need to do a pouch a pouchoscopy so you need to examine the pouch for recurrence of disease and malignancy so patient who has no pre-existing dysplasia or no risk factor for neoplasia they should be surveilled at the end of one year and thereafter every two to three years patients who have pre-existing dysplasia or risk factor for neoplasia should be should undergo a pouchoscopy at the end of six months and thereafter annually patients who have low grade dysplasia on surveillance pouchoscopy that is while you are surveilling the patient and you take a biopsy and you detect that there is low grade dysplasia they should undergo pouchoscopy subsequently every six months for eight years with biopsy being taken each time and if the patient shows progression from low grade dysplasia to high grade dysplasia then you can either do a mucosectomy with ideal pouch advancement or in patients who are non-compliant who know who you feel are not going to follow then you can exercise the power and do a permanent stroke so with this i end my talk thank you very much [Music] it was really amazing

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