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Proctectomy for UC?

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Posted 6/10/2014 11:48 AM (GMT 0)
This is something I have been thinking about for a while now but I have been unsuccessful in finding any papers that look into it. Since UC always starts at and includes the rectum, would removal of the rectum alone "cure" the disease, or would it just come back and start at the most distal part of the colon that remains?

Does anyone know of any papers that have looked into this?

Thanks!
Posted 6/10/2014 12:50 PM (GMT 0)
Yes, cut out part of the large intestine and uc will manifest itself elsewhere in the large intestine, so far from a cure. That's why they typically take all of the large intestine, even for those with refractory (that is doesn't respond to medicine treatment) proctitis. I couldn't quickly find a paper, you can look further at http://scholar.google.com.
Posted 6/10/2014 3:34 PM (GMT 0)
But has a proctectomy (as opposed to a full proctocoloectomy) ever been done on a UC patient or do they always just opt for the later?

Its just curious that the rectum is always involved; it would lead one to believe it is highly involved in the pathogenesis but I have never seen it get any sort of special attention...
Posted 6/10/2014 3:46 PM (GMT 0)
A qualified CR surgeon will remove both the rectum and the colon; I wouldn't see a surgeon who only offered removal of one of the two organs. UC will manifest again and most likely result in additional surgery. The other thing to consider is that with a small intestine hooked straight up to the anus (sans rectum) an adult's life would be fairly miserable. Very high frequency..higher than that with a jpouch as a jpouch is a false rectum and is constructed to hold waste.

Sue
Posted 6/10/2014 3:46 PM (GMT 0)
I can't see that it hasn't....hence the knowledge of spreading, etc.

q
Posted 6/10/2014 4:09 PM (GMT 0)

suebear said...
A qualified CR surgeon will remove both the rectum and the colon; I wouldn't see a surgeon who only offered removal of one of the two organs. UC will manifest again and most likely result in additional surgery. The other thing to consider is that with a small intestine hooked straight up to the anus (sans rectum) an adult's life would be fairly miserable. Very high frequency..higher than that with a jpouch as a jpouch is a false rectum and is constructed to hold waste.

Sue

Why/how would you hook up the small intestine if you still have the large intestine in place?

And do we know forsure that UC manifests again if only the rectum is removed? Thats kinda the main question Im asking : p
Posted 6/10/2014 4:18 PM (GMT 0)
Oops, mispoke.

Okay, I have never heard of anyone having the rectum removed but keeping the colon. However, there are lots of people who have had the colon removed; and kept the rectum. Most of those folks have needed additional surgery.

I think you will get a more qualified answer from a CR surgeon as to 'why' this type of surgery is not practiced. My feeling is that the long term success is very low.

Sue
Posted 6/10/2014 4:41 PM (GMT 0)

suebear said...
Oops, mispoke.

Okay, I have never heard of anyone having the rectum removed but keeping the colon. However, there are lots of people who have had the colon removed; and kept the rectum. Most of those folks have needed additional surgery.

I think you will get a more qualified answer from a CR surgeon as to 'why' this type of surgery is not practiced. My feeling is that the long term success is very low.

Sue

Well it certainly makes sense that there would be recurring inflammation if the rectum was left in, assuming it played a role in pathogenesis.

But ya, I didnt expect that someone hear would have a definitive answer, but I figured it was the best place to start at least. It just seems like such an obvious and simplistic idea that I figured someone would have thought about/tried it by this point.

Thanks for the replies!
Posted 6/10/2014 4:42 PM (GMT 0)
I would be real interested in seeing the evidence that surgeons are basing the decision to never remove just part of a colon. I highly doubt that it manifests elsewhere in people with distal disease at a rate higher than it spreads. Your odds are very good that it will not spread when you have distal and mild moderate.

The risks in the past for bowel resections was very high. Probably still high but much better. Have they updated the risk in their calculations? One of the major reasons for surgery is cancer or cancer risk. If you have a perfect colon other than the last 6 inches, does the risk of a second surgery out-way retaining most of your colon?

It is possible insurance will not pay and/or doctors simply don't want to do a surgery that fails 20% of the time. Not sure if just sigmoids and rectums are removed for other problems like cancer. Maybe retaining the rest isn't of much benefit. Maybe that the rectum is the most valuable part to a patient/health and that has to go with UC anyway.

My sigmoid is 99% of my UC problem and where all my polyups were and where my diverticulous is. I would consider removing it if surgery was a slam dunk.
Posted 6/10/2014 6:21 PM (GMT 0)
Well there definitely is a procedure to remove just the rectum, but as you brought up, Im not sure what the risks associated with it are. Hence why I made this thread; wanted to see if anyone had any experience with it with regard to UC.

But if it were me, Id be willing to risk having to undergo another surgery if they could just remove my rectum and not my entire colon. Im sure you would still have many of the normal issues associated with a J pouch, but they would likely be diminished if you had a working colon that could form stool properly.
Posted 6/10/2014 6:47 PM (GMT 0)
Yeah for UC everything has to go (proctocomectomy) or nothing at all. The odds would be very high for it to attack somewhere else.

I would assume just a rectum removal is done for someone who has rectal cancer.
Posted 6/10/2014 7:46 PM (GMT 0)
We're all assuming here because it just isn't done for UC but I'd assume that it would be risky if the UC came back as some are predicting because of scar tissue being a big concern for types of surgeries....if there is too much scar tissue they may not be able to operate effectively. One of the toughest areas to operate for J-pouch surgery is the lower abdominal area where another surgery would be needed due to the first protectomy not being affective.

I was the 2nd surgery of the day scheduled for my surgeon (mine was a step-2 J-pouch creation), the surgeon came into my waiting room and asked if I wanted to postpone my surgery because his first patient had so much scar tissue that from a 3 hour scheduled operation they were expecting was going to take 9-10 hours. He didn't tell what type of surgery it was but he did tell me the problem was the scar tissue all ready there with his first patient.
Posted 6/10/2014 9:33 PM (GMT 0)
@ ks1905 - I could definitely see that being an issue, but it would be interesting to have a case study, or baring that, some animal trials. Unfortunately animals trials in this case wouldnt be as telling because the UC induced with them doesnt mimic real UC enough (with regard to the pathogenesis at least).

Im going to keep looking because Id be shocked to find out that no one with UC has had just their rectum removed. Ill get back to you guys if I find anything out.
Posted 6/10/2014 9:52 PM (GMT 0)

Tornado6 said...
They do ultra / low anterior resection and coloanal anastomosis for colon cancer. This is removal of the sigmoid / rectum, and reconnection of the remaining colon. They could do this for UC, but you'd have to stay on maintenance meds. It is not an easy surgery, and it doesn't make sense for the vast majority of UC patients.

They also do Total Abdominal Colectomy with Ileorectal Anastomosis (IRA) surgery, usually for FAP, but sometimes IBD. The functional outcome for IRA is not that bad. This is ileum connected to anus, no pouch.

www.ncbi.nlm.nih.gov/pmc/articles/PMC1420918/

This is what you may wind up with if you find you have Crohn's in between 1 and 2 of a three part IPAA surgery.

As interesting as that is, it still doesnt answer whether or not the UC will manifest itself again after the procedure does it? Because obviously they CAN do these surgeries for anyone, but if the UC is going to come back then it doesnt make sense to just remove the rectum...
Posted 6/10/2014 10:03 PM (GMT 0)

Tornado6 said...
That's why you have to keep taking the medicine...

Yes, but my question is regarding the pathogenesis of the disease. If the rectum is involved in the pathogenesis then it may be a necessary factor in initiating the inflammation, so by removing it you may not even need the drugs. THATS what Im getting at, and I was trying to see if anyone had heard about any trials/studies concerning it, because it seems like such an obvious thing to investigate
Posted 6/11/2014 1:32 AM (GMT 0)
A low anterior resection does NOT remove the entire rectum and sigmoid unless a new pouch is constructed (it is possible and not uncommon in cancer cases to create a j-pouch using colon instead of small bowel). The fact is that quality of life is extremely low if there is no pouch, either the "original" pouch, the rectum, or a neopouch like a j-pouch (or a colostomy or ileostomy, for that matter). In the early 80s when j-pouches for UC were very new, some "lucky" patients received straight connections of the ileum to the anus, with no pouch created, under the hypothesis that the ileum would expand over time to become a pouch on its own. This did not happen, and those patients required revision surgery or permanent ileostomy.
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