Thread by @mjayoushe

@MondayNightIBD @SobiaMujtabaMD @FezaRemziMD @DCharabaty 1/ 35 yo F panUC on IFX 10mg q4wk, admitted with abdo pain, hematochezia, malaise. T 39 BP 95/63 HR 110 FCP 900 mcg/g. Abdo distended, TTP; CT: colonic wall thickening+edematous mucosa. Cdiff neg; WBC 15, Hb 6. No improvement despite IVCS+Abx. Which surgery is indicated #B2BPoll

@MondayNightIBD @SobiaMujtabaMD @FezaRemziMD @DCharabaty 2/ Indications for colectomy in UC:

📌Elective:

📍UC refractory to medical Rx

📍Steroid-dependant UC

📍Unresectable dysplasia, CA

📍Complications from medical Rx

📌Emergency:

📍Toxic megacolon

📍Fulminant colitis

📍Perforation

📍Severe Bleeding

@MondayNightIBD @SobiaMujtabaMD @FezaRemziMD @DCharabaty 3/ What is a toxic megacolon?

🔺Transverse colon > 6cm

🔺AND one:
T>101.5° F
HR> 120
WBC>10.5
anemia

🔺AND one:
Dehydration
altered mental status
electrolyte abnormality
hypotension

💡Recall our #B2B tweetorial on ASUC👇🏽👇🏽👇🏽

https://twitter.com/mjayoushe/status/1279430539783606273

@MondayNightIBD @SobiaMujtabaMD @FezaRemziMD @DCharabaty 4/ What is Fulminant colitis?

🔺> 10 BM/day
Continuous bleeding
Abdominal pain+ distention

🔺AND acute, severe toxic symptoms (see 👆🏼👆🏼👆🏼)

@MondayNightIBD @SobiaMujtabaMD @FezaRemziMD @DCharabaty 5/ 🏁Emergency ✂️
📌Subtotal Colectomy+ ileostomy+rectum in place
📌After pt recovered, nutrition optimized,off CS,option to complete proctectomy &end-ileostomy or 3-stage pouch
📌In🤰:Turnbull-Blowhole colostomy: colostomy for colonic decompression+loop ileostomy for💩passage

@MondayNightIBD @SobiaMujtabaMD @FezaRemziMD @DCharabaty 6/ What happens to the rectum left in place?

🔺Hartman pouch: the proximal end of rectum is stapled off

🔺Or rectosigmoid left is long enough to create a mucous fistula= ostomy to the skin to drain mucus/gas & prevent buildup

@MondayNightIBD @SobiaMujtabaMD @FezaRemziMD @DCharabaty 7/ 🔑Avoid “going in the pelvis” (proctectomy, IPAA construction) in sick patients

🔺Sick= severe active disease, steroids, malnourished, septic, hemodyn unstable

🔺↑ Risk anastomotic leak , pelvic sepsis

🔺↑ Risk pouch failure long term

@MondayNightIBD @SobiaMujtabaMD @FezaRemziMD @DCharabaty 8/ 🔺Diverting ileostomy used to be performed for emergent Sx in fulminant colitis

🔺Colon was not resected--> perforation risk and bleeding continued !!

🔺Mortality up to 70% !

🔺Not an optimal option!

@MondayNightIBD @SobiaMujtabaMD @FezaRemziMD @DCharabaty 9/ 🏁Elective ✂️→

💡2 stages✂️:
1- Total proctocolectomy (TPC) + ileal pouch anal anastomosis (IPAA)+ ileostomy
2- ostomy takedown

💡3 stages✂️:
1- Total colectomy (TAC)+ileostomy
2- proctectomy+IPAA+ ileostomy
3- ileostomy take down

@MondayNightIBD @SobiaMujtabaMD @FezaRemziMD @DCharabaty 10/ Remember why we create a #pouch #IPAA #Jpouch ?

🔺After colon + rectum✂️we need to recreate a reservoir for💩

🔺SB lumen size << rectum lumen

🔺End of SB looped in J shape & lumen “opened+sutured” together

🔺Pouch lumen now x2 SB lumen

🔺Pouch🧷🧶to anus = IPAA

@MondayNightIBD @SobiaMujtabaMD @FezaRemziMD @DCharabaty 11/ 🏁❌Not everyone is a candidate for IPAA

🔺Multiple medical comorbidities

🔺HGD/CA of distal rectum

🔺Anal canal requiring XRT and/or excision

🔺Fecal incontinence

🔺Older age (poor sphincter)

🔺Abdominal obesity

🔺Fertility preservation

Options 👇🏽

@MondayNightIBD @SobiaMujtabaMD @FezaRemziMD @DCharabaty 12/ TPC with Brooke ileostomy:

🔺Move end of SB out through opening in abd wall (stoma)

🔺Allows waste 💩 to exit body

🔺External bag worn over opening for waste

🏁Brooke ileostomies are incontinent = stool flows in bag freely

@MondayNightIBD @SobiaMujtabaMD @FezaRemziMD @DCharabaty 13/ TPC w/Kock pouch:
🔺Internal ileal pouch+nipple valve+ileal conduit leading to cutaneous stoma
🔺Koch pouch is a continent ostomy
🚫external bag
🔺Pt inserts thin catheter into stoma to empty reservoir into 🚽 🏁least common b/c of complications (eg slippage of nipple valve)

@MondayNightIBD @SobiaMujtabaMD @FezaRemziMD @DCharabaty 14/ TAC with ileorectal anastomosis (IRA)

〽In select patients, rare to have disease-free rectum

〽️Avoids pelvic dissection→ ↓risk of infertility or sexual dysfunction

🏁Option in M/F of childbearing age