Surgical options in ulcerative colitis

: Surgery is needed in every second patient with pancolitis. Historically four surgical options have been developed: conventional ileostomy, ileorectostomy, continent ileostomy (Kock's pouch) and ileo-anal pouch. However, in emergent or unclear situations subtotal colectomy, ileostomy and preservation of the rectum is the most suitable operation. After recovery and in elective indications proctectomy and proctocolectomy establish the general surgical standard. Today, in most cases ileo-pouch-anal anastomosis is performed instead of creation of an ileostomy. Both lowered frequency of defecation and acceptable continence contribute to a better quality of life. However, functional disturbances are not uncommon and result in most cases from complications of the demanding technique. Definitive cure of the colitis is in interference with the risk of pouchitis in about 30%. The cumulative probability to loose the pouch may rise to 15-20% in the long-term course. Thus, ileorectostomy may be considered as a first step of surgical treatment, since pelvic nerve damage is excluded, function is much better and persistent proctitis can be treated topically. The attractively is that ileo-anal pouch can be performed later on, when decreasing function and increasing risk of malignant change will eventually require proctectomy. A Kock-pouch is seldom considered, especially in patients with ileostomy wishing sure fecal control. But the continent reservoir becomes more and more interesting again since it can be reconstructed from a failed ileo-anal pouch without loss of bowel. Conventional ileostomy should be reserved for patients not suitable for reconstructive methods or those who consider pough operations risk. However, it is the safest procedure with absolute cure of disease. The optimal choice of method considers medical and surgical aspects as well as patients conception and desire.