tailieunhanh - Improved Outcomes in Colon and Rectal Surgery part 34

Improved Outcomes in Colon and Rectal Surgery part 34. Written by many of the worlds leading colorectal surgeons, this evidence-based text investigates the risks and benefits of colorectal surgeries. By using clinical pathways, algorithms, and case discussions, the authors identify the best practices for patient safety and positive outcomes to ensure that physicians correctly recognize potential problems and carefully manage complications | 31 Surgery for ulcerative colitis Patricia L Roberts CLINICAL VIGNETTE Challenging Case A 35-year-old male is undergoing an ileoanal pouch procedure for ulcerative colitis. Following transection of the ileum flush with the cecum the surgeon notes that it will be difficult for the pouch to reach the anus. Challenging Case Management Difficulties with the ileoanal pouch reaching the anus occur for two main reasons failure to mobilize the small bowel or patient-related factors such as obesity or a long narrow anal canal. Difficulty with reach is more common if a mucosectomy is performed rather than a double-stapled anastomosis. An S pouch may reach the anus easier than a J pouch. If the main reason for the pouch not reaching is patient obesity and a thickened mesentery an initial total abdominal colectomy ileostomy and Hartmann closure of the rectum may be performed. Following weight reduction an ileoanal pouch procedure can be performed. A series of technical maneuvers including mobilization of the small bowel up to the duodenum scoring the peritoneum over the superior mesenteric artery and the creation of mesenteric windows can facilitate pouch reach. If despite these maneuvers the pouch does not reach the pouch can be left in the pelvis a loop ileostomy created and after a period of several months the pouch can then be joined to the anus. Additional details of these technical maneuvers are described in the text. INTRODUCTION Ulcerative colitis is an inflammatory condition involving the colon and rectum. The incidence in the United States is cases per 100 000 person years. 1 Thus in this country there are approximately 26 000 new cases of ulcerative colitis diagnosed annually and 730 000 people with ulcerative colitis. 1 2 Although many patients are treated effectively with medical therapy approximately 23-45 of patients require colectomy. The risk of requiring colectomy is higher in patients with pancolitis than patients with left sided disease. 3 4 This .

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