Ulcerative Colitis in Children
Ulcerative Colitis (UC) is a type of inflammatory bowel disease (IBD) of the colon and rectum.  It is characterized by chronic inflammation which waxes and wanes.  Some patients develop prolonged periods of inflammation, chronic bleeding, or become steroid-dependent to manage symptoms.  These patients often present for surgical evaluation.
Mild ulcerative colitis and patients with long remission are managed medically with non-steroid medications.  Steroids are reserved for brief flareups.  These patients are usually managed by a board certified pediatric gastroenterologist.
Unlike Crohn disease, all cases of UC are potentially surgical candidates.  Ulcerative colitis can be cured surgically by removing the diseased colon.  Reconstruction is now available using small bowel.  This is often referred to as IPAA (ileal pouch anal anastomosis), IAPP (Ileo-Anal Pouch Procedure) or simply “J-pouch” because of it’s shape.  The operation, however, is not perfect.  It is important to understand the risks and expected outcomes of surgery for ulcerative colitis.
For an illustrated view of the body’s digestive system, click here.
Risks of Surgery
Bleeding
Infection
Anastomotic leak
Pouch failure or loss
Small bowel obstruction
Frequent stooling
Incontinence
Impotence
Readmission
Ileus
Electrolyte problems
Wound infection or breakdown
Anastomotic stricture of bowel (scarring at the connection)
Deep vein thrombosis (clot in leg veins)
Reoperation
Click here to review risk of biologic agents (Infliximab) on surgery
Alternatives to Total Proctocolectomy with J-pouch
Continued medical management
Biologics (Remacaide, etc)
Colectomy without reconstruction (ileostomy)
Other types of pouch include the W-pouch or straight pullthroughs (A variety of reconstructive procedure are available, but the J-pouch is the most widely used and well supported in the literature)
Koch pouch (catheterizable ostomy)
The J-pouch has 2 versions:  Stapled and hand-sewn.  The procedures differ slightly in outcome and risks.  We at Pediatric Surgeons of Phoenix generally prefer a very low laparoscopic stapled IPAA as our first choice, but care is individualized based on patient situation.
Hand Sewn
Advantages
removal of more diseased mucosa
decreased risk of cancer later in life
decreased need for surveillance endoscopyDisadvantages
generally an open (non-laparoscopic surgery)
technically more difficult
more stretch on blood vessels
difficulty distinguishing gas from stool
diverting ileostomy more common

Stapled
Advantages
Laparoscopic surgery
Better ability to distinguish gas from stool
Technically easier
Shorter operative times
J-pouch reaches with less stretch on bowel
Disadvantages
Slightly more mucosa may be left behind
Small risk of cancer in the remaining 2cm of bowel
Need for surveillance endoscopy

Results
Initially after surgery, bowel movements are frequent and very liquid.  Generally, a patient with an IAPP will have about 6 bowel movements per day by the end of the first year after surgery.  The risk of incontinence is low.  The risk of impotence is very low.  Anastomotic leak rates vary, but there is a small but significant chance of leaking from the J-pouch.  An ostomy may be performed preventively, or only if a leak occurs.
It is important that you discuss the risks, benefits, and options with your surgeon and gastroenterologist before making a decision.
Warning: Very graphic content related to the type of surgery, organs, procedures or trauma depicted
Open surgery:  J-pouch neorectum ready to be pulled through sphincter muscles
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Barium enema after J-pouch
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Lateral view of reconstructed rectum after J-pouch
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Ulcerative colitis in children: Surgical Considerations

Pediatric Surgeons of Phoenix – Phoenix, Arizona