Ulcerative colitis is the most common inflammatory bowel disease and follows a life-long relapsing remitting course. A significant minority of patients require surgery and this thesis aims to investigate areas for improvement at all stages of the patient’s journey through the surgical management of ulcerative colitis; from colectomy through potential restorative surgery, pouch dysfunction and eventual failure. Several methodologies have been employed, starting with epidemiological investigations of colectomy and restorative surgery, through clinical studies of novel imaging investigations, and tertiary centre data for subspecialist pouch excision.
Nationwide data have been interrogated to investigate epidemiological trends regarding colectomy rates and the nuances of contemporary medical salvage and subsequent colectomy. Nationwide data from England and Sweden were compared to quantify the very different approach to restorative surgery in two similar healthcare systems. In Sweden the rate of restorative surgery after colectomy reached 46%, compared with 33% in England. This finding was associated with the restorative procedure being an ileoanal pouch in 92% of the English patients, versus an ileorectal anastomosis in 59% of the Swedish.
Pelvic sepsis, mostly from pouch-anal anastomotic leak, is the main cause of ileoanal pouch dysfunction. A systematic review of the management of pouch septic complications was undertaken to identify areas for improvement. It was noted that routine imaging for early identification of pelvic sepsis is rare, and that there is an appreciable burden of asymptomatic anastomotic leaks diagnosed late at the time of de-functioning ileostomy reversal. This gave rise to two clinical studies of novel MRI investigations to improve the assessment of anastomotic integrity and pouch dysfunction, providing early normative data and a foundation for larger studies.
Ileoanal pouch excision for pouch failure is a relatively rare procedure with a large local series at St Mark’s. The local cohort data were utilised to investigate the morbidity and mortality associated with this procedure and establish the long-term perineal healing rate.
An IDEAL stage 2 study was designed, with ethics committee and funding approval, to prospectively evaluate the single stapled double purse string pouch anal anastomosis in comparison to the double stapled standard, ‘A Comparison of Anastomotic Interventions in a PRospective Cohort of ILeal Pouch Surgical Patients’ (CIRCILS).