This information is especially for patients who will undergo surgery.
Ileal Pouch Anal Reconstruction
Introduction
Ileal pouch anal reconstruction is a surgical technique designed
to allow removal of the entire colon and rectum, yet preserve the
anus and the normal route of bowel function. This is a technique
designed to allow patients to avoid a permanent ileostomy. Patients
with ulcerative colitis and familial polyposis who require surgical
removal of the colon and rectum are the most common candidates for
this type of procedure.
Definitions
Anastomosis
The word “anastomosis” means to make a surgical
connection between two hollow organs like two ends of bowel or two
ends of a blood vessel.
Ileal Pouch (Ileal Pouch Anal Anastomosis
- IPAA)
After surgery for disorders that require removal of the entire colon
and rectum, a new rectum can be constructed using a pouch made out
of small bowel. Although most pouches are formed by folding the
bowel on itself like a “J”, some are folded into “S”
and “W” conformations, hence the terms J, S, and W pouches.
J pouches have twice the volume of a normal loop of bowel while
S pouches have three times the volume, and W four times the volume,
simply because of the way the bowel is folded, sewn together, and
then opened to make one larger pouch. This pouch is attached in
the deep pelvis to the inside of the anus so that the patient may
eventually resume having bowel function in an manner that is close
to normal, hence the term “ileal pouch anal anastomosis”
or IPAA in the literature. Some surgeons use a surgical technique
that requires one to strip the lining (or mucosa) of the very last
portion of the rectum and leave the outer wall of the rectum (without
mucosa) in place. This is done with the belief that it helps patients
feel when the pouch is full and needs to be emptied. This technique
is called a rectal mucosectomy and is commonly done through the
anus. The pouch is then attached inside the cuff of rectal wall,
either with sutures or surgical staples. In addition to potentially
helping with sensation, another advantage of a rectal mucosectomy
is that it minimizes the amount of rectal mucosa left in place.
Retained mucosa, mucosa that is left behind, may pose a risk for
ongoing inflammation or possibly cancer formation in ulcerative
colitis patients, and is a risk for new polyps and cancer formation
in polyposis patients after surgery (see below). However, the anal
muscle dilation necessary for the mucosectomy has the disadvantage
of lengthening the operation and may weaken the anal sphincter which
in turn may predispose to difficulty with control of bowel movements.
Fortunately, as we have learned more about the operation, it has
become clear that the sensation of fullness that means the pouch
must be emptied is retained even without leaving a muscular cuff
of the rectum. In an individual patient, the decision to perform
a mucosectomy or not must be individualized -- based on patient
build, sex, and technical factors during the operation.
Ileal pouches that are taken into the pelvis have been devised to avoid a permanent ileostomy (see below). As a practical matter, J pouches are the easiest to make, the most reliable, can be made with stapling surgical instruments that make the procedure must faster and more secure, and J pouches function about the same as S and W pouches after one year. For these reasons, 98 % of pouches made in our hospital (and nationally) are J pouches. The major indication for an S pouch at the present time is that greater length can be gained from the spout or outlet of the S pouch, allowing bowel that might otherwise be too short to reach into the deep pelvis in a J to actually reach down deep. Another indication for an S pouch is that a narrow pelvis may not admit a J pouch, but will allow the S pouch where the wider part of the pouch is positioned up higher in the pelvis. On very rare occasions ( less than 1 %), the surgical team cannot get bowel (in any kind of pouch) to reach the pelvis. In these cases, the only option is a permanent ileostomy for technical reasons.
Ileostomy/Colostomy
An ileostomy is an end or loop of ileum, part of the small bowel,
that is brought out through the abdominal wall, sewn to the abdominal
wall on the inside, and then opened so that the bowel contents empty
into a bag. This bag is secured around the ileostomy to the patient’s
abdomen and must be emptied several times a day. A colostomy is
essentially the same thing but is made out of colon rather than
small bowel. Ileostomy contents are more watery and more irritating
to skin than stool, so ileostomies are generally created with more
projection above the skin so that the bowel contents empty into
the bag more reliably.
Continent Ileostomy
A continent ileostomy (i.e. Koch or Barnett pouch) is an ileostomy
that does not require the patient to wear a bag. This is achieved
by creating a pouch made out of small bowel inside the abdomen in
which intestinal contents are stored. A valved outlet to the pouch,
surgically created, prevents leakage until the pouch is drained
by a tube passed through the ileostomy. This must be done several
times a day. There are a number of different techniques described
for forming such ileostomies. Although this is the best option for
some patients, especially those who have poor anal sphincter muscle
function, such pouches are prone to scarring and breakdown that
in many patients require surgical correction or construction of
a new pouch, sacrificing additional small bowel. Regionally and
nationally, few patients receive continent ileostomies.
Ulcerative Colitis (UC)
The most common indication for pouch surgery is ulcerative colitis.
This is a type of inflammatory bowel disease that affects the innermost
lining (mucosa) of the colon and rectum, often visibly at colonoscopy
and always microscopically evident on biopsies of the bowel. We
do not know why this disease occurs though there is a great deal
of work being done to answer this question.
Not all patients with ulcerative colitis require surgery. Many either have mild symptoms or a course of disease that flares up occasionally requiring treatment then subsides. These patients are often best managed with medical treatment. Patients with a more severe form of the disease that leads to bloody stools, severe cramps and pain, that requires repeated admissions to the hospital for treatment or prolonged use of toxic drugs such as prednisone (a steroid medication) with potentially severe side effects-- such patients are often referred for surgical treatment to eliminate the colon and rectum that are so severely inflamed. On occasion, ulcerative colitis progresses so rapidly that the bowel is at risk for rupturing internally. This is termed toxic colitis and is a life-threatening disorder, often requiring emergency surgery. Other patients have active ulcerative colitis for years that never flares as seriously, but over time they develop an increasing risk of cancer. Patients with active ulcerative colitis over 10 years need to be concerned about this cancer risk and should be screened with periodic colonoscopy. Biopsies at the time of colonoscopy are screened for cancer and dysplasia. Dysplasia in such biopsies, a microscopic diagnosis of abnormal cells, is a strong predictor of increasing cancer risk and is often an indication to have the rectum and colon removed before a cancer can develop or get out of control.
Crohn’s Disease and Indeterminate Colitis
Ulcerative colitis is one kind of inflammatory bowel disorder. The
other kind is Crohn’s disease. Ulcerative colitis involves
the colon and rectum and never affects the small bowel, stomach,
esophagus, or other parts of the gastrointestinal tract. This distinguishes
it from Crohn’s disease where all parts of the gastrointestinal
tract from the mouth to the anus might be affected, and where the
disease usually involves the full thickness of the bowel wall not
just the mucosa. The pattern of the disease, areas of intense involvement
side by side with completely uninvolved areas (skip pattern), and
the microscopic appearance of bowel biopsies are the most useful
studies to distinguish Crohn’s disease from ulcerative colitis.
This is very important because patients with ulcerative colitis
are candidates for IPAA operations while those with Crohn’s
disease are generally NOT offered IPAA. In Crohn’s patients,
healing tends to be slow and may not be complete. Intestinal pouches
in Crohn’s patients tend to break down and leak, and tend to
develop fistulas or connections from the pouch to other bowel, to
the skin, or to other organs like the bladder or vagina.
Unfortunately, in some patients Crohn’s disease of the colon cannot be reliably distinguished from ulcerative colitis. These patients are given the diagnosis of “indeterminate colitis”. Since 90 % of these patients actually have ulcerative colitis, we usually offer otherwise suitable patients who need to have the colon and rectum removed, a pouch operation. Most will do well. About 50 % of Crohn’s patients who receive a pouch will have to have it removed, usually because of early or late complications that prevent full healing.
Familial Polyposis (also known as Adenomatous
Polyposis Coli - APC)
Familial polyposis is a genetic disorder that is either inherited
or, occasionally, occurs because of a new genetic mutation. The
effect of this disorder is that patients who may be male or female,
develop polyps or growth in the colon and rectum that eventually,
untreated, will inevitably result in the development of cancer.
These polyps can develop as early as late childhood. Patients with
such polyps may have normal bowel function and be without symptoms,
or may have occasional bleeding into the stool. Cancers that develop
in patients with untreated familial polyposis do so on average by
age 35 and can be very aggressive, often proving incurable by the
time they cause symptoms and are discovered. With this risk, patients
with familial polyposis are usually advised to have the organs at
risk, the colon and rectum, removed. Ileal pouch reconstruction
is often offered to avoid a permanent ileostomy. Unfortunately,
patients with familial polyposis are at risk for other disorders
also. They may also develop polyps in the upper part of the gastrointestinal
tract that, if present, often require surgical treatment. They are
also prone (5 - 15 %) to develop tumors called desmoids after bowel
surgery that, when present, often develop in the abdominal wall
or mesentery of the small bowel surrounding the blood vessels that
nourish the bowel. These tumors can be, depending on their location,
a very difficult management problem. After removal of the colon
and rectum (termed total proctocolectomy), patients with familial
polyposis need to be followed in the long term for these problems
with serial endoscopic exams of the stomach and first part of the
small bowel, and careful physical examination. Once detected, closely
related family members of a patient with familial polyposis should
also be evaluated for the genetic abnormality.
Surgical Therapy
Surgical treatment for UC and APC has two goals. The first is to
remove the diseased organs, the colon and rectum. The second is
to reconstruct the gastrointestinal tract in the most functional
form, taking into account what is best for an individual. For most
patients, this means replacing the rectum with a intestinal pouch
placed into the pelvis and emptying through the anus with the muscles
of the anus acting as the valve mechanism. For some patients with
poor anal muscle function, age over 60, poor general heath, or insufficient
intestinal length, it may require a permanent ileostomy. While both
goals may be accomplished during a single operation, some patients
require two and occasionally, three planned operations to safely
accomplish both goals (see below). Each option for surgery has benefits
and risks. The best option for an individual patient is that one
that minimizes risk while giving that patient the best chance for
a healthy life after surgery.
Indications for Surgery
The three indications for surgery are:
1. ulcerative colitis
- not controlled by medical treatment
- controlled with medical therapy, but unacceptable complications or side-effects have developed from the medications
- with bleeding, recurrent hospitalizations, or a life-threatening risk of perforation
- with associated dysplasia or cancer
2. indeterminate colitis (usually ulcerative colitis, see above)
3. familial polyposis
Patients considered for surgery must also be fit enough to tolerate the stress of a general anesthetic and a major surgical procedure, and after all that to still be able to heal! This is an important consideration in patients who are very severely ill from ulcerative colitis or who have suffered severe side-effects from drug therapy such as Prednisone and Imuran which, while effective at controlling the disease in some patients, also increase the risk of poor healing and surgical complications including infection, pouch leakage, and disruption of the abdominal wound.
Options for Surgery
Options for surgery are:
1. removal of rectum and colon and immediate IPAA reconstruction without ileostomy, with or without mucosectomy (One Stage - IPAA)
2. removal of rectum and colon and immediate IPAA reconstruction with a temporary ileostomy, with or without mucosectomy, followed by later closure of the ileostomy at a second operation (Two Stage - IPAA)
3. removal of rectum and colon with permanent ileostomy (One Stage - Permanent Ileostomy)
4. removal of colon leaving the rectum with temporary ileostomy, later removal of the rectum and IPAA with or without mucosectomy, possibly followed by another temporary ileostomy (Two or Three Stage - IPAA)
Factors that determine which of these is best for an individual patient include:
- patient age, weight, sex, and general health
- type of disease: ulcerative colitis vs. familial polyposis
- type, duration, and side-effects of medications
- patient continency (ability to control bowels)
- prior abdominal and especially, bowel surgery
- nutritional status
- technical factors during the actual operation, anastomoses, and integrity of the tissues
(Usual values of these factors that suggest one or another option)
| Option | Age (yrs) |
General Health | Long-term steroids | Continency | Abd Surgery | Nutritional Status | Technical Problems |
| 1 | <60 | Good | No | Good | Minimal | Good | None |
| 2 | <60 | Fair | Possibly | Good | Minimal | Fair | Possible |
| 3 | >60 | Fair to poor | Possibly | Poor | Common | Poor to fair | Possible |
| 4 | <60 | Poor | Often | Good | Minimal | Poor to fiar | Possible |
Option 1: One Stage - IPAA
The one stage IPAA treatment is reserved for patients aged less
than 60 with good continency, good general health, and no long-term
steroid treatment, in whom the technical steps of the operation
go well. Most patients with familial polyposis and well controlled,
stable ulcerative colitis should be considered for a one stage procedure.
With rare exceptions, these are all elective operations rather than
emergency operations. Patients having a one stage operation complete
the entire procedure of proctocolectomy and pouch reconstruction
during a single operation. The obvious advantage of doing the entire
operation in one stage is that when everything heals well, patients
do not need further surgery. However, there are several disadvantages.
First, right after surgery, many patients have some incontinence
due to stretching of the anal sphincter during the surgery. Add
to that the caustic nature of the stool that must be evacuated from
the pouch on average 12-15 times a day initially (until the pouch
stretches and adapts to absorb more) and you can understand that
many patients develop, predictably, a sore and tender bottom like
a diaper rash. The other disadvantage of Option 1, the one stage
procedure, is that the pouch must work immediately. If there is
a leak or other technical problem, patients can get peritonitis,
very ill, and require emergency surgery to drain the pouch and create
a diverting ileostomy. Although this is a rare problem, ileostomies
created under these circumstances must be kept for months while
the abdomen heals. The resulting scarring from healing of the leak
may also weaken or constrict the pouch so that long-term function
is compromised, may lead to an increased risk of bowel obstruction
over time, and may also lead to infertility women of child-bearing
age, due to scarring of the fallopian tubes. For these reasons,
if there is any significant question about the patient’s capability
to heal, about the strength of the tissues or the integrity of the
pouch, a temporary diverting ileostomy may be the safest course.
Often, the decision to omit an ileostomy is one that can only be
made during the last hour of the operation.
Option 2: Two Stage - IPAA
The two stage IPAA procedure, pouch and temporary DIVERTING ileostomy,
is generally offered to patients with poor nutrition or long-term
steroid use where their illness, nutrition status, or medications
pose a risk for good wound healing. Often patients are considered
for a two stage procedure because the activity of their disease
increases the risk of complications from pouch leak or failure.
An ileostomy diverts the bowel contents away from the pouch allowing
it to heal, making any leak a much more manageable problem. Ileostomies
in IPAA patients are often constructed from a loop of bowel and
may not have much projection above the skin because the pelvic attachment
of the pouch restricts some of the bowel mobility on the abdominal
wall. Once healing of the pouch and the pouch-anal anastomosis has
been proven by X-ray studies, the temporary ileostomy is closed
in a 1-2 hour operation and rather brief, 3-4 day hospital stay.
Option 3: One Stage - Permanent Ileostomy
Patients over the age of 60, those with significant anal incontinence
or poor anal sphincter function, and those with other medical problems
that would restrict their ability to heal well and develop a functional
pelvic pouch should consider a permanent ileostomy. This is the
simplest of the options provided above with the least difficult
recovery in general. However it does commit the patient to a permanent
stoma. In general, once the anal sphincter mechanism has been removed,
there is no option to consider later pelvic pouch creation since
the valve mechanism has been removed.
Option 4: Two or Three Stage - IPAA
Patients, usually only those suffering with ulcerative colitis,
who are severely ill from their disease are often considered for
a two or three stage procedure. Malnutrition, severe colonic bleeding
and anemia, high dose steroids, multiple or prolonged hospital stays
for colitis are the usual reasons to consider this option. The goal
of the first stage operation is to remove the majority of the disease,
removing the colon and leaving the closed off rectum in place while
creating a temporary ileostomy. With the majority of the diseased
bowel removed and the rectum no longer functioning to passage stool,
the patient’s disease is usually much easier to control. Medications
including steroids can be tapered down and often stopped completely,
though over a gradual process. Bleeding from colitis is stopped
and the patient’s nutrition can be improved because they can
again eat without bleeding and activating the colitis. Once the
patient has healed up and regained his or her health, usually off
any steroids (except occasional use of steroid enemas to control
rectal disease), the second stage of surgery is to remove the rectum
and create a ileal pouch as previously described, placing this into
the pelvis. Depending on how this operation goes and how well the
patient has healed, another diverting ileostomy may be created to
allow the pouch to heal. Alternatively, if appropriate, no ileostomy
is made and the pouch is allowed to start functioning. The same
advantages and disadvantages discussed in Options 1 and 2 pertain
to forming or avoiding a temporary ileostomy in these patients.
Preoperative Preparation
Preoperative preparation differs for the different patient groups.
1. Medications.
In patients on steroid medications such as Prednisone, attempts
at reducing the dose of prednisone may help reduce the risks of
surgery, but should not be reduced so far that the patient becomes
more acutely ill with malnutrition, bleeding, profuse diarrhea,
and a more severely inflamed bowel. Under these conditions, the
patient’s condition is actually a greater risk than a higher
dose of prednisone for surgical complications. If they have been
on prednisone prior to surgery, it is very important for patients
to continue taking some prednisone (even if the dose is lower) since
suddenly stopping this drug may lead to life-threatening complications.
Imuran should be stopped at least 1 week before surgery to prevent
problems with wound healing. Management of other medications will
be handled on an individual basis. In general, patients on medications
for hypertension and diabetes should continue taking these right
up to the time of surgery, and will be advised by the surgical team
or presurgical clinic about any modifications for the day of surgery.
2. Endoscopy.
All should have had a colonoscopy within 6 months to reduce
the risk of an unsuspected cancer in the colon or rectum. Familial
polyposis patients should undergo upper endoscopy to screen for
stomach or duodenal adenomas as previously discussed.
3. Preoperative Studies.
In some patients, measurement of the anal sphincter pressure using
anorectal manometry may be of value in predicting postoperative
continency. This will be decided during the preoperative evaluation.
Chest X-ray, cardiogram, and blood tests help us during the management
of an anesthetic and avoid the risk of clotting problems that might
lead to unexpected surgical bleeding. In anemic patients, we prepare
blood for possible transfusion during or after an operation, though
significant blood loss (over 500 cc’s) is rare with these operations.
Patients who wish to avoid transfusion under any circumstance should
indicate this at the time of signing the surgical consent form.
4. Consultations.
Often, patients are evaluated by our Medical Consultation team,
a team of physicians who assist the surgical services with the management
of complex medical conditions such as diabetes, hypertension, heart
and lung diseases, during the surgical treatment and recovery periods.
All patients will also be evaluated and counseled by the Preanesthesia
clinic, Those who are likely to require an ileostomy will also see
Wendy Valentine or Diane Britt, nurse enterostomal therapists who
will provide further information and help with stoma management.
5. Bowel preparation.
Just prior to surgery, all patients will be asked to complete a
mechanical bowel preparation, a cathartic such as Fleet’s phosphosoda
or Colyte, and to take some oral antibiotics. Written instructions
for these are provided in the clinic. These two steps are extremely
important since the quality of the prepared bowel is a critical
determinant of complications after surgery. The more stool and fluid
left in the colon and rectum, the more likely the patient will be
to have infectious complications, and the more likely the patient
is to end up with a temporary ileostomy due to spillage or other
intraoperative difficulties. After midnight on the day before surgery,
nothing should be taken by mouth, other than selected medications
with a sip of water.
6. Informed consent.
By reading this document and discussing the management of the bowel
problems under consideration, we hope that you will become better
informed about the complications and potential outcomes of this
type of surgery. It is very important that the patient understand
what the surgical plan is, how it may change, and what potential
complications can be anticipated. Not all complications can be avoided,
however our job is to detect them as soon as possible and to take
corrective measures quickly to minimize the risk of further difficulties.
7. Arrival on the day of surgery.
Most patients having one of these operation, unless acutely ill
from severe colitis, will be arriving at the hospital on the day
of surgery. All work-up and preparation for the surgery is commonly
done prior to the day of surgery. The schedule for the surgery day
is not determined until the evening before surgery, due to the importance
of looking at the entire schedule and order of operations so that
critical personnel and equipment are available for the operation.
The Presurgery Clinic will call you before your operation to confirm
the time of arrival. Unfortunately, unforeseen delays, longer operations,
and emergencies may change the schedule even on the day of surgery.
We try to minimize these delays but some are inevitable. In the
event of a delay, we will advise you and your family as soon as
possible and keep you informed.
Technical Aspects of Surgery
Technical stages of the operation depend on which option (discussed
above) is being followed. The following description deals with the
basic parts of the operation. On average, such operations take 4
- 7 hours to complete, depending on the exact procedure and the
nature of the patient.
A. Resident and Student participation in your care
The University of Washington is a teaching institution with nurses, medical students, and resident or trainee surgeons all acting as critical members of the team. However, your surgeon has responsibility for all aspects of your care, and all significant decisions about that care will be made by you and your family with the attending surgeon. In the operating room as on the ward, the attending surgeon conducts the operation that you and he or she have discussed, but every operation is assisted by several nurses, at least one medical student, and at least one resident surgeon. Having a team caring for you means that many members of the team are constantly reviewing your status and helping you and the attending keep fully aware of all vital sign and laboratory results that bear on your status and recovery. This is to everyone’s, especially the patient’s, advantage! It also helps train the next generation of physicians in as realistic a setting as possible.
B. Anesthesia and preparation
The anesthetic is administered in the operating room (OR). However, many patients receive a mild sedative prior to entering the OR. Some patients are candidates for an epidural anesthetic, a tube placed beside the spinal roots that carry pain signals. This is a very safe and commonly used adjunct to drugs administered by vein for anesthesia. When placed successfully, epidural catheters are useful for anesthetic management during the operation, and in 9 out of 10 patients, work well for postoperative pain control.
Once in the OR, monitors are connected and the patient is put off to sleep. A variety of medications are used for the anesthetic. As necessary, details of this management will be discussed with each patient during the preanesthesia visit, and immediately prior to surgery. Once asleep, a ventilator breathes for the patient. Many patients will have a tube inserted through the nose into the stomach, and all will have a catheter inserted into the bladder to monitor urine flow. This urinary catheter is generally left in place for 4-5 days, or until the epidural catheter is removed. Additional IV’s are also inserted on occasion depending on the judgement of the anesthesia team.
Depending on the plans for the surgery, the patient may be positioned lying flat and carefully padded and secured, or the legs may be placed into secure holders that allow the surgical team access to the bottom for removal of the rectum and attachment of the pouch inside the anus. A heating blanket is also used to maintain the patient’s temperature in the normal range during the operation, since this seems to be important for minimizing postoperative complications, including infections.
C. Incision
For most patients, the abdominal incision is down the midline of the abdomen, extending from the pubic bone below to above the belly button above. How far above the belly button this incision is extended depends on the mobility of the colon and small bowel that must be manipulated.
D. Colectomy (removal of the colon)
Removal of the colon is accomplished by dividing attachments of the right and left colon to the lateral walls of the abdominal cavity, dividing any adhesions (scars) to other organs such as the liver, gallbladder, or small bowel, dividing the attachment of the omentum to the colon (a sheet of fatty tissue that extends from the stomach to the colon), and finally dividing the blood vessels to the colon. These are tied with surgical suture or controlled with clips. In patients who are gravely ill with a very inflamed colon, the bowel may be paper thin and very fragile, so great care is taken to minimize the risk of a tear in the bowel that might lead to spillage of bowel contents inside the abdomen. Often, surgical stapling devices are used for parts of this procedure.
E. Proctectomy (removal of the rectum)
Removal of the rectum requires special care. The tubes carrying the urine from the kidneys to the bladder, the ureters, are identified and protected. In the male, the nerves that support potency, normal erectile function of the penis, are protected. The blood vessels of the rectum are progressively dissected from the upper rectum to the lower rectum, controlling the vessels with sutures or clips. Special retractors are necessary to allow surgery in the deep pelvis. Part of the procedure may be done from below, through the anus. When this maneuver is carried out as part of Options 1, 2, or 4, the purpose is to strip the mucosa or inner lining of the bowel off the very last part of the rectum (termed a mucosectomy) leaving the muscles of the rectal wall. This is done to help preserve sensation in the pouch that is brought in to replace the rectum but this same function is present in the muscles of the pelvic floor that remain, even if the entire rectum is removed. Recently, mucosectomy has been less commonly used to minimize the risk of incontinence with stretching of the anal muscles. When proctectomy is carried out as part of Option 3, the anal muscles are also removed and the wound where they used to be is sewn closed to heal.
F. J pouch (pouch to replace the rectum)
The most common pouch, the J pouch described previously, is usually constructed using a special surgical stapler. This device lays down four rows of staples and cuts between the middle two. The staples secure the two loops of bowel together, and the cut makes the two lumens into one big cavity, forming the pouch. The J is measured at 15 cm or 6 inches. Another stapler is commonly used to attach the pouch just inside the anus, though this anastomosis may also be sewn by hand.
G. Ileostomy (creation of a stoma)
In patients who require an ileostomy because of weak tissues, a poor bowel preparation, an incomplete staple line, or those having Option 3 (permanent ileostomy, see page 5 above), either the end of the bowel or a loop of small bowel is brought through a small hole made in the abdominal wall, usually in the right lower abdomen. The bowel is then secured to internally and externally with sutures. A stoma appliance, a plastic bag with a special adhesive rim, is then affixed to the skin around the stoma and the stoma is allowed to heal. Many different sizes and styles of appliance are available to allow the best fit to be made. Some are one piece, others come in two pieces, bag and skin adhesive patch. The enterostomal therapists will work with each patient who requires a stoma make sure that they understand how to fit, change, and manage their appliance. Some fine tuning may be required at first, and as the stoma heals and swelling recedes, a smaller size or shape may be necessary. Remember, like all other aspects of the healing process, patients with stomas must learn how they work and must be patient during the inevitable early frustrations of living with a stoma. Eventually, they become part of you, incorporated into your life and lifestyle.
H. Closure of the incision
Prior to abdominal closure, one or two drains may be placed into the pelvis, depending on the requirements of the procedure. These will usually be brought out through small stab incisions in the lower abdomen and secured with a suture. The incision is then closed in several layers. An inner layer closes the fascia or strength layer of the abdomen. Skins staples are usually used to close the skin layer and the incision is covered with a dressing that is left in place usually for three days.
I. Postoperative recovery and length of stay (LOS)
Patients should be able to cough, deep breath, move around in bed and, within 24 hours, get out of bed to sit up. We ask them to try to walk in the hall by the second day postoperatively. Most patients are in the hospital for 5 - 8 days, depending on age, extent of operation, and pace of recovery. To leave the hospital, patients must be able to care for themselves, be walking and dressing themselves, be eating adequately and having bowel function. They must have adequate pain relief with oral pain medications and have no evidence of infection, bleeding, or any other complications of the operation. Patient who have had an epidural catheter for pain management (see below) often have difficulty with urination until the epidural is stopped. Indeed, surgical manipulation in the pelvis is, even without the epidural catheter, may cause difficulty with urination for 4 - 7 days. For this reason, we leave the urinary catheter in at least 4 days or longer if the epidural catheter is still being used for pain.
J. pain management
Postoperatively, patients who received an epidural catheter may use this for pain. Sometimes, this is not feasible or does not work, in which case most patients will use a PCA (patient controlled analgesia) pump to give themselves small shots of pain medication when they are uncomfortable. This provides better control of the pain than waiting for the nurse or other care giver to administer pain medications. It is not uncommon for the pain management to require some adjustment. They may still have some discomfort or pain, but the level of this pain should not prevent breathing exercises and getting out of bed. Conversely, excessive pain medication may slow breathing and put the patient at risk of aspiration, or make the patient so sleepy that they are unable to assist with their recovery. We will do everything we can to identify those with too little or too much pain medication and change the dose, route, or drug to gain better control of postoperative discomfort. Prior to discharge, patients will be changed to an oral pain medication, usually oxycodone or Percocet (a mixture of oxycodone and Tylenol). Patients with allergies to these drugs or intolerance due to nausea may be given Vicodin or another replacement. Stool softeners are rarely necessary in patients having this operation due to the absence of the colon.
Recovery
Early Recovery
Patients with an ileostomy my expect to empty the pouch 4 or 5 times
a day, depending on diet and fluids consumed. They may suffer burns
to the skin around the stoma due to leak or poor appliance fit.
This eventually gets better as the patient learns how to manage
the pouch and the ileostomy function stabilizes.
Patients who had ulcerative colitis as the indication for surgery often feel immediately better after surgery. They have had a source of chronic illness and inflammation removed, and feel an immediately improvement. Their bowel function is often poor with frequent bloody bowel movements and the recovery after surgery is a definite improvement. Patients who have the surgery for familial polyposis often have few symptoms prior to surgery, and the recovery may be harder since they approach it from a different perspective.
The function of any of the ileal pouches is good, but for most patients it will never replace or function as well as a normally functioning rectum. Over time however, it usually gets progressively better and for most patients is a better alternative than a permanent end ileostomy.
Continency, or the ability to control bowel function is good but not perfect after formation of an ileal pouch. Most patients are continent during the day but may have minor incontinence during the night, requiring use of a pad. Continency improves over time as the sphincter muscles heal from surgery and strengthen, and as the consistency of the BM’s gets less liquid. Both before and certainly after surgery, patients are urged to do Kegel exercises, muscle strengthening exercises to tighten the anal sphincter muscle. Squeezing down and holding the squeeze for 15 to 20 seconds 10 to 30 times a day works the muscle and over time, will also increase its strength.
Patients with a functioning J pouch can initially expect 12 - 15 BM per day INITIALLY. These will be loose, watery, and may be caustic on the skin around the anus. Many patients find that use of zinc oxide ointment or bag balm to the skin around the anus helps protect it. Most patients initially use dietary modification, antidiarrheal agents, and supplementary dietary fiber to help control their stool frequency. Some experimentation is necessary but as healing and adaptation of the pouch progress, the diet can often be liberalized, antidiarrheal agents tapered, and the use of fiber reduced.
Dietary Modification. Patients should start off with a rather bland diet after surgery. Avoid things that caused diarrhea before the surgery. Liquids should be consumed separately from solids, rather than washing down a meal with a large volume of liquid. In patients with frequent loose stools or a high ileostomy output, dehydration and salt losses may become significant. In these situations, patients should drink juice or salt containing liquids, like GatoradeTM or PowerburstTM. Increasing fatigue, dizziness, thirst, or low blood pressure may be signs of dehydration and should be evaluated in the clinic or emergency room urgently. Often , a quick IV and modification of medications is all that is necessary. Occasionally, patients must be readmitted for several days of IV’s and further treatment.
Antidiarrheal Agents.
Most patients with a functioning J pouch start off on antidiarrheal
agents, most commonly Imodium. This is available as a prescription
or over the counter, but the former is cheaper. One or two tablets,
or one or two teaspoons of the Imodium elixir BEFORE meals and BEFORE
bedtime often slow bowel transit, improving absorption and reducing
stool volume and frequency. After several months, many patients
taper this medication off, or only use it episodically. Since patients
with a J pouch are always more prone to diarrhea (for example, with
a cold) due to the loss of the colon, having some around is often
a good idea especially on trips and special occasions. For patients
intolerant of Imodium or not sufficiently controlled by it, we may
try stronger medications such as Paregoric or Tincture of Opium,
but these latter medications may have side effects and are used
for only the occasional patient.
Dietary Fiber.
For some patients, increased fiber in the diet firms up the stool
and makes it easier to evacuate. For others, it increases volume.
Those who will benefit from it are hard to distinguish from those
who do not. Thus, we often try some fiber such as Metamucil or Fibercon,
to see if it will help. Addition of fiber should be done when no
other changes in medications or diet are going on, so that the effect
of the fiber is clearly distinguishable from the effects of the
other treatment changes.
Activity and Weight Restriction, Work
Recovery from surgery also requires healing of the abdominal incision.
Patients are asked to refrain from heavy lifting (<15 lb. max)
or vigorous physical activity for 6 weeks. Those receiving steroids
prior to surgery are asked to be cautious for 8 - 10 weeks, to avoid
hernia formation from wound disruption. Most patients are off narcotic
pain medication by 3 weeks and most are able to return to work after
4-6 weeks, assuming their recovery has been otherwise uncomplicated.
Driving is not allowed until the patient is off all narcotic pain
medications.
Late Recovery
Eventually, stool frequency subsides to 6 - 8 BM in a 24 hour period,
averaging 1 every other night but this may take up to a year to
occur. Some patients have a higher rate, some average only 2 - 3
per day. Younger patients seem to have better adaptive capabilities.
Some adaptation has even been documented to occur after 1 year.
Clinical Follow-Up
Patients are asked to return at 1 week and 1 month after completion
of the J pouch, with additional appointments to the clinic as necessary
and convenient. Many patients traveling to Seattle from a distance
achieve follow-up with their referring local physicians. After the
initial follow-up period, patients usually return at 3, 6, and 12
months to make sure that they are doing well, progressing as expected,
and modifying medications appropriately. Yearly follow-up thereafter
is appropriate. In selected patients, sigmoidoscopic evaluation
of the pouch is added to the routine digital anal examination for
stricture formation and pouch healing.
Complications of Surgery—Early
Cardiopulmonary
In any operation, there are some risks associated with the heart and lungs related to the anesthesia. The anesthesia is extremely carefully managed and such complications are rare but when they occur, can be life-threatening. Aspiration pneumonia, cardiac arrhythmia, or myocardial infarction all fall in this category. Older patients are at greater risk for these complications. Patient unable to perform lung exercises in the postoperative period are at risk for postoperative pneumonia, because of uncleared secretions.
Deep venous thrombosis and Pulmonary Embolism
All patients are at risk for developing clots in their legs during a long operation. Those with a prior history for deep vein thrombosis and especially those who have had pulmonary emboli (clots breaking off from the legs going to the lungs) are very high risk. For average risk patients, we place pressure stockings on the legs and squeeze the calves and thighs to promote blood flow during the operation. Unusual calf swelling or pain, mysterious fever, or shortness of breath in the postoperative period, may be signs of a deep vein thrombosis or pulmonary embolus. For high risk patients, blood thinners are often used before and after the operation to minimize risks of recurrence.
Infection
The nature of this surgery requires that the bowel be opened. Despite optimal bowel preparation, oral and IV antibiotics that are routinely administered, contamination from the open bowel still increases the risk of infection somewhat. Infections occur in the wound most often, but can also occur in the abdomen and pelvis. In the pelvis, often the first concern is for a leak from a functioning J pouch. The management of the infection includes identifying the extent of the problem either by CT or by reoperation, diverting the bowel with a stoma when the infection is associated with an anastomotic or staple line leak, and draining the infection with surgical or radiologically placed drains. All patients also receive antibiotic drugs. Infections can also occur in the urinary tract with the catheters that are placed during surgery, and in the lung (pneumonia).
Bleeding
Bleeding during or after surgery is rare in these operations, unless the patient has a disorder of coagulation that prevents normal clot formation. However, every postoperative patient is closely monitored for signs of bleeding in the first 24 to 48 hours after surgery. Bleeding that was detected very early might require reoperation. Others will require observation and replacement of the lost blood with transfusion.
Anastomotic leak
In patient who undergo surgery according to Option 1 (page 5) or an interval closure of an ileostomy, leakage of the pouch is a possibility. The incidence of this complication is about 3 - 5 %. It is more common in brand new pouches, rather than those protected and allowed to heal with an ileostomy. When it occurs, anastomotic leak usually becomes evident within 2 - 5 days of surgery and is marked by abdominal and/or pelvic pain, fever, rapid heart rate, and laboratory changes indicating new onset infection or inflammation. In some patients, the pattern is so unmistakably clear that immediate operation - to divert the bowel and drain the infection - is indicated. In others, a more subtle presentation may require CT scan or contrast study of the pouch to identify the area of the leak. Following treatment of the leak and recovery, patients often are asked to wait for 3 to 6 months before further surgery to close the stoma. Prior to any such surgery, extensive studies are necessary to make sure the leak has healed. Unfortunately, such leaks may compromise pouch function so that it never works as well, and may lead to infertility in some female patients due to scarring of the fallopian tubes.
Early small bowel obstruction
Patients who regain bowel function then have the sudden onset of nausea, vomiting, abdominal distension, and decreased bowel function, may be developing an early bowel obstruction. It may be difficult to distinguish this from a postoperative ileus (paralysis of the bowel), hence studies of the bowel with CT and barium are often undertaken. All patients with ileus and most with a postoperative bowel obstruction will resolve with bowel rest, occasionally another NG tube, IV fluids, and time. Some patients will require surgery to repair an early obstruction.
Complications of Surgery—Late
Pouchitis
Pouchitis is a condition of inflammation in the pouch that mimics ulcerative colitis, and seems to occur more often in patients with a history of severe ulcerative colitis. Symptoms of pouchitis are a sudden increase in the frequency of bowel movements, small frequent stools often with blood, pelvic pain, urgency, incontinence, and fever. The incidence in patients undergoing pouch surgery is 20 - 40 %. Some patients have a single bout, others have recurrent bouts. Stricture or narrowing of the pouch anal anastomosis may predispose to this problem. Treatment includes evaluation and treatment of pouch-anal strictures with an endoscopic exam of the pouch, followed by a course of metronidazole (Flagyl), an antibiotic. Some patients need additional antibiotic treatment such as ciprofloxacin (Cipro) and very rarely, inpatient aggressive treatment becomes necessary. Few require full bowel rest and steroid enemas. In patients with recurrent bouts of pouchitis, a supply of Flagyl is kept on hand at home or on trips, to be used at the first sign of recurrent disease. Rarely, patients have such a severe pattern of pouchitis, unresponsive to all treatment, that the pouch must be removed. The incidence of this is 1 %.
Pouch-anal anastomotic stricture formation
Pouch-anal anastomotic stricture is a narrowing of the anastomosis between the pouch and the inside of the anus. Such narrowing may predispose to pouchitis, and may make it difficult to evacuate the pouch completely, leading to incontinence. Reasons for stricture formation include a small leak at the anastomosis, poor blood flow to the anastomosis, or may be due to genetic characteristics that lead an individual patient to heal in that fashion. Some of the worst strictures, especially those that are recurrent or very dense, may be associated with Crohn’s disease, mistaken for ulcerative colitis.
Treatment for patients with an anastomotic stricture includes dilation (may need to be done in the operating room under anesthesia), inspection of the pouch, and then use by the patient of an anal dilator twice a day for 3 - 6 months until the scarring process has stabilized, to prevent recurrent strictures. The incidence of this complication is 5 - 10 %.
Small bowel obstruction
Due to the removal of the colon, all of the surgical options described above are associated with a 16 % lifetime risk of small bowel obstruction. Symptoms of bowel obstruction have been described above, but include nausea, vomiting, abdominal distension (variable), crampy abdominal pain, and decreased bowel function (gas and stool). Patient with these symptoms should seek medical attention quickly. In many cases, early aggressive treatment with IV’s, resting the bowel by stopping all eating and drinking, and use of a nasogastric tube (tube from nose to stomach) to suck out the stomach contents, is associated with a 50 % success rate in resolving the obstruction. The other 50 % will generally require surgery to repair the obstruction. Recurrent obstruction can occur unfortunately.
Hernia formation
In some patients, especially those requiring multiple operations or on high doses of steroid medication at the time of their first operation, thinning and tearing of the abdominal wall may occur leading to a hernia. This can present up to years after the operation as a lump or mass or sore area, especially after vigorous physical activity. Usually, the lump pushes out when the patient strains or stands, and returns to the abdomen when the patient relaxes and lies down. Such hernias occur under the midline or ileostomy (if present) wounds. Such wound hernias are rare, under 5 %, but when they occur, they often require another operation to correct the problem. Laparoscopic techniques may reduce the recovery time after surgery for such hernias.
University of Washington Experience
Surgeons at the University of Washington Medical Center, Harborview
Medical Center, and the Seattle Veterans Administration Hospital
currently perform this operation. Collectively, our experience is
in excess of 250 patients with J pouches with the majority done
at the UWMC campus. Over 90 % of patients who initially received
a pouch have retained it. No patient has died from complications
of the procedure and our complication rate is similar to other national
programs reporting experience with thousands of patients over the
past 5 years (i.e. Mayo Clinic, Cleveland Clinic). Our experience
in terms of continency, frequency of BM’s, and recovery are
as provided in the discussions above. When asked, over 90 % of those
offered a J pouch continue to prefer the pouch to a permanent stoma.
For that small group who suffered with chronic incontinence or uncontrolled
pouchitis after receiving a pouch, conversion to an ileostomy has
restored a good quality of life.
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