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Restorative
https://t.me/med1917
Proctocolectomy–Technical
Challenges of the Ileal Pouch-Anal
Procedure for Ulcerative Colitis
and Familial Adenomatous Polyposis
Peter Sagar
Abstract
Following the introduction of the operation of proctocolectomy with the use
of an ileal pouch to function as a reservoir, restorative proctocolectomy with
ileal pouch-anal anastomosis (IPAA) has been considered by most patients and
surgeons to be the ideal surgical procedure for the majority of patients with
chronic ulcerative colitis and familial adenomatous polyposis (FAP). The operation offers a good quality of life in many patients and, when successful, avoids
the need for a permanent ileostomy with the associated psychological, physical
and social problems associated with a permanent stoma. However, whilst most
patients obtain a good functional result there remains a significant morbidity
associated with the operation and the future potential for recurrent symptoms
from conditions such as pouchitis (1).
13
Keywords
Restorative proctocolectomy•Ileal pouch-anal anastomosis•Ulcerative
•
colitis
challenges
Long-term outcomes
Key Points
•
Restorative proctocolectomy with an ileal pouch has become the mainstay of
treatment for patients with ulcerative colitis and familial adenomatous polyposis
who wish to avoid a permanent ileostomy.
P. Sa ga r (B)
St James’s University Hospital, Leeds, UK
e-mail: petersagar@aol.com
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2024
M. Evans e t al. (eds.), Coloproctology, https://doi.org/10.1007/978-3-031-59630-8_13
Familial adenomatous polyposis•Surgical technique•Surgical
•
Functional outcomes•Complications•Ileal pouch function
•
327
328 P. Sagar
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•
The stapled J Pouch is the most popular anastomotic technique used; however, it
is advantageous for the pouch surgeon to be competent with mucosal proctectomy
and hand sewn technique.
•
Surgeons should be aware of the potential pitfalls intraoperatively and should be
familiar with procedures for mesenteric lengthening in the event of inadequate
length on the pouch to reach the pelvic floor.
•
Patients should be carefully counselled and monitored for both postoperative and
long-term complications.
13.1 Introduction
Following the introduction of the operation of proctocolectomy with the use of
an ileal pouch to function as a reservoir, restorative proctocolectomy with ileal
pouch-anal anastomosis (IPAA) has been considered by most patients and surgeons to be the ideal surgical procedure for the majority of patients with chronic
ulcerative colitis and familial adenomatous polyposis (FAP). The operation offers
a good quality of life in many patients and, when successful, avoids the need for a
permanent ileostomy with the associated psychological, physical and social problems associated with a permanent stoma. However, whilst most patients obtain a
good functional result there remains a significant morbidity associated with the
operation and the future potential for recurrent symptoms from conditions such as
pouchitis [1].
13.2 Principles of the Operation of IPAA
The operation may be performed as a one, two or three stage procedure. Patients
who present with fulminant colitis and require emergency surgery would typically
undergo a subtotal colectomy with end ileostomy and preservation of the rectum.
The rectum is best left as a long stump with marking non-absorbable sutures at the
apex to facilitate completion proctectomy at the time of the subsequent ileal pouch
procedure. If the rectal stump is left short either close to or below the peritoneal
reflection subsequent attempts at completion proctectomy and ileal pouch may be
compromised by the difficulty of removing the short rectal stump and therefore
prevent the patient having an ileal pouch.
It is helpful to either attach the proximal end of the rectal stump to the lower
midline abdominal wall to facilitate subsequent identification of the rectum or
to bury the proximal end of the rectal stump in the lower end of the abdominal incision/middle of the Pfannenstiel incision as this would also minimise the
consequences of a potential blow out from the rectal stump.
Patients opting for an elective IPAA would likely undergo a proctocolectomy
with ileal pouch either with (two stage procedure) or without a diverting ileostomy
(one stage procedure). Avoidance of a diverting loop ileostomy has the clear advantage of the patient not requiring a subsequent reversal of ileostomy but runs the
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increased risk of significant consequences from pelvic sepsis should there be an
anastomotic leak [2]. Patients who undergo IPAA with a diverting loop ileostomy
not only have the advantage of minimising the potential consequences of an anastomotic leak but also have the potential advantage of being aware of the day-to-day
practicalities of having an ileostomy should they find at some time in the future
that they are struggling with functional issues with the ileal pouch and wish to
have the pouch removed and have a permanent ileostomy.
13.2.1 Choice of Pouch Design
The first description of the design of the ileal pouch by Parks and Nicholls in 1978
involved the use of a three limbed pouch (a so-called S pouch) but issues with
the need to self-intubate this design of pouch lead to the description of initially
a two-limbed design (J pouch) and later a four-limbed design (W pouch) [3].
Although each of these designs of ileal pouch have their merits, the J pouch is by
far the most popular design in use today (Fig. 13.1). Construction of a J pouch is
simple: two or three firings of a linear stapler with inspection of the staple line to
ensure haemostasis. We would typically secure the blind end of the J pouch with
interrupted sutures to the afferent limb to prevent redundancy and would suggest
avoiding under running the staple line as this has been associated with possible
fistulation from the efferent limb of the J pouch.
13.2.2 The Ileal Pouch Anal Anastomosis
The original descriptions of the operation of IPAA stressed the importance of constructing the anastomosis at the dentate line to ensure complete removal of all
the rectal mucosa mainly due to the fear of leaving mucosa in situ with malignant potential. The procedure therefore involved a mucosal proctectomy with the
mucosa being dissected off the rectal muscular cuff from the dentate line proximally (for 5–15 cm) and the ileal pouch being brought through the denuded rectal
muscular cuff and anastomosed with sutures placed through the most dependent
part of the ileal pouch and secured at the dentate line [4]. Whilst this ensured
complete removal of all rectal mucosa it also removed the anal transitional zone of
mucosa, a region that is important in discrimination between flatus and faeces. This
loss of discrimination and compromise to the recto-anal inhibitory reflex adversely
affected faecal control, with nocturnal leakage and daytime seepage being a significant problem. Advances in staple technology led to the widespread adoption of a
double stapled pouch-anal anastomosis which simplified the procedure by avoiding
the need for a mucosal proctectomy, albeit with the potential to place the level of
the anastomosis too high relative to the anal sphincter complex. Not only did this
affect the functional result but by leaving inflamed rectal mucosa behind increase
the risk for subsequent malignant change. (Fig. 13.1 and 13.2).
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Fig.13.1 The classic ileal J
pouch-anal anastomosis
Mucosal proctectomy with hand sewn ileal pouch to dentate line anastomosis
continues to have a role however, in patients with high grade dysplasia or rectal
malignancy on the background of ulcerative colitis as well as in patients with
familial adenomatous polyposis particularly those patients with florid polypoidal
changes.
When performing a mucosal proctectomy with hand sewn IPAA, it is of critically important to ensure the most dependent part of the J pouch will be able to
reach down to the dentate line in order to construct a tension free anastomosis.
(Fig. 13.3) As a rough rule of thumb, checking that the lower part of the J pouch
sits comfortably 6 cm below the level of the symphysis pubis without tension
should allow the pouch to reach the dentate line for a safe and secure anastomosis.
In the event that the most dependent part of the pouch appears unlikely to be able
to reach safely down to the pelvic floor then increased length maybe achieved by
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Fig.13.2 Double stapled
IPAA
ensuring a full mobilisation of the small bowel mesentery to expose the third part
of the duodenum, the use of mesenteric windows and if necessary the division of
the ileocolic artery. Surgeons should be familiar with the technique of constructing
an S pouch as the efferent limb of the S pouch will gave greater chance of reach,
particularly in a tall patient.
Although the specific indications for a hand sewn IPAA mean that the technique
is not frequently performed, surgeons carrying out an IPAA may be faced with
failure of the stapling gun and therefore need to be familiar with and competent at
performing a hand sewn anastomosis. Exposure and assistance are critical, ideally
with both a surgeon at the top end and the surgeon at the perineum making sure
that the ileal pouch is correctly orientated as it is passed from the abdomen down
to the divided anal sphincter complex to prevent inadvertent twist. Both surgeons
should take care in gently encouraging the pouch to reach down to the dentate
line and avoid excessive traction which has the potential to tear the wall of the
pouch. Placement of four long loose sutures at 3, 6, 9 and 12 o’clock full thickness
through the pouch and use of these as stay sutures passed down from the abdomen
through the anus and then fixed in position before completing the anastomosis
helps the process. Perineal exposure is facilitated using either a Lone Star retractor
or Gelpi retractors and a J shaped needle offers improved manoeuvrability within
the narrow confines of the anal canal.
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Fig.13.3 Mucosal
proctectomy with the pouch
pulled through the rectal
muscular cuff after
mucosectomy
13.3 Post Operative Course and Potential Problems
J pouches are typically constructed using two or three firings of a linear stabling
device, but haemostasis is not necessarily guaranteed with such devices. Therefore,
the inside of the pouch should be checked for any bleeding points to allow under
running of these areas. Reactionary haemorrhage in recovery or within the first
few hours demands examination under anaesthesia with flexible endoscopy and
irrigation of the pouch ± injection of adrenaline solution to control the bleeding. If
there has been early disruption of the staple line at the IPAA, the defect may be
repaired with the use of transanal sutures. In the unlikely event that the haemorrhage cannot be controlled via a transanal approach then the pouch can be gently
packed with adrenaline-soaked gauze swabs, otherwise in extreme circumstances
a laparotomy with take down of the ileal pouch± reanastomosis is indicated.
Post operative intra-abdominal bleeding maybe from one of three sites: the
colonic bed (usually an ooze), lateral pelvic side walls or a slipped clip or ligature
from a mesenteric vessel [5]. Bleeding from a presacral vein is usually obvious at
the time of the operation and may be controlled with diathermy with or without the
application of a small piece of rectus muscle burnt on to the site of the bleeding
vein with the resulting eschar sealing the vessel.
Heightened awareness of the common postoperative problems is critical to the
successful outcome after IPAA. Pelvic sepsis is the bete noire of the ileal pouch
operation and a low threshold for a return to theatre with examination under anaesthesia may prevent more serious consequences [6]. Collections around the lower
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pouch may be drained through the anastomosis and close liaison with an experienced radiologist familiar with the potential post operative problems may prevent
subsequent loss of the pouch. Both CT imaging and MR imaging are key along
with radiological guided placement of a drain which may ameliorate subsequent
compromise of pouch function.
Small bowel obstruction is the most common complication after IPAA either
as result of adhesions or internal herniation [7]. The majority of cases settled with
conservative management with intestinal rest, analgesia, nasogastric suction, and
intravenous fluids.
13.3.1 Longer Term Problems
Strictures at the pouch-anal anastomosis are not uncommon with an incidence of
15 to 20% usually occurring because of fibrosis at the pouch-anal anastomosis
particularly if a small circular staple has been used i.e.,<28 mm. Such strictures
typically respond to Hegar’s dilatation and if the patient requires repeated dilatations, then the patient may use a St Marks anal dilator themselves on a regular
basis to prevent the need for repeated examination under anaesthesia [8].
Refractory strictures may respond to division of the structure and a flap
advancement but persistent strictures with dense scarring may require a transanal
dislocation of the pouch at the level of the anastomosis with advancement of the
pouch, excision of the stricture and re anastomosis [9] (Fig. 13.4a, b). Strictures
within the body of the pouch may result from Crohn’s disease but the possibility malignant change should always be recognised. Such strictures require biopsy
specifically to exclude malignancy.
When the suggestion of using staple techniques for the IPAA was first put
forward concerns were raised about the potential development of pouch-vaginal
fistulas. Whilst some pouch-vaginal fistulas may be the result of sepsis with breakdown of the anterior aspect of the IPAA and discharge through the vagina wall
others may arise as a result of the dissection around the lower anterior vagina
inadvertently entering a plane within the vagina wall and therefore predisposing
the patient to the subsequent development of a fistula. The ring of staples at the
IPAA may cause wearing tear on the posterior aspect of the lower vagina and
allow fistulation to develop. The fistula is short and can be difficult to visualise
but the use of a solution of methylene blue to irrigate the pouch with the placement of swabs in the vagina may help to delineate the course of the track. The
track is typically low. Surgical correction of a pouch vagina fistula is difficult and
whilst a mucosal flap advancement, either transanal or transvaginal, is the standard
approach patients should be advised that success is at best 50% [10]. The transvaginal approach allows direct access to the external opening and avoids the risk of
stretching the anal sphincter. A mucocutaneous flap is raised excising the vaginal
end of the fistula and curetting the track whilst closing the anal end of the fistula
with dissolvable sutures. Initial results with collagen plugs were encouraging but
long-term success was not achieved [11].
334 P. Sagar
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Fig.13.4 a and b Pouch advancement for anastomotic stricture
The incidence of pouchitis increases with time after IPAA with 40% of patients
experiencing at least one episode of pouchitis in the first 10 years rising to 70% of
patients within 20 years of surgery. Diagnosis requires a triad of clinical history,
with increased frequency of loose stools, lower abdominal discomfort and malaise,
endoscopic appearances of inflammation and ulceration of the mucosa with exudate and contact bleeding and histological evidence of acute inflammatory infiltrate
with crypt abscesses. Physicians should resist labelling any symptoms of pouch
dysfunction as pouchitis until this triad has been confirmed ideally using the Pouchitis Disease Activity Index as this provides a simple objective and reproducible
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scoring system. Otherwise, a heterogeneous group of patients with potentially
alternative diagnoses are labelled with pouchitis and disappointed when treatment
of the condition fails [12].
Patients with proven pouchitis typically respond to oral antibiotics using either
ciprofloxacin or metronidazole. Five percent of all patients develop recurrent or
persistent pouchitis and may require cyclical treatment with antibiotics. Rifaxamin
may be of use in refractory cases.
13.4 Crohn’s Disease
Histologically, difficulties remain in differentiating between chronic ulcerative colitis and Crohn’s disease and inevitably a small proportion of patients who undergo
an ileal pouch procedure will eventually be diagnosed with Crohn’s disease, not
infrequently with the original histopathological diagnosis being ulcerative colitis
even when reviewed with the benefit of hindsight. Whilst Crohn’s disease has
typically been a contraindication for ileal pouch procedure, patients with disease
limited to the colon and rectum with no evidence of involvement to the small bowel
or anus may be offered an IPAA with appropriate counselling and consent [13].
The advent of the biologicals in the late 1990’s and the subsequent development
of a series of new biologics has revolutionised the management of Crohn’s disease in general and offers therapeutic options for patients with ileal pouches who
ultimately turn out to have Crohn’s disease rather than ulcerative colitis. A late
diagnosis of Crohn’s disease after IPAA does not necessarily require excision of
the pouch and permanent ileostomy, rather, the patient requires joint management
with the Gastroenterologists and consideration of the use of immunosuppressives
and biologics to maintain the pouch in situ with an acceptable functional outcome.
13.5 Conclusion
In summary, restorative proctocolectomy with an ileal pouch has become the
mainstay of treatment for patients with ulcerative colitis and familial adenomatous polyposis who wish to avoid a permanent ileostomy. Patients and surgeons
alike should be aware of the potential pitfalls intraoperatively and the postoperative course of the patient must be monitored carefully with early recognition of
post operative pelvic sepsis with intervention as indicated. Patients also need to be
aware of the potential long-term complications and appreciate the implications of
recurrent episodes of acute pouchitis on symptoms and quality of life.
336 P. Sagar
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proctocolectomy without ileostomy. Dis Colon Rectum. 1997;40(9):1019–22.
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