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216
K.-H. Vestweber
27
started around the 1930s. Nissen and Wagensteen
tried to construct ileoanal anastomoses.
In the second half of the 1940s, it was mainly
who tried to cure ulcerative colitis by colectomy
and transanal mucosectomy [11].
Another essential step in the supply of colectomized patients was reached in the 1950s by the
construction of a prominent ileostomy by Brooke
[12]. is made a major step forward in stoma
care. Aylett at the same time treated a series of
patients successfully by ileorectostomy [13].
e continent ileostomy with a pouch system
was introduced by Kock in the end of the 1960s
[14]. e emptying of the pouch has to be done by
catheterisation with an intestinal tube.
Parks and Nicholls have introduced the ileoanal pouch surgery into clinical practice since
1978 [15]. e relatively simple and well-functioning J-pouch was described by Utsunomiya in
1980 [16]. e J-pouch is currently the most
widely used reconstruction worldwide.
Anal Canal-Sustaining Colectomy
e colectomy with preservation of the anal canal
can be performed in one or more steps.
In patients with poor general condition or
massive immunosuppression or as an emergency
operation, a three-stage procedure might be preferred.
First the subtotal colectomy is performed.
e rectal stump should be le relatively long in
order not to be confronted with scars and problems resulting from previous pelvic dissection.
We usually perform the resection at the sigmarectum junction without going further into pelvic dissection. e staple line of the rectal stump
is usually additionally oversewn by single
absorbable sutures. In very few cases, we create a
mucus stula with the remaining stump in the
le lower abdominal quadrant. e remaining
rectal stump can be treated quite well by transanally applicated local preparations. Aer recovery of the patient, the ileoanal pouch
reconstruction will be performed with a covering loop ileostomy; this can usually be closed
aer 6–12 weeks.
e two-stage operation corresponds with a classical approach. It is the routine procedure for elective
operations. e colectomy is made, the pouch ileoanal reconstruction is performed, and a protective
loop ileostomy is created in the right lower abdominal
quadrant. Aer recovery and denite healing of the
anal anastomosis, the reversal of the stoma follows.
Even a single-stage procedure is possible and
supported by scientic evidence [17]. We use this
approach with the “ideal patient”. e colectomy
should be performed without problems, the anal
conditions are ideal and in particular the ideal
pouch can be sewn without tension into the anal
canal. Additionally, the patient should not be on
immunosuppressive drugs. In such patients, we
use a thick bladder catheter, which is introduced
into the pouch and xed to the buttocks for a few
days. Pouch evacuations are easily possible and
without stress for the patient.
The Pouch Design
Many design options for the ileum pouch have
been described, and even now, new variants are
still presented.
We prefer a variation of the J-pouch with
15 cm length of the edges. e GIA stapler is
introduced from the oral aspect. e peak of the J
will not be touched; a little tissue bridge remains
usually. Maybe because of undisturbed blood supply at the region of the anastomosis, there have
been few complications with the construction.
Additionally there are no crossing staple lines at
the level of the anastomosis. Usually this little
bridge makes no problems, but if so it can be cut
quite easily from transanally by using a stapling
device.
e anastomosis of the pouch can be done in
double stapling technique; some advantages have
been described. Special attention is necessary not
to leave a too long rectal stamp with diseased
colitis mucosa. We prefer especially in patients
with dysplasia in the rectum the transanal mucosectomy of 2cm length. e pouch is xed by stay
sutures in the mucosectomized muscle cu and
the anastomosis created by single stitches using
the exposure by a Lone Star retractor.
Colectomy andDenite Ileostomy
One option aer total colectomy is the creation
of denite ileostomy. e reason for this decision
is oen faecal incontinence preoperatively which
usually worsens aer pouch reconstruction.
Other reasons are previous anal stula and
abscesses; sometimes it is a personal decision of
the patient aer having contacted other patients
with ileostomy or pouch reconstruction. Usually
Surgical Technique and Dicult Situations from Karl-Heinz Vestweber
217
27
. Fig. 27.11 A “classical” ileostomy position in the right
lower abdominal quadrant. Because of problems with
stoma care, a transposition into the very low left abdominal quadrant was necessary
the ileostomy is positioned in the right lower
abdominal quadrant. Meticulous planning of the
ostomy position is essential. Sometime probatory wearing of the ostomy appliance is very
helpful. Most oen the position of the ileostomy
is on a line between the spina iliaca anterior
superior and umbilicus at the medial third of this
connecting line, but sometimes this area is not
suitable.
. Figure 27.11 shows the preparation phase
before changing a stoma which was created in an
unfavourable position. e ileostomy has to be
repositioned in the le lower abdominal quadrant, because the recent stoma cannot be handled. e right-sided position is created just at
the usual place in the right lower quadrant. If the
patient is in a supine position, like the usual
positioning during surgery, the ostomy site
seems to be suitable. If the patient sits, a major
wrinkle interferes with the appliances. e new
position at the le side may be high up in the
upper quadrant or low as marked with the cross
(
. Fig.27.12).
e ileostomy should be everted. e top of the
stoma is best 2–3cm above skin level. e stitch
technique is advisable in a 3-point manner. e
stitch starts at the skin level from inside to outside
and then catches the edge of the bowel, and the
third point xes the bowel wall at the best area to x
the intended eversion height. All nodules aer tying
are inside. e appliances can easily be positioned
and there is no wick eect by the suturing materials.
. Figure27.13a–c shows this technique of cre-
ating an end and loop ileostomy.
. Fig. 27.12 Position of the ileostomy, when the
patient is sitting. The ileostomy is covered by a deep
wrinkle. The marked position in the very low left abdominal quadrant is possible; alternatively a high up position
in the right upper quadrant is also acceptable
a
c
. Fig. 27.13 Sketch of an end and loop ileostomy. a
The xating stitch has three points. It comes intracutaneously from the inner to outer side, next the edge of the
bowel wall and then the seromuscular bowel wall to x
the eversion. b The terminal ileostomy nished, all knots
are inside and cannot be seen. c Loop ileostoma with
underlying plastic tube
b
Pouch Redo Surgery
“Redo” operations aer ileum pouch reconstructions are complex and dicult procedure; the surgical morbidity is high.
e main long-term problems aer pouch
reconstructions are strictures at the pouch-anal
anastomosis or in the anal canal. Usually this ste-
218
K.-H. Vestweber
27
a
c
. Fig. 27.14 a A contrast enema years after colectomy
and J-pouch reconstruction. A dilated large pouch can be
seen without pouch outlet obstruction. b Massive dilatation
in the small bowel above the pouch. c Intraoperative ndings:
d
b
c
A huge “mega-pouch” and massively dilated small bowel.
d Resected specimen of the J-pouch; major reduction in size.
e Situation at the end of operation: Reduced pouch in the
pelvis and operatively reduced small bowel slings
nosis can be dilated easily; oen several dilatations are required before an acceptable diameter
can be achieved. In some cases, it can make sense
to instruct the patients for self-dilatations– best
with one nger. Oen this has an acceptable
eect.
Perioperative abscesses oen result in persisting stulae or new stulae without abscesses
sometimes occur. ose stulae can be treated
following the rules of classic stula surgery.
Revision of the stulae tract and closing with stula plugs or advancement ap techniques are
sometimes suitable. One major procedure for
that is a partial or complete pouch advancement,
sometimes a transanal procedure is possible, and
in few cases, an abdominal operation is necessary. Complex pouch redo procedures are
reported especially from Mayo and Cleveland
Clinic [18– 20].
An example for one of the pouch reoperations is
shown in . Fig.27.14a–d. Several years aer restor-
ative colectomy for ulcerative colitis, the young
female patient complained of bowel motility disturbances and incomplete and fragmented pouch
evacuations. With time the complaints increased
with major abdominal distensions, but no complete
obstruction happened. Further diagnostic (contrast
medium enema) shows a mega- pouch and massive
dilated small bowel above the J-pouch. ere was
no stenosis of the intestine especially not at the
pouch outlet and no pouchitis was present. e
impaired bowel function inuenced the life of the
patient signicantly; therefore, an operative intervention to reduce pouch size was planned.
. Figure 27.14c shows the intra-abdominal
situation aer laparotomy. A massive dilated
J-pouch extends to the middle and upper
abdomen full of gas, and further small bowel
loops dilated above the pouch. No stenosis could
be found, no pouchitis.
We decided to reduce the size of the pouch to
an average volume and also to reduce the diameter of the small bowel loops.
. Figure27.14d shows the resected part of the
pouch; of course the dissection of the mesentery
has to be meticulous and near the bowel wall to
avoid interference with the blood supply of the
aboral part of the pouch le in the deep pelvis.
Surgical Technique and Dicult Situations from Karl-Heinz Vestweber
219
27
a
a
b
b
. Fig. 27.16 a Specimen of a long rectal stump after
colectomy and J-pouch. A villous adenoma with dysplasia
could be found. b The former pouch was renewed after
resection of the diseased residual rectum and a new handsewn anastomosis with the anal canal was performed
. Fig. 27.15 a The contrast enema shows a stenosis
atthe upper end of the pouch. The patient initially was
diag nosed with ulcerative colitis. After colectomy histologic examination of the removed colon revealed Crohn’s
disease. b The resected upper pouch shows involvement by
Crohn’s with the stenosis
. Figure27.14e shows the situation at the end
of the reconstruction with the new anastomosis to
the residual part of the pouch in the pelvis and the
diameter reduction of the small bowel. e patient
recovered from the operation with a signicantly
improved functional situation lasting for years.
. Figure 27.15a shows the contrast enema
study of a young man around 10 years aer colectomy and J-pouch reconstruction because of
ulcerative colitis. Meanwhile the diagnosis had to
be changed to Crohn’s disease. e pouch function was acceptable for years but then obstructive
symptoms occurred. A major stenosis at the oral
end of the pouch could be found.
e stenosis at the entrance of the pouch was
resected. Again special attention had to be directed
to the blood supply of the remaining pouch.
. Figure27.15b shows the resected specimen
with stenosis due to Crohn’s disease.
One further patient presented with transanal
bleeding aer colectomy and J-pouch reconstruction using the double stapling technique.
Dysplasia was present at the previous operation.
e examination of the anal and pouch region
showed villous growth in a remaining rectal
stump of about 5cm length. Biopsies revealed cellular dysplasia in villous adenomas. During reoperation, the pouch was dissected out of the pelvis;
a transanal complete mucosectomy was performed. Aer resection of the long rectum stump,
a new pouch-anal canal handsewn anastomosis
was created.
. Figure27.16a shows the specimen with the
villous area.
220
K.-H. Vestweber
27
. Figure 27.16b shows the reconstructed
pouch which was anastomosed to the anal canal.
ere were no complications aer surgery.
Reoperations aer major problems with ileoanal pouches are worthwhile. e Mayo Clinic
results show aer around 10 years of follow-up
that 80 % of the revised pouches are still in
function. Even for Crohn’s disease, the pouch
function rate is 60 % [21].
27.2 Cancer andUlcerative Colitis#
Aer long-lasting ulcerative colitis disease, the risk
of developing colonic cancer increases. Epithelial
cell dysplasia is very oen the precursor of cancer.
We recommend colectomy aer diagnosis of dysplasia has been conrmed by too independent pathologists. It seems to be dicult to dierentiate between
low-, middle- and high-grade dysplasia. Small cancers oen cannot be recognised during conventional
colonoscopy. If staining and microscopic endoscopy
helps should be evaluated in the future.
Our own patients show a high rate of malignancy during elective colectomy because of ulcerative colitis. 62 of 311 colectomy patients had to be
diagnosed with already cancer. is rate of around
20 % is high compared to international data [22].
27.3 Conclusions
Aer total colectomy, we usually use a J-pouch
ileoanal anastomosis for reconstruction. In the
majority of cases, a loop ileostoma is created for
temporary diversion. In special very favourite
cases, we use a single-stage procedure; in emergency situation, a three-stage procedure is
pre ferred. Recently the colectomies can be performed minimally invasive by laparoscopy, even
in a single- port technique [2].
Considering dysplasia or colitis-associated
adenomas with dysplasia (Dalm), we recommend
prompt surgery.
Complications aer pouch surgery like stulae
and stenosis can very oen be treated successfully
by reoperation. If unexpected Crohn’s disease is
diagnosed aer colectomy and Crohn’s diseasespecic complications arise, revisions with the
aim of preserving the pouch are worthwhile.
For anastomosing the J-pouch, we use double
stapling techniques or the classical transanal
mucosectomy especially in patients with multilocular dysplasia. e pouch is xed rst in the
muscular cu by sutures then the handsewn anastomosis with the anal mucosa can be performed.
27.4 Abdominal Drains
AfterOperations Because
ofCrohn’s Disease
ofUlcerative Colitis
Usually abdominal drainage is avoided aer nishing procedures for Crohn’s or ulcerative colitis.
It makes no dierence if an anastomosis or only a
stoma is created. Aer careful haemostasis a drain
as indicator of bleeding can be avoided.
Drains are used when there is something to
drain.
Especially in Crohn’s patients, abscesses are
common. Usually they are intended to drain preoperatively by percutaneous drains.
If intraoperatively an abscess cavity remains
so, drains are put in and those stay as long as
necessary and as short as possible.
ab
Surgical Technique andDicult Situations fromKarl-Heinz Vestweber
27.5 Dicult Situations
Case 1
Grade II: An Underestimated Local Situation
A 44-year-old patient after ileocoecal resection in 1994, because of
classical stricturing terminal ileocolitis Crohn, had a reresection 13
years later.
In 2012 a new episode of
symptomatic stenosis occurs.
Abdominal pain especially after
eating and a deterioration in general health conditions occurred.
The diagnostic check showed a
conglomeration of bowel in the
lower and middle left abdominal
quadrant; additionally there was a
suspicion of intestinal stulation
which was proved by hydro-MRI
(. Fig.27.17).
Several attempts of conservative treatment were not successful.
Despite the two previous opera-
tions, a new surgical procedure has
to be done. The median scar after
the previous laparotomies was
used as entry to the abdomen.
As expected there were massive dense adhesions and the conglomeration of small and large
bowel with pus in between the
bowel slings. After further exploration a large stula became apparent
this stula originates from the prestenotic parts of the anastomosis.
The problem: While dissecting the
bowel out, a penetration into the retroperitoneum with dense connective scarring tissue includes the left
ureter. It was extraordinarily dicult
and time consuming to free the ureter from the surrounding tissue.
221
Solution: At the end the ureter
had no lesion and the short parts
of the bowel including the stula
and abscess could be resected
(. Fig. 27.18a, b). A prolonged
antibiotic treatment was continued according to the microbiology
report.
Analysis: The greatest difficulty
during this operation was to dissect out the ureter. A preoperative ureter probe transvesically
would have been of major advantage.
Result: The postoperative course
was uneventful; immunosuppressive
therapy with azathioprine was initiated.
27
. Fig. 27.17 a, b Hydro-MRI of a patient with several recurrences of Crohn’s disease showing a conglomera-
tion of bowel and enteric stulae
a
b
. Fig. 27.18 a Specimen of large and small bowel with connective tissue infection in Crohn’s disease. b After
further preparation a narrow stenosis and a large stula could be veried
27
222
K.-H. Vestweber
Case 2
Grade III: Patient with Dicult Therapy
The patient had a long-lasting history of Crohn’s disease. He had several previous operations followed
by multiple complications, which
includes an “open abdomen”. There
was a suspicion of short bowel syndrome. An anastomosis had been
constructed between small bowel
and left-sided colon. The “open
abdomen” has been covered by skin
only, resulting in a very fragile
abdominal wall. Now a relevant disturbance of bowel passage happened and hydro-MRI showed two
relevant stenoses in the left large
bowel – one of those at the anastomosis of small and large bowel
(. Fig. 27.19). The patient additionally suered from chronic renal
failure.
Problem: Is the only reasonable
approach a surgical procedure?
How massive and invasive
would the operative procedure be?
Solution: Because of impossibility
of endoscopic dilatation of the
strictures and increasing symp-
toms, the decision for surgical
intervention was made.
Intraoperatively there were
complete adhesions of all bowel
loops and bowel with the abdominal wall structures. A long-lasting
complex adhesiolysis was necessary. After completely freeing the
small bowel, the rst stenosis
could be realised at the anastomosis from small to large bowel; the
other stenosis could not be found
initially. A colonoscopy revealed a
short but extremely narrow stricture in the sigmoid. Because of the
already short large bowel, a
bowel-sparing procedure was performed.
The anastomotic stricture was
resected as short as possible
(. Fig. 27.20), and the second sigmoid stenosis was treated by a
classical Heineke-Mikulicz strictureplasty. The stenosis was
opened longitudinally and closed
at right angles. The rst suture row
was an inverting continuing Connell suture and there after additional single stitches were made.
After nishing a colonoscopy was
performed ensuring tightness and
competence of the reconstruction,
also there was no intraluminal
bleeding (. Fig. 27.21).
Measuring the small bowel
2,70 cm could be documented –
no short bowel was apparent.
The abdominal wall was possible to close without a complex
hernioplasty. Before closing a large
Vicryl mesh covered the complete
abdominal content.
Result: The postoperative course
was completely uneventful. Evacuation of stool occurred 6–8 times
per day.
. Fig. 27.19 This hydro-MRI shows a prestenotic
dilated small bowel after recurrent Crohn’s disease
with prior ana stomosis between the ileum and
descending colon and at least one further colonic
stenosis
. Fig. 27.20 The stricture with ulcer at the
anastomosis between small bowel and descending
colon was resected and a new anastomosis created
. Fig. 27.21 At the very narrow sigmoid stenosis,
a Heineke-Mikulicz type of strictureplasty was done
Surgical Technique andDicult Situations fromKarl-Heinz Vestweber
Case 3
Grade IV: A Very Dicult Patient Situation:
A 16-year-old patient suered from
extended Crohn’s disease. He presented with an oesophageal involvement causing a stricture with severe
dysphasia. A conservative treatment
with dilatation was initiated. At the
end of one of the bougienages, he
complained of massive thoracic pain
and consecutively showed a severe
deterioration of his physical condition with signs of shock. An x-ray
examination showed free air in the
mediastinum. The endoscopy
revealed a deep long tear in the
oesophageal wall; tracheal involvement was suspected. Stenting was
not successful and the general condition of the young patient became
worse. Finally the decision for emergency thoracotomy was made.
Problem: Intraoperatively a long
rupture of the massive inamed
and scared oesophagus could be
found with an additional rupture
into the trachea.
Solution: A reconstruction of the
oesophagus was, because of the
severe destructive Crohn’s, not
possible. The only reasonable way
to go forward seemed to be esophagectomy. An anastomosis was
possible at the high thoracic or
better of the cervical part of the
oesophagus. The oesophagus was
completely mobilised and the tracheal lesion was closed using an
intercostal muscular ap. The
oesophagus was cut high up in the
thorax and mobilised down
through the hiatus esophagi.
Patient’s position was changed to
supine and an abdomino-cervical
approach was used for reconstruction. A stomach tube was constructed and retrosternally
transferred to the neck; the anastomosis was performed by single
stitches.
After some days of intensive
care, the patient has no further
problems.
223
Some years later the same
patients developed a severe toxic
Crohn’s colitis including perianal stulation. An urgent operation was
necessary, ending up in a Hartmann’s
procedure with ileostomy and a rectal stump. Several postoperative
complications happened including
severe abdominal wound infection.
At the end the situation relaxed.
After that there was pus
draining out of the rectal stump
and anal incontinence was
induced by severe fistulae.
Patients’ well-being was influenced significantly.
Very recently the remaining
rectum could be removed by
abdomino-perineal excision.
Result: The course of this severe
Crohn’s ended up in terminal ileostomy and oesophageal substitution by the stomach. The way of
decision-making was very dicult
and a great burden.
27
27
224
K.-H. Vestweber
Case 4
Grade I: Ideal Eect of Therapy
In a young male patient with a history of ulcerative
colitis for several years, a severe hemorrhagic
colitis developed. Parallel a necrotizing dermatitis
involved especially the upper part of the body
(. Fig.27.22).
Problem: Further conservative treatment expanding
immunosuppression or surgery?
Solution: Surgery was chosen, which was the favourite of the patient too.
A subtotal colectomy with a long rectal stump was performed. An end ileostomy was created. The intraoperative situation shows the severe colitis with dilated large
bowel (. Fig. 27.23). After colectomy the painful necrotizing dermatitis resolved stepwise (. Fig.27.24). The
next stage was rectal stump resection with J-pouch ileoanal anastomosis and a covering loop ileostomy. Three
months later, the ileostomy could be reversed.
Analysis: The prognosis of the very distressing necrotizing dermatitis could not be foreseen. At the end it
healed quickly.
. Fig. 27.22 Active painful necrotising dermati-
tis in a patient with ulcerative colitis
. Fig. 27.23 Acute, toxic ulcerative colitis with
dilated large bowel in the same patient
. Fig. 27.24 Healing of necrotizing dermatitis
around 3 months after colectomy
Surgical Technique andDicult Situations fromKarl-Heinz Vestweber
Case 5
Grade II: No Ideal Patient Situation
A young man suered from ulcerative colitis since more
than 10 years. A colitis-associated carcinoma of the
large bowel developed. At the same time, a toxic megacolon made an emergency colectomy necessary. A subtotal colectomy was performed with a rectal stump. The
colon was resected according to oncologic principles.
The tumour was localised in the transverse colon
(. Fig.27.25).
Problem: The preoperative sepsis persists postoperatively and the patient died as a consequence of sepsis.
Analysis: There was a coincidence of colitis-associated
carcinoma and the acute situation of severe toxic colitis. Patient situation deteriorates despite emergency
operation. In this case, an early operation before the
carcinoma and the toxic colitis developed would have
been the best approach.
. Fig. 27.25 Hemorrhagic, acute ulcerative
colitis presenting with a colonic cancer (T3) additionally
225
27
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