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272 L. Hultén
cancer control in ulcerative colitis. Gut 8(5):423–434
42. Delaini GG, Colucci G, Hulten L (2005) The ileoanal
pouch procedure in the long-term perspective: a criti-
cal review. Tech Coloproctol 9:187–192
43. Lee SW, Sonoda T, Milsom JW (2005) Three cases of
adenocarcinoma following restorative proctocolecto-
my with hand-sewn anastomosis for ulcerative colitis:
a review of reported cases in the literature. Colorectal
Dis 7(6):591–597
44. Svaninger G, Nordgren S, Oresland T, Hulten L (1993)
Incidence and characteristics of pouchitis in the Kock
continent ileostomy and the pelvic pouch. Scand J
Gastroenterol 28(8):695–700
45. Cox CL, Butts DR, Roberts MP et al (1997) Develop-
ment of invasive adenocarcinoma in a long-standing
Kock continent ileostomy: report of a case. Dis Colon
Rectum 40(4):500–503
46. Setti-Carraro P, Ritchie JK, Wilkinson KH et al (1994)
The first 10 years’ experience of restorative procto-
colectomy for ulcerative colitis. Gut 35(8):1070–1075
47. Gullberg K, Stahlberg D, Liljeqvist L et al (1997) Neo-
plastic transformation of the pelvic pouch mucosa in
patients with ulcerative colitis. Gastroenterology
112(5):1487–1492
48. Hulten L, Willen R, Nilsson O et al (2002) Mucosal
assessment for dysplasia and cancer in the ileal pouch
mucosa in patients operated on for ulcerative colitis: a
30-year follow-up study. Dis Colon Rectum 45
4:448–452
49. Borjesson L, Willen R, Haboubi N et al (2004) The risk
of dysplasia and cancer in the ileal pouch mucosa after
restorative proctocolectomy for ulcerative proctocoli-
tis is low: a long-term term follow-up study. Colorec-
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(6):494–498
50. O’Connell PR, Pemberton JH, Weiland LH et al (1987)
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Colorectal Dis 5(5):483–5
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Introduction
The failure rate of restorative proctocolectomy (RP)
varies from 5 to 15% of the cases [1, 2], but with the
lengthening of follow-up, the rate exceeds 15% [3].
Failure of the RP refers to the necessity of fashioning
a loop ileostomy with the pouch in site or the
removal of the pouch with definitive ileostomy. The
causes of failure include acute and chronic sepsis,
bad functioning in regard to mechanical and func-
tional causes and mucosal inflammatory processes.
Procedures for avoiding loss of anal function come
within the scope of salvage surgery.
Sepsis
Sepsis can be defined early or late. The incidence of
such complications varies in 5–25% of cases after
RPs [4, 5], and approximately half of these are
responsible for the failure of the surgical operation.
The majority of the cases depend on the anastomot-
ic complications regarding the pouch anal or regard-
ing the proximal ileum to the pouch. After modifica-
tion via mucosectomy’s technique, which is used
preliminarily to remove all disease (prone mucosa),
the sepsis rate is remarkably reduced. The experi-
ence of the surgeon in transanal surgery is the factor
that can meaningfully influence any complications
[3, 6, 7].
Early sepsis manifests itself as fever, tenesmus and
loss of pus through the anus. In a certain number of
cases, antibiotic therapy can resolve the infection. In
others, however, TC-guided transanal or transab-
dominal drainage is necessary. In some cases, it is
sufficient to open the pouch-anal anastomosis in
order to guarantee adequate transanal drainage. In
severe sepsis, laparotomic access is mandatory; it is
in these cases that the removal of the pouch from its
natural site is frequently carried out, whereas the
closing of the ileostomy is done infrequently.
In the experience of Heuschen [8] with 131
patients with sepsis, approximately 16% of these
could be treated conservatively. Failure was in rela-
tion to the procedure carried out. In fact, it occurred
in 6% of the cases after minimal surgery and in 47%
of the cases after major surgery. Consequently, it is
obvious that premature sepsis represents an impor-
tant risk factor regarding the success or failure of the
procedure.
Late sepsis generally manifests itself with the
appearance of abdominal or pelvic abscesses and/or
with formation of fistulas. In the case of circum-
scribed sepsis, surgical or TC-guided drainage can
resolve the inflammatory process, otherwise pouch
salvage surgery, with the removal of the pouch from
the pelvis and the positioning of it under the abdom-
inal wall along with the creation of a mucosal fistula,
can represent an adequate therapeutic choice. This
procedure was successful in five patients of eight in
the study of Keighley [9] and in two of four in the
study of the Mayo Clinic Group [10].
In Fazio’s study [11] of 35 patients with sepsis, of
which 29 had leakage of the ileo-anal anastomosis,
the patients were treated via abdominal surgery. The
rescue of the pouch was achieved in 21 out of 22
patients with ulcerative colitis, preserving transanal
evacuation to the detriment of the bowel function,
which was characterised by an evacuative frequency
of 9 motions within 24 h, (ranging between 4 and 35
motions). The quality of life (QoL) was good in 17
patients and bad in 13.
Cohen [12] performed salvage surgery on 24
patients and obtained acceptable results for 20. In 18
of these, the medium frequency of elimination was 5
evacuations/day and 1.5 nocturnally, with good con-
tinence in 13 of the patients. Galandiuk [13] operated
for intra-abdominal sepsis on 29 patients and report-
ed 17 failures, which emphasises that the possibility
for failure increases with time.
Heuschen [8] reports 131 patients with sepsis on
706 PR. In the experience of the author, early sepsis
involves a greater risk of failure that increases with
time at a rate of 20
% at 3 years and 40% at 10 years.
The site of the fistula is proximal to the pouch in 13%
of cases, at the level of the neorectal cuff in 31% and
Salvage Surgery After Restorative Proctocolectomy
Francesco Selvaggi, Guido Sciaudone, Antonio Giuliani, Crescenzo Di Stazio,Ilaria Guadagni
274 F. Selvaggi, G. Sciaudone, A. Giuliani, C. Di Stazio, I. Guadagni
at the level of the ileo-anal anastomosis in 50% of
cases. Treatment has been conservative in 18% of
cases, with transanal surgery in 25% of cases and
abdominal in 56% of cases. The difference in the fail-
ure is higher after major surgery (45%) than minor
surgery (5%). The failure was also correlated to the
dehiscence of the pouch-anal anastomosis and to the
presence of a pouch-vaginal fistula. Experiences up
to now demonstrate a great variability of results in
relation to the severity of sepsis, the site regarding
the pouch-anal anastomosis and to the duration of
the follow-up.
Gorfine [14] of Mount Sinai in New York reports
on 1 185 RPs: 51 patients with sepsis from leakage of
the pouch-anal anastomosis in which 85 surgical pro-
cedures were carried out including 48 transanal sur-
geries in patients without ileostomy, 37 transanal
surgeries in patients with ileostomy and 4 abdominal
and perineal operations in patients with ileostomy.
In 40% of patients he obtained a good result at a
medium follow-up of 65 months. Comparing patients
with and without ileostomy who received a surgical
transanal procedure, the author did not see any evi-
dence of differences in results. Moreover, he reports
on the failure in all patients who had abdominal sur-
gery. The author concludes, that in order to obtain
good results, more surgical procedures are necessary,
so that there are no differences between patients with
and without ileostomy, which emphasises the failure
of abdominal procedures used in the attempt to res-
cue the pouch.
Dehni [15] reported on the experience acquired
from 54 patients who underwent salvage surgery, of
which 47 had sepsis. In 19 patients with cases of
abscess, he utilised a transanal approach preceded by
surgical or radiological transanastomotic or perineal
drainage. In the remaining cases he preferred an
abdominoperineal approach. Altogether, 27 of the 40
patients evaluated after abdominoperineal surgery
and 13 of the 18 after transanal surgery, obtained sat-
isfactory results. Of the patients operated on for sep-
sis, 44 at a medium follow-up of 30 months obtained
good results. Crohn’s disease was subsequently diag-
nosed in three patients out of four who had pouch
failure after salvage surgery.
Pouch-Vaginal Fistula
The symptoms of pouch-vaginal fistula consist of
leakage of secretion or gas from the mucosa and/or
faecal leakage through the vagina or the perineum.
Its incidence is equal to approximately 5–10% of
patients operated on for RP. The treatment depends
on the severity of the symptoms. In the case of mini-
mal symptoms, the application of a seton tie could be
sufficient, even if long-term data on it does not exist
[16].
In the case of incontinence, a defunctioning
ileostomy can be performed and a seton tie can be
inserted for drainage. Once the sepsis has been
resolved, recanalisation will be possible. The inser-
tion of a seton tie is probably the technique of choice
in the presence of a cryptoglandular fistula. Ileosto-
my alone, in fact, is not in a position to guarantee sat-
isfactory results [17].
Surgical procedures can be divided into abdomi-
nal and local. The first is concerned with abdominal
revision and the advancement of the ileo-anal anas-
tomosis. Local procedures, on the other hand, such
as advancement flap repair and endoanal or
endovaginal repair, precede fistulectomy.
It is obvious that the site of anastomosis influ-
ences surgical choice. According to some authors, in
the presence of anastomosis in the distal rectum, it is
possible to make a reconstruction and to perform a
more distal anastomosis with success in 21 out of 26
patients [12, 16, 17]. In the case of a fistula that is
derived from ileo-anal anastomosis, a local treatment
is recommended.
Advancement flap repair determines success in
50% of cases. Transvaginal repair allows a direct
access to the fistula avoiding sphincter damage. In
one study, five patients out of seven obtained good
results at a mean follow-up of 26 months [13]. Others
authors have reported good results in 11 patients out
of 14 at a mean follow-up of 18 months [18].
In reviewing the various results obtained with a
transvaginal approach, the closing of the fistula has
been demonstrated in 25 patients out of 35. Surgery
with an abdominal approach is in a position to
achieve good results in 80% of cases; with the per-
ineal approach the percentage falls to 50% of cases
[13, 16, 19, 20].
A further condition that can lead to the removal of
the ileal pouch is represented via malfunction. Such
an event is responsible for 20–40% of failure of the
pouch [9, 10]. Karoui [21] reports a removal rate of
35% for poor functioning (24 out of 58 removals) due
to outlet obstruction in 10 patients and incontinence
in 14 patients. The success rate after medical or sur-
gical treatment is extremely variable in the literature,
ranging between 33 and 100% of cases [9, 22
]. Surgi-
cal treatment can consist of an exclusively transanal
approach or a combined abdominoperineal
approach, depending on the reason of dysfunction
and technical feasibility [23]. The most frequent
causes of malfunction are represented by mechanical
obstruction, sphincter dysfunction, reduced capacity
of the reservoir or by mucosal inflammation [24].
The majority of the patients with poor functioning
have an evacuation frequency of 10 motions/24 h or
Salvage Surgery After Restorative Proctocolectomy 275
more, often associated with emission of small vol-
umes of faeces and the presence of urgency, inconti-
nence and evacuation difficulties [24].
Outlet obstruction (OO), which alone is responsi-
ble for 18–48% of the malfunction of the ileal reser-
voir [9, 10], can be determined by various factors
including stenosis of the pouch-anal anastomosis, a
long efferent limb (LEL) in an S-shaped form or by
the presence of a residual of rectal mucosa at the level
of the pouch-anal anastomosis (retained rectal
stump).
Stenosis of Pouch-Anal Anastomosis
Ogunbiyi’s study [9] on 198 PRs reports nine cases of
OO due to stenosis of the pouch-anal anastomosis in
four, LEL in two, prolapse of the pouch in one and
stenosis of the remaining ileum above the pouch in
two cases. All patients with stenosis of the pouch-
anal anastomosis underwent a reconstruction of the
reservoir with success in three patients out of four. A
pouchpexy was performed with success in the patient
with prolapse of the pouch. In the two patients with
LEL, the efferent limb was successfully removed. In
the two cases of stenosis above the pouch, one patient
showed no improvement of clinical conditions after
the construction of a pouch-anal anastomosis L/L,
while for the other patient who was diagnosed with
Crohn’s disease after the construction of the reser-
voir, the resulting strictureplasty was successful.
A stenosis of the pouch-anal anastomosis, requir-
ing a single dilatation, is described in the literature in
a variable percentage from 4–40% of cases [1, 13,
25–31]. This event is more frequent in patients with
UC [13, 28, 29] compared to those with FAP and
shows a double incidence regarding mechanical
anastomosis compared to those made by hand [29].
Senapati [31] in a study of 266 patients who under-
went PR, reported stenosis in 14.2 and 39% of the
patients, depending on whether the procedure had
been carried out via manual or mechanical anasto-
mosis. The first therapeutic approach to stenosis of
the pouch-anal anastomosis, is dilatation under
anaesthesia. With this procedure Senapati [31]
reports a success rate of 26%, while Galandiuk [13] at
a 31-month follow-up (range 1–98) reports a relapse
rate of 59% with failure in 16% of the cases. The same
author reports satisfactory results after repeated
dilatations in more than 50% of cases (23 patients out
of 42). In particular, in the case of a short stenosis, a
posterior strictureplasty can be indicated. Stenosis of
2 cm of length can be corrected by an exclusive
transanal approach. In the case of a long stenotic seg-
ment, on the other hand, a combined abdominoper-
ineal approach is recommended [32, 33].
According to Dehni’s [23] study of 23 patients who
underwent transanal surgery, 4 because of fibrous
stricture, the combined abdominoperineal conver-
sion is mandatory. The transanal approach with
removal of the stenosis and distal advancement of
the pouch is particularly indicated in cases with con-
comitant vaginal fistula [32].
The remaining therapeutic options consist of the
removal of the pouch with definitive ileostomy,
which was necessary in 2.5–15% of the cases, or by
abdominal salvage surgery, with removal of the
pouch, removal of the fibrotic ring and reconstruc-
tion of the pouch-anal anastomosis restoring the
proximal portion of pouch [24].
Maclean [34
] of the Mount Sinai Hospital of
Toronto, comparing patients who underwent rescue
of the pouch through an abdominal approach in
cases of pelvic sepsis or OO, reported a minor inci-
dence of complications (33.3 vs. 61.5%, p=0.047) in
patients with OO. This emphasises, moreover, that
there was a greater risk of malfunction in those cases
where it was necessary to refashion a new pouch then
where it was possible to modify the old reservoir,
depending on whether there was insufficient compli-
ance due to fibrosis and a reservoir lacking in volume
with a subsequent increase of evacuation frequency.
Long Efferent Limb
Parks and Nicholls’s S-pouch [35] or Fonkalsrud’s H-
pouch [22] can determine the formation of an effer-
ent limb of the terminal ileum, which constitutes the
proximal side of ileo-anal anastomosis. A long effer-
ent limb (LEL), >8 cm of length, fashioned in the first
“debut” cases of the S-reservoir, needed catheterisa-
tion of the pouch to achieve evacuation in more than
50% of the patients [36].
Fonkalsrud [22], in his study of 601 PRs, reports
an OO rate of 27.3%, with a success rate after surgical
review in 93% of cases. In this experience, however,
221 patients had an H-reservoir and 4 had an S-reser-
voir constructed in the early 1980s. Those made at
that time were abandoned because of an elevated
incidence of emptying with the necessity of catheter-
isation.
The removal of the LEL is possible through a
transanal approach, but it is technically feasible in
less than 30% of patients [22, 37]. The technique con-
sists of mobilisation of the pouch and separation of
the ileo-anal anastomosis. The efferent limb is
removed and a new manual anastomosis is fashioned
between the pouch and the anal canal.
Sagar [10], in a study of 1 770 ileal pouches, evi-
denced 9 LELs (5–11 cm), all of which were in
patients with an S-pouch, and 3 blind handle torsions
276 F. Selvaggi, G. Sciaudone, A. Giuliani, C. Di Stazio, I. Guadagni
in patients with J-pouches. After surgical treatment
of the nine patients with LEL, five demanded con-
struction of a new reservoir, which was successful in
seven cases (78%). In the three patients with blind
handle torsions, he did not fashion a new reservoir
and only one patient benefited from the surgical
treatment. Of a total of 26 patients who underwent
this treatment, failure of the surgical procedure was
recorded in 5, while 18 showed improvement which
included a change from needing catheterisation to
spontaneous evacuation [9, 10, 37, 38].
Retained Rectal Stump
The use of stapling in the realisation of the pouch-
anal anastomosis or the insufficient execution of
mucosectomy are the main causes of retention of rec-
tal mucosa. In fact, with the double stapling tech-
nique, a little stump of rectal mucosa of variable
length from 1.5–3 cm, in which the disease persists, is
left In Situ. A certain degree of inflammation is com-
monly found on the biopsies carried out on the resid-
ual cuff of the columnar epithelium. However, this
only causes symptoms in 2–15% of patients [39–42].
According to the experience of Herbst [38] in a
study of 16 PRs with OO, in half of the patients, the
functional disturbance was associated with an LEL of
the S-pouch, five were associated with a stenosis of
the pouch-anal anastomosis, and one was associated
with a stenosis associated to an LEL, while two were
associated with a long rectal stump. None of the
patients had the reservoir reconstructed during a
subsequent operation and surgery was successful in
80% of cases. The author concludes that with the use
of a mechanical pouch-anal anastomosis, the inci-
dence of a long rectal stump increases because of OO
[38].
Lavery of the Cleveland Clinic, in one study
focussing on 227 patients with PR, reports the pres-
ence of inflammation of the cuff, histologically
demonstrated, in 82% of cases. This condition gener-
ated a clinical symptomatology in only 14.7% of the
patients. The more frequent disturbances during cuf-
fitis are bleeding, burning and urgency; moreover,
neoplastic transformation of the residual rectal
mucosa is possible [39, 40, 43]. Local treatment with
steroids can determine remission of symptoms, but
often definitive resolution of clinical presentation is
possible only with surgical therapy.
Five patients of the series of Dehni [23] received a
salvage procedure of the pouch for complications
due to a long rectal stump with the presence of severe
cuffitis in two cases, difficulty of emptying in two
others and development of carcinoma on the stump
in one case. Four of these patients demanded a new
anastomosis carried out via a transanal approach and
one demanded a review via an abdominalperineal
approach.
If the retained portion of mucosa is short, a
transanal approach can be possible, but in the major-
ity of the cases, a combined abdominoperineal
approach, that includes removal of the residual rec-
tum followed by manual mucosectomy and transanal
refashioning of the pouch-anal anastomosis is neces-
sary.
Curran [42] reports three cases where there was a
necessity to carry out a transanal mucosectomy for
resolution of the symptomatology. In one of these
cases the removal of the pouch was necessary. Fazio
obtained good results associating the advance of the
reservoir to a transanal [44].
Small Volume Reservoir
The first type of reconstruction after total procto-
colectomy was the straight ileo-anal anastomosis.
The unsatisfactory results of such a procedure
together with the studies of Nicholls [45], which
demonstrated the presence of an inverse relation
between evacuation frequency and reservoir capaci-
ty, determined the spread of the pelvic pouches.
However, constructing a pouch so as to have satisfac-
tory functional results is not sufficient, because an
adequate volume of the reservoir is necessary for the
functioning of the neo-rectum with a reduction of
evacuation frequency. In fact, insufficient volume of
the reservoir can be responsible for the elevated
number of evacuations and urgency. The demonstra-
tion of the importance of an adequate volume is rep-
resented in the differences in the results that can be
observed between the J and the W-pouch [46].
The pouch enema and above all the mano-vol-
umetry along with the determination of the threshold
volume (TV) and the maximum tolerated volume
(MTV) can define the capacity and compliance of the
reservoir exactly. Medical therapy (loperamide,
codeine and mass-forming drugs), often is not able to
improve the evacuation frequency, so therefore, an
abdominal operation becomes necessary in order to
enlarge the pouch. Herbst demonstrated a meaning-
ful reduction of evacuation frequency using this
method [38] and Fazio [11] used this method in 7 of
35 patients reoperated on for sepsis.
Klas [47] reported that in five cases of insufficient
volume of the reservoir for which he carried out a
conversion from a J to a W pouch, daily evacuation
frequency had been reduced, with much satisfaction
on behalf of the patients, from 13–8 to 5–8 and the
nocturnal episodes from 3–0 to 0–3. However, such
an increase of the pouch, which certainly represents
Salvage Surgery After Restorative Proctocolectomy 277
a more conservative method than ex novo construc-
tion of the reservoir, is not always feasible. This tech-
nique consists of the addition of a small intestinal
loop to the proximal part of the pouch without
removing it from its site, or as an alternative, mobil-
isation of the reservoir, modification of the J-pouch
in order to construct a W-reservoir and finally a
reconstruction of the pouch-anal anastomosis. In the
case of a J-pouch with a long blind stump, its inte-
gration with an L/L suture is sufficient for increasing
the volume of the pouch.
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Introduction
There are several clinical scenarios when the opera-
tion of ileal pouch-anal anastomosis does not go as
smoothly as planned, specifically with respect to
obtaining enough length to construct an anastomo-
sis. Although the technique of stapled ileal pouch-
anal anastomosis has greatly facilitated the ability to
obtain additional length, there are still situations in
which this is technically difficult. In addition, there
are situations in which a hand-sewn anastomosis is
required, for example, in the UC or FAP patient with
a low-lying rectal cancer, or the patient who has had
a very short Hartmann pouch where, due to distal
scarring, a stapler technically cannot be used to cre-
ate an anastomosis. The most common situations in
which it will be difficult to gain enough length to per-
form an “easy, tension-free anastomosis” are: [1]
those patients who are obese, [2] those in whom
reoperative surgery is performed and who have fore-
shortening of the mesentery due to scar tissue, [3]
those patients who, based on their body habitus, have
an unusually short small-bowel mesentery, [4]
patients with an unusually long torso, [5] patients
with familial adenomatous polyposis (FAP) who have
mesenteric desmoid disease, as well as [6] patients
who for a variety of reasons have undergone prior
small-bowel resection. In these situations, particular
attention to detail with respect to mobilization of the
small-bowel mesentery and certain technical tips can
be extremely helpful in facilitating the course of the
operation. This chapter will be divided into two sec-
tions, the first dealing with maneuvers to help gain
additional mesenteric length and allow the terminal
ileum and J-pouch to reach the anal canal more easi-
ly and the second, with maneuvers to facilitate con-
struction of a loop ileostomy in these individuals,
which can itself be extremely difficult.
Maneuvers to Gain Additional Mesenteric Length
Mobilization of the Small-Bowel Mesentery
One of the key maneuvers in gaining length of the
ileal J-pouch is complete mobilization of the small-
bowel mesentery. The small-bowel mesentery
adheres to the retroperitoneum in a diagonal fashion
beginning in the lower right quadrant, extending
upwards toward the left upper quadrant. The entire
mesentery of the small bowel should be mobilized to
the level of the second and third portions of the duo-
denum (Fig. 1). Division of the filmy adhesions
between the small bowel mesentery and the duode-
num permit additional stretch of the small bowel
mesentery. In doing this maneuver, one must be
careful not to do too much mobilization. Injudicious
mobilization or use of electrocautery in the vicinity
Management of the Difficult Ileal Pouch-Anal
Anastomosis and Temporary Ileostomy
Susan Galandiuk
Fig. 1. Mobilization of the small-bowel mesentery up to the
level of the third portion of the duodenum
280 S. Galandiuk
of the pancreas can actually result in pancreatitis and
should be avoided.
Peritoneal Windowing
The visceral peritoneum acts almost like a “sausage
casing” in terms of holding in or confining the
mesentery of the small bowel. If the visceral peri-
toneum covering the mesentery of the small bowel is
sharply incised, the small-bowel mesentery stretches
more easily. Because the blood supply to the ileal
pouch is extremely important, much care needs to be
taken when performing this maneuver. In order to do
this, while avoiding injury to any of the underlying
blood vessels, a very fine hemostat can be gently
inserted underneath the peritoneum in order to lift it
away from the underlying blood vessels and the elec-
trocautery used to gently divide the peritoneum
(Fig. 2a). This is done at 1 or 2-cm increments in a
horizontal step-ladder-type fashion, while an assis-
tant applies distal traction to the point of the termi-
nal ileum that is chosen to be the apex of the J-pouch
(Fig. 2b). As soon as the peritoneum is divided at
each point, there is a gaping of the peritoneum in this
area. When the anterior surface of the small-bowel
mesentery’s peritoneum is “windowed” in this man-
ner, the small-bowel mesentery is then “flipped” or
turned cranially so that it lies over the upper portion
of the patient’s abdomen and chest. Subsequently,
the identical maneuver is then performed on the pos-
terior aspect of the peritoneum covering the small-
bowel mesentery beginning just above the level of the
third portion of the duodenum and proceeding dis-
tally towards the mesenteric portion of the segment
of terminal ileum chosen to be the apex of the J-
pouch. One can usually gain approximately 2–3 cm
or more of additional mesenteric length via this
maneuver (Fig. 2c).
Division of Either the Ileocolic or Superior Mesenteric Blood
Vessels
If the above maneuvers are still insufficient for pro-
viding adequate mesenteric length, some of the blood
vessels supplying the terminal ileum can be divided.
If the colectomy is performed at the same time as the
ileal J-pouch anal anastomosis, it is important to pre-
Fig. 2a-c. Peritoneal windowing to gain additional mesenteric length. a A hemostat is inserted underneath the peritoneum
to lift it away from the underlying mesenteric blood vessels. b Electrocautery is then used to divide the peritoneum in a
step-ladder-type fashion at regular intervals. c Several centimeters of additional mesenteric length can be gained using this
maneuver
a
b
c
Management of the Difficult Ileal Pouch-Anal Anastomosis and Temporary Ileostomy 281
serve the entire course of the ileocolic vessels. This is
important so that, if additional mesenteric length is
required, this vessel can be used as the main pouch
blood supply. This is unfortunately not an alternative
in patients who have already had a prior colectomy
and present at a later stage for ileal J-pouch anasto-
mosis. The terminal ileum is characterized by its
arcade-like blood supply. Either the distal superior
mesenteric or the ileocolic vessels can be divided,
provided that the other blood vessels are intact and
that good bowel perfusion can still be maintained via
these arcades [1]. If there is inadequate mesenteric
length, by placing distal traction on the J-pouch, one
can easily ascertain by palpation alone whether the
ileocolic vessels or the distal superior mesenteric ves-
sels are under more tension. These vessels can be felt
as tight cords or bands even in obese patients when
the pulses of the vessels cannot easily be palpated. If
one or the other of these vessels feels to be under
more tension, these vessels can be clamped, divided
and ligated and additional mesenteric length
obtained. If there is a question as to what effect divi-
sion of these vessels would have on pouch viability,
vascular clamps can be used to occlude these vessels,
and pouch viability ascertained before they are divid-
ed. With this technique, an additional 2–3 cm of
mesenteric length can be attained.
Stapled Ileal Pouch-Anal Anastomosis
Performing stapled ileal J-pouch anal anastomosis is
by far the easiest method with respect to mesenteric
length, because in this situation, the transanally
placed stapler pushes the perineum towards the
abdomen and small-bowel mesentery, reducing the
length needed by several centimeters compared to
hand-sewn techniques. Purse string sutures are not
reliable and frequently are placed incorrectly.
Because of this, incomplete “doughnuts” are com-
mon. I prefer to use a triple-staple approach, in
which no purse string suture is used[2]. The anvil of
the stapler is placed through the enterotomy through
which the GIA staplers that created the J-pouch are
fired. This enterotomy is in turn then closed using a
linear stapler and the shaft of the anvil pierced
through the bowel just adjacent to this linear staple
line. Since no purse string suture is required, the
bowel is less likely to tear and there are fewer techni-
cal problems with the anastomosis, especially if an
anastomosis is constructed under tension. In the very
obese patient, the extra-large straight St. Marks
retractor is invaluable. This is particularly useful in
the patient who is well over 150 kg (Fig. 3), and par-
ticularly in obese male patients in whom the narrow
pelvis further makes dissection difficult. The only
compromise one may have to accept with a stapled
ileal J-pouch anal anastomosis is that, in a very large
patient, one may have to accept an anastomosis that
would be higher above the dentate line than in the
ideal situation. In these cases, surveillance may need
to be performed more frequently and one must be
prepared to perform a mucosectomy should this
become necessary. This clearly becomes a very seri-
ous issue in the case of familial adenomatous poly-
posis when one may also be dealing with patients
who might not be compliant with follow-up surveil-
lance. This must be discussed in great detail with
patients preoperatively, particularly in the United
States where many of these patients have a low rate of
follow-up.
What to Do in Case of Extremely Difficult Hand-Sewn
Anastomosis
Do not despair. Even in the most difficult circum-
stance, do not give up and excise the anal canal. I
have frequently seen this done, and know from per-
sonal experience, that even in the most awful case
when one thinks that all is lost, when one fears that
there will be leaks and problems with healing, the
anastomosis can still heal primarily and the patient
obtain a satisfactory functional result. Even when the
ileal J-pouch tears when it is brought down to the
anal canal due to a large amount of tension on the
anastomosis, it may still heal. One must, however,
realize that the more tension there is on an anasto-
mosis, the more likely the patient is to have a stric-
ture postoperatively. It is therefore extremely impor-
Fig. 3. Even in very large patients, ileal pouch-anal anasto-
mosis can be performed. The extra-large straight St. Marks
retractor is particularly helpful such as in this patient with
a body mass index of 46.1
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