Feza H RemziMD and Victor W Fazio MB MS

Restorative proctocolectomy (RP) with ileal pouch anal anastomosis (IPAA) has become the gold standard of surgical treatment for ulcerative colitis (UC) (Parks and Nicholls, 1978). In many series, > 90% of procedures for UC involve RP/IPAA. This may be performed as (1) a primary procedure, of total proctocolectomy (TPC) and IPAA, with temporary loop ileostomy or (2) a multistaged with subtotal colectomy oversew of rectal stump and end ileostomy, followed by completion proctectomy IPAA and loop ileostomy, with final (third) procedure being closure of loop ileostomy. Figure 79-1 outlines indications for surgery.

In a few cases (up to 10% of RP cases) the procedure is done in one stage, TPC and IPAA without loop ileostomy (Fazio et al, 1995). This is an alternative we will use in well-motivated and informed patients who are:

1. Aware of the 5 to 10% leak rate from the pouch anal anastomosis and the possibility that an urgent ileostomy may be required in the early postoperative period (Tjandra et al, 1993; Remzi et al, in press).

2. Aware that recovery—both hospital stay and recovery time (return of stamina) to return to work and social activities—may be double that of the usual 6 to 7 day

Ileo Anal Pouch
FIGURE 79-1. Legend: Indications for surgery. IPAA= ileal pouch-anal anastomosis; TPC= total proctocolectomy. *Absence of perianal or small bowel disease. **Presence of adverse/clinical/radiologic indicators.

hospital stay and the 2-month normal recovery time. This is due to the combination of recovery from a major abdominal procedure as well as from the obligatory early excessive stool frequency accompanying a one-stage operation due to undesirable consequences of early postoperative sphincter function. Thus, we will consider the one-staged operation

3. Where there is no toxicity or features adverse to tissue healing (prednisone dose < 20 mg/d, diabetes, immunosuppressive therapy)

4. Where the operation has proceeded effortlessly with minimal blood loss (no transfusion requirement) and hemostasis is considered excellent

5. Where there has been no difficulty in getting the pouch to reach the anus without excessive tension

6. Where intact tissue rings (doughnuts) have been obtained using the double stapled technique

7. Where on table pouch/anastomotic testing with air has shown no anastomotic or pouch leak.

Paradoxically, this may be the procedure of choice in obese patients who cannot lose weight preoperatively. In those individuals, addition of a temporary ileostomy may produce such tension on the superior mesenteric artery (the determining factor for the ease of reach of the pouch to the anus) that we believe the completed IPAA may be excessively vulnerable to leak or disruption.

In our recent review, patients who had one-stage pouch procedure were younger, more often female, smaller in body surface area, on lesser doses of steroids, and required less blood transfusions at the time of their surgery than those who had required ileostomy at the time of the IPAA (Remzi et al, in press). We believe avoidance of diverting ileostomy with these stringent criteria is pivotal to prevent postoperative septic complications and potentially pouch loss in the long term.*

Other Procedures for UC Patients

1. Subtotal or total colectomy and ileostomy. This is preferred in patients:

• Where there is a diagnostic dilemma (features that are ambiguous for Crohn's disease [CD] versus UC, eg, patchy colonic disease, backwash ileitis)

• Patients on very large doses (eg, 50 to 60 mg/d) of prednisone

• Patients with toxic colitis or megacolon

• Gross obesity, where ability to lose weight is precluded by high dose steroid

• Malnutrition, especially hypoalbuminemia

We prefer suturing the stapled-across rectosigmoid stump to the distal aspect of the incision. This places

*Editor's Note: Patients and referring doctors should, as stated, realize that the period of adjustment postoperatively can last 4 months. However, they have avoided an ileostomy.

the suture line extraperitoneally, and if breakdown at the staple line occurs, drainage from the rectal stump can be controlled via a lower incisional fistula without the patient becoming septic. Following subtotal colec-tomy (STC) and ileostomy, and favorable histology review, patients may undergo completion proctectomy and IPAA some 5 to 6 months later.

2. Total colectomy and ileorectal anastomosis: This may be the procedure of choice in two situations, both requiring absence of florid or significant rectal disease.

• Patients with distant metastases (liver, lung) where colon cancer complicates UC

• The young(er) woman who is anxious to maximize her chances of child bearing.

There is evidence that RP/IPAA with its necessary pelvic adhesions postoperatively will diminish fertility due to peritubal and peri-ovarian adhesions (Ording et al, 2002). Additionally, we usually do oophoropexy and apply hyaluronidase/methyl cellulose film (Seprafilm, Genzyme, Cambridge, MA) to the gonadal structures to limit such adhesions. Patients may undergo rectal resection and conversion to a pelvic pouch in 30 to 50% of cases—should disabling proctitis occur or rectal cancer risk become significant with future pregnancies. Following RP and IPAA, we recommend cesarean section due to the risk of sphincter injury with episiotomy or prolonged or difficult labor. Although data from several sources attest to the early good pouch function with vaginal delivery, the studies are flawed by the lack of adequate follow up of pouch function in the middle-aged woman, many years "out" from IPAA (Juhasz et al, 1995).

3. TPC and ileostomy: This has been the standard surgical treatment of UC and is appropriate when:

• The patient is not unduly concerned about having a permanent ileostomy.

• Anal sphincter function is poor. We note however, that preoperative anal incontinence may be due to very active rectal disease reflecting urgency, rather than true sphincter deficiency. Such patients merit anal physiology testing, with particular emphasis on resting pressure. Values above 35 to 40 mm of mercury do not contraindicate RP when the concern is preoperative sphincter function (Halverson et al, 2002).

• Cancer of the lower third of the rectum is present.

• There is a history of radiation to the abdomen and concern for radiation enteritis at the time of the laparotomy.

• The patient is elderly. Our studies show that when patients over the age of 70 years undergo RP/IPAA, although they perceive quality of life to be good/satisfactory, pad usage and continence is considerably greater than in their younger counterparts. Careful discussion must be had with these older patients before offering them RP (Delaney et al, 2002).

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