Issues and Controversies

Pouch Construction

A variety of pouch techniques and configurations have been described including the J, S, W, and lateral isoperi-staltic (H) types. The functional results of these various pouch designs appear to be comparable, where the J pouch is easiest to construct and has functional outcomes identical to those of more complex designs (Johnston et al, 1996). We prefer the J pouch, as it is simple to make using a linear stapler cutting technique, can be done rapidly in s 5 minutes, and has no obstructive defecation sequelae. The S pouch is occasionally used when excessive anasto-motic tension is predictable in a given patient. It usually reaches 2 to 4 cm farther than does the J pouch and is useful in patients with a short fat mesentery, and long, narrow pelvis when the reach of the ileal pouch to the anal canal can be a problem. In our practice, this is especially true in patients who are obese or where mucosectomy and hand-sewn anastomosis is indicated due to neoplasia. Care is exercised to limit the exit conduit to s 2 cm as obstructive defecation—necessitating pouch emptying by periodic catheter intubation—may ensue.

Anastomotic Issues

The two main ways in which the pouch can be joined to the anal canal are by stapling and by hand sutured techniques. For a stapled anastomosis, it is necessary to leave a 1 to 2 cm strip of anal transitional mucosa to allow transanal insertion of the staple head. This zone is usually referred to as the anal transitional zone (ATZ). This creates a controversy, which centers on the potential advantages and disadvantages of leaving a mucosal cuff of rectal mucosa. The potential advantages include better functional results, lower rate of septic complications, and ease of construction, whereas disadvantages include possible malignant or premalignant transformation of the columnar epithelial cells in the retained mucosal cuff, cuffitis, and a longer, more difficult surgery. The prospective randomized trials have not shown a difference in functional outcome and septic complications between the two methods (Sonoda and Fazio, 2000). However these studies warrant careful analysis, because of relatively short term follow up and because the small number of cases studied make them vulnerable to type II error. our initial studies comparing the two types of techniques showed less septic complications and better functional outcome favoring stapled anastomosis (Ziv et al, 1996). The most recent study of over 2,000 patients from our institution continued to show superior functional results in patients with stapled anastomosis, where the septic complications showed some increased trend in mucosectomy group but did not reach the statistical difference of the prior study from our institution (Remzi et al, 2002).

We believe that the major complication of pouch surgery is sepsis secondary to anastomotic dehiscence and this, in turn, is due to excessive anastomotic tension. We believe, the least septic complication rates occur when the ileal pouch is stapled to the top of the anal columns 1 to 2 cm above the dentate line.

This ATZ is vulnerable to neoplastic and/or acute symptomatic inflammatory change. Our studies show that in the absence of synchronous colonic carcinoma at the time of index TPC and IPAA for UC, the risk of dysplasia is negligible and cancer in the ATZ has yet to be reported. From an oncogenic standpoint, stapled IPAA is therefore safe (Remzi et al, 2003). We do, however, recommend ATZ surveillance and biopsy. our current recommendation for the management of risk of ATZ dysplasia and selection of type of anastomosis to be used in creation of IPAA is summarized in Figure 79-2. Further data is needed before this examination frequency can be relaxed, in our view. For patients with synchronous colorectal cancer, dysplasia in lower two-thirds of rectum or primary sclerosing cholangitis, postoperative ATZ dysplasia is a substantial risk and complete anal mucosec-tomy is recommended at time of RP (Kartheuser et al, 1996; Remzi et al, 2003; Marchesa et al, 1997).

If a patient has undergone stapled IPAA for cancer complicating UC (usually first diagnosed in the colectomy specimen), then close follow up (eg, annual or 6-month biopsies) is recommended. We were successful in preserving the pelvic pouch in two patients who underwent late transanal muco-sectomy and pouch advancement for late development of ATZ dysplasia (Fazio and Tjandra, 1994). So, why not do mucosectomy in every case? We believe that anal sphincter stretch is considerable and protracted when hand-sewn techniques with mucosectomy are used.This produces significant and prolonged reduction in resting sphincter tone and is associated with higher rates (compared to stapled IPAA) of nocturnal incontinence, seepage, and pad usage, by

FIGURE 79-2. Management of risk of anal transitional zone (ATZ) dysplasia. IPAA = ileal pouch-anal anastomosis; PSC = primary sclerosing cholangitis.

patients during daytime and nighttime (Remzi et al, 2002; Tuckson et al, 1991). In the patients without risk factors for ATZ dysplasia (absence of synchronous cancer or dysplasia in the rectum), the continence factor is a compelling one in our advocating stapled IPAA. When the risk factors for ATZ dysplasia are present, the balance of risk/benefit comes down in favor of complete mucosectomy in our view.

A final point on this issue: if we see a patient whose body habitus suggests that anastomotic tension will be excessive with a hand-sewn anastomosis, we will lay out the pros and cons of a stapled alternative even if adverse oncologic indicators are present. We believe the patient should be given full data on this issue to allow a measured decision to be made along with the caveats (viz surveillance) attendant with a decision to pursue restorative proctocolectomy.

Perioperative and Postoperative Issues

Sepsis Pelvic sepsis is the most serious early complication of ileal pouch operations and is one of the main causes of pouch failure. The rate of sepsis after ileoanal pouch construction ranges from 5 to 24% (Fazio et al, 1995). It may be due to suture line leaks, or bacterial contamination of the surgical space during the operation. Etiologic risk factors predisposing to pelvic sepsis are local and general inflammatory changes, such as malnutrition, prolonged steroid usage, hypoalbuminemia, anemia, and hypoxemia. Fever, perineal pain, purulent discharge, and leukocytosis are the most common presenting symptoms of sepsis.

Leaks may develop from the pouch-anal anastomosis, from the pouch itself or from tip of the J pouch. Anastomotic tension and bowel ischemia are the two main factors associated with high leakage rates after IPAA.

Anastomotic leaks may be asymptomatic "sinuses" that originate from the anastomosis, and they are most often diagnosed at the time of pouchography when the patient returns for the takedown of the ileostomy. Such radiologically detected leaks represent incomplete healing of the anastomosis or the ileal pouch. The leaks will usually heal spontaneously by deferring the closure of the ileostomy for a few months. A repeat Gastrografin enema should be performed 3 to 6 months later for evaluation. If no abscess cavities are present and the sinus track leading from the anastomosis is narrowed or obliterated, then ileostomy closure can be performed.

In a symptomatic patient who is stable, not septic, and has no peritonitis, initial treatment for a leak should include intravenous (IV) antibiotic therapy, drainage, and bowel rest. Antibiotic coverage should include both aerobic gram-negative and anaerobic organisms. In the presence of a sizeable pelvic abscess, percutaneous drainage under computed tomography guidance may prevent the need for re-laparotomy.

In some instances, a minor leak results in a small pre-sacral collection. Examination under anesthesia allows evaluation of the abscess collection and passage of a transanal catheter into the cavity for daily irrigation. The catheter may be safely removed when there is clinical and radiologic evidence of resolution of the abscess cavity.

Emergent surgical intervention may be required for patients who are treated with nonoperative therapy whose signs and symptoms worsen and those with generalized peritonitis or high output pouch-cutaneous fistulas, although this is uncommon, especially in the presence of a diverting ileostomy. The surgical intervention should be preceded by immediate fluid resuscitation and administration of IV broad spectrum antibiotics.

Sinuses, fistulas, or leaks that persist after treatment, may require repeat IPAA or permanent ileostomy (Baixauli et al, 2004). They may also suggest the presence of underlying CD. Sepsis, sinuses, or fistulas (eg, pouch anastomotic vaginal fistulas), which appear late (over 6 months) from

IPAA, are often indicative of CD, although not always (Shah et al, 2003). The management ranges from intermittent antibiotic therapy (ciprofloxacin and metronidazole with or without local seton drainage) pouch advancement flap-through to repeat IPAA with fistula exclusion. The latter is used if the former is unsuccessful.

Constipation Prescription

Constipation Prescription

Did you ever think feeling angry and irritable could be a symptom of constipation? A horrible fullness and pressing sharp pains against the bladders can’t help but affect your mood. Sometimes you just want everyone to leave you alone and sleep to escape the pain. It is virtually impossible to be constipated and keep a sunny disposition. Follow the steps in this guide to alleviate constipation and lead a happier healthy life.

Get My Free Ebook

Post a comment