Open Restorative Proctocolectomy
Robert R. Cima
Indications/ContraindicationsIn the majority of patients with chronic ulcerative colitis (CUC), the preferred operation is the restorative proctocolectomy, also known as an ileal pouch anal anastomosis (IPAA). The advantages of the IPAA are that it removes the diseased organs, the colon and rectum, while preserving the normal route of defecation thus avoiding the need for a permanent ostomy. Since its introduction in the early 1980s, the published experience has demonstrated that IPAA is a technically challenging operation with fairly predictable functional outcomes that are durable over long-term follow-up.
The surgical approach to patients with CUC is divided into two broad categories: emergent and elective surgical intervention. Indications for emergent intervention in CUC include the following:
Fulminant colitis
Toxic megacolon
Colonic perforation
Massive hemorrhage
Fortunately, with a better understanding of the natural history of CUC and improved medical treatment options these situations arise less frequently. However, approximately 10% of newly diagnosed CUC patients present with fulminant colitis. In these emergent situations, the goal of the surgical procedure is to address a life-threatening clinical situation without precluding a future restorative procedure. In emergent situations, there is no role for proceeding to an IPAA. IPAA is time-consuming and unnecessarily increases the complexity of the surgery predisposing to significant complications.
In a patient with known CUC or indeterminate colitis who requires emergent operation, the procedure of choice is the subtotal colectomy with end ileostomy. The advantages of this approach are as follows:
The majority of the diseased organ is removed
Afterward the patient can improve their overall health and nutritional status
The patient can be weaned from all immunosuppressive medications
The rectum is left in situ allowing the patient to proceed at a later date to an IPAA without any deleterious impact on the functional outcomes
Thankfully, most IPAAs are performed under elective circumstances. In these situations the indications for surgery are as follows:
Failure of medical therapy to control symptoms
Relief of the deleterious side effects of medications
The development of intestinal dysplasia
Treatment of an intestinal malignancy
The contraindications to IPAA are steadily decreasing. Relative contraindications included the following:
Advanced age. Traditionally, age over 55–60 was considered a contraindication to IPAA because of presumed poor functional outcomes related to incontinence. However, a number of studies have reported acceptable functional results in patients in whom IPAA was performed in their 70s and even 80s
Planned or desired pregnancy in the near term after IPAA. IPAA has a significant negative impact on the ability to become pregnant
History of frequent or prolonged perianal sepsis (abscesses, fistulas)
Obesity makes the operation extremely difficult but in appropriately selected candidates it can be performed successfully
Colonic Crohn’s disease traditionally has been considered an absolute contraindication to IPAA. Recently, some authors have reported in highly selected patients without any history of small bowel or anal Crohn’s disease the outcomes of IPAA are similar to CUC patients. Despite these few reports most would consider Crohn’s disease an absolute contraindication to IPAA
Absolute contraindications include the following:
Frequent incontinence episodes not associated with flares of disease activity
Need for pelvic radiation
Small bowel or anal Crohn’s disease
Preoperative Planning
Patients need to visit with an enterostomal therapist for preoperative stoma marking and to begin education regarding the care of the stoma.
Routine use of oral antibiotics or a mechanical bowel preparation is not required. However, a patient should receive one or two tap water enemas the morning of surgery.
If the patient is currently on steroids or has taken them within the last 6 months, a stress dose of steroids is given in the perioperative period.
Intravenous antibiotics are administered within 60 minutes of incision.
Ideally, a thoracic epidural catheter is placed for postoperative pain control.
Lower extremity sequential compression devices are placed and activated prior to the induction of anesthesia.
5,000 units of subcutaneous heparin is administered.
Intraoperative Considerations
Positioning
All patients require a padded chest strap placed securing them to the table.
A forced air warming device is placed over the torso and head.
The patient is positioned in modified Lloyd-Davies lithotomy with both arms padded, protected, and tucked against the torso.
The legs are placed in leg holder that allows the hips and thighs to be flat with respect to the abdomen but the lower leg to be positioned downward (i.e., Yellofin® Stirrups, Allen® Medical Systems).
The use of leg holders minimize the chance of patient movement on the table during positioning changes as well as permitting access to the perineum for placement of a circular stapler or a vaginal manipulator if required.
Technique
A lower midline incision is made and extended cephalad to gain enough exposure to safely mobilize the hepatic and splenic flexure of the colon. The lowest extent of the incision should be the top of the pubic bone. This optimizes the exposure for the pelvic dissection and performing the anastomosis. The upper extent of the incision will vary contingent upon the size of the patient and the height of the splenic flexure.
The abdomen is thoroughly explored for any unexpected findings. Most importantly, the small bowel is inspected for any evidence of Crohn’s disease.
The entire abdominal colon is mobilized from its lateral and retroperitoneal attachments. Care is taken to identify the course of both ureters down into the pelvis.
The mesentery of the colon is divided close to the origin of the vessels with the exception of the right colon. The mesentery of the right colon is divided close to the colon to protect the ileocolic vessel. This vessel may later need to be divided in order to achieve maximal length of the small bowel but it should be preserved initially until it is determined if the vessel must be divided.
The small bowel mesentery is then mobilized up to the duodenum and away from the head of the pancreas. It is essential that all the small bowel mesenteric attachments to the duodenum are divided to ensure that maximal small bowel mesenteric length is achieved in order to allow the ileal pouch to reach to the upper anal canal without tension.
The terminal ileum is divided close to the ileocecal valve by a single firing of a linear cutting stapler.Related posts:
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