Open Restorative Proctocolectomy and Ileal Pouch-Anal Anastomosis
Alexis Grucela
David M. Schwartzberg
Michael J. Grieco
Mitchell Bernstein
INDICATIONS/CONTRAINDICATIONS
The surgical treatment of ulcerative colitis (UC) has evolved over the past century, from what was initially an unknown disease process, to a surgically curable disease. In the 1950s, total proctocolectomy with Brooke ileostomy or ileo-rectal anastomosis became the standard of care for UC and familial adenomatous polyposis (FAP) through the pioneering work of Alfred Strauss, Sir Brian Brooks, and Rupert Turnbull. The ileo-rectal anastomosis avoided a permanent stoma; however, it left the diseased rectum in situ that continued to be at risk for developing carcinoma. Advances in anastomotic techniques led to the ileal-anal anastomosis, first with an S-shaped ileal reservoir by Sir Alan Parks and John Nicholls from London’s St. Mark’s Hospital. J-, W-, and H-pouches soon followed from Japan under the guidance of Utsunomiya Kock, Longmire, and Kock. Today, the J-pouch has become the reservoir of choice secondary to its fast and technically easier construction, good functional results, and long-term durability.
Restorative proctocolectomy with ileal J-pouch-anal anastomosis (IPAA) is now the procedure of choice for patients with mucosal ulcerative colitis (MUC) and FAP.
Advantages of IPAA:
Removes the diseased colon and rectum
Markedly reduces the risk of colon and rectal cancer
Preserves the normal route of defecation, thus avoiding the need for a permanent ileostomy
The surgical approach to patients with CUC is divided into two broad categories, elective and emergent. Emergent intervention, usually consisting of total abdominal colectomy with end ileostomy, without proctectomy, is performed for CUC patients for the following indications (Table 29-1):
Fulminant colitis
Toxic megacolon
Colonic perforation
Massive hemorrhage
TABLE 29-1 Indications for Surgery in Ulcerative Colitis | ||||||||||||
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In acutely ill patients, the operative goal is to address the life threatening clinical situation by removing the diseased colon and allowing the patient to restore to a healthier state with improved nutrition, and off of immunosuppressive medications, such as steroids and anti-tumor necrosis factor (anti-TNF)-α agents, prior to the next staged operation to remove the rectum and construct the J-pouch. Staged operations offer these advantages to the patient prior to their IPAA construction:
Improved overall health
Improved nutritional status
Opportunity to be weaned from steroids
Weaned from biologics and other immunosuppressive medications
An in -situ rectum without violation of anatomic planes
IPAA is not undertaken during emergent operations because the physiologic milieu of the patient is not the proper setting for a complicated J-pouch construction. The rectum is spared, and proctectomy avoided leaving physiologic pelvic planes untouched for IPAA construction in the future. The increase in the understanding of the pathophysiology of CUC along with the addition of anti-TNF-α medications has resulted in a significant decrease in the number of emergent cases for fulminant colitis per year; however, approximately 25% of newly diagnosed CUC patients will still require proctocolectomy.
Most IPAAs are performed under elective circumstances. Indications for surgery are as follows (Table 29-1):
CUC refractory to medical management
Patients who are steroid dependent
Deleterious side effects of medications
The development of malignancy or dysplasia-associated lesion or mass
Stricture
Patient choice to avoid medication cost
Relative contraindications to IPAA include the following:
Advanced age: Traditionally, age over 70 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 been shown to have a negative impact on fecundity. Women wishing to become pregnant may elect a staged operation. Laparoscopic procedures have reduced the negative impact on fertility.
History of frequent or prolonged perianal sepsis (abscesses, fistulas).
Obesity: Obesity makes the operation extremely difficult, and mesenteric length is an issue, but in appropriately selected candidates it can be performed successfully.
Crohn’s disease: Crohn’s disease has historically been considered an absolute contraindication to IPAA. Crohn’s enteritis still remains a contraindication along with patients with perianal Crohn’s disease. However, it has been shown that in highly select patient populations with Crohn’s colitis and rectal sparing, an IPAA can be offered with acceptable outcomes.
Absolute contraindications include the following:
Frequent incontinence episodes not associated with flares of disease activity
Need for pelvic radiation
Crohn’s enteritis and/or perianal Crohn’s disease
PREOPERATIVE PLANNING
Formal discussions with the patient and family/support system must ensue because operative options and outcomes must be relayed to the patient. Although the goal is to restore intestinal continuity with IPAA, there are patients who will not be able to have a restorative proctocolectomy for anatomic or functional reasons, or the initial diagnosis of Crohn’s disease prohibiting pouch formation.
Education on functional results of the IPAA is important, including managing expectations with regards to frequency of bowel movements and potential for seepage, pad usage, or need for chronic anti-diarrheal medications.
Consultation with an enterostomal therapist for preoperative stoma marking and education is important. The preferred site for a diverting loop ileostomy is through the rectus muscle, inferior and to the right of the umbilicus.
There is no routine use of oral antibiotics and mechanical bowel preparation; however, some surgeons prefer one or two tap water enemas the morning of surgery to evacuate the rectum.
If the patient is currently on steroids or has taken them within the last 6 months, stress dose steroids are considered in the perioperative period and tailored to operative findings.
SURGERY
Positioning
The patient should be positioned on the operating room table lying on a padded material to avoid slipping while in Trendelenburg position and avoid nerve damage (i.e., Pink Pad Pigazzi Positioning System, Xodus Medical, New Kensington, PA ).
The patient is positioned in modified lithotomy with both arms padded, protected, and tucked against the torso.
The legs are placed in stirrups, which allow the hips and thighs to be flat with respect to the abdomen but the lower leg to flexed at the knee with protection of the head of the fibula and peroneal nerve, while minimizing pressure on the calf (i.e., Yellofins Stirrup, Allen Medical Systems, Acton, MA ).
All patients require a padded chest strap placed to secure them to the table. All intravenous lines and electrocardiogram leads should be avoided with the strap.
A forced air warming device is placed over the torso and head.
Rectal irrigation can be performed.
Intravenous antibiotics are administered within 60 minutes of incision and 5,000 units of subcutaneous heparin are administered.
A thoracic epidural catheter can be considered for postoperative pain control.
Lower extremity sequential compression devices are placed and activated prior to the induction of anesthesia.
The abdomen is prepped and draped in the standard fashion.
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 expose the pubic symphysis. This optimizes the exposure for the pelvic dissection and anastomosis. The upper extent of the incision will vary, contingent upon the body habitus of patient and the location of the splenic flexure. A fascial wound protector is placed (e.g., ALEXIS Wound Protector/Retractor, Applied Medical, Rancho Santa Margarita, CA).
The abdomen is first thoroughly explored for any unexpected findings. Most importantly, the small bowel is inspected for any evidence of Crohn’s disease.
The operation is approached in a lateral-to-medial fashion. The entire abdominal colon is first mobilized from its lateral and retroperitoneal attachments. Care is taken to identify the course of both ureters down into the pelvis without violating the retroperitoneal plane.
To avoid multiple repositioning of the operating room table, the right side is started first with the right side elevated and slight Trendelenburg, followed by the left, and then the remaining transverse colon addressed usually with reverse Trendelenburg position.
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 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.
FIGURE 29-1 The rectum is mobilized, and a nerve sparing dissection is carried out posteriorly down to the pelvic floor.
The small bowel mesentery is then mobilized up to the third part of the duodenum, to the most superior point possible. 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 after removal of the ligament of Treves by a single firing of a linear cutting stapler.
When the abdominal colon is fully mobilized and divided, the patient is placed in steep Trendelenburg position, and the pelvic dissection is begun. A total mesorectal excision is performed. The presacral space is entered, and the superior hemorrhoidal vessel is divided. The rectum is mobilized, and the areolar tissue is divided with cautery, and a nerve sparing dissection is carried out posteriorly down to the pelvic floor (Fig. 29-1).
The lateral attachments are divided. The anterior peritoneal reflection is scored, and the plane is opened (Fig. 29-2) and developed between the rectum and vagina in females, and seminal vesicles in males.
A digital examination is performed to ensure that the rectum is dissected circumferentially down to the pelvic floor/top of the anal canal (Fig. 29-3).Related posts:
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