Description of procedure

This procedure involves the surgical removal of colon, rectum, and anus with creation of a permanent Brooke ileostomy.

Indications

Most patients are suitable candidates for this operation irrespective of age. The choice of this operation is often appropriate for patients who wish to avoid the problems associated with ileoanal pouch procedure (IPAA) (eg the need for a second procedure to close the stoma, risk of pouchitis, poor function, or long term risk of pouch failure) or those who are not suitable candidates for a resortative procedure, especially in elderly patients and those with poor sphincter function.

Contraindications

Body habitues, especially obesity can make construction of a good Brooke ileostomy difficult.

Operative factors

The operative technique is well described. The most important parts of the operation are the preoperative assessment of the stoma site (the aid of an enterostomal therapist is helpful), the pelvic dissection to avoid damage to the autonomic nerves of the pelvis which can cause erectile and ejaculation dysfunction, and careful anal excision as perineal wounds can be difficult to heal (level 5)

Intersphincteric perineal dissection has become the technique of choice for anal excision in these patients. With this technique the anus and distal rectum are removed through a small skin incision with the dissection being carried out in the plane between the internal and external anal sphincter. This leaves the external sphincter and levator muscle complex available for closure.

Complications

Delayed perineal wound healing is well documented as a problem (level 5). In a Mayo Clinic study of 89 patients with chronic ulcerative colitis only 61% had a healed perineal wound by thirty days, and by 200 days this had increased to 80% but 4% never healed. Intersphincteric perineal dissection improves the chance of primary healing. Proctectomy can result in damage to the pelvic autonomic nerves (impotence 5% retrograde ejaculation 3%) and dyspareunia (12–30% of females) (level 5).

Outcome

Proctocolectomy with Brooke ileostomy repeatedly scores the lowest in comparative quality of life studies between the four operations (level 3). In an actuarial analysis of stomal complications in 150 patients who had their stoma for UC for 20 years, stomal complications occurred in 76% (level 5). The most common complications were skin problems (cumulative probability of 34%), retraction (17%), parastomal herniation (16%), and prolapse (11%). The cumulative probability of having a revision is 23% at 20 years.

Sexual function improves in many related to an improved overall wellbeing but the presence of a stoma is reported in 30% of ileostomomates to make sexual intercourse more difficult, and 50% feel themselves to be less sexually desirable. Despite the disadvantages, proctocolectomy with Brooke ileostomy remains a viable option in older patients and those who may not be candidates for a sphincter saving operation.

Description of procedure

This operation involves removal of the abdominal colon with creation of an ileorectal anastomosis leaving the diseased rectum in situ and is the simplest sphincter saving operation.

Indications

The main indication for ileorectal anastomosis is the wish of the patient to avoid a permanent stoma and avoid an IPAA, either temporarily or permanently. It is a one-stage operation, with minimum hospital stay and complications. The risk of bladder and sexual dysfunction secondary to pelvic nerve injury is low.

Ileaorectal anastomosis is particularly useful in patients with indeterminate colitis when an ileostomy can be avoided, and if the disease subsequently declares itself to be Crohns Disease the optimum procedure for avoiding an ileostomy has been performed. A patient with marginal sphincter control may be better with an ileorectal anastomosis than a pouch, and it may be also be indicated in patients found to have metastatic colon carcinoma at the time of laparotomy.

Contraindications

The operation should not be undertaken were there is active rectal disease. The ability to make an ileorectal anastomosis requires a quiescent or minimally inflamed rectum if the procedure is to be successful. It is not a suitable operation for patients whose main symptom is frequency with uncontrolled bowel movement. It is not a suitable operation for those with colonic or rectal dysplasia (level 5).

Operative factors

It is a standard operative technique and is well described. The rectum should be transected at the level of the sacral promontory, and not mobilized, so as to avoid damage to the nervi erigentes, while descending over the edge of the pelvis and passing down to the inferior hypogastric plexuses.

Complications

The patients are at risk of the standard perioperative complications of a colectomy and anastomosis, and any immunosuppressed patients may be at slightly higher risk of septic complications. The most important long term problem is that of possible rectal cancer. The risk of developing a subsequent rectal carcinoma is up to 5–6% at 20 years, 15% at 30, 18% at 35 years which mandates regular endoscopic surveillance (level 5). Cancers that do present are often at an advanced stage (level 5).

Outcome

Although quality of life is generally good in carefully selected patients, they do not feel as if they are cured of UC and may require chronic maintenance therapy to treat proctitis. The functional results are variable and depend on rectal compliance and the extent and activity of the UC. Good functional results are obtained in about 80–90% of carefully selected patients, with an average of 4–5 stools per 24 hours and nocturnal evacuation occurring in about 35% of patients. However, about 50% will require antidiarrheal medication although generally their function is better than that reported for ileal-anal pouches (level 5).

The cumulative probability of having a functional ileorectal anastomosis at 10 years is 50% and 20 years 32% (level 5). Failure is more common in those patients who have an ileorectal anastomosis at an younger age, and most common cause for failure is severe diarrhoea due to inflammation in the rectum. Previous ileorectostomy does not preclude a future IPAA (level 5).

Description of procedure

The Kock pouch procedure involves a standard proctocolectomy with creation of an ileal pouch with a valve to render the pouch continent. The pouch is emptied by tube intubation two to four times daily. An external appliance is not needed.

Indications

Today the main indication for a Kock pouch is in those patients seeking an alternative to a conventional ileostomy owing to skin problems or psychosocial and sexual problems, or failed ileoanal pouch procedures. Anal sphincter dysfunction or a low rectal cancer associated with UC may be suitable for a Kock pouch. It is suitable for patients who have previously undergone a proctocolectomy and Brooke ileostomy who wish conversion due to dissatisfaction with the ileostomy.

Contraindications

The main contraindications to the pouch are patients where there is a strong possibility of Crohns Disease due to the high rate of fistula formation, obstruction, and leakage. Relative contraindications include previous resection of a significant amount of small bowel, age of the patient over 60, co-existing serious medical illness, and obesity.

Operative Factors

Following removal of the colon and rectum, the terminal 45 cm of ileum is used to construct the Kock pouch; 5 cm for the outlet, 10 cm for the nipple value, 30 cm for the reservoir (3 × 10 cm). An S shaped reservoir is initially constructed. The valve is created by intussusception of the terminal ileum into the pouch, with prior stripping of the mesentery and fat over the ileum that is to be made into the nipple value. The ileum is intussuscepted, and either stapled or sutured in place. The exit spout leading to the pouch can be placed in an inconspicuous location on the lower abdomen.

Complications

The main problem with the Kock pouch is the high complication rate (level 5). Reoperation rates as high as 35% within the first 2 years have been reported by experienced centers, and in centers with limited experience it is reported as being much higher. The most common problem is nipple valve dysfunction. The nipple value appears to be inherently unstable and slippage results in inability or difficulty with intubation, and usually incontinence of the pouch. The diagnosis can usually be confirmed by clinical exam or contrast study, sometimes pouchoscopy is helpful. The pouch usually needs intubation as a temporary measure and operative revision of the value as a permanent solution. Multiple variations of the Kock pouch have been described attempting to minimize the mechanical failures.

Value necrosis can occur early following construction of the pouch. It is due to ischaemia resulting from excision of the peritoneum and fat from the mesentery of the segment of ileum forming the value, or placement of staples across the mesentery and blood supply to the value.

Fistulae are reported to occur in 8–12% of patients. They may be internal or external, with the internal often involving the valve and the external usually from the pouch to the skin. The use of mesh to support the valve complex seems to be associated with a higher incidence of fistulae, however consideration of a diagnosis of Crohns Disease is important. Treatment of the fistula usually involves reoperation and excision of the value with reconstruction of a new one.

Pouchitis is not uncommon occurring between 8–42% of patients. The variable incidence reported is probably due to the variability in definition, small numbers of patients and short follow-up in most studies. Pouchitis is characterized by diarrhoea, abdominal cramps and fever, and usually responds to metrondazole.

Outcome

Overall the level of satisfaction with a well functioning Kock pouch is excellent (level 3). Quality of life studies show that Kock pouch patients performed better than Brooke ileostomy patients in terms of sport and sexual function, but not as well as patients after ileoanal pouch operations. In a Cleveland Clinic study 80% of patients felt that their body image was improved after conversion of their conventional ileostomies. The main problem with the procedure is the high rate of complications requiring revisional surgery.

Description of procedure

The operation involves resection of the colon and rectum, with formation of an ileal pouch, and pouch-anal anastomosis (IPAA). The procedure was first described by Sir Alan Parks of St Mark's Hospital in London.

Indications

IPAA is now the surgical procedure of choice in most patients with UC (level 3).

Contraindications

Patients less than 60 years of age are preferred (level 4). Exceptions have been made in extremely physiological fit individuals with acceptable results. Short obese patients are advised to lose weight prior to operation as the ability of the ileal pouch to reach the anus for anastomosis is compromised by the limited mobility of a short thick small bowel mesentery. Tall patients can also be a challenge to get the pouch to reach the anus for anastomosis.

Other contraindications include low rectal cancer, and patients where there is serious concern that the underlying diagnosis might be Crohns Disease. Ileoanal pouch failure is common if Crohns Disease is diagnosed after a pouch has been constructed then management should be aimed at the Crohns Disease itself, and the pouch doesn't have to be removed unless there is a major problem with function or fistula. In patients with UC and rectal cancers, mucosectomy is required to remove all the dysplasic mucosa, and any post operative radiotherapy may affect ileal pouch compliance, resulting in poor function. The anal sphincter needs to be of good quality. If there is any question, anal manometery should be performed. Patients who have psychological problems, emotional instability, poor motivation or are non-compliant may have difficulty adjusting to the psychological stress associated with an ileoanal pouch, and should be carefully evaluated before surgery.

Operative factors

Since its creation, the operation has undergone multiple modifications to improve functional results. The operation is usually undertaken in two stages, the first being the proctocolectomy, ileal pouch construction, pouch-anal anastomosis, and formation of a defunctioning loop ileostomy. The second stage is usually undertaken 2–3 month latter and consists of closure of the loop ileostomy. There are select patients who have undergone a single-stage operation with acceptable results, however peripouch sepsis with resulting fibrosis, can lead to loss of pouch compliance and poor function (level 5). This is the commonest cause for pouch failure and as such most surgeons prefer to defunction the pouch, as it reduces the chance of complications should a leak occur.

The ileal pouch is constructed using one of the several pouch designs, which include the J-pouch, S-pouch and W-pouch. The ultimate choice of pouch design is largely the surgeon's preference, studies to date suggesting that J and W produce similar results. The S pouch is considered an inferior design, especially when there is a long exit spout, as this can cause obstructive defecation problems which at times require intubation of the pouch to empty it (level 3). The J-pouch design is the most commonly used in part due to the ease of construction.

The choice of pouch-anal anastomosis is controversial. There are two options either a transanal mucosectomy with hand-sutured anastomosis between the pouch and the dentate line or a stapled technique with the anastomosis 1.5–2 cm above the dentate line preserving part of the anal transition zone. The mucosectomy technique was thought to remove all the diseased mucosa and climinate the risk of cancer, however recent evidence suggests that despite surgical mucosectomy, rests of mucosa still exist and so there is in persisting need for postoperative surveillance. Advocates of the stapled techniques suggest that it is technically easier and has better functional results. To date the published randomized and case control studies demonstrate no significant long functional differences between the two techniques, however there are a number of studies in progress (level 2).

Complications

Mortality from the operation is less than 1%. The most common complications of IPAA are pelvic sepsis, small bowel obstruction, stricture, and pouchitis (level 5). Perioperative pelvic sepsis occurs in 5–8% of patients. Poor nutritional status and immunosuppressive medications such as prednisone, cyclosporin and azathioprine are predisposing factors. Many patients can be treated by CT guided catheter drainage and antibiotics. The functional outcome after IPAA complicated by pelvic sepsis is poor.

Bowel obstruction is common following all types of surgery for UC. The annual risk for patients following IAPP is 1 in 25, 1 in 49 for a Kock pouch, 1 in 66 for a proctocolectomy and Brooke ileostomy, and 1 in 71 for colectomy and ileorectal (level 5).

Anastomotic stricture occurs in 4–16% of patients. Some degree of anal stricture may be found at the time of ileostomy closure, which is best treated by gentle dilatation. Predisposing factors include pelvic sepsis, anastomotic tension and ischaemia. The stricture may cause outlet obstructive symptoms, diarrhoea, and anal pain. The vast majority respond to dilatation, though in 60% this may have to be repeated.

Pouchitis is a condition characterized by increased stool frequency, bloody stools, abdominal cramps or pain, and fever. The aetiology is unknown. The incidence varies from 7% to 50% according to the definition of pouchitis used and the duration of follow-up. The Mayo Clinic reported, that the cumulative risk of acute pouchitis was 15% at one year, 36% at five years, and 46% at 10 years. Pouchitis is most common in patients with primary sclerosing cholangitis (PSC) and who are ANCA positive. Metronidazole is the treatment of first choice. Many other treatments in refractory cases have been used such as ciprofloxacin, corticosteroids, amoxycillin/clavulinic acid, erythromycin, tetracycline, allopurinol, 5-aminoacetic acid, short-chain fatty acids enemas and cyclosporin retention enemas. It is rare for pouchitis alone to be the cause of IPAA failure and excision.

Outcome

In experienced hands, the results with IPAA are good. Stool frequency is typically 5–7 per 24 hours, including 1 bowel motion at night. Gas/stool discrimination is possible in 60–75% of patients. Day time incontinence where present is usually minor, however at night 20–25% of patients wear a pad. Antidiarrheal medications is common in the first year with 50–75% taking medication daily however after a year this falls to 25–30%. Day and night time function may improve over a year after which it remains stable for at least ten years (level 5). The early decrease in stool frequency is most likely due to the pouch expansion and the improvement in sphincter function that is seen over the first year.

Pouch failure is infrequent reported at between 2–9% over 10 years (level 5). The most common reasons for pouch failure are pelvic sepsis, gross faecal incontinence, Crohns Disease, and chronic pouchitis.

Pregnancy and vaginal delivery are possible and do not affect the long term results after IAPP (level 5). Although the frequency of nocturnal stooling increases during pregnancy, neither daytime stool frequency nor continence appear to be adversely affected, and neither vaginal delivery or caesarean section appears to adversely affect longer term pouch function.

Quality of life in patients with IPAA is better than that of patients with Brooke ileostomies, Kock pouches and medically treated patients with UC (level 3). It is the combination of good functional results and quality of life which argues strongly in support of IPAA as the operative procedures of choice in UC.