Ileal Pouch-Anal Anastomosis

WHAT ARE THE SURGICAL OPTIONS FOR BENIGN DISEASE OF THE COLON AND RECTUM?

Patients with benign disease of the colon and rectum, particularly ulcerative colitis and familial polyposis, often require removal of the colon and rectum to cure the disease and prevent cancer. Following this operation, there are several alternatives for the patient for future management of their intestinal contents.

The safest and simplest alternative has been bringing the small intestine to the skin as an ileostomy in the lower abdomen and using an external collecting devise or bag. In some patients a pouch can be made within the abdomen and brought to the skin with a valve so that rather than having an external bag, the intestinal contents can be drained by a tube as necessary. A few patients are able to retain part of the rectum and have the small intestine sewn directly to the rectum, but many run the risk of persistent disease or cancer. More recently, however, a technique for maintaining anal function has been developed. This ileal pouch-anal anastomosis has become an attractive option for many patients.

WHO CAN HAVE THIS PROCEDURE?

The ileal pouch-anal anastomosis can be performed on patients with either ulcerative colitis or familial polyposis. The rectum must still be in place and the results are better if the rectum is not severely diseased. Anal sphincter function must be adequate. Patients more than 60 years of age and those with significant medical problems are not considered good candidates. The procedure generally is discouraged in individuals with Crohn's disease, previous intestinal resections or cancer of the rectum. The procedure is usually performed at the same time as the colectomy, but this may not be advisable where emergency operation is required.

WHAT ARE THE ADVANTAGES OF THIS OPERATION?

The advantages of the procedure are that the diseased colon and rectal mucosa are completely removed, eliminating the possibility of recurrent disease and cancer often seen after anastomosis of the ileum to the intact rectum. Also, complications and inconvenience of an ileostomy are avoided. Many patients feel that the improved body image helps maintain more normal social and functional habits. Because dissection of the rectal muscle is not required, potential complications involving urinary and sexual dysfunction are less frequent after this procedure than after a total removal of the rectum.

HOW DOES THE POUCH-ANAL ANASTOMOSIS WORK?

The ileal pouch-anal anastomosis is an alternative to total removal of the colon and rectum and ileostomy in patients with ulcerative colitis or familial polyposis. There are two components to the procedure.

First: Rectal muscles, including the anal sphincter, are preserved at the time of colon removal by removing only the diseased rectal mucosa or lining. Removing the colon and rectal mucosa will cure the disease and prevent cancer.

Second: A pelvic reservoir pouch is constructed out of a portion of the remaining small intestine which is then pulled through the rectal muscle and sewn to the skin around the anus. Intestinal continuity is maintained so that intestinal contents follow the normal course to the pelvic pouch. The contents accumulate until the urge to defecate develops, then the pouch empties the contents through the anal sphincter. With a successful procedure, the patient will have complete control over gas and stool and will have five or six soft bowel movements daily.

WHAT HAPPENS AFTER THE OPERATION?

The length of hospitalization at the initial operation is similar to that for total removal of the colon and rectum which would be approximately seven days. A temporary ileostomy is usually required while the pouch and anastomosis heal. At the time of discharge, the intestinal contents will be entering the ileostomy appliance and there will only be small amounts of mucous coming through the anal anastomosis. Approximately two months after this operation, an x-ray study of the pouch and anastomosis will be done to make sure healing has occurred satisfactorily. A second operation is then required to removed the ileostomy and allow the intestinal contents to enter the pouch and reservoir. This operation is less extensive than the first operation but requires approximately five days in the hospital.

At the time of discharge after ileostomy closure, bowel movements will be occurring frequently and will be loose. This may require treatment with antidiarrheal agents to prevent soreness in the perianal skin. Dietary restrictions are usually unnecessary except avoiding food intake after the evening meal. Over the next several months, the bowel movements will become thicker and less frequent so that within six to twelve months after the operation there will be approximately six soft bowel movements a day with control of both fluid and gas. Following complete healing of the operation and with adequate function, there should be minimal physical or dietary limitations.

WHAT ARE THE RESULTS OF THE OPERATION?

The procedure has been performed on several thousand patients in the United States over the past 15 years. Experience suggests that the procedure is associated with complications in approximately one-third of the patients. These complications are usually minor but may include major problems such as: suture line leaks, pelvic and wound infections and intestinal obstruction or blockage. A temporary ileostomy is usually required for the first two months after the procedure. Satisfactory control of bowel movements is achieved in 90% of patients. The remainder may require an ileostomy. Some patients wear a pad at night because of mucous drainage while sleeping. Most patients have five or seven soft bowel movements daily within six to twelve months after operation. Stools are initially more frequent but improve as the pouch enlarges, sphincter tone improves and the intestine absorbs more fluid from its contents.

WHAT ARE THE LONG TERM EFFECTS OF THE PROCEDURE?

Patients undergoing this operation have now been evaluated for 10 to 15 years. Bowel function appears to remain stable. The two most common long term problems are bowel obstruction and inflammation of the pouch, called pouchitis. Pouchitis usually is treated by antibiotics. Occasionally further operation will be necessary to reverse the pouch or anastomosis. Women of child bearing age have been able to have children, including vaginal deliveries.

HOW SATISFIED ARE PEOPLE WITH THE PROCEDURE?

In our experience, overall 50% of patients feel they have an excellent results, 26% satisfactory results, 11% tolerable results and 11% poor results. The majority of patients return to work, have insignificant dietary restrictions and minimal restriction of other activities.

PATIENT SATISFACTION AFTER ILEAL POUCH - ANAL ANASTOMOSIS

 

Yes

No

Return to normal sense of well being

74%

26%

Return to normal work/activity

82%

18%

Prefer to ileostomy

95%

5%

Recommend to others

92%

8%

Significant dietary restriction

18%

82%

Avoid certain foods

60%

40%

Altered timing of meals

29%

71%

Changed size of meals

24%

76%

FUNCTIONAL LIMITATIONS AFTER ILEAL POUCH ANAL ANASTOMOSIS

Activity

None

Mild

Moderate

Severe

Family Relationships

84%

8%

5%

3%

Sexual Activity

63%

13%

8%

16%

Social Activity

61%

26%

11%

3%

Sports

50%

29%

11%

11%

Other recreation

61%

29%

5%

5%

Travel

74%

16%

3%

8%

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