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Ileo-Pouch Anal Anastomosis Guide
There are two decisions that a patient with inflammatory bowel disease will need to make. The first is whether to have an operation, and the second is which operation to have.
There are only three reasons why one should decide to have surgery. These are: the risk of malignancy, life-threatening complications, and medical intractability. Only you can make the decision as to whether surgery is appropriate.
If you decide that surgery is appropriate, the next decision is which operation to have. There are four different operations to consider; all four are acceptable, however, each one has advantages and disadvantages. You must weigh those and decide which surgery is right for you.
Brooke Ileostomy
The first option is the Brooke ileostomy. The word ileostomy comes from ileum, the lowest part of the small intestine (bowel), and stoma, or opening. An ileostomy creates an opening at the end of the small bowel. The bowel is then brought out through a small hole in the abdominal wall where the liquid intestinal contents can flow out of the body at any time. An external bag must be worn over the opening at all times to collect the stool.
An ileostomy is a simple procedure that has been around for more than 50 years and its complications are well known. It allows for a high quality of life and will not limit your lifestyle any more than you choose to let it. Nevertheless, it does require an external appliance and, for either social or psychological reasons, many patients seek to avoid it.
Continent Ileostomy
The second option is a continent ileostomy, also known as a Kock pouch, T-pouch, or Barnett pouch. These are internal reservoirs surgically created from the small bowel. The end of the small bowel is brought out through the abdomen. The opening is generally flush with the abdominal wall and an external appliance is not routinely needed. The advantage to this option is that it avoids the use of a permanent external bag.
The disadvantage is that it still requires an opening in the abdominal wall. The internal reservoir must be emptied of stool at least three times per day. This is done by inserting a tube through the abdominal opening into the internal reservoir. In about 20% of cases, stool begins to leak out of the opening. If it does leak, another major operation will be necessary to correct the problem. Although it was a common procedure 30 years ago, it is now rarely performed in patients who are having their colon removed.
Abdominal Colectomy and Ileorectal Anastomosis
The third option is to remove the colon but leave the rectum alone,
attaching it directly to the small bowel. This is called an abdominal
colectomy and ileorectal anastomosis. This option is not available
to many. In most patients the rectum is too severely diseased to
allow it to remain in place. However, in about 10% of patients,
the rectum can be salvaged. This option offers the advantage of
a one-stage operation that eliminates most of the disease.
The disadvantage is that the remaining rectum can become diseased or develop cancer. Some surgeons argue that the results are so good with the ileoanal procedure, ileorectal anastomosis should no longer be used. However, this option is attractive in that it does not burn any bridges. If the remaining rectum does show signs of disease or cancer, which happens in about half of the cases, it can be removed and one of the other alternatives can then be performed.
The fourth and final option, and the focus of this booklet, is the pull-through, or ileoanal procedure. This is the most commonly performed procedure today for patients with ulcerative colitis or familial polyposis.
Ileoanal Procedure
With the ileoanal procedure, the entire colon and rectum is removed, but the anus is preserved. A small segment of the lowest part of the rectum also may be preserved to facilitate putting the bowel back together. If it is possible to save these one or two centimeters of rectum, bowel sensitivity and control seems to be improved.
When this operation is performed, a temporary diverting ileostomy is usually done. This ileostomy will remain in place until the patient is off all medications, is feeling well, and has regained preoperative strength. It can be closed no sooner than six weeks after the initial operation. After stoma closure, the patient should anticipate an adjustment period of several months. Later, when the pouch is mature, the patient can expect five to seven bowel movements per day. However, it is not the number of bowel movements that is most important, but the fact that there should be minimal urgency associated with the bowel movements.
For some patients, the stool frequency is a problem. If your lifestyle, involves spending extended time in areas where a bathroom is not available, then perhaps the ileoanal approach is not a good option.
First Surgery (Creation of the pouch)
A temporary ileostomy is created to divert the small bowel contents away from the newly created reservoir so it may heal.
Second Surgery (Closure of the ileostomy)
1. Approximately six weeks after the first surgery, the ileostomy is closed.
2. Food now enters the mouth, moves into the stomach, then through the small intestine into the reservoir.
3. Waste is stored in the reservoir until the need to have a bowel movement.
Stool is then passed through the anus.
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