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Continent Ileostomy and Ileoanal Procedures
Gastrointestinal and Hepatobiliary Malignancies
0039-6109/86 $0.00
+
.20
Continent Ileostomy and lIeoanal Procedures Oliver H. Beahrs, M.D. *
For certain pathologic conditions involving the colon and rectum, total proctocolectomy is required if the patient is to return to good health and be protected against more serious complications of the diseases. Inflammatory diseases requiring proctocolectomy include chronic ulcerative colitis and granulomatous colitis (Crohn's disease). These conditions require surgical treatment when symptoms become intractable or when complications of perforation, abscess, obstruction, and toxic symptoms develop. For longstanding disease, surgical removal of the large bowel is necessary to protect the patient against the risk of cancer development. Proctocolectomy is also necessary for certain neoplastic diseases, particularly familial polyposis. If the colon and rectum are not removed for this condition, the risk of cancer development is significant. Occasionally, proctocolectomy is necessary for multiple cancers of the colon and rectum, whether occurring simultaneously or nonsimultaneously. Several decades ago, a stem-type ileostomy was established for removal of the colon and rectum. In this instance, the terminal ileum was brought through a stab wound in the abdominal wall. One of the first attempts to resolve this problem was in 1942, when Dragstedt suggested that an ileal stoma could be skin grafted. 4 In this procedure, the exposed segment of ileum was protected and serositis did not develop. In these cases, if the skin graft took, a satisfactory spout was formed over which an appliance could be placed to collect the discharge from the stoma. In some respects, this was a satisfactory procedure but unfortunately, over time, spillage of ileal content over the skin-grafted stoma resulted in inflammatory reaction in the skin graft and the skin graft "wore out." This resulted in shortening of the stoma and the development of stenosis and led to obstruction of the ileostomy, fistula formation, and skin problems. When these things occurred in about 5 years after the initial surgical procedure, the skin-grafted ileostomy had to be revised. A real step forward was made in 1952, when Brooke suggested that an *Professor of Surgery Emeritus, Mayo Medical School, Rochester, Minnesota
Surgical Clinics of North America-Vol. 66, No.4, August 1986
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OLIVER
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BEAHRS
ileostomy could be immediately matured by complete eversion of the ileum backward upon itself, leaving a stoma of 3 to 5 cm in length. 2 The procedure was accomplished by securing the ileum in the abdominal wall, and on eversion of the bowel wall backward upon itself, the edges of the bowel were attached to the skin level, completely covering all exposed serosa. A year later, Turnbull and erile suggested that an ileal stoma could be immediately matured by mucosal grafting of the exposed ileum. 13 This was accomplished by removal of the serosa and muscularis on the distal 3 to 5 cm of ileum and eversion of the remaining mucosa back over the remaining exposed ileum. This procedure was somewhat more difficult to accomplish than the Brooke type of ileostomy and failed on occasions when there was loss of mucosa. Because there were infrequent complications to the Brooke type of ileostomy, it survived as the standard procedure when an abdominal stoma is required. ACCEPTABILITY OF BROOKE ILEOSTOMY Because it was assumed that the quality of life with a Brooke ileostomy was acceptable to patients requiring proctocolectomy, Roy and associates reviewed 497 cases of patients with ileostomy and, in particular, inquired by questionnaire and interview the acceptability of the ileostomy to them in terms of their general health and physical activity. 12 Almost 90 per cent indicated that their general health was good or excellent. Only 5 per cent blamed the ileostomy for failure to be in perfect health. Sixty-six per cent enjoyed normal dietary habits. Ninety-six per cent returned to their previous employment, and many felt that they were more capable of working because of better health. Eighty-two per cent enjoyed various types of leisure activities, and only seventeen per cent discontinued participation in sporting activities. Twenty-six per cent did state that they experienced some skin problems around the stoma. Based on this review, it was reasonable to conclude that a Brooke type of ileostomy was an acceptable exchange for the pathology that required the proctocolectomy and the symptoms related to it. It should be noted that 14 per cent of the patients required some type of revision of the stoma because of complications that occurred with it over a period of time. All patients, however, objected to the necessity of continually wearing an appliance to collect the discharge from the ileostomy, over which there was no voluntary control. During the 1950s and 1960s, the improvement and increased availability of equipment to manage an ileostomy contributed greatly to the management of an ileal stoma. Also, the training of enterostomal therapists significantly improved patient care. THE CONTINENT ILEOSTOMY (KOCK POUCH) The next great step forward in the management of patients requiring proctocolectomy came in 1969, when Kock suggested that a continent
CONTINENT ILEOSTOMY AND ILEOANAL PROCEDURES
835
ileostomy could be established with a pouch just within the abdominal cavity just proximal to the ileal stoma. 6 The continent ileostomy then gave the patient control over evacuation of intestinal content and eliminated the need to wear an external appliance constantly. The Procedure The Kock pouch requires the use of the terminal 45 cm of ileum. The proximal 30 cm of this segment is opened and sutured together in such a way as to create a pouch, which at the time of creation will hold about 100 ml of content. The pouch is made by bringing the bowel together in a horseshoe manner; after the loop is approximated, the loop is opened and the pouch is completed by bringing the apex of the open loop to the opposite end of the opened loop. At first it was suggested that continence could be developed by bringing the ileum distal to the pouch through the rectus muscle at an oblique angle or through crossed fibers of the rectus muscle. Initial experience with these methods resulted in about a 50 per cent failure rate. Kock then suggested that continence most likely could be established by developing a nipple valve using the ileum distal to the pouch. The nipple valve is specifically a reverse intussusception of the bowel backward into the pouch creating an intussusception of approximately 5 cm in length. The ileum distal to the nipple valve is then brought through the abdominal wall and the stoma established flush with the skin level by approximating the end of the ileum to the skin. Although the establishment of the pouch is not a complicated procedure, the establishment of the nipple valve is, primarily because a complication of the procedure is the reduction or the disintussusception of the nipple valve, which then results in incontinence, and the patient in turn loses the benefit of the procedure. To try to prevent this complication from occurring, the surgeon should secure the nipple valve in position using multiple rows of nonabsorbable suture, or the nipple valve can be held in place with several rows of staples. At the base of the intussusception, it has likewise been suggested that either fascia or Marlex mesh might be used to prevent disintussusception. The base of the nipple valve in the pouch should be carefully anchored to the parietal peritoneum and deep fascia of the abdominal wall directly beneath the stoma. An evacuation tube should be left through the nipple valve into the pouch for a period of 2 to 3 weeks, keeping the pouch decompressed and the anatomic parts in place while healing occurs. Over a period of time, the pouch dilates so that it will hold 500 to 600 ml of content or more. The patient voluntarily evacuates the pouch two to four times a day using a special 28-30 French catheter to do so. Between intubations, it is necessary to wear a small pad or a Band-Aid over the stoma, because there is frequently a little mucus secreted from the exposed mucosa of the stoma. Results The continent ileostomy is a viable alternative to a Brooke ileostomy for patients requiring a proctocolectomy. With increased experience in the technical aspects of the procedure, the results have significantly improved. Although previously plagued with up to a 30 per cent revision rate, it is
836
OLIVER
H.
BEAHRS
currently much more successful in experienced hands. The continent ileostomy appears to contribute significantly to the social and psychologic well-being of these patients. My experience suggests that improved surgical technique makes this procedure a safe and favorable alternative to the traditional Brooke ileostomy.l Ninety-seven per cent of the patients believe they are in good health, while only 3 per cent think that their health is poor. Ninety-three per cent of the patients were pleased with the pouch: 56 per cent were totally satisfied, and 37 per cent were partially satisfied. Seven per cent were dissatisfied with the pouch as it was functioning at the time of their interview. After the operation, 90 per cent of the patients found that their weight was stable. Of the 10 per cent whose weight was unstable, most found that their weight had increased over the preoperative period. Fifty-nine per cent believed their pouch was always continent for stool and 43 per cent always found it continent for gas. Ninety per cent of patients thought their pouch was continent from the social standpoint. Thirteen per cent reported that their pouch was never continent for stool and that it was therefore necessary to wear an appliance. Forty-two per cent of the patients occasionally had difficulty with intubation. These problems were minimal, and only 10 per cent had problems periodically that they regarded as significant. Eighty-three per cent of the patients were comfortable and confident with evacuation of the pouch in public places. Sixteen per cent of the patients indicated that there were some minor skin problems, primarily secondary to the slight secretion of mucus. On review, 43 per cent of the patients required additional surgery after creation of the continent ileostomy, but in many instances further surgical procedures were not related to the pouch itself. With regard to excision or revision overall, the need for such a procedure is decreasing with increased experience, presumably on the basis of surgical modifications and improved techniques. Thus, for the first 150 patients, the rate of revision was 33 per cent, whereas in the last 100 patients it was 18 per cent. Seventy-six per cent of the patients were actively employed, this being essentially all patients who chose to be employed. Forty-three per cent of the patients believed their work tolerance was improved after creation of the pouch; only 11 per cent thought it was worse. Eighty per cent of the patients found that the continent ileostomy did not interfere with their social activity, travel, use of clothing, or sports. Sexual activity remained for the most part unchanged in 64 per cent of the patients but was considerably improved in 25 per cent. Of the patients who had a Brooke ileostomy converted to a continent ileostomy, 55 per cent believed that the continent ileostomy represented a considerable improvement in the quality of life, whereas 40 per cent regarded their life-styles as having been basically unchanged. Although the numbers speak for themselves, there is concern about the rather large reoperation rate. However, the experience suggests overall that the continent ileostomy does contribute to the social and psychologic well-being of our patient population. Recent experience does suggest that the incidence of pouch revision is decreasing on the basis of surgical modifications and improved techniques.
CONTINENT ILEOSTOMY AND ILEOANAL PROCEDURES
837
In general, it might be stated that the continent ileostomy is a viable alternative in the management of selected patients who require proctocolectomy. Maximal success in its use requires careful preoperative selection and evaluation together with careful, well-planned postoperative teaching and management.
ILEOANAL PROCEDURES Although the continent ileostomy eliminates the necessity for wearing an external appliance, it does still result in a stoma in an abnormal location and require use of a tube for evacuation. The patient in many respects would prefer evacuation through the normal perineal route (the anus) and voluntary control over evacuation without the use of any type of equipment. For this reason, there has long been interest in re-establishing intestinal continuity by anastomosis of the ileum to the anus following proctocolectomy. It was Nissen, in 1933, who first reported an ileoanal anastomosis. 7 Subsequently, Ravitch 10 and Ravitch and Sabiston l l reported their experience. However, difficulties with the procedure, lack of success in some patients, and the morbidity associated with the procedure precluded its general acceptance as a satisfactory alternative to an abdominal stoma. In subsequent years, many others have reported the use of the ileoanal anastomosis or with variations of it with some success. 5, 8, 9, 14 In addition to a straight ileoanal anastomosis, Parks has suggested an "s" pouch proximal to the anastomosis to serve as a reservoir. 8 Utsunomiya has suggested a "1" pouch.14 In the absence of a pouch created at the time of the surgical procedure, sometimes it requires a period of several months for the distal ileum to dilate and form its own ·reservoir after the procedure. Based on studies by Pemberton and associates, it appears that reconstruction with a "1" pouch and an ileoanal anastomosis is the most satisfactory of the several alternatives that have been reported. 9 Surgical Technique The proctocolectomy is carried out in the usual manner except in removing the rectum. Care is taken to carry the dissection close to the rectal wall to minimize the damage to the neural supply to the bladder and genitalia. Only the mucosa of the distal rectum is removed, preserving the muscular layer of this segment of the rectum. At one time it was thought essential that a significant length of the muscular layer be retained; however, it appears that this is not essential and possibly only about 5 cm of distal muscularis need be preserved. If a "1" pouch is formed, then the dependent portion of the "J" is brought through the muscular layer and anastomosed to the anus. If a straight ileoanal anastomosis is to be accomplished, the distal end of the ileum is passed through the muscular tube and the anastomosis completed between the ileum and the anus. If a pouch has been formed, it should be approximately 15 to 25 cm in length. It is essential that the pelvic area be drained to eliminate any accumulation of serum, blood, or exudate, which might lead to infection and abscess
838
OLIVER
H.
BEAHRS
formation. Also, it is well to consider a loop ileostomy proximal to the distal ileum to bypass the ileal content while healing takes place. The loop ileostomy is usually left in place for 8 to 12 weeks. If healing has been complete and satisfactory without development of abscess or fistula formation, then the ileostomy can be safely closed. Results Pemberton and associates, in review of their experience with the procedure, have reported that if morbidity is to be minimized, patients should be carefully selected for the procedure. 9 Of primary importance is that the patient has no evidence of dysfunction of the anal sphincter, and there should be absence of anal disease. An excellent candidate for the procedure might be a patient who has previously had an ileorectal anastomosis and now needs a proctectomy. In this instance, the distal ileum has already dilated up sufficiently to form reservoir capacity, and in such a case it is not always necessary to create a pouch. With appropriate selection of patients for the procedure, continence can be expected to be present in over 80 per cent of the cases, and bowel function can be expected to be in the range of six times, plus or minus two, on a daily daytime basis and approximately twice during the night. Very slight soiling might be expected in about 25 per cent of the patients during the daytime and about 50 per cent of the patients at night. Most patients are willing to accept this frequency of bowel function and slight soilage because evacuation is through the normal route and no equipment is necessary. In cases in which failure of the procedure has occurred, the patients can be reoperated and a Brooke type of ileostomy is established on the abdominal wall. It is usually inadvisable to consider establishing a continent ileostomy in these cases because this would put more small intestine in jeopardy should further complications occur.
SUMMARY It is fortunate today that several alternatives are available for reconstruction of the intestinal tract when proctocolectomy is required in the management of inflammatory diseases of the colon or multiple neoplastic diseases. The Brooke ileostomy proves to be very satisfactory and is acceptable to the majority of patients but does require the continual wearing of an appliance. For patients with chronic ulcerative colitis and a poorly functioning anal sphincter or one that is diseased, a continent ileostomy is the preferred procedure. However, in patients with a normally functioning anal sphincter, an ileoanal anastomosis, most often with a 'T' pouch, is the first alternative procedure to be considered because evacuation following this operation is through the normal route and requires no equipment. For patients with granulomatous colitis (Crohn's disease), it seems best to consider only the Brooke type of ileostomy because of the risk of recurrent inflammatory disease involVing the ileum. However, for colonic ulcerative colitis and familial polyposis, either the continent ileostomy or the ileoanal anastomosis is the preferred procedure to be considered.
CONTINENT ILEOSTOMY AND ILEOANAL PROCEDURES
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Dozois has reviewed in detail the technical aspects of the various surgical procedures, the indications for their use, the results that can be expected, and the comments of many of the contributors to the advances in the management of patients requiring proctocolectomy and one method or another of re-establishing a means for bowel evacuation. 3 With the various alternatives that are available today and the excellent results that can be expected when patients are properly selected, more patients with diseases of the colon and rectum requiring proctocolectomy can be offered the benefits of surgical treatment, returning them to society and improving their quality of life.
REFERENCES 1. Beart, R. W., Jr., Beahrs, O. H., Kelly, K. A., et al.: The continent ileostomy: A viable alternative. Mayo Clin. Proc., 54:643-645, 1979. 2. Brooke, B. N.: The management of an ileostomy including its complications. Lancet, 2:102-104, 1952. 3. Dozois, R. R.: Alternatives to Conventional Ileostomy. Chicago, Year Book Medical Publishers, 1985. 4. Dragstedt, L. R., Dack, G. M., and Kirner, J. B.: Chronic ulcerative colitis: A summary of evidence implicating Bacterium necrophorum as an etiologic agent. Ann. Surg., 114:653, 1941. 5. Fonkalsrud, E. W.: Total colectomy and endorectal ileal pull-through with internal ileal reservoir for ulcerative colitis. Surg. Gynecol. Obstet., 150:1-8, 1980. 6. Kock, N. G.: Intra-abdominal "reservoir" in patients with permanent ileostomy: preliminary observations on a procedure resulting in fecal "continence" in five ileostomy patients. Arch. Surg., 99:223-230, 1969. 7. Nissen, R.: Demonstration en aus der operativen chirurgie zunachst einige beobachtungen aus der plastischen chirurgie. Zentralbl. Chir., 60:883-888, 1933. 8. Parks, A. G., Nicholis, R. J., and Belliveau, P.: Proctocolectomy with ileal reservoir and anal anastomosis. Br. J. Surg., 67:533-538, 1980. 9. Pemberton, J. H., Heppell, J., Beart, R. W., Jr., et al.: Endorectal ileoanal anastomosis. Surg. Gynecol. Obstet., 155:417-424, 1982. 10. Ravitch, M. M.: Anal ileostomy with sphincter preservation in patients requiring total colectomy for benign conditions. Surgery, 24:170-187, 1948. 11. Ravitch, M. M., and Sabiston, D. C., Jr.: Anal ileostomy with preservation of the sphincter: A proposed operation in patients requiring total colectomy for benign lesions. Surg. Gynecol. Obstet., 84:1095-1099, 1947. 12. Roy, P. H., Sauer, W. G., Beahrs, O. H., et al.: Experience with ileostomies: Evaluation oflong-term rehabilitation in 497 patients. Am. J. Surg., 119:77-86, 1970. 13. Turnbull, R. B., Jr., and Crile, G., Jr.: Mucosal grafted ileostomy in the surgical treatment of ulcerative colitis. J.A.M.A., 1958:32, 1955. 14. Utsunomiya, J., Iwama, T., Imajo, M., et al.: Total colectomy, mucosal proctectomy, and ileoanal anastomosis. Dis. Colon Rectum, 23:459-466, 1980. Mayo Clinic 200 First Street S. W. Rochester, Minnesota 55905
0039-6109/86 $0.00
+
.20
Continent Ileostomy and lIeoanal Procedures Oliver H. Beahrs, M.D. *
For certain pathologic conditions involving the colon and rectum, total proctocolectomy is required if the patient is to return to good health and be protected against more serious complications of the diseases. Inflammatory diseases requiring proctocolectomy include chronic ulcerative colitis and granulomatous colitis (Crohn's disease). These conditions require surgical treatment when symptoms become intractable or when complications of perforation, abscess, obstruction, and toxic symptoms develop. For longstanding disease, surgical removal of the large bowel is necessary to protect the patient against the risk of cancer development. Proctocolectomy is also necessary for certain neoplastic diseases, particularly familial polyposis. If the colon and rectum are not removed for this condition, the risk of cancer development is significant. Occasionally, proctocolectomy is necessary for multiple cancers of the colon and rectum, whether occurring simultaneously or nonsimultaneously. Several decades ago, a stem-type ileostomy was established for removal of the colon and rectum. In this instance, the terminal ileum was brought through a stab wound in the abdominal wall. One of the first attempts to resolve this problem was in 1942, when Dragstedt suggested that an ileal stoma could be skin grafted. 4 In this procedure, the exposed segment of ileum was protected and serositis did not develop. In these cases, if the skin graft took, a satisfactory spout was formed over which an appliance could be placed to collect the discharge from the stoma. In some respects, this was a satisfactory procedure but unfortunately, over time, spillage of ileal content over the skin-grafted stoma resulted in inflammatory reaction in the skin graft and the skin graft "wore out." This resulted in shortening of the stoma and the development of stenosis and led to obstruction of the ileostomy, fistula formation, and skin problems. When these things occurred in about 5 years after the initial surgical procedure, the skin-grafted ileostomy had to be revised. A real step forward was made in 1952, when Brooke suggested that an *Professor of Surgery Emeritus, Mayo Medical School, Rochester, Minnesota
Surgical Clinics of North America-Vol. 66, No.4, August 1986
833
834
OLIVER
H.
BEAHRS
ileostomy could be immediately matured by complete eversion of the ileum backward upon itself, leaving a stoma of 3 to 5 cm in length. 2 The procedure was accomplished by securing the ileum in the abdominal wall, and on eversion of the bowel wall backward upon itself, the edges of the bowel were attached to the skin level, completely covering all exposed serosa. A year later, Turnbull and erile suggested that an ileal stoma could be immediately matured by mucosal grafting of the exposed ileum. 13 This was accomplished by removal of the serosa and muscularis on the distal 3 to 5 cm of ileum and eversion of the remaining mucosa back over the remaining exposed ileum. This procedure was somewhat more difficult to accomplish than the Brooke type of ileostomy and failed on occasions when there was loss of mucosa. Because there were infrequent complications to the Brooke type of ileostomy, it survived as the standard procedure when an abdominal stoma is required. ACCEPTABILITY OF BROOKE ILEOSTOMY Because it was assumed that the quality of life with a Brooke ileostomy was acceptable to patients requiring proctocolectomy, Roy and associates reviewed 497 cases of patients with ileostomy and, in particular, inquired by questionnaire and interview the acceptability of the ileostomy to them in terms of their general health and physical activity. 12 Almost 90 per cent indicated that their general health was good or excellent. Only 5 per cent blamed the ileostomy for failure to be in perfect health. Sixty-six per cent enjoyed normal dietary habits. Ninety-six per cent returned to their previous employment, and many felt that they were more capable of working because of better health. Eighty-two per cent enjoyed various types of leisure activities, and only seventeen per cent discontinued participation in sporting activities. Twenty-six per cent did state that they experienced some skin problems around the stoma. Based on this review, it was reasonable to conclude that a Brooke type of ileostomy was an acceptable exchange for the pathology that required the proctocolectomy and the symptoms related to it. It should be noted that 14 per cent of the patients required some type of revision of the stoma because of complications that occurred with it over a period of time. All patients, however, objected to the necessity of continually wearing an appliance to collect the discharge from the ileostomy, over which there was no voluntary control. During the 1950s and 1960s, the improvement and increased availability of equipment to manage an ileostomy contributed greatly to the management of an ileal stoma. Also, the training of enterostomal therapists significantly improved patient care. THE CONTINENT ILEOSTOMY (KOCK POUCH) The next great step forward in the management of patients requiring proctocolectomy came in 1969, when Kock suggested that a continent
CONTINENT ILEOSTOMY AND ILEOANAL PROCEDURES
835
ileostomy could be established with a pouch just within the abdominal cavity just proximal to the ileal stoma. 6 The continent ileostomy then gave the patient control over evacuation of intestinal content and eliminated the need to wear an external appliance constantly. The Procedure The Kock pouch requires the use of the terminal 45 cm of ileum. The proximal 30 cm of this segment is opened and sutured together in such a way as to create a pouch, which at the time of creation will hold about 100 ml of content. The pouch is made by bringing the bowel together in a horseshoe manner; after the loop is approximated, the loop is opened and the pouch is completed by bringing the apex of the open loop to the opposite end of the opened loop. At first it was suggested that continence could be developed by bringing the ileum distal to the pouch through the rectus muscle at an oblique angle or through crossed fibers of the rectus muscle. Initial experience with these methods resulted in about a 50 per cent failure rate. Kock then suggested that continence most likely could be established by developing a nipple valve using the ileum distal to the pouch. The nipple valve is specifically a reverse intussusception of the bowel backward into the pouch creating an intussusception of approximately 5 cm in length. The ileum distal to the nipple valve is then brought through the abdominal wall and the stoma established flush with the skin level by approximating the end of the ileum to the skin. Although the establishment of the pouch is not a complicated procedure, the establishment of the nipple valve is, primarily because a complication of the procedure is the reduction or the disintussusception of the nipple valve, which then results in incontinence, and the patient in turn loses the benefit of the procedure. To try to prevent this complication from occurring, the surgeon should secure the nipple valve in position using multiple rows of nonabsorbable suture, or the nipple valve can be held in place with several rows of staples. At the base of the intussusception, it has likewise been suggested that either fascia or Marlex mesh might be used to prevent disintussusception. The base of the nipple valve in the pouch should be carefully anchored to the parietal peritoneum and deep fascia of the abdominal wall directly beneath the stoma. An evacuation tube should be left through the nipple valve into the pouch for a period of 2 to 3 weeks, keeping the pouch decompressed and the anatomic parts in place while healing occurs. Over a period of time, the pouch dilates so that it will hold 500 to 600 ml of content or more. The patient voluntarily evacuates the pouch two to four times a day using a special 28-30 French catheter to do so. Between intubations, it is necessary to wear a small pad or a Band-Aid over the stoma, because there is frequently a little mucus secreted from the exposed mucosa of the stoma. Results The continent ileostomy is a viable alternative to a Brooke ileostomy for patients requiring a proctocolectomy. With increased experience in the technical aspects of the procedure, the results have significantly improved. Although previously plagued with up to a 30 per cent revision rate, it is
836
OLIVER
H.
BEAHRS
currently much more successful in experienced hands. The continent ileostomy appears to contribute significantly to the social and psychologic well-being of these patients. My experience suggests that improved surgical technique makes this procedure a safe and favorable alternative to the traditional Brooke ileostomy.l Ninety-seven per cent of the patients believe they are in good health, while only 3 per cent think that their health is poor. Ninety-three per cent of the patients were pleased with the pouch: 56 per cent were totally satisfied, and 37 per cent were partially satisfied. Seven per cent were dissatisfied with the pouch as it was functioning at the time of their interview. After the operation, 90 per cent of the patients found that their weight was stable. Of the 10 per cent whose weight was unstable, most found that their weight had increased over the preoperative period. Fifty-nine per cent believed their pouch was always continent for stool and 43 per cent always found it continent for gas. Ninety per cent of patients thought their pouch was continent from the social standpoint. Thirteen per cent reported that their pouch was never continent for stool and that it was therefore necessary to wear an appliance. Forty-two per cent of the patients occasionally had difficulty with intubation. These problems were minimal, and only 10 per cent had problems periodically that they regarded as significant. Eighty-three per cent of the patients were comfortable and confident with evacuation of the pouch in public places. Sixteen per cent of the patients indicated that there were some minor skin problems, primarily secondary to the slight secretion of mucus. On review, 43 per cent of the patients required additional surgery after creation of the continent ileostomy, but in many instances further surgical procedures were not related to the pouch itself. With regard to excision or revision overall, the need for such a procedure is decreasing with increased experience, presumably on the basis of surgical modifications and improved techniques. Thus, for the first 150 patients, the rate of revision was 33 per cent, whereas in the last 100 patients it was 18 per cent. Seventy-six per cent of the patients were actively employed, this being essentially all patients who chose to be employed. Forty-three per cent of the patients believed their work tolerance was improved after creation of the pouch; only 11 per cent thought it was worse. Eighty per cent of the patients found that the continent ileostomy did not interfere with their social activity, travel, use of clothing, or sports. Sexual activity remained for the most part unchanged in 64 per cent of the patients but was considerably improved in 25 per cent. Of the patients who had a Brooke ileostomy converted to a continent ileostomy, 55 per cent believed that the continent ileostomy represented a considerable improvement in the quality of life, whereas 40 per cent regarded their life-styles as having been basically unchanged. Although the numbers speak for themselves, there is concern about the rather large reoperation rate. However, the experience suggests overall that the continent ileostomy does contribute to the social and psychologic well-being of our patient population. Recent experience does suggest that the incidence of pouch revision is decreasing on the basis of surgical modifications and improved techniques.
CONTINENT ILEOSTOMY AND ILEOANAL PROCEDURES
837
In general, it might be stated that the continent ileostomy is a viable alternative in the management of selected patients who require proctocolectomy. Maximal success in its use requires careful preoperative selection and evaluation together with careful, well-planned postoperative teaching and management.
ILEOANAL PROCEDURES Although the continent ileostomy eliminates the necessity for wearing an external appliance, it does still result in a stoma in an abnormal location and require use of a tube for evacuation. The patient in many respects would prefer evacuation through the normal perineal route (the anus) and voluntary control over evacuation without the use of any type of equipment. For this reason, there has long been interest in re-establishing intestinal continuity by anastomosis of the ileum to the anus following proctocolectomy. It was Nissen, in 1933, who first reported an ileoanal anastomosis. 7 Subsequently, Ravitch 10 and Ravitch and Sabiston l l reported their experience. However, difficulties with the procedure, lack of success in some patients, and the morbidity associated with the procedure precluded its general acceptance as a satisfactory alternative to an abdominal stoma. In subsequent years, many others have reported the use of the ileoanal anastomosis or with variations of it with some success. 5, 8, 9, 14 In addition to a straight ileoanal anastomosis, Parks has suggested an "s" pouch proximal to the anastomosis to serve as a reservoir. 8 Utsunomiya has suggested a "1" pouch.14 In the absence of a pouch created at the time of the surgical procedure, sometimes it requires a period of several months for the distal ileum to dilate and form its own ·reservoir after the procedure. Based on studies by Pemberton and associates, it appears that reconstruction with a "1" pouch and an ileoanal anastomosis is the most satisfactory of the several alternatives that have been reported. 9 Surgical Technique The proctocolectomy is carried out in the usual manner except in removing the rectum. Care is taken to carry the dissection close to the rectal wall to minimize the damage to the neural supply to the bladder and genitalia. Only the mucosa of the distal rectum is removed, preserving the muscular layer of this segment of the rectum. At one time it was thought essential that a significant length of the muscular layer be retained; however, it appears that this is not essential and possibly only about 5 cm of distal muscularis need be preserved. If a "1" pouch is formed, then the dependent portion of the "J" is brought through the muscular layer and anastomosed to the anus. If a straight ileoanal anastomosis is to be accomplished, the distal end of the ileum is passed through the muscular tube and the anastomosis completed between the ileum and the anus. If a pouch has been formed, it should be approximately 15 to 25 cm in length. It is essential that the pelvic area be drained to eliminate any accumulation of serum, blood, or exudate, which might lead to infection and abscess
838
OLIVER
H.
BEAHRS
formation. Also, it is well to consider a loop ileostomy proximal to the distal ileum to bypass the ileal content while healing takes place. The loop ileostomy is usually left in place for 8 to 12 weeks. If healing has been complete and satisfactory without development of abscess or fistula formation, then the ileostomy can be safely closed. Results Pemberton and associates, in review of their experience with the procedure, have reported that if morbidity is to be minimized, patients should be carefully selected for the procedure. 9 Of primary importance is that the patient has no evidence of dysfunction of the anal sphincter, and there should be absence of anal disease. An excellent candidate for the procedure might be a patient who has previously had an ileorectal anastomosis and now needs a proctectomy. In this instance, the distal ileum has already dilated up sufficiently to form reservoir capacity, and in such a case it is not always necessary to create a pouch. With appropriate selection of patients for the procedure, continence can be expected to be present in over 80 per cent of the cases, and bowel function can be expected to be in the range of six times, plus or minus two, on a daily daytime basis and approximately twice during the night. Very slight soiling might be expected in about 25 per cent of the patients during the daytime and about 50 per cent of the patients at night. Most patients are willing to accept this frequency of bowel function and slight soilage because evacuation is through the normal route and no equipment is necessary. In cases in which failure of the procedure has occurred, the patients can be reoperated and a Brooke type of ileostomy is established on the abdominal wall. It is usually inadvisable to consider establishing a continent ileostomy in these cases because this would put more small intestine in jeopardy should further complications occur.
SUMMARY It is fortunate today that several alternatives are available for reconstruction of the intestinal tract when proctocolectomy is required in the management of inflammatory diseases of the colon or multiple neoplastic diseases. The Brooke ileostomy proves to be very satisfactory and is acceptable to the majority of patients but does require the continual wearing of an appliance. For patients with chronic ulcerative colitis and a poorly functioning anal sphincter or one that is diseased, a continent ileostomy is the preferred procedure. However, in patients with a normally functioning anal sphincter, an ileoanal anastomosis, most often with a 'T' pouch, is the first alternative procedure to be considered because evacuation following this operation is through the normal route and requires no equipment. For patients with granulomatous colitis (Crohn's disease), it seems best to consider only the Brooke type of ileostomy because of the risk of recurrent inflammatory disease involVing the ileum. However, for colonic ulcerative colitis and familial polyposis, either the continent ileostomy or the ileoanal anastomosis is the preferred procedure to be considered.
CONTINENT ILEOSTOMY AND ILEOANAL PROCEDURES
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Dozois has reviewed in detail the technical aspects of the various surgical procedures, the indications for their use, the results that can be expected, and the comments of many of the contributors to the advances in the management of patients requiring proctocolectomy and one method or another of re-establishing a means for bowel evacuation. 3 With the various alternatives that are available today and the excellent results that can be expected when patients are properly selected, more patients with diseases of the colon and rectum requiring proctocolectomy can be offered the benefits of surgical treatment, returning them to society and improving their quality of life.
REFERENCES 1. Beart, R. W., Jr., Beahrs, O. H., Kelly, K. A., et al.: The continent ileostomy: A viable alternative. Mayo Clin. Proc., 54:643-645, 1979. 2. Brooke, B. N.: The management of an ileostomy including its complications. Lancet, 2:102-104, 1952. 3. Dozois, R. R.: Alternatives to Conventional Ileostomy. Chicago, Year Book Medical Publishers, 1985. 4. Dragstedt, L. R., Dack, G. M., and Kirner, J. B.: Chronic ulcerative colitis: A summary of evidence implicating Bacterium necrophorum as an etiologic agent. Ann. Surg., 114:653, 1941. 5. Fonkalsrud, E. W.: Total colectomy and endorectal ileal pull-through with internal ileal reservoir for ulcerative colitis. Surg. Gynecol. Obstet., 150:1-8, 1980. 6. Kock, N. G.: Intra-abdominal "reservoir" in patients with permanent ileostomy: preliminary observations on a procedure resulting in fecal "continence" in five ileostomy patients. Arch. Surg., 99:223-230, 1969. 7. Nissen, R.: Demonstration en aus der operativen chirurgie zunachst einige beobachtungen aus der plastischen chirurgie. Zentralbl. Chir., 60:883-888, 1933. 8. Parks, A. G., Nicholis, R. J., and Belliveau, P.: Proctocolectomy with ileal reservoir and anal anastomosis. Br. J. Surg., 67:533-538, 1980. 9. Pemberton, J. H., Heppell, J., Beart, R. W., Jr., et al.: Endorectal ileoanal anastomosis. Surg. Gynecol. Obstet., 155:417-424, 1982. 10. Ravitch, M. M.: Anal ileostomy with sphincter preservation in patients requiring total colectomy for benign conditions. Surgery, 24:170-187, 1948. 11. Ravitch, M. M., and Sabiston, D. C., Jr.: Anal ileostomy with preservation of the sphincter: A proposed operation in patients requiring total colectomy for benign lesions. Surg. Gynecol. Obstet., 84:1095-1099, 1947. 12. Roy, P. H., Sauer, W. G., Beahrs, O. H., et al.: Experience with ileostomies: Evaluation oflong-term rehabilitation in 497 patients. Am. J. Surg., 119:77-86, 1970. 13. Turnbull, R. B., Jr., and Crile, G., Jr.: Mucosal grafted ileostomy in the surgical treatment of ulcerative colitis. J.A.M.A., 1958:32, 1955. 14. Utsunomiya, J., Iwama, T., Imajo, M., et al.: Total colectomy, mucosal proctectomy, and ileoanal anastomosis. Dis. Colon Rectum, 23:459-466, 1980. Mayo Clinic 200 First Street S. W. Rochester, Minnesota 55905