INTRODUCTION — A total proctocolectomy (TPC) is the surgical treatment option for patients who have failed medical management for ulcerative colitis, select patients with Crohn's disease (without evidence of anorectal disease), and patients with hereditary nonpolyposis colorectal cancer or synchronous colon cancers. In addition, because of an associated increased risk of colon cancer development, a TPC is offered as prophylaxis to patients diagnosed with familial adenomatous polyposis (picture 1).
The development of the continence-preserving procedure restorative proctocolectomy with ileal pouch-anal anastomosis (RPC-IPAA) has made surgical management a more attractive option than a TPC with a permanent end ileostomy. Both approaches can improve the quality of life and reduce the risk of colonic malignancy, and both can be performed as an open or laparoscopic procedure [1,2]. Optimal results depend upon surgical expertise, the clinical setting, and patient selection.
This topic will describe technical details of a laparoscopic approach to the RPC-IPAA.
DESCRIPTION — A restorative proctocolectomy with ileal pouch-anal anastomosis (RPC-IPAA) removes the entire colon and rectum while preserving the anal sphincter and, hence, normal bowel function and fecal continence [3-6]. The pouch serves as an internal pelvic reservoir for intestinal contents.
The optimal laparoscopic approach has not been established. A few variations of the procedure have been described that include hand-assisted and laparoscopically assisted techniques, a single-incision laparoscopic technique, robotic [7,8], transanal [9], and variations in construction of the ileal pouch [6,10-12].
ANATOMY — The anatomy of the colon and rectum is shown in the figures and reviewed elsewhere (figure 1 and figure 2 and figure 3 and figure 4 and figure 5). (See "Radical resection of rectal cancer", section on 'Surgical anatomy'.)
PATIENT SELECTION CRITERIA FOR LAPAROSCOPIC RPC-IPAA — Patients who have failed medical therapy for ulcerative colitis and Crohn's disease without rectal involvement, and those who are at great risk for colon cancer development, such as those with familial polyposis (FAP), are candidates for a restorative colectomy with ileal pouch-anal anastomosis (RPC-IPAA). Indications for the surgical management of inflammatory bowel disease and the role of colectomy in other high-risk clinical settings are discussed elsewhere. (See "Surgical management of ulcerative colitis", section on 'Indications for surgery' and "MUTYH-associated polyposis", section on 'Colorectal cancer surveillance' and "Lynch syndrome (hereditary nonpolyposis colorectal cancer): Cancer screening and management".)
For patients with a colon or rectal cancer, the surgical oncologic principles must be met, including resection of the mesentery and lymphatics and resection of an adequate distal margin. Patients with low rectal cancer requiring an abdominoperineal resection for oncologic reasons are not candidates for an ileal pouch procedure. (See "Surgical resection of primary colon cancer" and "Radical resection of rectal cancer".)
The surgical procedure and approach are based upon the clinical setting (elective versus urgent), patient preference (anal sphincter preservation), body habitus, oncologic criteria (prophylactic versus therapeutic), and previous intra-abdominal and pelvic operations.
Patient selection criteria for RPC-IPAA include [13-18]:
●Intact anal sphincter function.
●Desire to preserve physiologic defecatory function.
●Amenable to multiple procedures to construct acceptable ileal pouch-anal anastomosis.
●No severe obesity. A fatty ileal mesentery may cause the pouch to be rather bulky and ill-fitting in a narrow pelvis; furthermore, the ileal pouch may not reach the upper anal canal despite operative techniques designed to lengthen the ileal mesentery.
●For patients with colon or rectal cancer, the cancer must be completely resectable with adequate distal margins. (See "Radical resection of rectal cancer", section on 'Distal margin'.)
In addition to fecal incontinence, another absolute contraindication to an IPAA is a surgical emergency [19]. In the emergency setting, the majority of surgeons would perform a total abdominal colectomy with an end Brooke ileostomy and preservation of the anorectum followed by an IPAA at a later date [20,21]. Massive bleeding from the rectal stump identified intraoperatively is seldom an indication for an immediate total proctocolectomy, but more often for a near-total proctocolectomy with a very short rectal stump. The issue with such an approach is that retrieving the rectal stump to complete the proctectomy and construct the anastomosis becomes very difficult at the second operation.
In addition to meeting criteria for RPC-IPAA, patients must also fulfill criteria to undergo a laparoscopic approach, including ability to tolerate a pneumoperitoneum and having few previous intra-abdominal/pelvic operations and few adhesions. As experience with laparoscopic RPC-IPAA increases, previous abdominal operations and/or adhesions become a relative contraindication. Laparoscopy can be performed electively as well as in the urgent setting of acute fulminant colitis. A review of 207 consecutive patients undergoing a restorative proctectomy (RP) and restorative proctocolectomy (RPC) found that patients managed by the laparoscopic approach (n = 76) had a shorter median duration of hospital stay compared with patients managed by laparotomy (median stay six versus eight days) [22]. Patients undergoing a laparoscopic RPC also had similar rates of total complications (51 versus 61 percent), anastomotic leaks, 30 day readmission, reoperation, and stoma closure. The conversion from a laparoscopic approach to a laparotomy was 9 percent.
SURGICAL OPTIONS TO LAPAROSCOPIC RPC-IPAA — Proctocolectomy procedures are performed using open or laparoscopic approaches. With increasing experience with laparoscopic colorectal surgery, there are no absolute contraindications to laparoscopy, and the decision is based upon surgeon judgment, skills, and experience. Minimally invasive techniques are central to enhanced recovery after surgery protocols with advantages of a decrease in inflammatory mediators, improved pulmonary function with oncologic outcomes comparable to the open technique, faster return of bowel function, and reduced hospital length of stay. (See "Enhanced recovery after colorectal surgery", section on 'Minimally invasive surgery'.)
Patients who are not candidates for laparoscopy may be candidates for the open approach to the restorative proctocolectomy with ileal pouch-anal anastomosis (RPC-IPAA) procedure. For patients who are not candidates or who prefer not to undergo RPC-IPAA, a total proctocolectomy (TPC) with an end ileostomy is the alternative surgical option [13]. TPC with a permanent ileostomy can be performed using an open or laparoscopic approach.
Open RPC-IPAA — For patients who are candidates for RPC-IPAA but not candidates for the laparoscopic approach, an open procedure is the available alternative. Although obesity and previous abdominal operations often make laparoscopic colorectal procedures challenging, they are not considered absolute contraindications to laparoscopy.
The principles of an open resection are the same as those for a laparoscopic resection. (See 'Laparoscopic surgical approach RPC-IPAA' below.)
Total abdominal colectomy with temporary ileostomy — A staged procedure includes a total abdominal colectomy, temporary end ileostomy, and closure of the rectum (Hartmann's pouch) with or without construction of a mucous fistula. This approach is indicated in clinical settings such as pregnancy and acute fulminant colitis requiring urgent operative management, extreme obesity, a narrow pelvis, and uncertainty of diagnosis, such as ulcerative colitis versus Crohn's disease [23-25]. Because of the trend toward more frequent postoperative complications associated with malnutrition, corticosteroids [26], or infliximab [27], we typically perform a staged procedure for such patients [28].
This strategy avoids the morbidity associated with the rectal dissection, which can be potentially difficult and time consuming in an unstable patient, and maintains the option of an ileal pouch-anal anastomosis as a second stage. A delayed proctectomy is typically performed within three to six months after the initial operation. (See 'Staged procedure' below.)
Total proctocolectomy with permanent end ileostomy — A TPC with a permanent end ileostomy removes the entire colon, rectum, and anus and does not restore gastrointestinal continuity (picture 2 and picture 3). TPC is curative for patients with ulcerative colitis. For patients with inflammatory bowel disease complicated by locally advanced cancer involving the distal rectum, TPC is the procedure of choice.
The indications for a TPC with a permanent end ileostomy include [13]:
●Patient prefers a single operation
●Medically unable to tolerate an extended operation (eg, comorbidities, advanced age)
●Very low or ultra-low rectal cancer, not amenable to sphincter-sparing procedures (see "Surgical treatment of rectal cancer", section on 'Low anterior resection')
●Poor anal sphincter function associated with fecal incontinence
PREOPERATIVE PREPARATION
Pathology review — The diagnosis of ulcerative colitis or dysplasia should be confirmed, and Crohn's disease ruled out, by an expert gastrointestinal pathologist and/or a second opinion review of the biopsy slides.
Mucosectomy versus preservation of ATZ — Patients with a malignancy at the anal transition zone (ATZ) are not candidates for restorative proctocolectomy with ileal pouch-anal anastomosis (RPC-IPAA). For other patients, we have adopted a selective approach to preserving the ATZ. We perform a transanal mucosectomy, which removes all rectal mucosa, and a hand-sewn IPAA for inflammatory bowel disease (IBD) patients with biopsy-proven dysplasia, regardless of the degree or location [29-31], and for familial polyposis (FAP) patients with polyps involving the dentate line.
A stapled IPAA, which requires a small amount of rectal tissue to be spared for the anastomosis, preserves the ATZ in the rectal cuff [32] and is performed only in patients with no evidence of ATZ dysplasia of any grade and no polyps at the dentate line.
The techniques of hand-sewn versus stapled IPAA are also discussed in another topic. (See "Surgical management of ulcerative colitis", section on 'Anastomotic technique'.)
Ostomy site selection — If an ileostomy, either temporary or permanent, is planned, a stoma therapist is required to mark the abdominal site for the ileostomy. (See "Overview of surgical ostomy for fecal diversion", section on 'Preparation and counseling'.)
Mechanical bowel preparation — While some studies suggested that mechanical bowel preparation (MBP) may not be required to safely perform a laparoscopic colectomy, others suggested benefit when MBP is used with oral antibiotics [33]. In our practice, we prescribe MBP and oral and intravenous antibiotics to all patients undergoing IPAA, except for those with acute fulminant colitis. For oral antibiotics, patients typically receive 1000 mg of metronidazole and neomycin each by mouth at 1, 3, and 11 PM the day before surgery. (See "Overview of colon resection", section on 'Bowel preparation'.)
Antimicrobial prophylaxis — Intravenous antibiotic prophylaxis is reviewed elsewhere (table 1). We do not continue antibiotics postoperatively. (See "Antimicrobial prophylaxis for prevention of surgical site infection following gastrointestinal procedures in adults".)
Antimicrobial prophylaxis for prevention of surgical site infection is administered 0 to 2 hours prior to making the incision to begin the colectomy (table 2). (See "Antimicrobial prophylaxis for prevention of surgical site infection in adults".)
Venous thromboembolism prophylaxis — Patients undergoing intra-abdominal surgery are at a moderate-to-high risk for developing a deep venous thrombosis (DVT) [34]. All patients scheduled for colonic resection should receive primary prophylaxis. Prevention of DVT is discussed in detail separately. (See "Prevention of venous thromboembolic disease in adult nonorthopedic surgical patients".)
Enhanced recovery after surgery — We have instituted an enhanced recovery after surgery (ERAS) protocol that includes giving patients carbohydrate loads at midnight and at four hours before surgery and premedicating patients with Tylenol, nonsteroidal anti-inflammatory drugs (NSAIDs), and alvimopan and gabapentin before surgery. Enhanced recovery after colorectal surgery is discussed in further detail separately. (See "Enhanced recovery after colorectal surgery".)
LAPAROSCOPIC SURGICAL APPROACH RPC-IPAA — Laparoscopic restorative proctocolectomy with ileal pouch-anal anastomosis (RPC-IPAA) can be performed in a single setting or as a staged procedure.
Single-stage procedure — The single-stage procedure includes the proctocolectomy and immediate construction of the IPAA, without a temporary ileostomy to protect the anastomosis.
Resection of colon and rectum — The general principles for performing a laparoscopic-assisted RPC-IPAA include:
●Ports and extraction sites – For our single-stage laparoscopic IPAA operations, we use four 5 mm trocars placed as shown in the figure (figure 6 and picture 4) and a 5 mm 30º laparoscope. The general approach for peritoneal access and placement of ports is reviewed separately. (See "Abdominal access techniques used in laparoscopic surgery".)
●Exploration – Each operation is started by completely evaluating the small intestine from the ligament of Treitz to the ileocecal valve to rule out concomitant pathologies. For example, despite preoperative radiologic imaging and histologic evaluations to confirm the diagnosis of ulcerative colitis, patients have subsequently developed signs and symptoms of Crohn's disease following IPAA [35].
●Mobilization and dissection – The colon is mobilized from the right to the left. The monitors are placed at the head of the table to facilitate the intra-abdominal portion of the procedure (figure 7).
•The ileocolic vascular pedicle is identified, ligated, and divided (picture 5).
•The mesentery is divided using the laparoscopic 5 mm vessel sealing devices.
•The ascending colon is mobilized in the submesenteric avascular plane, using a medial-to-lateral technique and avoiding injury to the underlying structures (picture 6 and figure 8).
•The transverse colon is mobilized by dividing the greater omentum to provide an unobstructed view of the transverse mesocolon leading to the splenic flexure (picture 7 and figure 9). It is possible to achieve a high ligation of the middle colic vessels if indicated (figure 1).
•The splenic flexure is mobilized using a combination medial-to-lateral and lateral-to-medial technique (figure 10). The visualization with the 30º laparoscope makes this step easier and more controlled than in open surgery.
•The descending colon is mobilized using a medial-to-lateral technique, down to the level of the pelvic brim. The laparoscopic monitors are moved to the foot of the bed to facilitate identification of the superior hemorrhoidal artery and pelvic structures (picture 8 and figure 11).
•The peritoneum overlying the sacral promontory on the right side is incised, and through the submesenteric window, the left ureter and gonadal vessels are visualized (picture 9 and figure 12 and figure 13). The superior hemorrhoidal artery (picture 10) and the inferior mesentery vein are now divided.
•The rectum is sharply dissected in the avascular plane, posterior to the mesorectum (figure 14). The avascular plane is readily identified and limits blood loss. While some surgeons may preserve the mesorectum when performing a total proctocolectomy for a benign diagnosis [36], we advocate including it with the resection for the following reasons: the plane between the rectum and mesorectum is vascular and the risk of retrograde ejaculation is negligible with the improved optics of the high-definition cameras available. The rectal dissection proceeds laterally dividing the lateral ligaments, then anteriorly (figure 14).
●Bowel transection and specimen extraction:
•A classic Pfannenstiel incision is made suprapubically (figure 6).
•The specimen is exteriorized through this incision (picture 11) [37].
•The terminal ileum is divided extracorporeally with a stapling device in preparation for construction of the ileal pouch [6]. (See 'Construction of ileal pouch' below.)
•The rectum is transected at the level of the dentate line using an open stapling device rather than an endoscopic stapler to avoid overlapping staple lines that can result from multiple applications of the endoscopic device.
•When performing a transanal approach, the dissection of the rectum is performed through a transanal port device. The use of an appropriate high-flow insufflation device with smoke evacuation is mandatory to obtain a stable operating field and satisfying visibility. Dissection is typically performed by monopolar cautery. The complete proctectomy can be performed transanally, or the surgeon can dissect the proximal part of the rectum from the abdomen [9]. (See "Transanal endoscopic surgery (TES)".)
Construction of ileal pouch — The J-pouch is the preferred ileal reservoir because of the efficiency of construction and optimal functional results. Alternatives to the J-pouch configuration for the ileal reservoir include three- and four-limbed pouches, such as an S or W pouch. These alternative configurations are rarely performed due to the complexity of construction [6]. A randomized trial that included 94 patients found no long-term benefits for patients managed with a W-pouch compared with those managed with a J-pouch [38]. At one year, patients undergoing a J-pouch had a higher daily bowel movement frequency compared with patients with a W-pouch (7 versus 5). In addition, patients with a J-pouch also had a higher daytime bowel movement frequency (6 versus 4), but no difference in nocturnal frequency. After nine years of observation, bowel function for patients undergoing the W-pouch had a similar 24 hour bowel movement frequency compared with patients undergoing the J-pouch (6 versus 6.5). In addition, there was no difference in daytime frequency, nocturnal function, incontinence, and quality of life. However, the time for construction of the W-pouch was significantly longer (215 versus 195 minutes).
We perform the construction of the J-pouch through the Pfannenstiel incision [39]. The general principles for construction of a J-pouch include:
●The terminal ileum is mobilized laparoscopically to the root of the mesentery at the level of the duodenum.
●The length of ileum required for construction of the pouch is approximately 30 to 40 cm in length. The pouch is constructed as follows [39,40]:
•Identify the most dependent loop of the terminal ileum.
•Lengthen the mesentery if foreshortened or mobilize the third portion of the duodenum so that the most dependent portion of the pouch will reach the pubic symphysis.
•Place a 30 inch long marking suture at the apex of this loop (picture 12).
•Fold the loop back on itself and secure with silk sutures (picture 13).
•Create an enterotomy on the antimesenteric surface of the proximal loop and the distal loop. Insert a linear stapler to construct the pouch (picture 14).
●The pouch is everted with the mucosal layer as the outer surface as we proceed with stapling the ileal limbs to create a pouch (picture 15). This technique allows us to precisely place the next stapler and to achieve hemostasis on the staple line. When we reach the apex of the pouch and complete the side-to-side anastomosis with adequate hemostasis, the pouch is inverted with the serosal layer as the outer surface (picture 16). We prefer this technique as it eliminates the trauma to the apex, which will serve as the site for the ileal-anal anastomosis.
●The ileal enterotomies are approximated in two layers with an inner layer of absorbable sutures and an outer layer of nonabsorbable suture.
Ileal pouch-anal anastomosis — The general principles for construction of the ileal pouch-anal anastomosis (IPAA) include:
●The IPAA is performed using the stapled or hand-sewn technique, depending upon the preference of the surgeon. We perform a hand-sewn IPAA for patients with biopsy-proven dysplasia or cancer and a stapled IPAA when there is no evidence of anal transition zone (ATZ) dysplasia. (See 'Mucosectomy versus preservation of ATZ' above.)
•Using the stapled technique, the center rod and anvil of the circular stapler is advanced to the apex of the pouch, delivered through the apex, and secured in place with a purse-string suture. The shaft of the circular stapler is inserted transanally and the anastomosis constructed.
•In case of a hand-sewn anastomosis, after the transanal mucosectomy is completed, the pouch is marked with three stay sutures that are delivered through the anus (picture 17). The hand-sewn anastomosis between the pouch apex and the anal canal at the level of the dentate line is constructed in two layers with absorbable sutures through the anus (picture 18).
Pelvic drains — Pelvic drains are used in the clinical setting of fecal spillage. Since in our practice the dissection is performed in the presacral avascular space, the use of pelvic drains is rarely indicated.
Temporary loop ileostomy — The benefit of using a diverting loop ileostomy to reduce the risk of an anastomotic leak or dehiscence has not been clearly established [41]; however, we selectively use this approach to minimize the risk of a leak, dehiscence, or pelvic sepsis [6,42,43].
The decision to construct a temporary diverting loop ileostomy (conventional two-stage) in our practice does not follow any strict guidelines. We typically reserve this procedure for clinical settings where there is moderate or greater tension on the ileal-anal anastomosis and/or preoperative usage of corticosteroids or anti-TNF therapy, malnutrition, serious intraoperative blood loss, or other such risks for a leak or dehiscence. (See "Management of anastomotic complications of colorectal surgery", section on 'Dehiscence and leaks'.)
The construction of a loop ileostomy is described elsewhere (figure 15). (See "Overview of surgical ostomy for fecal diversion", section on 'Loop ostomy with a defunctionalized distal limb'.)
Staged procedure — The staged procedures include a total abdominal colectomy, preservation of the rectum, and a temporary end ileostomy at the initial operation, followed by a period of recovery and a delayed construction of the IPAA. At the time of the pouch construction, the decision is made intraoperatively to either avoid a diverting ileostomy (modified two-stage) or to proceed with diversion (three-stage). Ileostomy closure is typically scheduled after 8 to 12 weeks if a contrast pouchogram and/or pouchoscopy have shown complete healing of the anastomosis. The routine use of imaging studies prior to ileostomy closure is debated [44].
First stage
Total colectomy and end ileostomy — The first stage includes a laparoscopic total abdominal colectomy with an end ileostomy, performing the colectomy similar to that described for the single-stage approach. A proctectomy is not performed in this setting. (See 'Resection of colon and rectum' above.)
If performing the total colectomy as an urgent procedure, we often use a hand-assisted approach, which can facilitate the procedure and requires less operating time. Hand-assisted laparoscopic approaches include using the nondominant hand through a hand port device, typically inserted through a small incision in the suprapubic location (figure 16). The ileostomy site, the primary access point to the abdomen, and two additional 5 mm trocars are inserted via incisions in the umbilicus and the left lower quadrant (picture 19).
Preservation of the rectum and pelvic vasculature — The descending colon is dissected to the level of the sacral promontory and divided, preserving the superior hemorrhoidal pedicle to lower the risk of rectal stump ischemia and dehiscence. The rectal stump can be managed as a mucous fistula (rectum sutures to the abdominal wall) or a Hartmann's operation (oversewing of the rectal stump), depending upon the surgeon's preference and the severity of the inflammatory disease in the rectosigmoid colon. The risk of massive postoperative hemorrhage from the preserved rectum is rare [21].
We prefer a Hartmann's operation since the mucous fistula drains blood and/or mucous and complicates postoperative management for the patients. We also insert a large rectal tube into the rectal stump for decompression and drainage for a minimum of five days to limit the risk of "blowout" complications.
Second stage — At this stage of the procedure, the rectum will be resected and the IPAA constructed.
Timing of second procedure — The timing of the second stage of the procedure depends upon the patient's general condition and rationale for a staged procedure but is typically performed between three and six months after the first stage [27,45-47]. The decision to proceed with the second, and most important, stage should be individualized and based upon clinical judgment, rather than a fixed guideline. Specifically, these patients should be weaned off all preoperative medication and have normalization of nutritional parameters.
Abdominal access — The ileostomy is taken down and the peritoneal cavity is accessed through this ostomy site via a 12 mm trocar. The remainder of the trocars are inserted as previously described (figure 6 and picture 4). (See 'Resection of colon and rectum' above.)
Delayed construction of ileal pouch — The same criteria to construct either a stapled or a hand-sewn anastomosis apply to a staged operation. A Pfannenstiel incision is utilized for rectal transection, pouch construction, and anastomosis as previously described. (See 'Construction of ileal pouch' above and 'Ileal pouch-anal anastomosis' above.)
Temporary diversion — The same criteria for constructing a diverting loop ileostomy apply to a staged operation. (See 'Temporary loop ileostomy' above.)
Rectal tube insertion — For the clinical settings where there is a large amount of tension on the anastomosis, we perform a diverting loop ileostomy and insert a small caliber rectal tube into the rectum. The rectal tube is secured to the perianal skin and remains in place often past discharge from the hospital, to prevent anastomotic stricture. (See 'Closure of temporary ileostomy' below.)
INTRAOPERATIVE CHALLENGES — The principle intraoperative challenges that a surgeon may encounter include [6]:
●Failure of the ileal pouch to reach the pelvic floor – The most common reasons for an ileal pouch to fail to reach the pelvic floor include a foreshortened mesentery from acute inflammation and suboptimal body habitus (eg, obesity, narrow pelvis).
●Failure of the anastomotic devices – An incomplete anastomotic doughnut (incomplete stapled ring) or demonstrated air leak must be immediately addressed and corrected with a hand-sewn repair. If the repair cannot be performed through the Pfannenstiel incision, a transanal approach is performed. A diverting loop ileostomy should also be performed in this clinical setting.
●Patent anal stump in a staged procedure – Technical failure of the linear stapler used to divide the rectum can result in an incomplete stapled suture line. The failed staple line should be repaired with hand-placed sutures.
POSTOPERATIVE MANAGEMENT — Postoperative management of colectomy patients has evolved, with contemporary emphasis on early postoperative feeding, early ambulation, reduction of perioperative fluid volume, pain management, and avoidance of intra-abdominal drains [48-55].
Enhanced recovery programs — The components and results of enhanced recovery protocols are reviewed separately. (See "Enhanced recovery after colorectal surgery".)
Thromboprophylaxis — Venous thromboprophylaxis is continued postoperatively until discharge. For high-risk patients (eg, cancer), we continue prophylaxis for 30 days with low-molecular-weight heparin. The prevention of venous thromboembolism is reviewed elsewhere. (See "Prevention of venous thromboembolic disease in adult nonorthopedic surgical patients", section on 'Pharmacologic dosing'.)
Unanticipated splenectomy — If an inadvertent splenectomy is necessary and performed without prophylaxis, immunizations to avoid sepsis should be administered no sooner than 14 days after the procedure [56]. Immunization and prevention of sepsis in the asplenic patient is reviewed separately. (See "Prevention of infection in patients with impaired splenic function".)
Management of pelvic drains — If pelvic drains were used, they are removed within 48 hours.
Management of rectal tubes — If a rectal tube is placed to avoid an anastomotic stricture secondary to tension on the anastomosis, the tube remains in place post-hospital discharge as long as tolerated by the patient or is removed when there is no indication of an anastomotic complication.
Closure of temporary ileostomy — The temporary diverting loop ileostomy is closed after approximately three months [6]. Typically, a flexible sigmoidoscopy and dynamic barium contrast study is performed before closure of the ileostomy to confirm anastomotic healing/patency.
RISK FACTORS FOR POUCH FAILURE — Twenty-one preoperative risk factors were evaluated as potential indicators for pouch failure using a novel random forest methodology. In a review of 3754 patients undergoing an ileoanal pouch, a forest of 3000 random survival trees was grown to estimate pouch failure for each patient and to identify important risk factors that maximize survival prediction [57].
The following factors increased the risk of pouch failure using a multivariable regression analysis:
●Completion proctectomy versus total proctocolectomy (hazard ratio [HR] 1.44, 95% CI 1.08-1.93)
●Hand-sewn versus stapled anastomosis (HR 1.72, 95% CI 1.23-2.42)
●Crohn's disease diagnosis versus mucosal ulcerative colitis, indeterminate colitis, and familial adenomatous polyposis (FAP) (HR 2.37, 95% CI 1.48-3.79)
●Diagnosis of diabetes versus no diabetes (HR 2.67, 95% CI 1.46-4.89)
When patients with FAP (n = 233) were excluded from the analysis, the following variables were associated with an increased risk of pouch failure:
●Hand-sewn versus stapled anastomosis (HR 1.71, 95% CI 1.21-2.43)
●Crohn's disease diagnosis versus mucosal ulcerative colitis, indeterminate colitis (HR 2.28, 95% CI 1.42-3.65)
●Diagnosis of diabetes versus no diabetes (HR 2.46, 95% CI 1.27-4.76)
Crohn's disease involving the ileal pouch is generally associated with a high failure rate and pouch-related fistulas [58]. The complications associated with failure are extensive, and the options for reconstructive surgery in patients with Crohn's disease should be questioned [59]. On the other hand, in a series of 204 patients with Crohn's disease who underwent primary IPAA, overall 10 year pouch retention was 71 percent [60]. Pouch retention rates were higher and functional results were most favorable when the diagnosis of Crohn's disease was established preoperatively or immediately following surgery (85 to 87 percent 10 year pouch retention). Outcomes in patients with delayed diagnosis were worse, but half still retained their pouch at 10 years.
In addition, excessive weight gain is a risk factor for pouch failure. In a multivariate analysis of 846 patients undergoing a restorative proctocolectomy with nine months of observation, patients experiencing weight gain were significantly more likely to develop pouch failure compared with patients without weight gain (18.4 versus 12.3 percent, HR 1.69, 95% CI 1.01-2.84, p = 0.048) [61].
MORTALITY AND MORBIDITY — The techniques for performing a laparoscopic restorative proctocolectomy with ileal pouch-anal anastomosis (RPC-IPAA) have been refined and simplified since the procedure was first described. The in-hospital and 30 day mortality rates are low (<1 percent) [37]; however, overall morbidity rates approach 65 percent [6,37,62-67].
Adverse sequelae of mechanical, inflammatory, functional, neoplastic, and metabolic conditions related to the pouch can occur postoperatively [68]. Early and late postoperative complications include bowel obstruction, anastomotic dehiscence, pelvic abscess, wound infection, urinary tract infection, anastomotic stenosis requiring mechanical dilatation, large enteric losses from ileostomy, impotence, retrograde ejaculation, and dyspareunia (table 3) [37,65,68-71]. Hemorrhage from the rectal stump in staged procedures is rare [24].
Acute and chronic complications can necessitate removal of the ileal reservoir and construction of a permanent ileostomy [62,66,72-75]. For example, a retrospective review of 1005 patients total undergoing an IPAA found that the pouch was removed in 15 of 858 patients (1.7 percent) with ulcerative colitis and 19 of 147 patients (12.9 percent) with a diagnosis other than ulcerative colitis [66].
Pelvic sepsis — Pelvic sepsis is a common early complication of IPAA and occurs in 6 to 16 percent of patients [37,62-64,66,70]. Postoperative anastomotic leak with pelvic sepsis is associated with poor pouch function [6].
Portal vein thrombosis can occur in patients with intra-abdominal septic complications. In a retrospective review of 702 patients undergoing an RPC-IPAA, 94 patients had a computerized scan (computed tomography [CT] scan) to assess abdominal pain, fever, leukocytosis, and/or delayed bowel function [76]. Septic complications were responsible for these symptoms in 45 patients (48 percent), and 20 patients (21 percent of those scanned, 3 percent of total) were found to have a portal vein thrombosis.
The long-term impact of pelvic abscess was illustrated by the following observations [70]:
●Transabdominal salvage surgery was required in 55 percent and local surgery in 8 percent.
●Pouch failure occurred in 26 percent, usually within two years.
●Daytime incontinence was significantly more common in the patients who kept their reservoir. These patients also had significantly more restricted ability to perform work, domestic, and recreational activities compared with patients in whom an abscess had not developed.
A controlled septic condition does not preclude salvage surgery. Furthermore, excision of the pouch is associated with a high risk of complications, particularly delayed perineal wound healing [77,78].
Pouchitis — Pouchitis is the inflammation of the ileal reservoir and is the most common late postoperative complication. It typically involves the ileal mucosa, but it may also extend transmurally, and affects from approximately 25 to 40 percent of patients undergoing an IPAA [66,79,80].
Pouchitis represents an acute and chronic condition and is associated with poorer long-term bowel function results. Even in the absence of clinically active pouchitis, patients who have suffered at least one episode of pouchitis have a poorer long-term functional result after IPAA [79,80]. The following studies illustrate the frequency and complications associated with pouchitis:
●In a prospective study of 120 patients with ulcerative colitis keeping a bowel habit diary when free from symptoms of acute pouchitis, patients with at least one episode of pouchitis (n = 50) were significantly more likely to experience major incontinence compared with those without pouchitis (37 versus 17 percent) [79]. Patients with a history of pouchitis were also significantly more likely to report minor incontinence (75 versus 45 percent) and less-formed stools (31 versus 24 percent) and were more likely to wear a protective pad at night (40 versus 13 percent) or during the day (21 versus 7 percent). Two-thirds of patients had multiple episodes of pouchitis, chronic pouchitis developed in six, and the pouch was removed in two patients.
●In another series, the cumulative probability of suffering at least one episode of clinical pouchitis was 18 and 48 percent at 1 and 10 years, respectively [81].
Several other pouch disorders have been recognized, such as irritable pouch syndrome and anismus (anorectal dysfunction) (algorithm 1) [68]. The pathogenesis, clinical manifestations, and treatment are discussed separately. (See "Pouchitis: Epidemiology, pathogenesis, clinical features, and diagnosis".)
Anal transition zone inflammation — Acute and chronic inflammation is common following an IPAA for patients with ulcerative colitis. In a retrospective review of 225 patients with a stapled IPAA, acute inflammation at the anal transition zone (ATZ) was identified in 4.6 percent of patients, chronic inflammation in 84.9 percent, and normal mucosa in 10.5 percent; no patient had evidence of dysplasia [29].
The presence of inflammation at ATZ, however, does not negatively affect functional outcomes or quality of life [29,30]. (See "Surgical management of ulcerative colitis", section on 'Surgical complications'.)
Anal transitional zone dysplasia — ATZ dysplasia after stapled IPAA is infrequent and is usually self-limiting. ATZ preservation did not lead to the development of cancer with a minimum of 10 years of follow-up. Long-term surveillance is recommended to monitor dysplasia. If repeat biopsy confirms persistent dysplasia, we perform a mucosectomy with perineal pouch advancement and neo-ileal pouch-anal anastomosis [82].
Diverting ostomy complications — Closure of the diverting loop ileostomy is also associated with frequent postoperative complications [83]. Ileostomy closure is associated with significant complications; one large series of 1504 patients reported a morbidity rate of 11.4 percent and a mortality rate of 0.06 percent [84]. Small bowel obstruction accounted for more than half of the complications. A number of factors have been implicated in morbidity after ileostomy closure, including the interval between primary surgery and closure [85], method of closure (stapled versus sutured) [86], and impaired function of the distal defunctioned limb [87].
Unusual complications — A number of unusual late complications have been described, including [88-90]:
●Superior mesenteric artery syndrome
●Solitary ileal ulcer
●Traumatic ileal ulcer perforation
●Fibroid polyps
●Mucosal prolapse with outlet obstruction
●Puborectal spasm
●Sacral osteomyelitis
●Volvulus
●Pharmaco-bezoar
Minimally invasive versus open approach — Based upon observational studies, the complication rates and functional outcomes of the laparoscopic total proctocolectomy are similar to that of the open approach; however, patient acceptance, body image, cosmesis, and quality of life are better with the laparoscopic approach [91,92]. A prospective study of 73 patients undergoing a laparoscopic restorative proctocolectomy had significantly less blood loss (231.5 versus 305.0 mL), a faster return of bowel function (flatus) (2.6 versus 3.6 days), and a lower incidence of incisional hernias (0 versus 8.8 percent) compared with 106 patients undergoing the open approach [91]. Patients undergoing a laparoscopic approach had no statistical difference in hospital mortality (1.4 versus 0 percent), prolonged ileus (4.1 versus 2.9 percent), anastomotic septic complications (19.2 versus 11.8 percent), or strictures requiring mechanical dilation (19.2 versus 25.5 percent).
A systematic review and meta-analysis of studies comparing robotic with laparoscopic IPAA showed that operating time was significantly longer in robotic cases, but estimated blood loss was significantly less and hospital stay was significantly shorter in favor of robotic surgery. There were nonsignificant reductions in complications and readmission rates and a nonstatistically significant trend of fewer complications in robotic procedures. The authors concluded that the robotic platform is safe to use for IPAA procedures but there is minimal evidence for clinical advantages [93].
FUNCTIONAL RESULTS — Long-term functional results and quality of life with a pelvic ileal reservoir are typically superior to that of patients with a Brooke ileostomy, continent Kock ileostomy, or medically treated colitis [6,30,94-96]. Even patients with chronic inflammation of the anal transition zone (ATZ) reported better functional parameters and improved quality of life after an ileal pouch-anal anastomosis (IPAA) when compared with patients with no retained rectal tissue in the IPAA (mucosectomy, hand-sewn anastomosis) [30]. For example, in a retrospective review of 294 patients with ulcerative colitis undergoing a restorative proctocolectomy with ileal pouch-anal anastomosis (RPC-IPAA), patients with retained rectal mucosa (stapled IPAA, n = 66) and chronic inflammation at the ATZ were significantly more likely to report complete continence compared with patients undergoing a mucosectomy (no retained rectal mucosa, hand-sewn IPAA) (90.3 versus 66.8 percent) [30].
RPC-IPAA can also be performed in the pediatric population with good gastrointestinal function, quality of life, and satisfaction. Based upon a retrospective review of 433 patients with a mean age of 18 years, patients undergoing a one-stage RPC-IPAA (n = 237) or an initial subtotal colectomy followed by a delayed completion proctocolectomy with IPAA, the majority of patients were fully continent (86 percent); had no day seepage (84 percent) or night seepage (74 percent); and denied dietary (71 percent), social (85 percent), work (86 percent), or sexual restriction (88 percent) [97]. Mean follow-up was 108.5 months. The patients' preoperative diagnoses included ulcerative colitis, intermediate colitis, familial adenomatous polyposis, and Crohn's disease.
After surgery, the quality of life and defecatory and bowel function plateau at approximately one year and remain constant, with more than 90 percent of patients satisfied with the outcome of the operation and quality of life [37]. Long-term functional results and quality of life are best illustrated by a 30 year retrospective study of patients who underwent RPC-IPAA for chronic ulcerative colitis. At 30 years, 93 percent of patients maintained a functional pouch, although stool frequencies increased slightly (5.7 to 6.2 during the day; 1.5 to 2.1 at night) compared with at one year. The cumulative probability of pouchitis, stricture, obstruction, and fistula were 80, 57, 44, and 16 percent, respectively. Quality-of-life scores remained stable over the 30 years [98]. Two large studies looked at health-related quality of life (HRQoL) after pouch failure [99]. Overall, patients with a failed pouch reported significantly worse physical function, social functioning, energy level, and physical role function compared with the group with a functioning pouch.
Our group reported on long-term functional results in a prospective observational study on laparoscopic-assisted IPAA [91]. The overall average number of daily bowel movements was similar between the laparoscopic and open groups. There was a trend toward improved stool consistency with mostly pasty bowel movements in the laparoscopic group. There were no significant differences in fecal continence between the groups. In the laparoscopic group, only 20.8, compared with 21.9, percent of patients in the open group reported some degree of incontinence. Fewer patients in the laparoscopic group used pads during the daytime and nighttime. The quality of life was similar between the groups. The majority of the patients rated their quality of life as better or much better compared with before their IPAA or before ileostomy closure.
In studies using a body image questionnaire consisting of a body image scale and a cosmetic scale, patient satisfaction with cosmetic result was significantly higher in the laparoscopic-assisted group ] compared with the open surgery group [92]. Accordingly, body image scores were also higher in the laparoscopic-assisted group than in the open group, although this difference was not statistically significant. Although functional outcomes and HRQoL have been shown to be similar after laparoscopic versus open IPAA, better patient acceptance and improved cosmesis combined with a decreased risk of hernia formation make laparoscopic IPAA the preferred surgical approach to ulcerative colitis.
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Ulcerative colitis in adults" and "Society guideline links: Laparoscopic and robotic surgery".)
SUMMARY AND RECOMMENDATIONS
●Operation – A restorative proctocolectomy with ileal pouch-anal anastomosis (RPC-IPAA) is a major surgical procedure that removes the entire colon and rectum while preserving the anal sphincter. The ileal pouch serves as an internal pelvic reservoir for intestinal contents. (See 'Description' above.)
●Management of anal transition zone
•For patients with no dysplasia or malignancy at the anal transition zone (ATZ) and no polyps at the dentate line, we perform an ATZ-sparing IPAA by constructing a stapled ileal pouch. (See 'Mucosectomy versus preservation of ATZ' above.)
•For patients with dysplasia or cancer at the ATZ or polyps at the dentate line, we perform a mucosectomy (resection of all rectal mucosa and ATZ) and construct a hand-sewn IPAA pouch (see 'Mucosectomy versus preservation of ATZ' above). Patients with locally advanced low rectal cancer are not candidates for an RPC-IPAA.
●Pouch construction – For most patients, we recommend the J-pouch for the construction of the ileal reservoir (Grade 1B). The advantages of the J-pouch include greater technical efficiency and similar long-term results (eg, 24 hour bowel movement frequency, nocturnal frequency) compared with the more complex W-pouch approach. However, at one year, patients undergoing a W-pouch had fewer 24 hour bowel movement frequencies. (See 'Construction of ileal pouch' above.)
●Diverting loop ileostomy – The benefit of using a diverting loop ileostomy to reduce the risk of an anastomotic leak or dehiscence has not been clearly established. The decision to construct a temporary diverting loop ileostomy in our practice does not follow any strict guidelines. We typically reserve this procedure for clinical settings where there is moderate or greater tension on the ileal-anal anastomosis and/or preoperative usage of corticosteroids or other such factors that may increase the risk of an anastomotic leak or dehiscence. (See 'Temporary loop ileostomy' above.)
