Proctocolectomy and Ileostomy to Pouch Surgery for Ulcerative Colitis

Abstract

The development of continence-preserving and sphincter-preserving procedures for operation of ulcerative colitis has a long and interesting history. Reported clinical results on the continent ileostomy (Kock pouch) and the pelvic pouch procedure have often been enthusiastic; and when confronted with the options patients have mostly been in no doubt in selecting "the best operation." However, even if the continent ileostomy and subsequently restorative proctocolectomy were great innovations, it is by no means obvious that they should be recommended as the first choice for all patients. For patients old enough to join in a responsible discussion the pros and cons of the various operations available today must first be carefully described and a decision reached that reasonably meets the patient's wishes and that seems to the surgeon to be soundly based. When comparing the postoperative morbidity, long-term outcome, and quality of life assessment of the options, such a decision is in fact far from easy. Thus panproctocolectomy and ileostomy for ulcerative colitis can be considered a comparatively safe, predictable operation that can cure the patient and allow a short hospital stay, a quick recovery, and rehabilitation. It should also enable the patient to be free of hospital supervision after a year or so. Although there is a major change in body image and sexual disturbances may occur, the operation is in fact still the yardstick by which the other options should be compared. Despite the great attraction of rectum- and sphincter-preserving operations, there will always be patients for whom panproctocolectomy and a conventional end-ileostomy is the superior alternative. The ileal pouch operations are technically demanding and should probably best be restricted to specialist centers even in the future. Complications, if they arise, are often serious, and the hospital stay is often counted in weeks. The functional result may be good, but defects in continence are common and sexual dysfunction is a problem for many of these patients. The pouchitis syndrome is a great disappointment, and recent reports on subsequent epithelial dysplasia and even development of cancer are alarming. The long-term results are in this respect still uncertain. Careful patient selection, with full discussion with the patient and his or her family are essential before a decision on a continent ileostomy or a pelvic pouch is reached. Strong motivation toward avoidance of a conventional ileostomy is important. When compared with the imperfect functional results and the high morbidity associated with the pelvic pouch procedure, there is at present a great revival of interest for total colectomy with ileorectal anastomosis. It is still a useful operation and should be seriously considered particularly in the young. The functional results are comparatively good. Sexual function is well preserved. The use of the operation may enable the teenager to regain good health and finish education and family planning. Due to the cancer risk the need for subseq...

The place for colectomy and ileorectal anastomosis: a valid surgical option for ulcerative colitis?

“…The median hospital stay was 7 days (range, [4][5][6][7][8][9][10][11][12][13][14][15]. In 23 patients (72%), the postoper-238 ative course was uneventful.…”

“…However, against the background of the considerable experience accumulated over the years, IPAA does not seem to be the panacea it was once thought to be [11]. Even if performed by an experienced surgeon, it is a demanding procedure with a high risk of complications and the functional results are far from perfect in many patients, with frequent bowel evacuations and imperfection of continence.…”

Long-Term Adjustment to Living With an Ileal Pouch-Anal Anastomosis

“…1,2 Bowel function has been thoroughly investigated in patients with an IPAA and is measured by means of frequency of bowel movements, urgency, and incontinence. Studies have reported a median frequency of bowel movements of 6 times per 24 hours (range, [2][3][4][5][6][7][8][9][10][11][12][13][14][15], and most patients also emptied the pouch during at least 1 night per week. 3,4 Studies on health-related quality of life (HRQoL) using general QoL questionnaires show no differences between persons with an IPAA and normal populations.…”

The ileoanal pouch procedure in the long–term perspective: a critical review

“…In this respect, the reports vary only slightly and this is the case also when different surgical techniques are compared. Most authors claim excellent functional outcomes and high levels of patient satisfaction [1][2][3]. However, the operation carries a high potential for complications, even in the hands of an expert surgeon.…”