Ileoanal Reservoir Surgery

Definition
Purpose
Demographics
Description
Diagnosis/Preparation
Aftercare
Results
Morbidity/mortality
Alternatives

Definition

Ileoanal reservoir surgery or ileoanal anastomosis is a two-stage restorative procedure that removes a part of the colon and uses the ileum (a section of the small intestine) to form a new reservoir for waste that can be expelled through the anus. This surgery is one of several continent surgeries that rely upon a newly created pouch to replace the resected colon and retain the patient’s sphincter for natural defecation. Ileoanal reservoir surgery is also called a J-pouch, endorectal pullthrough, or pelvic pouch procedure.

Purpose

A number of diseases require removal of the entire colon or parts of the colon. Proctolectomies (removal of the entire colon) are often performed to treat colon cancer. Another surgical option is the creation of an ileoanal pouch to serve as an internal waste reservoir—an alternative to the use of an external ostomy pouch. An ileoanal reservoir procedure is performed primarily on patients with ulcerative colitis, inflammatory bowel disease (IBD), familial polyposis, or familial adenomatous polyposis (FAP), which is a relatively rare cancer that covers the colon with 100 or more polyps. FAP is caused by a gene mutation on the long arm of human chromosome 5. Ileoanal reservoir surgery is recommended only in those patients who have not previously lost their rectum or anus.

Demographics

The prevalence of familial adenomatous polyposis (FAP) in the United States is two to three cases per 100,000 persons. It develops before age 40 and accounts for about 0.5% of colorectal cancers; this figure is declining, however, as more at-risk families are undergoing detection and prophylactic colon surgery. The annual incidence of ulcerative colitis is 10.4-12 cases per 100,000 people. The prevalence rate is 35-100 cases per 100,000. People of Jewish descent have two to four times the risk of developing ulcerative colitis than people from other ethnic backgrounds. About 20% of ulcerative colitis patients require surgery of the colon.

Description

Conventional ileoanal reservoir surgery is an open procedure that is done in two stages. In the first stage, the surgeon removes the diseased colon and creates a pouch. The second stage is performed three months later, when the temporary drainage conduit is closed and the newly created reservoir allows the patient to defecate in the normal fashion. Both surgeries can also be done together, bypassing the creation of a temporary ileostomy.

Some surgeons use a laparoscopic approach to ileoanal surgery. This technique involves the insertion of scaled-down surgical instruments and a scope that allows the surgeon to see inside the abdomen through several relatively small incisions (about 3.5 inches [9 cm] compared to 6 inches [16 cm] for an open procedure) in the abdominal wall. Studies indicate that there are few differences in the rates of mortality or complications between laparoscopic surgery and conventional open surgery. Because the incisions are smaller, patients typically require less pain medication with laparoscopic surgery.

Ileoanal surgery includes the following steps:

• The surgeon isolates the ileum or small segment of bowel.
• The segment is then attached to the anus with absorbable sutures.
• A pouch is created out of the small bowel above the anus.

KEY TERMS

Anastomosis— A surgically created joining or opening between two organs or body spaces that are normally separate.

Colon— The portion of the large intestine where stool is formed.

Continent— Able to hold the contents of the bladder or bowel until one can use a bathroom. A continent surgical procedure is one that allows the patient to keep waste products inside the body rather than collecting them in an external bag attached to a stoma.

Ileoanal anastomosis— A reservoir for fecal waste surgically created out of the small intestine. It retains the sphincter function of the anus and allows the patient to defecate in the normal fashion.

Ileum— The third and lowest portion of the small intestine, extending from the jejunum to the beginning of the large intestine.

Polyp— Any mass of tissue that grows out of a mucous membrane in the digestive tract, uterus, or elsewhere in the body.

Sphincter— A circular band of muscle fibers that constricts or closes a passageway in the body.

Stent— A thin rodlike or tubelike device made of wire mesh, inserted into a blood vessel or a section of the digestive tract to keep the structure open.

Stoma (plural, stomata)— A surgically created opening in the abdominal wall to allow digestive wastes to pass to the outside of the body.

• If the surgeon is performing the procedure in two stages, he or she creates a temporary ileostomy. An ileostomy is a tubular bowel segment attached to a stoma at the abdomen that drains into a bag outside the abdomen.
• In the second-stage operation, the surgeon uses an open abdominal procedure to close the temporary pouch.

The surgeon will insert stents to bypass the surgical site and divert urinary and digestive wastes to the outside of the body, thus allowing the new connection between the ileum and the anus to heal properly.

Diagnosis/Preparation

The diagnosis of FAP is usually made after symptoms caused by polyps in the colon, such as rectal bleeding, diarrhea, and abdominal pain, have led to a physical examination, the taking of a family history, and in some cases a genetic test. Ulcerative colitis or inflammatory bowel disease patients have usually been treated with medical alternatives before they decide to have surgery. All patients who are candidates for an ileoanal procedure will have an evaluation of the upper gastrointestinal tract, an x ray of the small bowel, and a colonoscopy with a pathology review. Most patients will also be given a sigmoidoscopy and a digital rectal examination.

The surgeon will need to perform an ileostomy in about 5-10% of cases because the patient’s rectal muscles are not strong enough for an anastomosis. This possibility is discussed with the patient, as well as the fact that complications in surgery may lead to an ostomy procedure. The placement of a stoma must be decided in the event that an ileostomy is necessary. The physician evaluates the patient’s abdomen while the patient is sitting and then standing, in order to avoid placing the stoma inside a fatty fold of the abdomen. A stomal therapist is often called in to prepare the patient for the possibility that an appliance will be needed. In addition to the medical and surgical considerations of the procedure, the patient requires psychological preparation regarding the changes in function and appearance that accompany this surgery.

Prior to surgery, the patient must undergo a bowel preparation, which includes a clear-liquid diet for two days before the procedure. In addition to drinking nothing but clear fluids, the patient must have a cleansing enema until the bowel runs clear. The importance of a thorough bowel preparation must be explained to the patient, because leakage from the bowel during surgery can be life-threatening.

Aftercare

Open ileaoanal reservoir surgery is a lengthy procedure (as long as five hours) with a slow recovery rate (approximately six weeks) and a relatively long stay in the hospital (about 10 days). The catheters and stents that were used are removed several days after surgery. The patient will be introduced to a special diet in the hospital, and the diet will be altered if needed in response to changes in the chemistry of the colon. The patient’s stools are measured, and he or she is monitored for dehydration. In addition, the patient will have the opportunity to discuss his or her concerns about care of the new reservoir and frequency of defecation with staff members before leaving the hospital.

WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?

An ileoanal reservoir procedure is performed by a gastrointestinal surgeon specializing in reconstructive bowel or colon surgery. The operation takes place in a general hospital as an inpatient procedure.

Results

For carefully selected patients this procedure, developed over 30 years, is the preferred form of radical colon surgery when the patient’s sphincter and rectum are still intact. The advantage of the ileoanal reservoir surgery is that the patient has an internal pouch for the collection of waste material and can pass this waste normally through the anus. Bowel movements may be more fluid, however, and more frequent with the new reservoir. In a small percentage of cases, the surgeon may eventually need to perform an ileostomy due to complications. In one quality of life study for patients who have undergone ileoanal reservoir surgery, researchers found only slight differences in their general health and level of daily activity compared with subjects recruited from the general population.

Morbidity/mortality

Morbidity rates with this procedure have decreased over time due to improvements in technique. The most common complication is inflammation of the pouch, which occurs in as many as 40% of patients. This complication can be treated with medication. Other complications include severe scarring around the incision, and some risk of injury to the nerves that control erection and bladder function. In one major study of 379 patients, researchers at the University of Cincinnati reported that 79 patients had pouch infections (24.3%) and another 20 patients required further surgery for obstructions of the small bowel (6.2%).

Alternatives

The major surgical alternative to an ileoanal reservoir procedure is an ileostomy. In an ileostomy, the patient’s fecal matter drains into a plastic bag attached to a stoma on the outside of the patient’s abdomen or into a pouch attached to the abdominal wall to be withdrawn through a plastic tube.

QUESTIONS TO ASK THE DOCTOR

• How often has this procedure been performed in this hospital?
• Am I a candidate for a laparascopic operation?
• How many surgeries of this kind have you performed?
• How likely is it that I might have to have an ileostomy once I am in surgery?

Resources

BOOKS

Lange, Vladimir, MD. Be a Survivor: Colorectal Cancer Treatment Guide, 1st ed. Los Angeles, CA: Lange Productions, 2006.

Larson, Carol Ann, and Kathleen Ogle. Positive Options for Colorectal Cancer: Self-Help and Treatment, 1st ed. Alameda, CA: Hunter House, 2005.

Levin, Bernard, MD, et al. American Cancer Society’s Complete Guide to Colorectal Cancer, 1st ed. Atlanta: American Cancer Society, 2005.

Pemberton, John H., and Sidney F. Phillips. “Ileostomy and Its Alternatives.” In Sleisenger and Fordtran’s Gastrointestinal and Liver Disease, 7th ed. Philadelphia, PA: Elsevier Science, 2002.

“Tumors of the Gastrointestinal Tract: Large-Bowel Tumors.” In The Merck Manual of Diagnosis and Therapy, edited by Mark H. Beers, MD, and Robert Berkow, MD. Whitehouse Station, NJ: Merck Research Laboratories, 1999.

PERIODICALS

Allison, Stephen, and Marvin L. Corman. “Intestinal Stomas in Crohn’s Disease.”Surgical Clinics of North America 81, no. 1 (February 1, 2001): 185–95.

Blumberg, D., and D. E. Beck. “Surgery for Ulcerative Colitis.”Gastroenterology Clinics of North America 31 (March 2002): 219–235.

Pasupathy, S., K. W. Eu, Y. H. Ho, and F. Seow-Choen. “A Comparison Between Open Versus Laparoscopic Assisted Colonic Pouches for Rectal Cancer.” Techniques in Coloproctology 5 (April 2001): 19–22.

Robb, B., et al. “Quality of Life in Patients Undergoing Ileal Pouch-Anal Anastomosis at the University of Cincinnati.” American Journal of Surgery 183 (April 2002): 353–360.

ORGANIZATIONS

American Gastroenterological Association, American Digestive Health Foundation. 7910 Woodmont Aveenue, 7th Floor, Bethesda, MD 20814. (301) 654-2055. www.gastro.org.

American Society of Colon and Rectal Surgeons. 85 W. Algonquin Rd., Suite 550, Arlington Heights, IL 60005. www.fascrs.org.

Crohn’s and Colitis Foundation of America. 386 Park Ave. S., 17th Floor, New York, NY 10016. (800) 932-2423. www.ccfa.org.

National Digestive Diseases Information Clearinghouse. 2 Information Way, Bethesda, MD 20892-3570. http://www2.niddk.nih.gov.

United Ostomy Association, Inc. (UOA). 19772 MacArthur Blvd., Suite 200, Irvine, CA 92612-2405. (800) 826-0826. www.uoa.org.

OTHER

MDconsult.com. “Inflammatory Bowel Disease (Crohn’s Disease and Ulcerative Colitis).” www.MDconsult.com.

“Surgery for Ulcerative Colitis.” Crohn’s and Colitis Foundation of American March, 2006. http://www.ccfa.org/info/surgery/surgeryuc.

Nancy McKenzie, PhD

Laura Jean Cataldo, RN, EdD

Ileorectal anastomosis seeIleoanal anastomosis

Ileoanal Anastomosis

Definition
Purpose
Demographics
Description
Diagnosis/Preparation
Aftercare
Risks
Normal results
Morbidity and mortality rates
Alternatives

Definition

Ileoanal anastomosis is a surgical procedure in which the large intestine is bypassed and the lower portion of the small intestine is directly attached to the anal canal. It is also called an ileal pouch-anal anastomosis.

Purpose

An ileoanal anastomosis is an invasive procedure performed in patients who have not responded to more conservative treatments. The small intestine is composed of three major sections: the duodenum, which is the upper portion into which the stomach empties; the jejunum, which is the middle portion; and the ileum. The ileum is the last portion of the small intestine and empties into the large intestine. The large intestine is composed of the colon, where stool is formed, and the rectum, which empties to the outside of the body through the anal canal.

Surgical removal of the bowel is usually a procedure of last resort for a patient who has not responded to less invasive medical therapies. For example, many patients with ulcerative colitis, an inflammatory condition of the colon and rectum, can be treated by medications or dietary changes that control the symptoms of the disease. For patients who fail to respond to these approaches, however, the creation of an ileoanal anastomosis removes most or all of the diseased tissue. Certain types of colon cancer and a condition called familial adenomatous polyposis, or FAP, in which the inner lining of the colon becomes covered with abnormal growths, may also be treated with ileoanal anastomosis.

Demographics

Most patients—more than 85%—who undergo an ileoanal anastomosis are being treated for ulcerative colitis; familial adenomatous polyposis is the next most common condition requiring the surgery. The average age of patients at surgery is 35 years, and the majority of patients are male.

Description

A surgical anastomosis is the connection of two cut or separate tubular structures to make a continuous channel. To perform an ileoanal anastomosis, the surgeon detaches the ileum from the colon and the anal canal from the rectum. He or she then creates a pouch-like structure from ileal tissue to act as a rectum and connects it directly to the anal canal. This procedure offers distinct advantages over a conventional ileostomy, a procedure in which the ileum is connected to the abdominal wall. A conventional ileostomy leaves the patient incontinent (i.e., unable to control the emptying of waste from the body) and unable to have normal bowel movements. Instead, the patient’s waste is excreted through an opening in the abdominal wall into a bag. An ileoanal anastomosis, however, removes the diseased large intestine while allowing the patient to pass stool normally without the need of a permanent ileostomy.

An ileoanal anastomosis is usually completed in two separate surgeries. During the first operation, the surgeon makes a vertical incision through the patient’s abdominal wall and removes the colon. This procedure is called a colectomy. The inner lining of the rectum is also removed in a procedure called a mucosal proctectomy. The muscles of the rectum and anus are left in place so that the patient will not be incontinent. Next, the surgeon makes a pouch by stapling sections of the small intestine together with surgical staples. The pouch may be J-, W-, or S-shaped, and acts as reservoir for waste (as the rectum does) to decrease the frequency of the patient’s bowel movements. Once the pouch is constructed, it is connected to the anal canal to form the anastomosis. To allow the anastomosis time to heal before stool begins to pass through, the surgeon creates a temporary “loop” ileostomy. The surgeon then makes a small incision through the abdominal wall and brings a loop of the small intestine through the incision and sutures it to the skin. Waste then exits the body through this opening, which is called a stoma, and collects in a bag attached to the

KEY TERMS

Anastomosis (plural, anastomoses)— A surgically created joining or opening between two organs or body spaces that are normally separate.

Colon— The portion of the large intestine where stool is formed.

Continent— Able to hold the contents of the bladder or bowel until one can use a bathroom. A continent surgical procedure is one that allows the patient to keep waste products inside the body rather than collecting them in an external bag attached to a stoma.

Enterostomal therapist— A health care provider who specializes in the care of patients with enterostomies (e.g., ileostomies or colostomies).

Ostomy— The surgical creation of an opening from an internal structure to the outside of the body.

Polyp— Any mass of tissue that grows out of a mucous membrane in the digestive tract, uterus, or elsewhere in the body.

Stoma (plural, stomata)— A surgically created opening in the abdominal wall to allow digestive wastes to pass to the outside of the body.

outside of the abdomen. In an emergency situation, the surgeon may perform the colectomy and ileostomy during one operation, and create the ileal pouch during another.

In the second operation, the surgeon closes the ileostomy, thus restoring the patient’s ability to defecate in the normal manner. This second procedure generally takes place two to three months after the original surgery. The surgeon detaches the ileum from the stoma and attaches it to the newly created pouch. A continuous channel then runs from the small intestine through the ileal pouch and anal canal to the outside of the body. In some instances, the surgeon may decide to combine the two surgeries into one operation without creating a temporary ileostomy.

Diagnosis/Preparation

Because an ileoanal anastomosis is a procedure that is done after a patient has failed to respond to other therapies, the patient’s condition has been diagnosed by the time the doctor suggests this surgery.

The patient meets with the operating physician prior to surgery to discuss the details of the surgery and receive instructions on pre- and post-operative

WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?

Ileoanal anastomoses are usually performed in hospital operating rooms. They may be performed by a general surgeon, a colorectal surgeon (a medical doctor who focuses on diseases of the colon, rectum, and anus), or a gastrointestinal surgeon (a medical doctor who focuses on diseases of the gastrointestinal system).

care. Immediately before the operation, an intravenous (IV) line is placed in the patient’s arm to administer fluid and medications, and the patient is given a bowel preparation to cleanse the bowel for surgery. The location of the stoma is marked on the skin so that it is placed away from bones, abdominal folds, and scars.

Aftercare

Following surgery, the staff will instruct the patient in the care of the stoma, placement of the ileostomy bag, and necessary changes regarding diet and lifestyle. Visits with an enterostomal therapist (ET) or a support group for individuals with ostomies may be recommended to help the patient adjust to living with a stoma. After the anastomosis has healed, which usually takes about two to three months, the ileostomy can then be closed. A dietician may suggest permanent changes in the patient’s diet to minimize gas and diarrhea.

Risks

Risks associated with any surgery that involves opening the abdomen include excessive bleeding, infection, and complications due to general anesthesia. Specific complications following an ileoanal anastomosis include leakage of stool; anal stenosis (narrowing of the anus); pouchitis (inflammation of the ileal pouch); and pouch failure. Patients who have received a temporary ileostomy may experience obstruction (blockage) of the stoma; stomal prolapse (protrusion of the ileum through the stoma); or a rash or skin irritation around the stoma.

Normal results

After ileoanal anastomosis, patients will usually experience between four and nine bowel movements during the day and one at night; this frequency generally decreases over time. Because of the nature of the

QUESTIONS TO ASK THE DOCTOR

• Why are you recommending an ileoanal anastomosis?
• What type of pouch will be created?
• Will an ileostomy be created? When will it be reversed?
• Are there any nonsurgical alternatives to this procedure?
• What kind of ongoing ostomy care will be needed?
• When will I be able to resume my normal diet and activities?

surgery, persons with an ileoanal anastomosis retain the ability to control their bowel movements. They can refrain from defecating for extended periods of time, an advantage not afforded by a conventional ileostomy. One study found that 97% of patients were satisfied with the results of the surgery and would recommend it to others with similar disorders.

Morbidity and mortality rates

The overall rate of complications associated with ileoanal anastomosis is approximately 10%. Between 10% and 15% of patients will experience at least one episode of pouchitis, and 10–20% will develop postsurgical pelvic or wound infections. The rate of anastomosis failure requiring the creation of a permanent ileostomy is approximately 5–10%.

Alternatives

An ileostomy is a surgical alternative for patients who are not good candidates for an ileoanal anastomosis. If the patient wishes to retain continence, the surgeon may perform a continent ileostomy. Portions of the small intestine are used to form a pouch and valve; these are then directly attached to the abdominal wall skin to form a stoma. Waste collects inside the internal pouch and is expelled by insertion of a soft, flexible tube through the stoma several times a day.

Resources

BOOKS

Pemberton, John H., and Sidney F. Phillips. “Ileostomy and Its Alternatives.” Chapter 105 in Sleisenger and For-dtran’s Gastrointestinal and Liver Disease, 7th ed. Philadelphia, PA: Elsevier Science, 2002.

Porrett, Theresa and Anthony McGrath. Stoma Care (Essential Clinical Skills for Nurses), 1st ed. Malden, MA: Wiley-Blackwell; 2005.

Rayson, Elizabeth. Living Well with an Ostomy, 1st ed. Victoria, Canada: Your Health Press, 2006.

Sklar, Jill and Manuel Sklar. The First Year: Crohn’s Disease and Ulcerative Colitis: An Essential Guide for the Newly Diagnosed, 2nd ed. New York: Marlowe & Company, 2007.

PERIODICALS

Becker, James M. “Surgical Therapy for Ulcerative Colitis and Crohn’s Disease.” Gastroenterology Clinics of North America 28 (June 1, 1999): 371–90.

ORGANIZATIONS

Crohn’s and Colitis Foundation of America. 386 Park Ave. S., 17th Floor, New York, NY 10016. (800) 932-2423. www.ccfa.org.

United Ostomy Association, Inc. (UOA). 19772 MacArthur Blvd., Suite 200, Irvine, CA 92612-2405. (800) 826-0826. http://www.uoa.org.

Wound, Ostomy and Continence Nurses Society. 15000 Commerce Parkway, Suite C. Mt. Laurel, NJ 08054. 888-224-WOCN (9626). http://www.wocn.org/

OTHER

“Surgery for Ulcerative Colitis”. Crohn’s and Colitis Foundation of America. March, 2006. http://www.ccfa.org/info/surgery/surgeryuc.

Stephanie Dionne Sherk

Laura Jean Cataldo, RN, EdD

Ileoanal reservoir surgery

Definition

Ileoanal reservoir surgery or ileoanal anastomosis is a two-stage restorative procedure that removes a part of the colon and uses the ileum (a section of the small intestine) to form a new reservoir for waste that can be expelled through the anus. This surgery is one of several continent surgeries that rely upon a newly created pouch to replace the resected colon and retain the patient's sphincter for natural defecation. Ileoanal reservoir surgery is also called a J-pouch, endorectal pullthrough, or pelvic pouch procedure.

Purpose

A number of diseases require removal of the entire colon or parts of the colon. Proctolectomies (removal of the entire colon) are often performed to treat colon cancer. Another surgical option is the creation of an ileoanal pouch to serve as an internal waste reservoir—an alternative to the use of an external ostomy pouch. An ileoanal reservoir procedure is performed primarily on patients with ulcerative colitis, inflammatory bowel disease (IBD), familial polyposis, or familial adenomatous polyposis (FAP), which is a relatively rare cancer that covers the colon with 100 or more polyps. FAP is caused by a gene mutation on the long arm of human chromosome 5. Ileoanal reservoir surgery is recommended only in those patients who have not previously lost their rectum or anus.

Demographics

The prevalence of familial adenomatous polyposis (FAP) in the United States is two to three cases per 100,000 persons. It develops before age 40 and accounts for about 0.5% of colorectal cancers; this figure is declining, however, as more at-risk families are undergoing detection and prophylactic colon surgery. The annual incidence of ulcerative colitis is 10.4–12 cases per 100,000 people. The prevalence rate is 35–100 cases per 100,000. People of Jewish descent have two to four times the risk of developing ulcerative colitis than people from other ethnic backgrounds. About 20% of ulcerative colitis patients require surgery of the colon.

Description

Conventional ileoanal reservoir surgery is an open procedure that is done in two stages. In the first stage, the surgeon removes the diseased colon and creates a pouch. The second stage is performed three months later, when the temporary drainage conduit is closed and the newly created reservoir allows the patient to defecate in the normal fashion. Both surgeries can also be done together, bypassing the creation of a temporary ileostomy .

Some surgeons use a laparoscopic approach to ileoanal surgery. This technique involves the insertion of scaled-down surgical instruments and a scope that allows the surgeon to see inside the abdomen through several relatively small incisions (3.5 inches [9 cm] or about compared to 6.3 inches [16 cm] or for an open procedure) in the abdominal wall. Studies indicate that there are few differences in the rates of mortality or complications between laparoscopic surgery and conventional open surgery. Because the incisions are smaller, patients typically require less pain medication with laparoscopic surgery.

Ileoanal surgery includes the following steps:

• The surgeon isolates the ileum or small segment of bowel.
• The segment is then attached to the anus with absorbable sutures.
• A pouch is created out of the small bowel above the anus.
• If the surgeon is performing the procedure in two stages, he or she creates a temporary ileostomy. An ileostomy is a tubular bowel segment attached to a stoma at the abdomen that drains into a bag outside the abdomen.
• In the second-stage operation, the surgeon uses an open abdominal procedure to close the temporary pouch.

The surgeon will insert stents to bypass the surgical site and divert urinary and digestive wastes to the outside of the body, thus allowing the new connection between the ileum and the anus to heal properly.

Diagnosis/Preparation

The diagnosis of FAP is usually made after symptoms caused by polyps in the colon, such as rectal bleeding, diarrhea, and abdominal pain, have led to a physical examination , the taking of a family history, and in some cases a genetic test. Ulcerative colitis or inflammatory bowel disease patients have usually been treated with medical alternatives before they decide to have surgery. All patients who are candidates for an ileoanal procedure will have an evaluation of the upper gastrointestinal tract, an x ray of the small bowel, and a colonoscopy with a pathology review. Most patients will also be given a sigmoidoscopy and a digital rectal examination.

The surgeon will need to perform an ileostomy in about 5–10% of cases because the patient's rectal muscles are not strong enough for an anastomosis. This possibility is discussed with the patient, as well as the fact that complications in surgery may lead to an ostomy procedure. The placement of a stoma must be decided in the event that an ileostomy is necessary. The physician evaluates the patient's abdomen while the patient is sitting and then standing, in order to avoid placing the stoma inside a fatty fold of the abdomen. A stomal therapist is often called in to prepare the patient for the possibility that an appliance will be needed. In addition to the medical and surgical considerations of the procedure, the patient requires psychological preparation regarding the changes in function and appearance that accompany this surgery.

Prior to surgery, the patient must undergo a bowel preparation, which includes a clear-liquid diet for two days before the procedure. In addition to drinking nothing but clear fluids, the patient must have a cleansing enema until the bowel runs clear. The importance of a thorough bowel preparation must be explained to the patient, because leakage from the bowel during surgery can be life-threatening.

Aftercare

Open ileaoanal reservoir surgery is a lengthy procedure (as long as five hours) with a slow recovery rate (approximately six weeks) and a relatively long stay in the hospital (about 10 days). The catheters and stents that were used are removed several days after surgery. The patient will be introduced to a special diet in the hospital, and the diet will be altered if needed in response to changes in the chemistry of the colon. The patient's stools are measured, and he or she is monitored for dehydration. In addition, the patient will have the opportunity to discuss his or her concerns about care of the new reservoir and frequency of defecation with staff members before leaving the hospital.

Results

For carefully selected patients this procedure, developed over 30 years, is the preferred form of radical colon surgery when the patient's sphincter and rectum are still intact. The advantage of the ileoanal reservoir surgery is that the patient has an internal pouch for the collection of waste material and can pass this waste normally through the anus. Bowel movements may be more fluid, however, and more frequent with the new reservoir. In a small percentage of cases, the surgeon may eventually need to perform an ileostomy due to complications. In one quality of life study for patients who have undergone ileoanal reservoir surgery, researchers found only slight differences in their general health and level of daily activity compared with subjects recruited from the general population.

Morbidity/mortality

Morbidity rates with this procedure have decreased over time due to improvements in technique. The most common complication is inflammation of the pouch, which occurs in as many as 40% of patients. This complication can be treated with medication. Other complications include severe scarring around the incision, and some risk of injury to the nerves that control erection and bladder function. In one major study of 379 patients, researchers at the University of Cincinnati reported that 79 patients had pouch infections (24.3%) and another 20 patients required further surgery for obstructions of the small bowel (6.2%).

Alternatives

The major surgical alternative to an ileoanal reservoir procedure is an ileostomy. In an ileostomy, the patient's fecal matter drains into a plastic bag attached to a stoma on the outside of the patient's abdomen or into a pouch attached to the abdominal wall to be withdrawn through a plastic tube.

Resources

books

Pemberton, John H., and Sidney F. Phillips. "Ileostomy and Its Alternatives" In Sleisenger and Fordtran's Gastrointestinal and Liver Disease, 7th ed. Philadelphia: Elsevier Science, 2002.

"Tumors of the Gastrointestinal Tract: Large-Bowel Tumors." In The Merck Manual of Diagnosis and Therapy, edited by Mark H. Beers, MD, and Robert Berkow, MD. Whitehouse Station, NJ: Merck Research Laboratories, 1999.

periodicals

Allison, Stephen, and Marvin L. Corman. "Intestinal Stomas in Crohn's Disease." Surgical Clinics of North America 81, no. 1 (February 1, 2001): 185-95.

Blumberg, D., and D. E. Beck. "Surgery for Ulcerative Colitis." Gastroenterology Clinics of North America 31 (March 2002): 219-235.

Pasupathy, S., K. W. Eu, Y. H. Ho, and F. Seow-Choen. "A Comparison Between Open Versus Laparoscopic Assisted Colonic Pouches for Rectal Cancer." Techniques in Coloproctology 5 (April 2001): 19-22.

Robb, B., et al. "Quality of Life in Patients Undergoing Ileal Pouch-Anal Anastomosis at the University of Cincinnati." American Journal of Surgery 183 (April 2002): 353-360.

organizations

American Gastroenterological Association, American Digestive Health Foundation. 7910 Woodmont Aveenue, 7th Floor, Bethesda, MD 20814. (301) 654-2055. <www.gasto.org.>

American Society of Colon and Rectal Surgeons. 85 W. Algonquin Rd., Suite 550, Arlington Heights, IL 60005. <fascrs.org,>

National Digestive Diseases Information Clearinghouse. 2 Information Way, Bethesda, MD 20892-3570. <www.niddk.nih.gov.>

United Ostomy Association, Inc. (UOA). 19772 MacArthur Blvd., Suite 200, Irvine, CA 92612-2405. (800) 826-0826. <www.uoa.org.>

other

MDconsult.com. Inflammatory Bowel Disease (Crohn's Disease and Ulcerative Colitis). <www.MDconsult.com.>

Nancy Mckenzie, PhD

WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?

An ileoanal reservoir procedure is performed by a gastrointestinal surgeon specializing in reconstructive bowel or colon surgery. The operation takes place in a general hospital as an inpatient procedure.

QUESTIONS TO ASK THE DOCTOR

• How often has this procedure been performed in this hospital?
• Am I a candidate for a laparascopic operation?
• How many surgeries of this kind have you performed?
• How likely is it that I might have to have an ileostomy once I am in surgery?

Ileoanal anastomosis

Definition

Ileoanal anastomosis is a surgical procedure in which the large intestine is bypassed and the lower portion of the small intestine is directly attached to the anal canal. It is also called an ileal pouch-anal anastomosis.

Purpose

An ileoanal anastomosis is an invasive procedure performed in patients who have not responded to more conservative treatments. The small intestine is composed of three major sections: the duodenum, which is the upper portion into which the stomach empties; the jejunum, which is the middle portion; and the ileum. The ileum is the last portion of the small intestine and empties into the large intestine. The large intestine is composed of the colon, where stool is formed, and the rectum, which empties to the outside of the body through the anal canal.

Surgical removal of the bowel is usually a procedure of last resort for a patient who has not responded to less invasive medical therapies. For example, many patients with ulcerative colitis, an inflammatory condition of the colon and rectum, can be treated by medications or dietary changes that control the symptoms of the disease. For patients who fail to respond to these approaches, however, the creation of an ileoanal anastomosis removes most or all of the diseased tissue. Certain types of colon cancer and a condition called familial adenomatous polyposis, or FAP, in which the inner lining of the colon becomes covered with abnormal growths, may also be treated with ileoanal anastomosis.

Demographics

Most patients—more than 85%—who undergo an ileoanal anastomosis are being treated for ulcerative colitis; familial adenomatous polyposis is the next most common condition requiring the surgery. The average age of patients at surgery is 35 years, and the majority of patients are male.

Description

A surgical anastomosis is the connection of two cut or separate tubular structures to make a continuous channel. To perform an ileoanal anastomosis, the surgeon detaches the ileum from the colon and the anal canal from the rectum. He or she then creates a pouch-like structure from ileal tissue to act as a rectum and connects it directly to the anal canal. This procedure offers distinct advantages over a conventional ileostomy , a procedure in which the ileum is connected to the abdominal wall. A conventional ileostomy leaves the patient incontinent (i.e., unable to control the emptying of waste from the body) and unable to have normal bowel movements. Instead, the patient's waste is excreted through an opening in the abdominal wall into a bag. An ileoanal anastomosis, however, removes the diseased large intestine while allowing the patient to pass stool normally without the need of a permanent ileostomy.

An ileoanal anastomosis is usually completed in two separate surgeries. During the first operation, the surgeon makes a vertical incision through the patient's abdominal wall and removes the colon. This procedure is called a colectomy. The inner lining of the rectum is also removed in a procedure called a mucosal proctectomy. The muscles of the rectum and anus are left in place so that the patient will not be incontinent. Next, the surgeon makes a pouch by stapling sections of the small intestine together with surgical staples. The pouch may be J-, W-, or S-shaped, and acts as reservoir for waste (as the rectum does) to decrease the frequency of the patient's bowel movements. Once the pouch is constructed, it is connected to the anal canal to form the anastomosis. To allow the anastomosis time to heal before stool begins to pass through, the surgeon creates a temporary "loop" ileostomy. The surgeon then makes a small incision through the abdominal wall and brings a loop of the small intestine through the incision and sutures it to the skin. Waste then exits the body through this opening, which is called a stoma, and collects in a bag attached to the outside of the abdomen. In an emergency situation, the surgeon may perform the colectomy and ileostomy during one operation, and create the ileal pouch during another.

In the second operation, the surgeon closes the ileostomy, thus restoring the patient's ability to defecate in the normal manner. This second procedure generally takes place two to three months after the original surgery. The surgeon detaches the ileum from the stoma and attaches it to the newly created pouch. A continuous channel then runs from the small intestine through the ileal pouch and anal canal to the outside of the body. In some instances, the surgeon may decide to combine the two surgeries into one operation without creating a temporary ileostomy.

Diagnosis/Preparation

Because an ileoanal anastomosis is a procedure that is done after a patient has failed to respond to other therapies, the patient's condition has been diagnosed by the time the doctor suggests this surgery.

The patient meets with the operating physician prior to surgery to discuss the details of the surgery and receive instructions on pre- and post-operative care. Immediately before the operation, an intravenous (IV) line is placed in the patient's arm to administer fluid and medications, and the patient is given a bowel preparation to cleanse the bowel for surgery. The location of the stoma is marked on the skin so that it is placed away from bones, abdominal folds, and scars.

Aftercare

Following surgery, the staff will instruct the patient in the care of the stoma, placement of the ileostomy bag, and necessary changes regarding diet and lifestyle. Visits with an enterostomal therapist (ET) or a support group for individuals with ostomies may be recommended to help the patient adjust to living with a stoma. After the anastomosis has healed, which usually takes about two to three months, the ileostomy can then be closed. A dietician may suggest permanent changes in the patient's diet to minimize gas and diarrhea.

Risks

Risks associated with any surgery that involves opening the abdomen include excessive bleeding, infection, and complications due to general anesthesia. Specific complications following an ileoanal anastomosis include leakage of stool, anal stenosis (narrowing of the anus), pouchitis (inflammation of the ileal pouch), and pouch failure. Patients who have received a temporary ileostomy may experience obstruction (blockage) of the stoma, stomal prolapse (protrusion of the ileum through the stoma), or a rash or skin irritation around the stoma.

Normal results

After ileoanal anastomosis, patients will usually experience between four and nine bowel movements during the day and one at night; this frequency generally decreases over time. Because of the nature of the surgery, persons with an ileoanal anastomosis retain the ability to control their bowel movements. They can refrain from defecating for extended periods of time, an advantage not afforded by a conventional ileostomy. One study found that 97% of patients were satisfied with the results of the surgery and would recommend it to others with similar disorders.

Morbidity and mortality rates

The overall rate of complications associated with ileoanal anastomosis is approximately 10%. Between 10% and 15% of patients will experience at least one episode of pouchitis, and 10–20% will develop postsurgical pelvic or wound infections. The rate of anastomosis failure requiring the creation of a permanent ileostomy is approximately 5–10%.

Alternatives

An ileostomy is a surgical alternative for patients who are not good candidates for an ileoanal anastomosis. If the patient wishes to retain continence, the surgeon may perform a continent ileostomy. Portions of the small intestine are used to form a pouch and valve; these are then directly attached to the abdominal wall skin to form a stoma. Waste collects inside the internal pouch and is expelled by insertion of a soft, flexible tube through the stoma several times a day.

Resources

books

Pemberton, John H., and Sidney F. Phillips. "Ileostomy and Its Alternatives." In Sleisenger and Fordtran's Gastrointestinal and Liver Disease, 7th ed. Philadelphia: Elsevier Science, 2002.

periodicals

Becker, James M. "Surgical Therapy for Ulcerative Colitis and Crohn's Disease." Gastroenterology Clinics of North America 28 (June 1, 1999): 371-90.

organizations

Crohn's and Colitis Foundation of America. 386 Park Ave. S., 17th Floor, New York, NY 10016. (800) 932-2423. <www.ccfa.org>.

United Ostomy Association, Inc. 19772 MacArthur Blvd., Suite 200, Irvine, CA 92612-2405. (800) 826-0826. <www.uoa.org>.

other

Hurst, Roger D. "Surgical Treatment of Ulcerative Colitis." Crohn's and Colitis Foundation of America. [cited May 1, 2003]. <www.ccfa.org/medcentral/library/surgery/ucsurg.htm>.

Stephanie Dionne Sherk

WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?

Ileoanal anastomoses are usually performed in hospital operating rooms. They may be performed by a general surgeon, a colorectal surgeon (a medical doctor who focuses on diseases of the colon, rectum, and anus), or a gastrointestinal surgeon (a medical doctor who focuses on diseases of the gastrointestinal system).

QUESTIONS TO ASK THE DOCTOR

• Why are you recommending an ileoanal anastomosis?
• What type of pouch will be created?
• Will an ileostomy be created? When will it be reversed?
• Are there any nonsurgical alternatives to this procedure?
• When will I be able to resume my normal diet and activities?