Evolution & New Trends of Restoration following

ProctocolectomyMohan Samarasinghe

Clinical Fellow

St Mark’s Academic Institute

St Mark’s Hospital

Why Proctocolectomy?• Ulcerative Colitis (UC)

• Familial Adenomatous Polyposis (FAP)

• Selected Hirschsprung’s disease (HD) - (Mostly historic)

Why Restoration?

Patients demanded it, Pushed surgeons to find a way

because

“..rather die than having a stoma”

Restoration? How?A brief account of history and evolution to

understand why do we do, what we do now…

Rudolph NissenFirst ileo-anal anastomosis of a 16y boy with polyposis

who underwent total excision of colon and

rectum in 1932

Presented in a discussion at a meeting of Berlin

Gesellschaft für Chirurgie (surgical society) in 1933

Mark M RavitchFirst to show serious Interest in preserving

gut continuity and sphincter preservation using ‘Anal Ileostomy’

for those requiring proctocolectomy for

benign diseases

Mark M Ravitchin 1947:

Experimented in dogs on procedure for accomplishing an anal ileostomy, which they thought might be feasible in man with some modification(Surg Gynecol Obstet [Now JACS] 1947)

in 1948: Published results of 2 patients who underwent ‘anal ileostomy’ (Surgery 1948)

Problems of Ravitch’s Anal ileostomy

• Difficult to control effluent • Increased frequency • Perianal excoriation • Fluid imbalance • Delayed healing of perianal wounds, wound

breakdown with fistulation/ abscess formation • Frequent ileal obstruction, colics and

cramping pain (?Ileal kinking/Plicae circularis) • Distal ileal necrosis (?Mesentry entraptment)

“If the rate of bowel movements are diminished to a reasonable

minimum, the bulk of these problems will be solved”

….Valiente & Bacon AJS 1955

Valiente & Bacon :1955

• Experimented constructing an ileal pouch for pull through following total (procto)colectomy

• Two pouch designs • 7 dogs • 2 success

Two dogs survived

• Weight gain • 3-5 stools per day • Liquid stools → mushy • Barium XRay - Good size pouch • Complete barium washout in 48hr

Nils G KockIntroduced ileal

reservoir as a continent bladder replacement in

1962

Attempted to achieve faecal continence in

patients with permanent ileostomy by

adopting ileal reservoir used in bladder

replacement in 1969

Sir Alan Parks & R J NichollsProctocolectomy without

ileostomy for ulcerative colitis

(BMJ 1978) First to successfully

reconstruct a neorectum using a ileal pouch

following removal of the colon and rectum (rectal

mucosectomy) without having to have a a

permanent ileostomy

30cm of terminal ileum

Three 8cm limbs of ileum folded and S pouch created

Last 5cm untouched to serve as a conduit

Rectal mucosectomy done

Pouch sits on rectal muscular sleeve

Ileo-anal end to end anastomosis at dentate line

Intact anal sphincter used for continence (BJS 1980)

Results of Parks’ Procedure

• Anatomical rectal mucosectomy • Good reproducible pouch outcome • Spontaneous defecation was not

consistent in some cases - Required catheter decompression. ? Last 5cm of intact ileum

J Utsunomia’s J Pouch (1980)

J Utsunomia’s J Pouch (1980)• Refined rectal mucosectomy • Demonstrated that low situated

ileal reservoir (eg: J pouch) performs better than a high situated one

• GIA stapler use in pouch construction

• Frequency was 3-6 per day

Fonkalsrud’s ‘H’ Pouch (1982)

Fonkalsrud’s ‘H’ Pouch • GIA stapler use in pouch

construction • Fixed ileal catheter for flushing • Long intra-rectal ileum distal to

pouch • Long pouch - less frequency • Multi-stage procedure

R J Nicholls’ J & W Pouch (1985)

R J Nicholls’ J Pouch (1985)• Side to end ileo-anal anastomosis • Eliminates the last ileal segment which

believed to be the reason needing catheterisation therefore eliminating the need to catheterise

• Less complications • Intestinal obstruction requiring laparotomy

was significantly less in J pouch compared to S pouch

R J Nicholls’ W Pouch (1987)

• J pouch - higher stool frequency and night evacuation

• In search for benefits of a J pouch (not needing catheterisation) but with better stool frequency

• Preserving Side to end ileo-anal anastomosis

J vs W• J: easy construction, benefits from

staplers, needs only 30-40cm of ileum, if long enough, functions well

• W: time consuming to construct, difficult to do with staplers, Uses 50cm of ileum. Only marginally better than J pouch in stools frequency

Ileal Pouch = J Pouch

Safe Proctectomy (1988)

Close Rectal VS MesorectalClose Rectal

• Less straightforward Mesorectal

• Embryological plane • Bloodless dissection

Nerve injury rates are not significantly different between two techniques

Mucosectomy VS Stapler

• Mucosectomy removes ATZ: Incontinence, early septic complications risk is higher, Ineffective in 7%

• Staplers may leave ATZ: Dysplasia risk is higher (4.5%), Cuffitis

• CA following IPAA - in both mucosectomy and stapler groups

Defunction or Not• Two vs One stage • Financial benefits • No difference in complication rates in

selected groups • No longterm steroids • Absolutely no tension anastomosis • Otherwise healthy patients

• If complicated: High price?

Laparoscopic/SIL IPAA

• Laparoscopic colonic mobilisation • Extracorporial bowel division and

pouch construction • May help to reduce pelvic adhesions • Early return of bowel function • Reduced hospital stay

Early Complications• Acute pelvic sepsis 5-24% • Anastomotic leaks 5-18% • Small bowel obstruction 15-44%

(5-20%) • Pouch bleeding • Pouch–rectostomy (double-

stapled anastomosis)

ComplicationsLeak from IPAA 7 - 18% Anastomotic sinus 2–8% Symptomatic stricture 16% Chronic pelvic sepsis 6% Pouch–cutaneous fistula 5% Pouch–vaginal fistula 3–15% Small bowel obstruction requiring operation 5-20% Cuffitis 5-16% Symptomatic pouchitis (cumulative incidence at 10 years) 40% Symptomatic portal vein thrombosis 6% Ultimate failure of pouch 4%

Permanent diversion 1% Pouch excision 3%

Structural Pouch Failure

TAMIS/TATME• Transanal Minimally Invasive Surgery (TAMIS) -

Trans Anal Total Mesorectal Excision (TATME) • Hybrid of TEM & SILS with conventional lap

instruments • Benefits of TEM at a fraction of the cost • In patients with a narrow pelvis, the TAMIS

approach with its ability to increase the mobilization of the rectum and improve visibility, may be valuable

TAMIS

• Uses SILS platform • Benefits from advanced air

insufflators (AirSeal) • Specially designed CEEA staplers

with long anvil probes (Frankenman)

Why TAMIS/TATME?

Structural Pouch Failure

Double Stapled Anastomosis

LeaksBelieved to be

associated with peri-pouch sepsis and

subsequent poor pouch function

Double stapled anastomosis leak rate:

3-4%

WHY TAMIS• No need to transect rectum

through abdominal approach • Single stapled anastomosis • No stapler-on-stapler line • No side pockets • Can expect higher anastomosis

integrity hence less leaks

References• Turnbull RB, Weakley FL, Hawk WA, Schofield P. Choice of operation for the toxic

megacolon phase of non-specific ulcerative colitis. Surg Clin N Am. 1970;50:1151–69.

• Nissen R. Demonstrationen aus der operativen chircurgie zunachst einige Beobachtungen aus der palstichen Chirur- gie. Zentralbl Chir. 1933;60:883.

• Ravitch M, Sabiston DC. Anal ileostomy with preservation of the sphincter. Surg Gynecol Obstet. 1947;84:1095–9.

• Valiente MA, Bacon HE. Construction of pouch using pantaloon technic for pull-through of ileum following total colectomy; report of experimental work and results. Am J Surg. 1955;90:742–50.

• Kock NG. Intra-abdominal “reservoir” in patients with permanent ileostomy. Preliminary observations on a pro- cedure resulting in fecal “continence” in five ileostomy patients. Arch Surg. 1969;99:223–31.

• Parks AG, Nicholls RJ. Proctocolectomy without ileostomy for ulcerative colitis. Br Med J. 1978;2:85–8.

• Utsonomiya AJ, Iwama T, Iamjo M, et al. Total colectomy, mucosal proctectomy and ileoanal anastomosis. Dis Colon Rectum. 1980;23:459–66.

• Nicholls RJ, Pezim ME. Restorative proctocolectomy with ileal reservoir for ulcerative colitis and familial adenoma- tous polyposis: a comparative of three reservoir designs. Br J Surg. 1985;72:470–4.

• Nicholls RJ, Lubowski DZ. Restorative proctocolectomy: the four loop (W) reservoir. Br J Surg. 1987;4:564–6.

• Fonkalsrud EW, Stelzner M, McDonald N. Construction of an ileal reservoir in patients with a previous straight endorectal ileal pull-through. Ann Surg. 1988;208:50–5.

• Sagar PM, Pemberton JH. Intraoperative, postoperative and reoperative problems with ileoanal pouches. Br J Surg. 2012;99:454–68.

• Sugarman HJ, Newsome HH. Stapled ileoanal anastomosis without a temporary ileostomy. Am J Surg 1994;167:58–66

• Young-Fadok TM, Dozois EJ, Sandborn WJ, Tremaine WJ. A case matched study of laparoscopic proctocolectomy and ileal pouch-anal anastomosis(PC-IPAA) versus open PC-IPAA for ulcerative colitis. Gastroenterology 2001;A-452:2302

• Geisler DP, Condon ET, Remzi FH. Single incision laparoscopic total proctocolectomy with ileopouch anal anastomosis. Colorectal Dis. 2010;12:941-943

• Atallah S, Albert M, Larach S. Transanal minimally invasive surgery: a giant leap forward. Surg Endosc. 2010;24(9):2200–2205. doi: 10.1007/s00464-010-0927-z

Thank you