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.
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.
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.
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 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.
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.
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.
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 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%).
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.
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.
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.
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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.
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Nancy Mckenzie, PhD
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.
I was not offered any of the options quoted, is this because of the infection or for other reasons I'm not party too.
Mr S.Whall
England.
Can anyone help me pleaser as this is imparing my lifestyle?
Thanks
When I had the ostomy, I hated it. It was a problem with maintaining it for a number of days (and the appliances are expensive). I had one set fail while I was away from home for 2 days and was forced to repair it in order to get by until I got home. I found that the skin around the stoma got raw and irritated. The solution was a coating that is available from the company that supplied the ostomy appliances. This coating sealed the skin from irritants (feces) and mad the adhesive wafers stick much better and longer. It was also helpful to use the stoma paste which acts like caulking to help seal the hole. It also prevented the cut hole of the wafer from irritating the area around the stoma.
Since the reversal (and thank God, the elimination of the ostomy) I have dealt with the irritation of the anus and surrounding area. The surgeon had originally prescribed A & D Ointment, which I found worked OK but not all the time or completely. I have found it to be very beneficial to use baby wipes following elimination to make sure the area is completely clean. Using Tucks antiseptic pads helped greatly with anal the irritation. It has also been very helpful to keep the anus and surroundings lubricated with the ointment. The Desitin type ointments did not work well for me. One thin that I did find helped with the healing was Bag Balm. The high lanolin content completely healed my skin pretty quickly. Now that it has healed, I have success using the Vitamin A&D ointment that I found at Walmart. It is generic (their brand) and very inexpensive. $1.62 for a 4 oz. tube. Since it is so cheap, I use it liberally and it has helped keep me from getting irritated.
My surgeon also suggested that I take Metamucil at bedtime to help firm my stool. That has helped a lot, although I think I need to use it twice a day as my late day stools get to be loose again. I am also taking my evening dose earlier as I believe that it will help keep me from having as many movements at night
I know that I am going on. I hope that this information is helpful to someone, as I have had to learn it by trial and error. I guess we all have to. Please feel free to email me at canvasmakr@gmail.com with questions or comments.
If anyone has a similar situation I would like to hear how they are handling things. Thank you.
I take about 8 30mg pills per day which I have cut down from 12.