Indications

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The choice of the ideal surgical procedure for treating these patients is based upon the following considerations:

- the need of definitive treatment with a one-stage procedure that allows a complete removal of the diseased tissue and avoids the risk of cancer.

- The possibility of restoring the anatomy as well as the bowel function and the faecal continence.

- The outcome and the complications of different surgical procedures.

- The patient's skills in managing the new condition and coping with the possible complications.

- And, above all, the possibility of improving the quality of life of the patient, which implies the evaluation of multiple functional and psychological factors.

Nowadays, restorative proctocolectomy is certainly the gold-standard technique for treating patients with ulcerative colitis or familial adenomatous polyposis [5,6]. Nevertheless, there are still a few patients in which the proctocolectomy along with definitive ileostomy may be considered a good indication. The proctocolectomy with perineal excision and definitive ileostomy may be an indication of necessity in patients presenting with cancer or severe dysplasia of the very low rectum or anus [7]. In these cases, the choice of this surgical procedure should be based on the tumour stage and the need for radiotherapy. In other cases, the indications are more controversial and are still being debated. Provided that all the alternatives are discussed with the patient, the decision of the surgeon should be drawn from a sort of balance between the factors mentioned above. In elderly patients with a longstanding disease and a weak sphincter, a one-stage procedure with definitive ileostomy could be beneficial and better accepted by the patient. Similarly, all the patients with sphincter damage, particularly women with post-obstetric neu ropathic sphincter trauma, might be good candidates for a definitive ileostomy. In these patients, the excision of the rectum to the level of the perineal muscles and the removal of the diseased anal mucosa could lead to disappointing results in terms of continence with much more discomfort and distress symptoms for the patient than a well-managed ileostomy. All the patients should be correctly informed about the outcome and the possible complications after restorative proctocolectomy such as diarrhoea, nocturnal soiling and recurrent pouchitis, so that patients who refuse to take these risks can be candidates for a proctocolectomy with a definitive ileosto-my. Other patients are too psychologically weak and unstable to cope with the uncertainties of the outcome of a restorative procedure or are not available to attend the strict follow-up that is mandatory when an ileal pouch-anal anastomosis has been performed [8]. Furthermore, the definitive ileostomy, as salvage surgery, constitutes the last option for patients who previously underwent a restorative proctocolectomy in which the ileal pelvic pouch had to be removed [9]. The emergency operations are a particular problem. In patients with a previously detected severe inflammatory anorectal involvement, continuous bleeding from the ultra-low rectum or a perforation at this site may occasionally constitute an indication for a radical proctocolectomy without anastomotic reconstruction. Nevertheless, some authors suggest that even in these cases the rectum should be mobilised at the level of the levator ani and transected at the anorectal junction so that a pelvic pouch might be subsequently performed [4]. However, it should be stressed that, recently, many authors have reported that, in emergency, the primary procedure is more frequently a total colectomy with an ileostomy. They suggest that in these circumstances the surgeon should do a minimal intervention, and subsequently the patient may undergo a restorative proctectomy or an ileo-rectal anastomosis [10]. Emergency operations certainly have more complications such as a higher risk of fistula and pelvic nerve damage, and in these cases the surgeon's experience plays an important role in the choice of surgical options [11].

The surgeon and the stoma care nurse should arrange a pre-operative meeting with the patients whenever an elective procedure is performed. In order to make the right choice, the patient and the partner have to be aware of the alternative procedures such as restorative proctocolectomy with an ileal pelvic pouch and total colectomy with ileo-rectal anastomosis. The procedures have to be carefully described to the patients with particular attention to technical details, drawings and literature data. Moreover, they should be correctly informed about the quality of life and the possible implications of these operations. Particularly, some aspects of both the procedures have to be discussed such as complications, continence, soiling, diarrhoea, dietary restrictions, social restrictions and the necessity of long-term follow-up. The patient should be reassured that a stoma care unit is always available for all his needs. However, above all, the information given to the patients must be as objective as possible since, patients potentially unsuitable for the restorative operation may be persuaded by the excessive enthusiasm of the surgeons for the pouch procedure [8].

Once a decision to perform a definitive ileostomy has been taken, the surgeon is requested to make a second choice: whether or not to perform a continent reservoir ileostomy according to a modified Kock technique instead of a conventional Brooke ileostomy [12, 13]. Nowadays, the Kock ileostomy is rarely used as the primary treatment for ulcerative colitis or familial adenomatous polyposis due to the other alternative surgical options that are available and the surgical and metabolic complications associated with the reservoir ileostomy [14]. Nevertheless, besides the above-mentioned indications for conventional ileostomy, patients who have a poorly functioning ileoanal pouch and who are unsatisfied with their continence and quality of life, may be suitable for a conversion to a continent reservoir ileostomy [9,15]. Similarly, the continent reservoir may be proposed to a limited cohort of selected and strongly motivated patients who have previously had a terminal conventional ileostomy. However, it is necessary to stress that there is an important learning curve for this operation and, just because nowadays the indications are rare, only a few centres have acquired sufficient experience with the procedure.

Even in this case, a detailed description of the procedure and its aims should be given to the patient, since a failure of the reservoir exposes the patient to the risk of a reoperation, a further loss of 50-60 cm of the ileum along with consequent metabolic derangement and, finally, the need for wearing a conventional appliance for the stoma. Therefore, it is obvious that the possibility of evaluating whether or not the procedure will be successful depends on a clear and objective definition of the aims of the reservoir ileostomy. Some authors have described these aims as the possibility of achieving a pouch completely continent to the gas and faeces with a capacity of 800-1 000 ml. This pouch should be emptied by a catheter no more than two or three times a day, without the urgency of draining at night, and the catheterisation should take no longer than 15 min. The exit conduit of the stoma should be invisible under the clothes and there should be no need of wearing a stoma bag as the mucous discharge should be minimal and there is complete control achieved by the application of a disposable dressing over the stoma. Finally, there should be no restrictions of food intake, sexual activities, work or any other social functions [8].

A careful selection of these patients is of paramount importance. A psychological assessment should be made in order to verify the real motivation of the patient and the psychological profile, thus excluding psychologically unstable patients who are seeking attention. The social environment should be evaluated as well as the physical skill of the patient to manage the pouch. Some patients have been described as having badly managed and perforated the pouch during catheterisation, others, with psychological lability, manipulate and deteriorate the pouch themselves; likewise, the elderly patients should not be considered for this procedure. Patients with pathological and psychological dietary disturbances such as the alcoholic, the anorexic, the bulimic, the obese and the very thin should be excluded. Particular attention should be paid to the patients who have previously undergone abdominal surgery, because the presence of thick adhesions may be a contraindication. Moreover, previous small-bowel resections, gastrectomy or pancreatic insufficiency are criteria for exclusion since in these cases there is an increased risk of electrolyte deficiency and metabolic complications. Finally, the emergency operation may be considered a contraindication for this procedure.

In 1997, Williams reported ten cases of Kock pouch construction. Four patients had a primary conventional proctocolectomy with a Kock pouch for ulcerative colitis with good long-term results. Six patients who had previously undergone restorative proctocolectomy for ulcerative colitis were converted to reservoir ileostomy. Among these latter, the reservoir was successful in four patients and failed in two: one due to sepsis and one due to obesity [8].

Although many authors consider a diagnosis of Crohn's disease as an absolute contraindication for a Kock pouch construction, this particular topic is still being debated [16]. In most of the reported cases, the patients with Crohn's disease who had a reservoir ileostomy as the primary operation, had a diagnosis of ulcerative colitis at the time of the first operation and, only subsequently, was the underlying diagnosis of Crohn's disease confirmed. In these patients, the diagnosis is usually achieved by the histological examination of the colon specimen in the early postoperative period or, later—via the analysis of the removed ileal pouch as a consequence of complications. In these latter cases, the histological examination of the colon, at the time of the first operation, has features similar to those of the ulcerative colitis, but the subsequent pouch complications reveals

Crohn's disease. Some of these patients with Crohn's disease develop complications in the early post-operative period such as sepsis, fistula, bleeding and poor functional results requiring pouch excision; others, after years of good functional results, begin to have the typical symptoms of pouchitis. These patients complain of abdominal pain, fever, diarrhoea with high volume of fluid discharge and loss of electrolytes, bleeding, obstruction and difficult catheter-isation. Frequently, they are classified as having chronic pouchitis and only the endoscopic biopsy allows the correct diagnosis of the underlying Crohn's disease. In these recurrent forms of Crohn's disease, medical treatment rarely achieves good results and, often, the patients end up with the removal of the pouch and a conventional ileostomy. Myrvold and Kock, in their important study that was a milestone in this specific area, reported only 27% of complications out of a total of 52 patients with Crohn's disease who underwent a reservoir ileosto-my. The same incidence of complications was found in patients operated on for ulcerative colitis or familial adenomatous polyposis [17]. Other authors reported similar results in a small subset of patients with Crohn's disease. These authors suggested that patients with Crohn's disease confined to the colon and no evidence of disease to the small bowel, after a minimum follow-up of 5 years might be candidates for a reservoir ileostomy. Similarly patients with indeterminate colitis without evidence of disease to the ileum might be suitable for the Kock ileostomy [18]. On the contrary, Handelsman reported four pouch excisions out of eight patients operated on with Crohn's disease compared to only two pouch excisions in 87 patients with ulcerative colitis, so that he concluded that the suspicion of Crohn's disease is a contraindication to continent reservoir ileostomy.

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