Total Proctocolectomy with Brooke End Ileostomy

Total proctocolectomy has the advantage of removing all disease, thereby obviating the risk of subsequent malignancy. Controversy exists about the role of primary total proctocolectomy in urgent cases, as the procedure is more demanding and associated with higher morbidity rate. Pelvic dissection is more difficult, risk of injury to the autonomic nerve plexuses and possibility of septic sequelae are increased in spite of improvements in bowel prepa ration. As a general rule, such an extensive operation should be avoided. However, current candidates for total proctocolectomy with Brooke end ileostomy include elderly patients in good condition with poor anal sphincter function, patients with massive rectal bleeding or distal rectal cancer invading the anal sphincter and patients who have a personal preference for this surgical option. Complications, such as impotence and perineal wound breakdown, can be reduced if an intersphincteric proctectomy is performed. Continent ileostomy as functioning Kock pouches [44-46], the Barnett pouch or the T-pouch [34, 47] have achieved some level of acceptance. However, these procedures are associated with numerous complications and are performed largely in referral centres where the need for reoperations is lower than 10%.

End ileostomy as described by Brooke [48] is actually the gold standard in patients not qualified for a restorative procedure. The two major complications of end ileostomy, high output and stoma stricture, were best prevented by the technique of stoma eversion that Brooke reported in 1952 [49]. Sufficient stoma length, its proper seating and its relationship to the waistline should be emphasised and are of major concern. The site for ileostomy is a little below the midway point between the umbilicus and the right anterior iliac spine. A button of skin is excised, the rectal fascia is incised and a noncrushing instrument is inserted between the lateral fibres of the right rectum muscle. The ileum is withdrawn through the ileostomy site. At least 5 or 6 cm of ileum should be brought above the skin level. The mucosa is everted and anchored with interrupted sutures to the skin. The complete ileosto-my should extend upward from the skin level at least 2.5-3 cm. The mesentery of the ileum is anchored to the abdominal wall laterally, and the right lumbar gutter is closed off to avoid potential postoperative internal hernias. The chances of peristomal hernia, fistula, retraction and stenosis are minimal.

The Brooke ileostomy is the easiest and quickest type of stoma. The function of stoma begins 3-4 day after is construction. This ileostomy is always used in patients unable to manage intubations required for a continent ileostomy, such as children, the aged and the physically handicapped. It can be difficult to construct in obese patients; a loop ileostomy provides a satisfactory solution.

Despite the advantages, the Brooke ileostomy and the loop ileostomy carry some potential disadvantages. Patients are completely incontinent for gas and stool; bags are uncomfortable; and some patients develop peristomal dermatitis, obstructive ileitis and clinical backwash ileitis. Manifestations of intestinal malfunction may require vigourous replacement of fluid and electrolytes. Alteration in intestinal flora, often caused by the preoperative use of antibiotics, should be of great concern.

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