A permanent ileostomy following removal of the colon can be avoided in selected patients by removing all diseased colon and rectum down to the top of the columns of Morgagni or the pectinate line, followed by construction of an ileal reservoir, with anastomosis of the anal canal (FIGURE 1). Patients with ulcerative colitis (UC) and polyposis are candidates for this procedure, but those with Crohn’s disease are generally not because of the potential for involvement of the small intestine. The patient must have an adequate anal sphincter by digital examination or, better yet, by manometry. The rectum should be free of ulcerations, abscesses, stricture, fissures, or fistulas. This is especially important in patients with UC. This procedure can be considered in patients who are strongly opposed to an ileostomy and who are available for prolonged close follow-up. The patient should thoroughly understand the uncertainties of postoperative anal control and the need to have patience during the early months after the operation. The procedure is not recommended for frail, elderly patients and those who have fecal incontinence. Obesity may make it impossible to perform the anal pouch anastomosis. In patients with familial adenomatous polyposis, desmoid tumors involving the small bowel mesentery can make it difficult to obtain adequate length to reach the anus with the pouch. All patients should realize that a permanent ileostomy sometimes can be required because of factors not known until the procedure is underway.
Various surgical procedures have been used in an effort to improve long-term anal continence. It is questionable whether any procedure currently used is always completely successful, and the patient should be informed of this uncertainty. Increasing experience suggests that the use of some type of anal pull-through procedure has a reasonable chance of providing more comfort than the terminal ileostomy or the ileal abdominal pouch.
Although an ileoanal pouch can be created at the time of total proctocolectomy without a protective stoma as a single-stage procedure, most experts recommend a two-stage procedure with a diverting loop ileostomy. It is prudent to perform a three-stage procedure in emergent conditions and in the face of poor nutrition or hemodynamic instability and profound immunosuppression. A permanent ileostomy is performed with subtotal colectomy, leaving the rectum in place and the superior hemorrhoidal vessels undivided. This also offers the chance to review the pathology of the colon to further exclude Crohn’s disease. After several months, an ileoanal anastomosis is considered, and a diverting ileostomy is created at the time of the pouch. After a suitable recovery, the temporary ileostomy is closed, making this a three-stage procedure. Various pouches have been advocated. They include the J pouch (FIGURE 2A), the three-loop S pouch (FIGURE 2B), the lateral isoperistaltic ileal reservoir (FIGURE 2C), and the four-loop W reservoir (FIGURE 2D).
Documentation of the pathologic process ...