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A permanent ileostomy following removal of the colon can be avoided in selected patients by removing all diseased colon 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 and polyposis are candidates for this procedure, but those with Crohn's disease are 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 fistulae. This is especially important in patients with ulcerative colitis (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 patients older than 65 years and those who have fecal incontinence. Obesity may make it impossible to perform the anal pouch anastomosis. In patients with Familial Adenomatous Polyposis (FAP) desmoids 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 can sometimes be required due to factors not known until the procedure is underway.
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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 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.
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A prolonged period of preoperative hyperalimentation or nonalimentation with catabolism may be avoided by a staged procedure, especially in the presence of toxic megacolon, poor general condition, or rectal disease. 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 ...