Plate 89

The adequacy of the blood supply to the reservoir is again double-checked. Two interrupted sutures with needles attached (Figure 15) are anchored on each side of the two-finger opening in the reservoir. These sutures are passed by the surgeon down through the anus, and the reservoir is placed in the proper position from above.

The two sutures on each side are then anchored to either side of the opening at the level of the dentate line (Figure 16). An additional suture is placed in the midline anteriorly and posteriorly. Eight or ten additional sutures may be required to ensure an accurate anastomosis. These sutures include the full thickness of the ileal wall, as well as a portion of the internal sphincter (Figure 17).

Any openings in the mesentery are closed with interrupted sutures to avoid intestinal hernia. The pelvic peritoneum is closed about the pouch to avoid twisting or displacement. A suture may be placed to anchor the pouch to each side of the muscular rectal cuff to secure the pouch in position and lessen the possible tension on the suture in the dentate line anastomosis. Some prefer to insert a rubber drain between the wall of the pouch and the rectal cuff. The rubber tissue drain is brought out anteriorly.

While it is tempting to avoid an ileostomy, fewer postoperative complications result if a complete diversion of the fecal stream is accomplished by ileostomy. The defunctioning ileostomy is performed through a small opening in the left lower quadrant about 40 cm from the pouch (Figure 18). It is advisable to ensure complete diversion of the fecal stream (Figure 19) by intussuscepting up the proximal limb or stoma over the rod (see also Plate 58).

Steroid therapy is gradually decreased until it can be omitted completely. The bladder catheter is removed after testing for sensation after a few days. The diet is slowly increased, but may need to be adjusted or limited depending upon the incidence of diarrhea.

Incidental obstruction, pelvic sepsis, and local problems around the ileostomy are occasional complications after the operation. Before closure, the integrity of the pouch and the anal anastomosis is evaluated by radiographic procedures with water-soluble contrast. Direct evaluation of the anastomosis for patency is also necessary. Frequently it strictures or develops a web across it requiring examination with sedation in the GI lab. Pouchoscopy can also be performed at this time. If no problems exist, the ileostomy is closed within 4 months.

The major consideration involves the degree of anal continence that has been achieved. Patience is required during the first year, as the capacity of the pouch increases and sphincter control gradually improves. The control of diarrhea during the day and soiling at night are of major concern and may require adjustment in bulk and type of food, as well as special medication. The number of daily stools varies, with an average of six per day and one or two per night. Patients with polyposis usually have fewer bowel movements per day than patients with ulcerative colitis.

A troublesome complication is a poorly defined syndrome known as pouchitis. The stools are increased in frequency with malaise, fever, and bloody stools, along with abdominal cramps. This complication is far more common in patients with ulcerative colitis than in those with multiple polyposis. Specific medication and dietary adjustments are indicated. This procedure is believed to be associated with chronic residual stasis. Intestinal obstruction may occur in 10 percent more of the patients.

Patients with this operation require frequent, long-term follow-up evaluations.