Abstract

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We present the long-term results of a unique consecutive series of 101 single layer W ileoanal pouch reconstructions (63 male, 38 female; age range 10-76 years, median 36 yrs) over a ten year period in a tertiary referral centre.
All procedures were carried out by the same consultant colorectal surgeon using an interrupted single layer suture technique for the W ileal pouch construction and a stapled pouch-anal anastomosis, covered with a temporary loop ileostomy. 54 patients underwent primary restorative proctocolectomy and 47 patients with a previous colectomy and ileostomy underwent restorative proctectomy, 12 having been referred with a very short rectal stump (
There was no operative mortality. One patient developed necrotizing fasciitis involving a drain site and 2 patients had significant pouch haemorrhage. One late death occurred after closure of the ileostomy related to pouch ischaemia in an older diabetic man. Two men developed fistula from the pouch-anal anastomosis. One was successfully treated with gracilis transposition, the other required pouch excision. There are presently 99 functioning pouches. 10 patients have clinical and histological evidence of pouchitis requiring treatment with steroids and/or antibiotics with good effect. 55 randomly selected patients (38 male, 17 female) underwent functional assessment.
Median pouch stool frequency was 5 during the day and 1 during the night. 84% were fully continent and 13% had minor incontinence. 51% had little or no discrimination of fluid from flatus. The median number of anti-diarrhoeal drugs used was 1. 89% of patients made no changes to their diet, 5.4% made moderate adjustments and less than 2% made significant changes. 25% patients developed some degree of sexual dysfunction. This was more common in tertiary referrals with a very short rectal stump. 20% of patients developed transient urinary retention with 1 patient requiring long-term self catheterization. 80% of the patients reported no disadvantages in social or professional life, 13% had minor social life disturbances not affecting their professional lives and 3.6% had a significantly disturbed professional and social life. Interestingly, 3.6% admitted to an improvement in their lifestyle.
Restorative proctocolectomy with a single layer interrupted suture W ileoanal pouch, which is not widely practised, offers excellent long-term clinical and functional results with an extremely low failure rate.

Introduction

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Restoration of intestinal continuity with ileal pouch-anal anastomosis is currently a universally accepted option in the surgical treatment of patients with ulcerative colitis and familial adenomatous polyposis, amongst other indications.  Over the years, the procedure has undergone various technical modifications in attempts to reduce complications and improve the functional outcome following surgery.  These include type of rectal dissection, pouch design, construction technique, method of anastomosis and the creation of a temporary covering ileostomy.  This study reports our unique experience over a ten-year period in treating a large consecutive series of patients within a tertiary referral centre in whom a W pouch was constructed using an interrupted single-layer suture technique.  These include a challenging subgroup of patients who were referred with a very short rectal stump.

Methods

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During the period 1993 to 2003, all patients undergoing ileal pouch-anal anastomosis (IPPA) under the care of a single consultant colorectal surgeon (JSV) were recruited to a prospective study. They comprised 63 males and 38 females. Their ages ranged from 10 – 76 years (median 36.9 years). Of the 101 patients in the study, 54 underwent restorative proctocolectomy and ileal pouch-anal anastomosis. In the remaining 47, a completion proctectomy and ileoanal pouch was performed as a second stage procedure, these patients having undergone previous colectomy for medically uncontrollable disease. Of these, 28 patients were tertiary referrals, 12 of whom had a very short rectal stump in situ (
Indications for Surgery
Eighty-nine procedures were performed for presumed refractory ulcerative colitis (UC). The final histological diagnosis confirmed UC, in 83, indeterminate colitis in 4 and Crohn’s disease in two. Other indications were familial adenomatous polyposis in 3, UC with cancer in 3. UC with dysplasia-associated mass lesion in 2, hereditary non-polyposis colorectal cancer, 2, and megarectum in 2.
Surgical Technique
Following bowel preparation and appropriate prophylactic measures, proctocolectomy or proctectomy was performed. This was achieved through a midline Laparotomy and complete mobilization of the colon and rectum. All major ileal vessels were preserved. In the pelvis, the mesorectum was excised en bloc with the rectum, taking care to preserve the hypogastric plexus. The pelvic dissection was continued anteriorly in the plane of Denonvillier’s fascia down to the pelvic floor. The anorectal junction was stapled with a 30 mm linear stapler (TX30, Ethicon Inc. Somerville, NJ, USA) prior to transaction 1-2cms above the dentate line. A W shaped ileal reservoir was constructed with four 10cm limbs sutured with interrupted 3/0 Bralon (Ethicon Inc. Somerville, NJ, USA) serosubmucosal technique. Pouch-anal anastomosis was constructed with a large circular stapler (CDH29, Ethicon Inc. Somerville, NJ, USA) inserted per anum and cross-stapling through the linear staple line. All pouches were covered with a temporary loop ileostomy. A large silastic tube drain was placed in the pelvis and a 24FG foley cathether inserted 10cms into the pouch and taped to the perianal skin for drainage. Both of these were retained for seven days. Details of the operation time, blood loss and blood transfusion were recorded at the time of surgery. In those patients who had a very short rectal stump in situ (n=12), dissection was aided by insertion of a rigid sigmoidoscope or assistant’s finger per anum. This facilitated identification of the rectal stump and separation of the bladder and seminal vesicles or vagina from the rectum during dissection prior to a difficult completion proctectomy. A contrast pouchogram was performed to confirm full healing after six weeks prior to reversing the loop ileostomy.
Statistics
Wilcoxon signed rank test was used to analyse the differences in the duration of procedure, blood loss and post-operative hospital stay between groups of patients.

Results

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Table 1 shows patient demographics and Table 2 shows details of the duration of operation, blood loss, blood transfusion and hospital stay between patients undergoing primary restorative proctocolectomy and those undergoing a second stage restorative completion proctectomy. No significant differences were identified in any of these parameters between the two groups.
Functional Results
Pouch Function
Median pouch frequency was five stools during the day and one during the night. 51% had little or no discrimination of fluid from flatus. See Table 3 for details.
Sexual Dysfunction
25% of the patients developed some degree of sexual dysfunction. See Table 4.
Bladder Dysfunction
20% of patients developed transient urinary retention with only 1 patient requiring long-term intermittent self catheterization.
Diet and Lifestyle
89% of patients made no changes to their diet, 5.4% moderate adjustments and less than 2% made significant changes after the operation. 80% of the patients reported no disadvantages in social or professional life, 13% had minor social life disturbances not affecting their professional lives and 3.6% had a significantly disturbed professional and social life. 3.6% of patients admitted to an improvement in their lifestyle since having the operation.
Early complications
Minor early problems managed conservatively
Seven patients with subacute small bowel obstruction were managed conservatively. Other minor problems managed conservatively including urinary tract infections, wound infection, retention of urine and high output ileostomy.
Early problems managed with surgical/radiological intervention
One patient each developed intraperitoneal bleeding, necrotising fascitis, burst abdomen, retracted ileostomy, pelvic abscess, subphrenic abscess and pelvic abscess. All these patients needed some form of surgical or radiological intervention as shown in Table 5.
Late complications
Patients developed a mild to moderate degree of anal stenosis, only 5 of whom needed EUA and dilatation. Pouchitis was confirmed in 10 patients (clinical, endoscopic and histology), all of whom responded to medical treatment. One young female patient developed incomplete bladder emptying and requires self-catherisation. 1 patient developed peritonitis secondary to perforation of small bowel close to the ileostomy. He underwent laparotomy and refashioning of the ileostomy. There were a total of 10 cases of small bowel obstruction, 3 of whom required revision of their loop ileostomy.
The most distressing late problem was a varying degree of chronic sexual dysfunction for which some patients were referred to an urologist. It appeared to be more common after completion proctectomy in patients with a very short rectal stump. 7 cases of anastomotic leaks were identified in this study. Six on of these were noted on the pouchogram with no clinical sequelae. These patients were managed conservatively and repeat pouchogram before closure of ileostomy showed full healing.
Closure of Ileostomy
100 of the 101 ileostomies were successfully closed and have functioning pouches. There are presently 99 functioning pouches ( one late death).

Discussion

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Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) is currently the preferred procedure for many patients with ulcerative colitis and familial adenomatous polyposis who require colectomy (1). It is an alternative to panproctocolectomy and permanent ileostomy for such patients. Utsunomiya of Japan described the popular J pouch in 1980 (2). In 1987, Nicholls & Lubowski from England described the W Pouch (3).This is the only large series of interrupted single layer W pouches performed by a single surgeon. The single layer allows expansion of the pouch and is therefore more compliant compared to stapled or continuous double layer pouches possibly leading to better functional outcome (4, 5). The W pouch completely fills the dead space in the pelvis leaving less space for any potential pelvic collections.
The main indications for IPAA were ulcerative colitis and premalignant conditions like FAP. During the period of this study it was not our practice to offer IPAA to patients known to have Crohn’s colitis for fear of pouch failure due to disease recurrence (6).
However, the histology of two of the post-operative patients initially diagnosed as UC showed features of Crohn’s colitis. To date none of the Crohn’s patients have developed any immediate or delayed post-operative problem due to recurrence but thorough follow-up and endoscopic surveillance are being followed. All four patients with indeterminate colitis have done well.
Pouch surgery is known to be associated with a high but acceptable rate of complications. In our series small bowel obstruction was one of the most common early complications recorded, as observed in other studies (7, 8, 9). It presented as an early problem in 7% of the patients slightly more than reported elsewhere (6). Bowel obstruction was seen in 10% as a late problem.
Pouchitis is defined by some as a histologically proven inflammation on biopsy and some as a clinical syndrome developing changes in stool frequency, continence and fever responding to antibiotics (7). The aetiology is likely to be due to bacterial overgrowth within the pouch (10). It is also suggested that pouch ischaemia due to division of one or more mesenteric vessels during construction may be a significant factor (7). In our study 20% of the patients developed pouchitis, this was histologically confirmed in only 10%. All these patients responded to antibiotics. Some series report a pouchitis incidence of 50%.
In this study the major late complication was pouch anal stenosis in 39% cases. Anastomotic stricture is common after IAP anastomosis (11). 5% of these patients needed EUA and dilatation not more than three times.
Perianal sepsis was seen in 2.6% requiring incision and drainage. The most important risk factor in developing perianal sepsis with pouch is the initial disease type. It is found to be greater in patients with UC than FAP (12). None of our patients with Crohn’s disease developed perianal sepsis, but longer follow-up is needed.
All patients were given a loop ileostomy after IPAA. Although some studies have shown that ileostomy is not necessary, sepsis can jeopardize the functional results of operation and a covering stoma prevents this problem (1). Closure of ileostomy was associated with once case of perforation and pulmonary embolism but no major complication or death occurred.
We reported a slightly higher sexual dysfunction rate because of the high volume of tertiary referrals with short rectal stumps (
Restorative proctectomy with an interrupted single layer W ileoanal pouch offers excellent long-term clinical and functional results with the lowest reported failure rate.

Reference(s)

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3. Nicholls RJ, Lubowski DZ. Restorative proctocolectomy: the four loop (W) reservoir. Br J Surg. 1987 Jul;74(7):564-6.
4. Fowler AL, Turner BN, Thomson WH. A study of the complications and pelvic visceral function after restorative proctocolectomy and W pouch construction. Colorectal Dis. 2003 Jul; 5(4):342-6.
5. Hewett PJ, Stitz R, Hewett MK. Harry E. Bacon Oration. Comparison of thefunctional results of restorative proctocolectomy for ulcerative colitis between the J and W configuration ileal pouches with sutured ileoanal anastomosis. Dis Colon Rectum. 1995 Jun;38(6):567-72.
6. Yamamoto T, Allan RN, Keighley MR. Audit of single-stage proctocolectomy for Crohn's disease: postoperative complications and recurrence. Dis Colon Rectum. 2000 Feb;43(2):249-56.
7. Simchuk EJ, Thirlby RC. Risk factors and true incidence of pouchitis in patients after ileal pouch-anal anastomoses. World J Surg. 2000 Jul;24(7):851-6.
8. Meagher AP, Farouk R, Dozois RR, Kelly KA, Pemberton JH. J ileal pouch-anal anastomosis for chronic ulcerative colitis: complications and long-term outcome in 1310 patients. Br J Surg. 1998 Jun;85(6):800-3.
9. Stein RB, Lichtenstein GR. Complications after ileal pouch-anal anastomosis. Semin Gastrointest Dis. 2000 Jan;11(1):2-9.
10. Shepherd NA, Hultén L, Tytgat GN, Nicholls RJ, Nasmyth DG, Hill MJ, Fernandez F, Gertner DJ, Rampton DS, Hill MJ, et al. Pouchitis. Int J Colorectal Dis. 1989 Dec;4(4):205-29.
11. Kelly KA, Pemberton JH, Wolff BG, Dozois RR. Ileal pouch-anal anastomosis. Curr Probl Surg. 1992 Feb;29(2):57-131.
12. Gecim IE, Wolff BG, Pemberton JH, Devine RM, Dozois RR. Does technique of anastomosis play any role in developing late perianal abscess or fistula? Dis Colon Rectum. 2000 Sep;43(9):1241-5.

Source(s) of Funding

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None

Competing Interests

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None

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