Surgical Options - Pelvic Pouch

Prior to the 1970's, individuals with ulcerative colitis and certain individuals with familial polyposis who required surgery to treat their disease underwent a total proctocolectomy. This surgery involves removal of the colon, rectum, anus and sphincter muscles and creation of an ileostomy. This operation cured the disease but left the individual with a permanent ileostomy. This procedure is still considered the safest with the least number of risks and long-term complications. The difficulty is in people's acceptance of the ostomy. As a result, surgeons over the years have attempted to develop alternatives to a permanent stoma. In the early 1970's, Professor Koch of Sweden created the Koch Pouch surgery. The colon, rectum, and anus, were removed and an internal abdominal pouch was constructed from small bowel. The construction of a nipple valve within the Koch Pouch produced a continent ileostomy. The concept was wonderful however the long-term complications and re-operation rates were and still are high. Today, this surgery is performed in a very small minority of cases.

In the late 1970's, surgeons in Britain and Japan first introduced the Pelvic Pouch or Ileoanal Reservoir procedure. As a result, the surgical approach to ulcerative colitis and familial polyposis was revolutionized. The pelvic pouch procedure has become the "gold standard" for those individuals who require surgery to treat their disease. The Pelvic Pouch Procedure involves different surgical scenarios depending on the individual's state of health at the time of surgery.

A question most frequently asked is whether the Pelvic Pouch Procedure can be performed laparoscopically. Pelvic pouches are done laparoscopically at Mount Sinai as well as other centres. It appears that those who have had a laparoscopic intestinal procedure do recover from the operation faster than those done with an open procedure. They often are eating sooner after surgery, and are likely to be discharged sooner from hospital and return to work or school after a relatively short convalescence. In addition, since the incisions are smaller, the resulting scars are smaller. While the number of patients treated laparoscopically remain small, the results are encouraging.

Many patients can be considered candidates for laparoscopic surgery. At Mount Sinai, the colorectal surgeons work as a team, offering a laparoscopic approach whenever appropriate. In some instances, such as emergency procedures, it is impossible to arrange for a laparoscopic assessment and the procedure must proceed using the open technique. In a few cases, initial laparoscopy is performed, but the surgeon is unable to complete the operation with the laparoscope and so converts to an open procedure.

The following describes the different surgical scenarios for the Pelvic Pouch Procedure

Scenario One: "One-Stage Surgery"

In patients who are relatively healthy, not actively bleeding or on high doses of steroids, the Pelvic Pouch will be constructed during the first stage. The colon and rectum are removed leaving the anus, the pelvic muscles and nerves. The pouch or reservoir is created using two loops of small intestine (J-shaped pouch). The pouch is anastamosed or joined to the anus using either staples or stitches. To protect the join, a temporary loop ileostomy is made. An opening is made in the abdomen and a loop of small intestine is brought out. The stool passes into an external appliance. Thus no stool passes through the internal pouch initially.

A pouchogram (x-ray of the pouch) is done at six weeks to determine healing. If healing takes place, the second step involves closure of the loop ileostomy and usually occurs at three months. No preparation is required for the X-ray.

The second operation includes closing the openings to the loop ileostomy thus re-establishing bowel continuity. The stool then passes through the small intestine, into the pouch or reservoir, and exits the body through the anus.

Scenario Two: "Two-Stage Surgery"

Stage One

In this scenario, two major procedures are done. In individuals who have been sick with their disease, have been on high dose steroids, actively bleeding, had significant weight loss or in situations where the disease has not been determined, the safest procedure to be done first is a subtotal colectomy. In a subtotal colectomy, the colon to the sigmoid region is removed, leaving the rectum, anus, pelvic muscles and nerves in place. An end ileostomy (opening in the small bowel or ileum), is established with or without a mucous fistula (opening on the abdomen for the passage of mucous or drainage from the rectum) depending on how diseased the rectum is at the time of surgery.

The goal following surgery is to allow the individual to regain weight, strength and energy, to decrease and eventually stop the steroids and then at a later date (three months or longer), proceed with the pelvic pouch.

Stage Two

In the second stage, the remaining sigmoid colon and rectum is removed leaving the anus, the pelvic muscles, and nerves. These are all necessary and important for voluntary control of bowel movements. A pouch or reservoir is created using two loops of small bowel (J-shaped pouch). The pouch is anastamosed or joined to the anus using either staples or stitches. The Pelvic Pouch procedure is usually completed at this second stage without the need for a second ostomy. A rectal tube placed in the pouch at the time of surgery is generally left in place for five to seven days to rest the join or the anastamosis of the pouch to the anus. Stool automatically drains into a bedside drainage bag.

Reconstruction

Reconstruction of the pouch is possible should the first one fail. Some reasons for pouch failure and the need for reconstruction include fistulas between the pouch and the vagina, infections/ abscesses in the pelvis, problems evacuating/emptying the pouch (due to long outlets of the pouch) or strictures. In most cases, the "old" pouch can be reused, but in some, the old pouch must be removed and a new one created.