Current controversies in pouch surgery. (Review Article).

Abstract: Restorative proctocolectomy with ileal pouch anal anastomosis has become the most commonly used procedure for elective treatment of patients with mucosal ulcerative colitis and familial adenomatous polyposis. Since its original description, the procedure has been modified in an attempt to obtain optimal functional results with low morbidity and mortality, and yet provide a cure for the disease. These modifications of the technique are discussed in this review, limited to the current points of controversy. We reviewed the current literature describing restorative proctocolectomy with ileal pouch anal anastomosis. The current "hot topics" for debate are transanal mucosectomy with hand-sewn anastomosis versus the double-stapled technique, the use of diverting ileostomy, indeterminate colitis, the role of laparoscopy, and indications for pouch surgery in the elderly. Longer follow-up of patients and increased knowledge and experience with pouch surgery, coupled with active prospective evaluation of the procedure are required to settle these issues. Patients must be fully informed to understand inherent risks of each choice.

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Restorative proctocolectomy with ileal pouch anal anastomosis has become the standard surgical option for the definitive treatment of mucosal ulcerative colitis and familial adenomatous polyposis. Since its first description by Sir Alan Parks in 1976, surgeons have debated some of the crucial points of this technique. These modifications have been discussed on numerous surgical panels in an attempt to reach a general agreement, but some controversies still persist. The choice between a transanal mucosectomy with hand-sewn anastomosis or an ileal pouch anal anastomosis with double stapling is one of the major points of controversy. In addition, some surgeons advocate the construction of a J pouch anal anastomosis without protective diversion to allow for a single-stage procedure. Another topic of debate is whether the patients with indeterminate colitis should have restorative proctocolectomy with J pouch versus simple resection with ileostomy. More recently, the role of laparoscopy in inflammatory bowel disea se has been debated. Finally, questions persist on the indications for this operation in older patients.

Mucosectomy versus Double Stapling

The original ileal pouch anal anastomosis as described by Sir Alan Parks is essentially a nearly total proctocolectomy with the preservation of the anal sphincter complex and a complete stripping of the mucosa of the anal canal. (1) This technique is in accordance with the main purpose of the procedure, namely to remove the diseased epithelium. Since its original description, several technical modifications have been introduced in an attempt to improve functional outcome. It was speculated that continence could be improved by minimizing the manipulation of the anus and by preserving the anal transition zone (ATZ), leaving the sphincter complex undisturbed as much as possible. (2) The ATZ, thought to be important in continence, contains nerve endings that differentiate solid and liquid stool from gas. (3-7)

Knight and Griffin (8) first described the technique of double stapling--closing the rectum with a stapler and performing the anastomosis through that staple line. In pouch surgery, the staple line is immediately cephalad to the dentate line, and the apex of the pouch is anastomosed to this using a circular stapler. (9) With the use of better designed staplers, the double stapled technique has gained popularity for its ease and speed. In addition, objective physiologic and subjective functional results have been shown, by many authors, to be good after double stapling. (10-13) In a comparison between double stapled and hand-sewn anastomosis with ileal reservoir, Sugerman and Newsome (14) found fewer complications, better functional results including better continence, and decreased hospitalizations in those patients who had stapled rather than hand-sewn anastomoses.

To justify the tedious and technically challenging task of performing a mucosectomy, proponents of transanal mucosectomy with hand-sewn anastomosis have raised the concern that using the double stapled technique will leave diseased mucosa, which could potentially become dysplastic and ultimately malignant. A prospective, randomized trial completed at St. Mark's Hospital in London showed no difference in functional outcome between transanal mucosectomy with hand-sewn anastomosis and nonmucosectomy, even though there was a difference in resting anal pressures in favor of the stapled technique. (15) At the time of the study, this physiologic difference did not reflect any clinical symptoms; however, symptoms could arise with increasing age and with general muscular weakening. Nonetheless, the authors concluded that transanal mucosectomy with hand-sewn anastomosis is not more likely to cause functional problems, and provides complete surgical removal of the disease. Similar conclusions have been supported by othe r authors. (16)

MacRae et al (17) noted, when comparing mucosectomy with the double stapled technique, that although the leak rate remained stable, leaks from a stapled anastomosis seemed to have a better prognosis than did leaks from a hand-sewn anastomosis. Surgeons at the Cleveland Clinic Foundation believe that stapled ileal pouch anal anastomosis is safer than hand-sewn anastomosis in patients with mucosal ulcerative colitis. (18) They found that the double stapled technique resulted in fewer septic complications and in fewer sepsis-related pouch excisions than the hand-sewn technique.

A double-stapled anastomosis does not necessarily imply leaving diseased mucosa behind; moreover, a mucosectomy does not assure complete eradication of disease. At least three reported cases of rectal carcinoma after restorative proctocolectomy occurred after mucosectomy. (19-21) In these cases, it appeared that islands of diseased epithelium had been left behind after an incomplete mucosectomy and subsequently covered with a pelvic pouch, making adequate endoscopic follow-up impossible. Alternatively, the double-stapled technique leaves a ring of mucosa that can be easily endoscopically surveyed, palpated, and biopsied as needed. Interestingly, a single stapled ileal pouch anal anastomosis has been proposed. (22) These results are comparable with those obtained after the double stapled technique, without the risk of retained rectal mucosa.

Some authors have recommended individualizing the operative technique to each specific patient, suggesting that mucosectomy is particularly suitable to patients with familial adenomatous polyposis, especially in situations where polyps are present in the distal third of the rectum. (23) The procedure is also recommended in patients with mucosal ulcerative colitis and synchronous colorectal cancer or rectal dysplasia. It is important that the surgeon performing the procedure, whether an advocate of transanal mucosectomy with hand-sewn anastomosis or the double stapled technique, be familiar with all technical options in the event of failure of the stapler or inability to use the stapler in certain situations.

Diversion versus No Diversion

Loop ileostomy for the temporary diversion of the ileal reservoir has been considered an integral part of the original procedure. This tenet was unchallenged until the Mayo Clinic reported that omission of a stoma did not significantly increase the complication rate. (24) There are several proponents of the single pouch without the use of a diverting ileostomy. (25-31) These studies report that septic complications and functional results are similar to results after an ileostomy. Moreover, there were fewer episodes of intestinal obstruction, fewer instances of reexploration, and fewer total days in the hospital.

In an earlier series at Cleveland Clinic Florida, none of the 110 patients who had an ileoanal pouch had clinical evidence of leaks when a diverting ileostomy was used. (32) Conversely, 3 of the 36 patients who had ileal pouch anal anastomosis without an ileostomy had leaks that required fecal diversion. (32) More ominous was the report from Williamson et al, (33) who found that a one-stage restorative proctocolectomy without a diverting ileostomy was associated with an increased risk to life. Furthermore, many surgeons have cautioned against restorative proctocolectomy and ileal pouch anal anastomosis without diversion. (34-36) The potential benefits of proximal diversion, which is thought to facilitate healing and protect the long ileoileal and ileoanal suture line from dehiscence, have to be weighed against the considerable morbidity that arises from the creation of an ileostomy. One such complication is high output of enteric fluid leading to dehydration in as many as 20% of cases. Other complications suc h as skin irritation, stoma retraction, or stoma prolapse are often encountered. All of these can be managed by adequate enterostomal nursing care and IV hydration. Seven percent of all ileostomies still require revision before closure. After the stoma is closed, these complications resolve, but the incidence of small bowel obstruction can be as high as 15%. Although the obstructions are most often managed nonoperatively, surgery is occasionally required. Moreover, septic complications may persist despite diversion and are sometimes associated with pouch loss. Long-term functional outcome of ileal pouch anal anastomosis without ileostomy is comparable to diverted cases for functional outcome with respect to bowel frequency and continence. (36)

Some criteria may be used to determine which patients should undergo diversion, but these areas have not yet been clearly defined or studied in a prospective randomized fashion. One such criterion is patient selection. Careful patient selection includes parameters such as the general health of the patient and associated comorbid factors such as nutritional status, presence of anemia, advanced age, and current use of steroids or other immunosuppressant drugs. Furthermore, intraoperative considerations including absence of tension, adequate vascularization of the anastomosis, lack of intraoperative complications, and satisfactory intraoperative testing of the integrity of the anastomosis are important. The development of a pelvic abscess in cases done without diversion can then be treated by percutaneous computed tomography-guided catheter drainage with the adjunct of diversion. A randomized study to compare diversion versus nondiversion is needed to evaluate whether the incidence of pelvic septic complications is indeed more frequent in the nondiversion group and whether the long-term sequelne after resolution of the sepsis result in worse pouch function in this group.

Indeterminate Colitis

In some cases, no clear distinction can be made between mucosal ulcerative colitis and Crohn's disease. Crohn's disease is a transmural disease that may involve any part of or the entire gastrointestinal tract and is prone to recurrence at the level of the anastomosis. It often requires surgical excision because of progression of the disease despite maximum medical therapy. Such disease may lead to excision of the ileal reservoir with a loss of much needed small bowel. It is consequently essential to be as accurate as possible with the diagnosis of mucosal ulcerative colitis before proceeding with surgery. In the past, the treatment of mucosal ulcerative colitis and Crohn's colitis was similar, involving proctocolectomy and permanent ileostomy. At the time of reviewing surgical specimens, pathologists were unable to differentiate between the two disease processes in 10 to 15% of cases. The incidence of pathologic indecision is higher when the colon is removed for acute colitis due to the severe inflammatory c hanges that alter the pathognomonic histopathologic characteristics of the two diseases. It is now accepted that even when patients are examined and repeatedly evaluated with multiple endoscopic biopsies and radiographic investigations, 5% are still classified as having "indeterminate colitis." (37-40) When a pouch is constructed and Crohn's disease is diagnosed from a pathologic specimen, the failure rate can be as high as 35%, whereas a failure rate of 6.5 to 19.0% occurs in patients with indeterminate colitis. (41-43) These numbers are compared with a 1.4 to 8.0% failure rate in patients with mucosal ulcerative colitis. (44) Patients with indeterminate colitis have a higher rate of anorectal septic complications. (45,46)

It is imperative that the diagnosis of Crhon's disease be excluded on the basis of an accurate history and complete physical examination, specifically targeting the presence of perianal septic disease. The review of previous colonoscopic reports to evaluate the distribution and extent of the inflammatory changes is essential in the proper assessment of these patients. An experienced radiologist should also review all of the available radiologic studies, and a small bowel series should be obtained. Moreover, all of the biopsies should be examined by a pathologist experienced in inflammatory bowel disease, and a second consultation from another pathologist should be obtained in all cases of indeterminate colitis. (47) When a final diagnosis cannot be reached, a subtotal colectomy with an ileostomy should be done, leaving the rectum without violating the pelvis and leaving intact the blood supply to the ileum in the event that the decision is made in the future to proceed with an ileal pouch anal anastomosis. Ev en after this cautious approach, there is still a group of patients in whom a clear diagnosis cannot be established. In patients with Crohn's disease, the functional results of the pouch, including bowel frequency and continence, are comparable to results in patients with mucosal ulcerative colitis. Thus, patients may proceed with ileal pouch anal anastomosis after being informed of the high risk of pouch failure and pouchitis if the diagnosis of Crohn's disease is ultimately arrived upon.

Role of Laparoscopy

The use of laparoscopic surgery for diseases of the colon and rectum began in the early 1990s. Peters (48) was the first to publish the results of laparoscopic treatment of inflammatory bowel disease. Laparoscopy appears to be a versatile and effective modality in the surgical management of inflammatory bowel disease in selected patients. (49) In the hands of skilled laparoscopic surgeons, laparoscopic total proctocolectomy with ileal pouch anal anastomosis is a safe, feasible, and effective procedure. Although early reports noted increased morbidity, improved techniques and equipment have produced early and late results that are comparable to those of standard laparotomy. (50-55) The advantages are improved cosmesis, decreased intraoperative fluid loss, lower occurrence of postoperative ileus, and less pain and discomfort. (56,57) The cosmetic benefit alone may be of paramount importance to some. However, the complication rate, including the need for blood transfusion and longer operating time, are significa ntly higher with laparoscopy than with standard ileal pouch anal anastomosis. (51)

Age Limitations

Initially, restorative proctocolectomy with ileal pouch anal anastomosis was recommended only in patients younger than 50 years of age. The increase in age and the overall decrease in morbidity rates have made the ileoanal reservoir a more attractive option for older patients. There is still no consensus among surgeons regarding the expectation and the surgical results after ileal pouch anal anastomosis. Most series at first analyzed the outcome and complications in patients more than 50 years old. (58,89) The results confirmed that the procedure was safe and feasible and yielded good functional results. Even patients in their sixth decade of life were evaluated and, again, no difference in either sphincter physiology before and after surgery was found. (60-63) Therefore, it appears that functional results and morbidity are independent of patients' age and, in appropriately selected individuals, age should not be used as an exclusion criterion. (64) Only one study revealed poorer functional outcome and increa sed complications in patients more than 55 years of age. (65)

Recently, Schwandner et al (66) studied whether age alone is a contraindication to laparoscopic colorectal surgery. Not only are laparoscopic procedures safe options in the elderly, but also the outcome of laparoscopic colorectal surgery in patients older than 70 years of age is similar to that noted in younger patients. (66)

Summary

Restorative proctocolectomy with ileal pouch anal anastomosis has become the standard for the elective surgical treatment of patients with mucosal ulcerative colitis and familial adenomatous polyposis, as the procedure is safe, curative, and applicable to most patients. With increased knowledge and experience in pouch surgery, many of 'the controversial issues surrounding the procedure since its introduction have been resolved. However, transanal mucosectomy with hand-sewn anastomosis versus double stapling, diversion versus nondiversion, and the indications for surgery in indeterminate colitis are still debated and remain under active investigation. There is no specific age limit for this procedure. The laparoscopic approach to the surgical management of ulcerative colitis remains to be further evaluated before it can be routinely recommended. However, in a time when patient demands are increasing, the future of laparoscopic colonic surgery in inflammatory bowel disease seems assured. Randomized prospective trials and longer follow-up are needed to finally settle these issues.

Accepted October 22, 2001.

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RELATED ARTICLE: Key Points

* There is no routine upper age limit for restorative proctocolectomy.

* A major advantage of laparoscopic performance of restorative proctocolectomy is improved cosmesis.

* The failure rate after restorative proctocolectomy in patients with indeterminate colitis is approximately 5 to 19%.

* The majority of cancers arising in the anal transitional zone after restorative proctocolectomy have been after mucosectomy.

* Indications for loop ileostomy include high-dose preoperative steroids, obesity, and preoperative malnutrition.

From the Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, FL.

Reprint requests to Steven D. Wexner, MD, Department of Colorectal Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL 33331. Email: [e-mail]

Copyright [c] 2003 by The Southern Medical Association 0038-4348/0319601-0032