This video demonstrates the approach to stapled ileoanal reservoir (Ileal pouch anal anastomosis (IPAA)) construction initiated utilizing enterotomy at the future reservoir inlet. This approach has the advantage of permitting reservoir eversion during construction to ensure hemostasis and limiting the apical enterotomy to a stab puncture for the sharp anvil trochar. Dr. F. Michelassi and Dr. G.E. Block originally described this technique in 1993, and the authors have made minor adaptations (1)
DOI: http://dx.doi.org/10.17797/4gf38v9mw2
Editor Recruited By: Jeffrey B. Matthews, MD
Prior to innovation of the ileal pouch anal anastomosis in the 1970s and 1980s, patients with ulcerative colitis or familial adenomatous polyposis (FAP) requiring surgery were typically offered total proctocolectomy and permanent ileostomy. For patients motivated to preserve continence, IPAA is highly desirable option. Different pouch configurations including J-, S-, W-, and H- pouches have been described; the latter three are less frequently constructed due to technical complexity and increased risk of "megapouch" leading to fecal stasis and dysfunction in the long term.
Ileoanal reservoir is offered as an elective restorative option after total proctocolectomy for ulcerative colitis or FAP. The approach to the ileal reservoir construction demonstrated herein can be utilized for both double-staple and hand-sewn ileoanal anastomotic technique for IPAA.
There are few contraindications to IPAA.
CROHN'S DISEASE: Though described in highly select instances of Crohn's colitis in the absence of small bowel and perianal disease, (2,3) Crohn's disease is widely considered a contraindication to IPAA.(4) Pouch construction in this setting is associated with a higher rate of pouch failure, with up to 50% pouch failure at 10-year follow up.(5,6) The video authors do not offer IPAA to patients with a known pre-operative diagnosis of Crohn's disease.
There are several cohorts in whom a restorative approach with IPAA may be technically difficult or even inappropriate, with an associated higher complication rate or poorer functional outcomes; appropriate pre-operative counseling is essential.
MORBID OBESITY: An overly fatty mesentery can interfere with ileal reservoir construction and reach, increasing the degree of tension on the anastomosis. Patients with a BMI > 30 have a significantly higher rate of pouch-related complications including stricture formation, inflammatory complications, and fistula formation.(7) Obesity does not appear to ultimately impact long-term pouch outcomes. (8)
PRIOR SMALL BOWEL RESECTION: Depending upon the location and extent of resection, prior incidental enterectomy may preclude pouch construction and reach to the anus.
ANAL SPHINCTER DYSFUNCTION: Patients with advanced fecal incontinence pre-operatively should not be offered a restorative procedure such as IPAA, if the incontinence is due to a sphincter defect or pelvic floor dysfunction rather than urgency related to active proctitis. However, continence is a complex mechanism not entirely explained by sphincter integrity, and abnormal anal manometry alone is not necessarily a contraindication to the procedure.(9)
ADVANCED AGE: Functional outcomes are slightly worse in older patients after restorative IPAA compared to younger patients, with increased rates of daytime and nighttime leakage, (10) and increased rate of dehydration episodes.(11) Motivated elderly patients with good sphincter function can be offered IPAA.
PELVIC RADIATION: Oncologic outcomes in patients with colitis-associated cancer are not affected by restorative IPAA, and functional outcome is similar to IPAA patients without cancer.(12) However, patients who undergo either pre-operative or post-operative pelvic radiation have increased risk of pouch failure and pouch dysfunction.(13,14) History of colitis-associated cancer or dysplasia increases the risk of developing a pouch neoplasia, and appropriate surveillance is indicated.(12,15)
The patient is placed in lithotomy with appropriate padding. Both arms are tucked in order to allow adequate surgeon and assistant working space for the pelvic dissection. Indwelling urinary catheter is routinely used, as is appropriate antibiotic and venous thromboembolism prophylaxis.
Initial steps to the procedure include laparoscopic, robotic, or open total proctocolectomy (for one- or two-stage IPAA), or ileostomy takedown and completion proctectomy (for reverse two-stage, or three-stage IPAA). The video authors favor a low transverse Pfannensteil incision with placement of a self-retaining wound protector for reservoir construction.
One-, two-, and three-stage approach to restorative proctocolectomy have been described. As a tertiary referral center, we treat many patients failing second or third-line attempt at rescue induction for ulcerative colitis, and due to their poor nutritional state we commonly utilize the three-stage approach with subtotal colectomy and end ileostomy performed as the initial procedure. The described approach to reservoir construction can be equally applied to one- and two-stage procedures.
Pre-operative workup includes digital rectal exam and detailed discussion of the risks and benefits of restorative IPAA, with attention paid to future pouch function, complications, sexual function, and special considerations in regard to fecundity for women of child bearing age. Finally, quality of life of IPAA as compared to permanent ileostomy is discussed.
Key technical and anatomic points for successful IPAA construction include: (1,16,17)
MOBILIZATION: Full mobilization of the cut edge of the terminal ileal mesentery to the level of duodenum. This requires careful division of the thin visceral peritoneum at the base of the ileal mesentery, at the level of the superior mesenteric artery and vein. When completed, the entire duodenal sweep is visible.
RECTAL TRANSECTION: We utilize a double-staple technique for pouch construction. After adequate dissection, distal rectal transection is performed at the level of the levator plate. Anteriorly this corresponds to the level of inferior border of the prostate in a male and to the perineal body in a female. When the rectum is palpated, the surgeon will appreciate the slight thickening representing expansion of the muscularis into the internal anal sphincter. In women great care must be taken to adequately dissect the rectovaginal septum away to avoid a rectovaginal fistula.
DETERMINING REACH: Traction is then applied to stretch the ileal mesentery over the pubis; the site with the most length (generally in line with the superior mesenteric artery) is then marked with an apical suture on the antimesenteric border. If the antimesenteric border can be stretched > 2 cm past the pubis, length will likely be adequate.
POUCH SIZE: We construct an ileal reservoir length of ~ 15 cm. Small reservoirs lead to increased frequency of bowel movements; larger reservoirs can lead to fecal stasis.
LENGTHENING MANEUVERS: If mesenteric length does not appear to be adequate, ensure adequate lateral and posterior dissection at the base of the ileal mesentery. Next, carefully release the mesenteric peritoneum overlying the superior mesenteric artery by sequential transverse scoring along the vessel length, and then repeating gentle traction on the future reservoir apex. These two maneuvers are usually sufficient. Judicious ligation of tertiary arcade vessels can provide additional 1-2 cm. Small atraumatic bulldog clamps can be used to ensure a critical vessel is not inadvertently divided.
J-POUCH ORIENTATION: As a technical point, there are two J-pouch configurations that can be constructed, thought of as 'stereo-isomers' of each other. Our approach to construction allows for the ileal reservoir mesentery to be oriented anteriorly; we feel this allows the reservoir to conform against the sacral convexity. Alternatively, the ileal reservoir can be constructed so that the mesentery lies posteriorly.
STAPLED ILEOANAL ANASTOMOSIS: Very gentle digital anal exam will highlight the 2-3 cm residual anal canal and distal rectum. The short length often permits passage of only the crown of the stapler. During introduction of the stapler, care must be taken not to apply too much forward force, which may disrupt the staple line. Prior to firing the stapler, the perineal operator will doubly ensure the rectovaginal septum is not incorporated in women, and that that the stapler is oriented parallel to the sphincter complex, and not through the levator plate.
Pelvic sepsis and anastomotic leak after IPAA is felt to be more common at the ileal reservoir-anal anastomosis rather than from the pouch staple line. Advantage of the described technique of reservoir construction limits the apical enterotomy to a stab puncture for the anvil trochar by permitting reservoir eversion during construction. Anastomotic dehiscence with this technique is low and comparable to other series that use the more commonly used technique of reservoir construction through an apical enterotomy.
A potential disadvantage is that this technique results in an additional enterotomy at the reservoir inlet that must later be closed. However, incidence of leak is extremely low, with no known instances of pelvis sepsis due to leak from this closure site.
INTRA-OPERATIVE: If reach is not achieved, the surgeon will ensure all possible lengthening maneuvers have been utilized. If reach remains inadequate, options include conversion to S-pouch for additional 1-2 cm reach, or more commonly, conversion to permanent ileostomy
EARLY: Anastomotic leak occurs in ~ 5% of patients. Incidence of pelvic sepsis with abscess formation is 5-8%. (18,19) If diverting ileostomy has been constructed, both anastomotic leak and sepsis are managed conservatively with antibiotics; some require reoperation for washout and drainage.
LATE: Both leak and sepsis can lead to late pouch complications including stricture formation (11%) and fistula (3%). Pouch-vaginal fistulas occur in ~7% of women and are due to incorporation of the rectovaginal septum into the anastomosis, secondary fistula due to leak, or are a manifestation of Crohn's disease. ~30% of patients will develop pouchitis; treatment begins with antibiotics. ~15% of patients will develop cuffitis of the retained rectal mucosa; most will respond to Canasa suppositories. (18, 19) Small bowel obstruction, prolapse, and volvulus are also described. Overall pouch failure is ~ 6% and significantly higher in patients with delayed diagnosis of Crohn's disease. (6)
The authors, Dr. Lisa M. Cannon, Dr. Roger Hurst, and Dr. Neil Hyman, have no relevant disclosures.
We thank Dr. Patrick L. Reavey for assistance with video production.
1. Michelassi F, Block GE. A simplified technique for ileal J-pouch construction. Surg Gynecol Obstet 1993;176(3):290-294
2. Panis Y, Poupard B, Nemeth J, et al. Ileal pouch/anal anastomosis for Crohn's disease. Lancet 1996;347:854-857
3. Regimbeau JM, Panis Y, Pocard M, et al. Long-term results of ileal pouch-anal anastomosis for colorectal Crohn's disease. Dis Colon Rectum 2001;44:769-778
4. Deutsch AA, McLeod RS, Cullen J, et al. Results of the pelvic-pouch procedure in patients with Crohn's disease. Dis Colon Rectum 1991;34:475-477
5. Sager PM, Dozois RR, Wolf BG. Long-term results of ileal pouch-anal anastomosis in patients with Crohn's disease. Dis Colon Rectum 1996;39:893-898
6. Melton GB, Fazio VW, Kiran RP, et al. Long-term outcomes with ileal pouch-anal anastomosis and Crohn's disease: pouch retention and implications of delayed diagnosis. Ann Surg 2008;248:608-616
7. Klos CL, Safer B, Jamal N, et al. Obesity increases risk for pouch-related complications following restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA). J Gastrointest Surg 2014;18:573-579
8. Kiran RP, Remzi FH, Fazio VW, et al. Complications and functional results after ileoanal pouch formation in obese patients. J Gastrointest Surg 2008;12:668-674
9. Takao Y, Weiss EG, Nogueras JJ, et al. Should ileoanal pouch surgery be denied to patients with low resting pressures? American Surg 1997;63:726-731
10. Chapman JR, Larson DW, Wolff BG, et al. Ileal pouch-anal anastomosis: does age at the time of surgery affect outcome? Arch Surg 2005;140:534-540
11. Pinto RA, Canedo J, Murad-Regadas S, et al. Ileal pouch-anal anastomosis in elderly patients: is there a difference in morbidity compared with younger patients? Colorectal Dis 2010;13:177-183
12. Gorfine SR, Harris MT, Bub DS, Bauer JJ. Restorative proctocolectomy for ulcerative colitis complicated by colorectal cancer. Dis Colon Rectum 2004;47:1377-1385
13. Zmora O, Spector D, Dotan I, et al. Is stapled ileal pouch anal anastomosis a safe option in ulcerative colitis patients with dysplasia or cancer? Int J Colorectal Dis 2009;24:1181-1186
14. Wu S, Kiran RP, Remzi FH, et al. Preoperative pelvic radiation increases the risk for ileal pouch failure in patients with colitis-associated colorectal cancer. J Crohns Colitis 2013;7(10):e419-426
15. Derikx LAAP, Kievit W, Drenth JPH, et al. Prior colorectal neoplasia is associated with increased risk of ileoanal pouch neoplasia in patients with inflammatory bowel disease. Gastroenterol 2014;146:119-128
16. Maggiori L, Michelassi F. Ileal J-pouch construction. J Gastrointest Surg 2013;17:408-415
17. Thirlby RC, Optimizing results and technique of mesenteric lengthening in ileal pouch-anal anastomosis. Am J Surg 1995;169:499-502
18. Fazio VW, Kiran RP, Remzi FH, et al. Ileal pouch anal anastomosis: analysis of outcome and quality of life in 3707 patients. Ann Surg 2013;257:679-685
19. Sherman J, Greenstein AJ, Greenstein AJ. Ileal J pouch copmlications and surgical solutions: a review. Inflamm Bowel Dis 2014;20:1678-1685
Authors
Carol Li, MD1*, Apoorva T. Ramaswamy, MD1*, Sallie M. Long, MD 1 , Alexander Chern, MD 1 , Sei Chung, MD 1 , Brendon Stiles, MD 2 , Andrew B. Tassler, MD 1
1Department of Otolaryngology-Head and Neck Surgery, Weill Cornell Medicine, New York, NY 2Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
*Co-First authors
Overview
The COVID-19 pandemic is an unprecedented global healthcare emergency. The need for prolonged invasive ventilation is common amid this outbreak. Despite initial data suggesting high mortality rates among those requiring intubation, United States data suggests better outcomes for those requiring invasive ventilation. Thus, many of these patients requiring prolonged ventilation have become candidates for tracheotomy. Considered aerosol generating procedures (AGP), tracheotomies performed on COVID-19 patients theoretically put health care workers at high risk for contracting the virus. In this video, we present our institution’s multidisciplinary team-based methodology for the safe performance of tracheotomies on COVID-19 patients. During the month of April 2020, 32 tracheotomies were performed in this manner with no documented cases of COVID-19 transmission with nasopharyngeal swab and antibody testing among the surgical and anesthesia team.
Procedure Details
The patient is positioned with a shoulder roll to place the neck in extension. The neck is prepped and draped in a sterile fashion with a clear plastic drape across the jawline extending superiorly to cover the head. An institutional timeout is performed. The patient is pre-oxygenated on 100% FiO2. A 2-cm vertical incision is made extending inferiorly from the lower border of the palpated cricoid cartilage. Subcutaneous tissues and strap muscles are divided in the midline. When the thyroid isthmus is encountered, it is either retracted out of the field or divided using electrocautery. The remaining fascia is then cleared off the anterior face of the trachea.
Prior to airway entry, the anesthesiologist pauses all ventilation and turns off oxygen flow. The endotracheal tube (ETT) is advanced distally past the planned tracheotomy incision, without deflating the cuff, if possible. If necessary, the endotracheal cuff is deflated partially to advance the tube, with immediate reinflation once in position. The surgical team then creates a tracheotomy using cold steel instruments. The cricoid hook is placed in the tracheotomy incision and retracted superiorly for exposure of the lumen. The tube is withdrawn under direct visual guidance, without deflating the endotracheal cuff if possible. The tracheotomy tube is placed, and to minimize aerosolization of respiratory secretions, the cuff is inflated prior to re-initiation of ventilation. The tracheotomy tube is then sewn to the skin using 2-0 prolene suture. A total of five simple stitches are placed around the tube to prevent accidental decannulation.
Indications/Contraindications
Candidacy for tracheotomy was determined on a case by case basis with consideration for progression of ventilator weaning, viral load, and overall prognosis. All patients who underwent tracheotomy were intubated prior to the surgery for a minimum of 14 days, able to tolerate a 90-second period of apnea without significant desaturation or hemodynamic instability, and expected to recover. Optimal ventilator settings included FiO2 = 50% and PEEP = 10 cm H20.
Instrumentation
A standard tracheostomy instrument tray was utilized, including the following: tonsil dissector, DeBakey forceps, right-angle retractors, cricoid hook, and tracheal dilator. Bovie electrocautery was also utilized.
Setup
Please refer to the diagrams depicted in the accompanying video.
Preoperative Workup
An apnea test was performed for 90 seconds to ensure that the patient had adequate reserve. Ventilator settings were optimized. If possible, systemic anticoagulation was paused.
Anatomy and Landmarks
Important landmarks include the thyroid cartilage, cricoid cartilage, and sternal notch. A high-riding innominate artery can be detected on imaging and with palpation during the surgery.
Advantages/Disadvantages
Given the unique benefits of tracheotomy in avoiding the laryngeal trauma associated with prolonged intubation, decreased dead space, and ease of trialing patients off of the ventilator, there is high motivation to perform tracheotomies in COVID-19 patients requiring intubation and prolonged mechanical ventilation. Major disadvantages include the risk of virus transmission among the surgical and anesthesia team.
Complications/Risks
Short-term complications include bleeding and infection, such as peristomal cellulitis. Long-term complications of tracheostomy include cartilage destruction or deformity, granulation tissue formation, and superficial scarring.
References: N/A
As technique and technology have evolved in the modern age, surgical emphasis has shifted steadily towards minimally invasive alternatives. In colon surgery, laparoscopy has been shown to improve multiple outcome metrics, including reductions in post-operative morbidity, pain, and hospital length of stay, while maintaining surgical success rates. Unfortunately, despite the minimally invasive approach, elective laparoscopic sigmoidectomy typically requires an abdominal wall extraction site, leaving a large incision in addition to the laparoscopic port sites. It also utilizes three different types of intestinal staplers, leading to an anastomosis that may have multiple intersecting staple lines, thereby potentially influencing the anastomotic integrity, as well as increasing procedural costs substantially.
We present a case of a totally robotic sigmoidectomy utilizing a single stapler technique and natural orifice specimen extraction in a patient with multiple, severe, recurrent episodes of sigmoid diverticulitis over a 2-year period.
Disclosure/ Conflict of interest: The authors whose names are listed above certify that they have NO affiliations with or involvement in any organisation or entity with any financial interest (such as honoraria; educational grants; participation in speakers ’bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patent-licensing arrangements), or non-financial interest (such as personal or professional relationships, affiliations, knowledge or beliefs) in the subject matter or materials discussed in this manuscript.
Review Stapled Ileoanal Reservoir for Restorative Ileal Pouch Anal Anastomosis.