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)
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.
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