Ulcerative colitis. As everyone pretty much knows, ileoanal anastomosis has replaced Brooke ileostomy as the operation of choice in most institutions for ulcerative colitis, because of the following factors: the disease is removed, the malignant potential largely eliminated, fecal continence is preserved, there is no stoma and we have fairly good data that the quality of life is improved.
The next two slides are my surgical experience with this problem over a five week period in January. Here are four patients who underwent this operation and look at the interesting mix of patients; polyposis, refractory, bad bleeding. This patient was stage II of a III stage disease. He had toxic megacolon. This patient was refractory to medical management and another four – again, this is only a five week period – this one had cancer. He’s a little older. We did a Brooke ileostomy, so that’s seven out of eight patients presenting had this ileoanal anastomosis. Here are two DALM lesions and another refractory to medical management. So the operation is being performed very frequently at our institution and interestingly for me, different indications. It’s an operation in evolution. There are problems with the operation if there are problems connecting the pouch to the anus, you can get a stricture, fistula and sepsis. And this can lead to fecal incontinence. You can have multiple stools. More about pouchitis in a minute. Not all patients are candidates because they are either too tall, too short, or overweight and older patients may not do as well as younger patients.
As I said, the operation has evolved from a simple, straight connection of the ileum to the anus with all sorts of problems, all they way down to a double-stapled ileoanal anastomosis. A small data set, which I’ll share with you in a minute, is based on 1,847 patients undergoing the operation, until 2006. Almost all of which had two stages of the procedure done, and I can perhaps talk to that later. Most of these were for ulcerative colitis and the follow-up was six years on mean. The operation we perform is shown here. It’s usually two stages, as I say. The colon is removed, the pouch is made and connected to the anus and the diverting ileostomy is constructed, because almost every one of these patients is ill and they are almost all on steroids. The average age is about 33. The male to female ratio is even. The stools per day, again – and this is in this group of 1,800 patients – was 10 a day so they were actively sick. Seventy percent of them had a sexual dysfunction preoperatively and most of them had two stages. This graph shows over a ten-year period of time the probability of a successful outcome. We tell our patients that there is a 91% to 92% chance of having a functioning pouch at the end of ten years. Interestingly, the number of stools per day at dismissal doesn’t change over a six-year period of time, so that stool frequency is fairly well fixed at about 5-8 in the 24 hour period fairly early in the postoperative course.
Recent Comments