evolution and new trends of restoration following proctocolectomy
TRANSCRIPT
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Evolution & New Trends of Restoration following
ProctocolectomyMohan Samarasinghe
Clinical Fellow
St Mark’s Academic Institute
St Mark’s Hospital
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Why Proctocolectomy?• Ulcerative Colitis (UC)
• Familial Adenomatous Polyposis (FAP)
• Selected Hirschsprung’s disease (HD) - (Mostly historic)
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Why Restoration?
Patients demanded it, Pushed surgeons to find a way
because
“..rather die than having a stoma”
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Restoration? How?A brief account of history and evolution to
understand why do we do, what we do now…
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Rudolph NissenFirst ileo-anal anastomosis of a 16y boy with polyposis
who underwent total excision of colon and
rectum in 1932
Presented in a discussion at a meeting of Berlin
Gesellschaft für Chirurgie (surgical society) in 1933
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Mark M RavitchFirst to show serious Interest in preserving
gut continuity and sphincter preservation using ‘Anal Ileostomy’
for those requiring proctocolectomy for
benign diseases
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Mark M Ravitchin 1947:
Experimented in dogs on procedure for accomplishing an anal ileostomy, which they thought might be feasible in man with some modification(Surg Gynecol Obstet [Now JACS] 1947)
in 1948: Published results of 2 patients who underwent ‘anal ileostomy’ (Surgery 1948)
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Problems of Ravitch’s Anal ileostomy
• Difficult to control effluent • Increased frequency • Perianal excoriation • Fluid imbalance • Delayed healing of perianal wounds, wound
breakdown with fistulation/ abscess formation • Frequent ileal obstruction, colics and
cramping pain (?Ileal kinking/Plicae circularis) • Distal ileal necrosis (?Mesentry entraptment)
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“If the rate of bowel movements are diminished to a reasonable
minimum, the bulk of these problems will be solved”
….Valiente & Bacon AJS 1955
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Valiente & Bacon :1955
• Experimented constructing an ileal pouch for pull through following total (procto)colectomy
• Two pouch designs • 7 dogs • 2 success
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Two dogs survived
• Weight gain • 3-5 stools per day • Liquid stools → mushy • Barium XRay - Good size pouch • Complete barium washout in 48hr
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Nils G KockIntroduced ileal
reservoir as a continent bladder replacement in
1962
Attempted to achieve faecal continence in
patients with permanent ileostomy by
adopting ileal reservoir used in bladder
replacement in 1969
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Sir Alan Parks & R J NichollsProctocolectomy without
ileostomy for ulcerative colitis
(BMJ 1978) First to successfully
reconstruct a neorectum using a ileal pouch
following removal of the colon and rectum (rectal
mucosectomy) without having to have a a
permanent ileostomy
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30cm of terminal ileum
Three 8cm limbs of ileum folded and S pouch created
Last 5cm untouched to serve as a conduit
Rectal mucosectomy done
Pouch sits on rectal muscular sleeve
Ileo-anal end to end anastomosis at dentate line
Intact anal sphincter used for continence (BJS 1980)
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Results of Parks’ Procedure
• Anatomical rectal mucosectomy • Good reproducible pouch outcome • Spontaneous defecation was not
consistent in some cases - Required catheter decompression. ? Last 5cm of intact ileum
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J Utsunomia’s J Pouch (1980)
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J Utsunomia’s J Pouch (1980)• Refined rectal mucosectomy • Demonstrated that low situated
ileal reservoir (eg: J pouch) performs better than a high situated one
• GIA stapler use in pouch construction
• Frequency was 3-6 per day
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Fonkalsrud’s ‘H’ Pouch (1982)
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Fonkalsrud’s ‘H’ Pouch • GIA stapler use in pouch
construction • Fixed ileal catheter for flushing • Long intra-rectal ileum distal to
pouch • Long pouch - less frequency • Multi-stage procedure
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R J Nicholls’ J & W Pouch (1985)
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R J Nicholls’ J Pouch (1985)• Side to end ileo-anal anastomosis • Eliminates the last ileal segment which
believed to be the reason needing catheterisation therefore eliminating the need to catheterise
• Less complications • Intestinal obstruction requiring laparotomy
was significantly less in J pouch compared to S pouch
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R J Nicholls’ W Pouch (1987)
• J pouch - higher stool frequency and night evacuation
• In search for benefits of a J pouch (not needing catheterisation) but with better stool frequency
• Preserving Side to end ileo-anal anastomosis
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J vs W• J: easy construction, benefits from
staplers, needs only 30-40cm of ileum, if long enough, functions well
• W: time consuming to construct, difficult to do with staplers, Uses 50cm of ileum. Only marginally better than J pouch in stools frequency
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Ileal Pouch = J Pouch
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Safe Proctectomy (1988)
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Close Rectal VS MesorectalClose Rectal
• Less straightforward Mesorectal
• Embryological plane • Bloodless dissection
Nerve injury rates are not significantly different between two techniques
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Mucosectomy VS Stapler
• Mucosectomy removes ATZ: Incontinence, early septic complications risk is higher, Ineffective in 7%
• Staplers may leave ATZ: Dysplasia risk is higher (4.5%), Cuffitis
• CA following IPAA - in both mucosectomy and stapler groups
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Defunction or Not• Two vs One stage • Financial benefits • No difference in complication rates in
selected groups • No longterm steroids • Absolutely no tension anastomosis • Otherwise healthy patients
• If complicated: High price?
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Laparoscopic/SIL IPAA
• Laparoscopic colonic mobilisation • Extracorporial bowel division and
pouch construction • May help to reduce pelvic adhesions • Early return of bowel function • Reduced hospital stay
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Early Complications• Acute pelvic sepsis 5-24% • Anastomotic leaks 5-18% • Small bowel obstruction 15-44%
(5-20%) • Pouch bleeding • Pouch–rectostomy (double-
stapled anastomosis)
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ComplicationsLeak from IPAA 7 - 18% Anastomotic sinus 2–8% Symptomatic stricture 16% Chronic pelvic sepsis 6% Pouch–cutaneous fistula 5% Pouch–vaginal fistula 3–15% Small bowel obstruction requiring operation 5-20% Cuffitis 5-16% Symptomatic pouchitis (cumulative incidence at 10 years) 40% Symptomatic portal vein thrombosis 6% Ultimate failure of pouch 4%
Permanent diversion 1% Pouch excision 3%
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Structural Pouch Failure
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TAMIS/TATME• Transanal Minimally Invasive Surgery (TAMIS) -
Trans Anal Total Mesorectal Excision (TATME) • Hybrid of TEM & SILS with conventional lap
instruments • Benefits of TEM at a fraction of the cost • In patients with a narrow pelvis, the TAMIS
approach with its ability to increase the mobilization of the rectum and improve visibility, may be valuable
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TAMIS
• Uses SILS platform • Benefits from advanced air
insufflators (AirSeal) • Specially designed CEEA staplers
with long anvil probes (Frankenman)
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Why TAMIS/TATME?
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Structural Pouch Failure
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Double Stapled Anastomosis
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LeaksBelieved to be
associated with peri-pouch sepsis and
subsequent poor pouch function
Double stapled anastomosis leak rate:
3-4%
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WHY TAMIS• No need to transect rectum
through abdominal approach • Single stapled anastomosis • No stapler-on-stapler line • No side pockets • Can expect higher anastomosis
integrity hence less leaks
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References• Turnbull RB, Weakley FL, Hawk WA, Schofield P. Choice of operation for the toxic
megacolon phase of non-specific ulcerative colitis. Surg Clin N Am. 1970;50:1151–69.
• Nissen R. Demonstrationen aus der operativen chircurgie zunachst einige Beobachtungen aus der palstichen Chirur- gie. Zentralbl Chir. 1933;60:883.
• Ravitch M, Sabiston DC. Anal ileostomy with preservation of the sphincter. Surg Gynecol Obstet. 1947;84:1095–9.
• Valiente MA, Bacon HE. Construction of pouch using pantaloon technic for pull-through of ileum following total colectomy; report of experimental work and results. Am J Surg. 1955;90:742–50.
• Kock NG. Intra-abdominal “reservoir” in patients with permanent ileostomy. Preliminary observations on a pro- cedure resulting in fecal “continence” in five ileostomy patients. Arch Surg. 1969;99:223–31.
• Parks AG, Nicholls RJ. Proctocolectomy without ileostomy for ulcerative colitis. Br Med J. 1978;2:85–8.
• Utsonomiya AJ, Iwama T, Iamjo M, et al. Total colectomy, mucosal proctectomy and ileoanal anastomosis. Dis Colon Rectum. 1980;23:459–66.
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• Nicholls RJ, Pezim ME. Restorative proctocolectomy with ileal reservoir for ulcerative colitis and familial adenoma- tous polyposis: a comparative of three reservoir designs. Br J Surg. 1985;72:470–4.
• Nicholls RJ, Lubowski DZ. Restorative proctocolectomy: the four loop (W) reservoir. Br J Surg. 1987;4:564–6.
• Fonkalsrud EW, Stelzner M, McDonald N. Construction of an ileal reservoir in patients with a previous straight endorectal ileal pull-through. Ann Surg. 1988;208:50–5.
• Sagar PM, Pemberton JH. Intraoperative, postoperative and reoperative problems with ileoanal pouches. Br J Surg. 2012;99:454–68.
• Sugarman HJ, Newsome HH. Stapled ileoanal anastomosis without a temporary ileostomy. Am J Surg 1994;167:58–66
• Young-Fadok TM, Dozois EJ, Sandborn WJ, Tremaine WJ. A case matched study of laparoscopic proctocolectomy and ileal pouch-anal anastomosis(PC-IPAA) versus open PC-IPAA for ulcerative colitis. Gastroenterology 2001;A-452:2302
• Geisler DP, Condon ET, Remzi FH. Single incision laparoscopic total proctocolectomy with ileopouch anal anastomosis. Colorectal Dis. 2010;12:941-943
• Atallah S, Albert M, Larach S. Transanal minimally invasive surgery: a giant leap forward. Surg Endosc. 2010;24(9):2200–2205. doi: 10.1007/s00464-010-0927-z
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Thank you