Presented at St Mark's Hospital Grand Rounds

1. Evolution & New Trends of
Restoration following
Proctocolectomy
Mohan Samarasinghe
Clinical Fellow
St Mark’s Academic Institute
St Mark’s Hospital

2. Why Proctocolectomy?
• Ulcerative Colitis (UC)
• Familial Adenomatous Polyposis (FAP)
• Selected Hirschsprung’s disease (HD) -
(Mostly historic)

3. Why Restoration?
Patients demanded it,
Pushed surgeons to find a way
because
“..rather die than having a stoma”

4. Restoration? How?
A brief account of history and evolution to
understand why do we do, what we do now…

5. Rudolph Nissen
First 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

6. Mark M Ravitch
First to show serious
Interest in preserving
gut continuity and
sphincter preservation
using ‘Anal Ileostomy’
for those requiring
proctocolectomy for
benign diseases

7. Mark M Ravitch
in 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)

10. 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)

11. “If the rate of bowel movements
are diminished to a reasonable
minimum, the bulk of these
problems will be solved”
….Valiente & Bacon
AJS 1955

12. Valiente & Bacon :1955
• Experimented constructing an
ileal pouch for pull through
following total (procto)colectomy
• Two pouch designs
• 7 dogs
• 2 success

14. Two dogs survived
• Weight gain
• 3-5 stools per day
• Liquid stools → mushy
• Barium XRay - Good size pouch
• Complete barium washout in 48hr

15. Nils G Kock
Introduced 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

17. Sir Alan Parks & R J Nicholls
Proctocolectomy 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

18. 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)

20. 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

21. J Utsunomia’s J Pouch (1980)

22. 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

23. Fonkalsrud’s ‘H’ Pouch (1982)

24. 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

25. R J Nicholls’ J & W Pouch
(1985)

26. 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

27. 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

29. 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

30. Ileal Pouch = J Pouch

31. Safe Proctectomy (1988)

32. Close Rectal VS Mesorectal
Close Rectal
• Less straightforward
Mesorectal
• Embryological plane
• Bloodless dissection
Nerve injury rates are not significantly
different between two techniques

33. 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

34. 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?

35. 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

36. 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)

37. Complications
Leak 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%

38. Structural Pouch Failure

39. 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

40. TAMIS
• Uses SILS platform
• Benefits from advanced air
insufflators (AirSeal)
• Specially designed CEEA staplers
with long anvil probes
(Frankenman)

41. Why TAMIS/TATME?

42. Structural Pouch Failure

43. Double Stapled Anastomosis

44. Leaks
Believed to be
associated with
peri-pouch sepsis and
subsequent poor
pouch function
Double stapled
anastomosis leak rate:
3-4%

45. 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

46. 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.

47. • 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

48. Thank you