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Zollinger's Atlas of Surgical Operations, 10e

CHAPTER 64: ILEOANAL ANASTOMOSIS

INDICATIONS
A permanent ileostomy following removal of the colon can be avoided in selected patients by removing all diseased colon and rectum down to the top
of the columns of Morgagni or the pectinate line, followed by construction of an ileal reservoir, with anastomosis of the anal canal (figure 1). Patients
with ulcerative colitis (UC) and polyposis are candidates for this procedure, but those with Crohn’s disease are generally not, because of the potential
for involvement of the small intestine. The patient must have an adequate anal sphincter by digital examination or, better yet, by manometry. The
rectum should be free of ulcerations, abscesses, stricture, fissures, or fistulae. This is especially important in patients with UC. This procedure can be
considered in patients who are strongly opposed to an ileostomy and who are available for prolonged close follow-up. The patient should thoroughly
understand the uncertainties of postoperative anal control and the need to have patience during the early months after the operation. The procedure
is not recommended for frail, elderly patients and those who have fecal incontinence. Obesity may make it impossible to perform the anal pouch
anastomosis. In patients with familial adenomatous polyposis (FAP) desmoid tumors involving the small bowel mesentery can make it difficult to
obtain adequate length to reach the anus with the pouch. All patients should realize that a permanent ileostomy can sometimes be required due to
factors not known until the procedure is underway.

Various surgical procedures have been used in an effort to improve long-term anal continence. It is questionable whether any procedure currently
used is always completely successful, and the patient should be informed of this uncertainty. Increasing experience suggests the use of some type of
anal pull-through procedure has a reasonable chance of providing more comfort than the terminal ileostomy or the ileal abdominal pouch.

A prolonged period of preoperative hyperalimentation or nonalimentation with catabolism may be avoided by a staged procedure, especially in the
presence of toxic megacolon, poor general condition, or rectal disease. A permanent ileostomy is performed with subtotal colectomy, leaving the
rectum in place, and the superior hemorrhoidal vessels undivided. This also offers the chance to review the pathology of the colon to further exclude
Crohn’s disease. After several months, an ileoanal anastomosis is considered and a diverting ileostomy is created at the time of the pouch. After a
suitable recovery the temporary ileostomy is closed making this a three-stage procedure. Various pouches have been advocated. They include the J
pouch (figure 2a), the three loop S pouch (figure 2b), the lateral isoperistaltic ileal reservoir (figure 2c), and the four-loop W reservoir (figure 2d).

PREOPERATIVE PREPARATION
Documentation of the pathologic process involved is done with biopsies taken from the anal canal as well as the rectum or colon. The stomach and
duodenum are inspected by gastroduodenoscopy. Patients with polyposis and UC patients with high-grade dysplasia should be informed of the
potential for malignancy. It is important to have medical and surgical agreement that surgical removal of the entire colon is in the best long-term
interest of the patient. Time is usually required for the patient to accept the recommendation and the patient can benefit from talking with another
patient who has undergone this procedure. The patient’s medications, including steroid therapy for UC, must be considered, and steroid therapy
continued. Intravenous antibiotics are given before operation, and any major blood volume deficit is corrected. Patients receive a clear liquid diet for a
day or two and an oral bowel preparation the day before.

In severe cases, some prefer a 6-week period of intense medication to keep the colon at rest permitting the inflammatory reaction to subside. Such
patients may be placed on total parenteral alimentation, systemic steroids and steroid enemas, and systemic antibiotics when UC is present. The rectal
mucosa is evaluated by sigmoidoscopic examination immediately prior to the operation. A large rectal tube is placed for irrigation with saline and
povidone-iodine antiseptic solution.

Preoperative consultation with an enterostomal therapy nurse can help with the patient’s understanding of the diverting and possibly permanent
ileostomy as well as help to position the stoma appropriately. Excellent patient-oriented literature is also available from professional and patient
support groups, which may aid the patient’s understanding of both the procedure and its wide variety of possible complications.

Men should be2021­5­25

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CHAPTER 64: ILEOANAL ANASTOMOSIS,
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ANESTHESIA
povidone-iodine antiseptic solution.
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Preoperative consultation with an enterostomal therapy nurse can help with the patient’s understanding of the diverting and possibly permanent
ileostomy as well as help to position the stoma appropriately. Excellent patient-oriented literature is also available from professional and patient
support groups, which may aid the patient’s understanding of both the procedure and its wide variety of possible complications.

Men should be counseled regarding the risk of impotence and retrograde ejaculation due to the pelvic dissection, and women should be counseled
regarding the risk of decreased fertility due to scarring in the pelvis.

ANESTHESIA
General endotracheal anesthesia is preferred.

POSITION
The patient is placed in the modified lithotomy position using Allen stirrups. This allows the abdominal as well as perineal dissections to be performed
without repositioning of the patient.

OPERATIVE PREPARATION
The rectum is given a very limited low-pressure irrigation, and the perianal skin and buttocks are given the routine skin preparation. Constant bladder
drainage is instituted and a nasogastric tube is inserted. The pubis and abdominal skin are also prepared in the routine fashion, and sterile drapes are
applied.

INCISION AND EXPOSURE

A lower midline incision that extends to the left of the umbilicus is made, and the abdomen is explored. Particular attention is given to the entire small
intestine to make certain there is no evidence of Crohn’s disease, which would contraindicate the operation. The involvement of the colon with
inflammation or polyposis is evaluated. In the presence of polyposis, the possibility of encountering an unsuspected site of malignancy or metastases
to the liver is ever present. If there is any question of Crohn’s colitis, the colon is resected and sent to the pathologist for gross and microscopic
verification.

DETAILS OF PROCEDURE
The colon may be constricted, friable, and quite vascular, with firm attachments to the omentum. Gentle traction is applied to avoid tearing the friable
bowel with resulting gross contamination. The mesentery of the colon can be divided and blood vessels ligated relatively near the bowel wall, except in
diffuse polyposis, where there is always a possibility of metastases to regional lymph nodes. It is judicious to have the pathologist evaluate the entire
specimen as soon as possible.

Before proceeding with the removal of the mucosa from the lower segment and before constructing the ileal reservoir, it is essential that sufficient
ileum has been mobilized to construct the pouch. Approximately 50 cm of terminal ileum is required for the construction of the ileal reservoir. Such
mobilization is accomplished by dividing the ileocolic vessels and the mesentery down to near the arcade of vessels at the very end of the ileum, but
none of the latter is ligated (figure 3). It may be necessary to evaluate the mobility of the small bowel all the way up to the ligament of Treitz with
division of any bands that tend to limit the mobility of the small intestine (figure 4). Incisions within the posterior peritoneum may be worthwhile to
provide added mobility. Some divide the last ileal arcade (figure 4). The adequacy of the blood supply involved should be evaluated frequently to be
certain a vigorous blood supply is sustained to the end of the mobilized ileal terminal. The end of the proposed pouch should reach at least to the
pubis, and preferably to the edge of the Bookwalter ring being used for retraction.

The dissection below the rectosigmoid junction is carried out close to the bowel wall to avoid damage to the presacral and parasympathetic nerves.
The rectal stump is washed out with povidone-iodine, and the bowel divided at the anorectal junction. This leaves a stump about 3 to 4 cm in length
(figure 5). Some prefer to have a longer rectal anal stump, which requires resection of the rectal mucosa from above rather than entirely through the
anus. Others use a stapling instrument for closure of the rectal stump.

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The dissection below the rectosigmoid junction is carried out close to the bowel wall to avoid damage to the presacral and parasympathetic nerves.
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The rectal stump is washed out with povidone-iodine, and the bowel divided at the anorectal junction. This leaves a stump about 3 to 4 cm in length
(figure 5). Some prefer to have a longer rectal anal stump, which requires resection of the rectal mucosa from above rather than entirely through the
anus. Others use a stapling instrument for closure of the rectal stump.

Many surgeons advocate leaving about 2 cm of mucosa above the columns. Recurrence of inflammatory bowel disease and malignant degeneration
are possible and careful follow-up is essential. In general, avoidance of rectal dilatation or eversion of the stump plus a high level of anastomosis
results in better fecal continence. In patients with high-grade dysplasia in the rectum, a traditional mucosectomy may be a better option, as it removes
all the mucosa. If this technique is done, a hand-sewn ileoanal anastomosis would be required. The J pouch is constructed by rotating the terminal
ileum clockwise to create a “J” shape (as seen from anteriorly) 15 cm long. The anterior ends are held by semicircular 000 silk sutures (figure 6). The
length is then checked as described above to ensure it will reach the pelvis. The distal antimesenteric end of the pouch is opened with electrocautery. A
linear stapler is then inserted and fired, creating a pouch from the two limbs (figure 7). Multiple firings are used to complete the full length of the pouch
(to reach the upper end, the distal end is telescoped onto the stapler). A 2-0 Prolene suture is then used to create a “whip-stitch” purse-string suture
around the opening in the tip of the pouch. An anvil of the circular stapler is then inserted and the purse-string tied around it (figure 8). The anvil must
sit so that the antimesenteric aspect of the ileum is draped across it. The circular stapling instrument is then inserted gently into the rectum by an
assistant. It is advanced up to the level of the stapled rectal stump. The sharp spike then pierces through the stump just posterior to the staple line and
it is approximated with the anvil (figure 9).The device is then closed and fired, taking care not to include adjacent structures such as the vagina. Naive
or too-vigorous insertion of the circular stapler instrument will rip through the very short rectal stump and make the procedure much more difficult.
Figure 10 demonstrates the completed J pouch with ileorectal stump anastomosis.

If the rectal mucosa is severely diseased, then a complete mucosal proctectomy may be indicated. The mucosa is excised from the dentate line up to
include the 3 or 4 cm of mucosa in the rectal stump. Some prefer to outline the dentate line with electrocoagulation followed by the submucosal
injection of 1:300,000 adrenaline solution (figure 11). This tends to elevate the mucosa and facilitate the dissection in a more bloodless field. All
mucosa must be completely removed. This dissection is often the most time-consuming part of the technical procedure and must be done with the
greatest care (figure 12). The underlying muscle and nerves must not be injured. A dry field is essential.
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CHAPTER
Some prefer64: ILEOANAL
to grasp ANASTOMOSIS,
the stump Page 3 / 6
with a Babcock forceps in the anus and everted out the anus (figure 13). This facilitates the removal of the mucosa
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under direct vision but may result in poor fecal continence (figure 14).

Others prefer to divide the mucosa at the top of the columns of Morgagni (figure 5). This avoids telescoping the rectal stump and lessens the possibility
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If the rectal mucosa is severely diseased, then a complete mucosal proctectomy may be indicated. The mucosa is excised from the dentate line up to
include the 3 or 4 cm of mucosa in the rectal stump. Some prefer to outline the dentate line with electrocoagulation followed by the submucosal
injection of 1:300,000 adrenaline solution (figure 11). This tends to elevate the mucosa and facilitate the dissection in a more bloodless field. All
mucosa must be completely removed. This dissection is often the most time-consuming part of the technical procedure and must be done with the
greatest care (figure 12). The underlying muscle and nerves must not be injured. A dry field is essential.

Some prefer to grasp the stump with a Babcock forceps in the anus and everted out the anus (figure 13). This facilitates the removal of the mucosa
under direct vision but may result in poor fecal continence (figure 14).

Others prefer to divide the mucosa at the top of the columns of Morgagni (figure 5). This avoids telescoping the rectal stump and lessens the possibility
of nerve injury where the patient may not be able to differentiate stool from flatus postoperatively.

If a mucosal proctectomy is performed, then a hand-sewn ileoanal anastomosis must be completed. This is demonstrated on page 235 in this chapter.

The adequacy of the blood supply to the reservoir is again double-checked. Two interrupted sutures with needles attached (figure 15) are anchored on
each side of the two-finger opening in the reservoir. These sutures are passed by the surgeon down through the anus, and the reservoir is placed in the
proper position from above.

The two sutures on each side are then anchored to either side of the opening at the level of the dentate line (figure 16). An additional suture is placed in
the midline anteriorly and posteriorly. Eight or ten additional sutures may be required to ensure an accurate anastomosis. These sutures include the
full thickness of the ileal wall, as well as a portion of the internal sphincter (figure 17).

Any openings in the mesentery are closed with interrupted sutures to avoid intestinal hernia. The pelvic peritoneum is closed about the pouch to avoid
twisting or displacement. A suture may be placed to anchor the pouch to each side of the muscular rectal cuff to secure the pouch in position and
lessen the possible tension on the suture in the dentate line anastomosis. Some prefer to insert a rubber drain between the wall of the pouch and the
rectal cuff. The rubber tissue drain is brought out anteriorly.
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CHAPTER 64: ILEOANAL
While it is tempting to avoidANASTOMOSIS, Page
an ileostomy, fewer postoperative complications result if a complete diversion of the fecal stream is accomplished by 4 / 6
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ileostomy. The defunctioning ileostomy is performed through a small opening in the left lower quadrant about 40 cm from the pouch (figure 18). It is
advisable to ensure complete diversion of the fecal stream (figure 19) by intussuscepting up the proximal limb or stoma over the rod (see also Chapter
full thickness of the ileal wall, as well as a portion of the internal sphincter (figure 17). Access Provided by:

Any openings in the mesentery are closed with interrupted sutures to avoid intestinal hernia. The pelvic peritoneum is closed about the pouch to avoid
twisting or displacement. A suture may be placed to anchor the pouch to each side of the muscular rectal cuff to secure the pouch in position and
lessen the possible tension on the suture in the dentate line anastomosis. Some prefer to insert a rubber drain between the wall of the pouch and the
rectal cuff. The rubber tissue drain is brought out anteriorly.

While it is tempting to avoid an ileostomy, fewer postoperative complications result if a complete diversion of the fecal stream is accomplished by
ileostomy. The defunctioning ileostomy is performed through a small opening in the left lower quadrant about 40 cm from the pouch (figure 18). It is
advisable to ensure complete diversion of the fecal stream (figure 19) by intussuscepting up the proximal limb or stoma over the rod (see also Chapter
51).

POSTOPERATIVE CARE
Steroid therapy is gradually decreased until it can be omitted completely. The bladder catheter is removed after testing for sensation after a few days.
The diet is slowly increased, but may need to be adjusted or limited depending upon the incidence of diarrhea.

Incidental obstruction, pelvic sepsis, and local problems around the ileostomy are occasional complications after the operation. Before closure, the
integrity of the pouch and the anal anastomosis is evaluated by radiographic procedures with water-soluble contrast. Direct evaluation of the
anastomosis for patency is also necessary. Frequently it strictures or develops a web across it requiring examination with sedation in the GI laboratory.
Pouchoscopy can also be performed at this time. If no problems exist, the ileostomy is closed within 4 months.

The major consideration involves the degree of anal continence that has been achieved. Patience is required during the first year, as the capacity of the
pouch increases and sphincter control gradually improves. The control of diarrhea during the day and soiling at night are of major concern and may
require adjustment in bulk and type of food, as well as special medication. The number of daily stools varies, with an average of six per day and one or
two per night. Patients with polyposis usually have fewer bowel movements per day than patients with UC.

A troublesome complication is a poorly defined syndrome known as pouchitis. The stools are increased in frequency with malaise, fever, and bloody
stools, along with abdominal cramps. This complication is far more common in patients with UC than in those with multiple polyposis. Specific
medication and dietary adjustments are indicated. This procedure is believed to be associated with chronic residual stasis. Intestinal obstruction may
occur in 10% more of the patients.

Patients with this operation require frequent, long-term follow-up evaluations.

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stools, along with abdominal cramps. This complication is far more common in patients with UC than in those with multiple polyposis. Specific
medication and dietary adjustments are indicated. This procedure is believed to be associated with chronic residual stasis. Intestinal obstruction mayby:
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occur in 10% more of the patients.

Patients with this operation require frequent, long-term follow-up evaluations.

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