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- Clin Colon Rectal Surg
- v.35(6); 2022 Nov
- PMC9797272
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Clin Colon Rectal Surg. 2022 Nov; 35(6): 453–457.
Published online 2022 Nov 4. doi:10.1055/s-0042-1758135
PMCID: PMC9797272
PMID: 36591394
Surgical Treatment of Mucosal Ulcerative Colitis
Guest Editor: David M. Schwartzberg, MD, FACS
Jennifer L. Miller-Ocuin, MD1 and David W. Dietz, MD1
Author information Copyright and License information PMC Disclaimer
Abstract
The history of pouch surgery is rooted in surgical innovation to improve quality of life in patients requiring surgical extirpation of the colon and rectum. From the early straight ileoanal anastomosis to the continent ileostomy to the modern ileal pouch anal anastomosis (IPAA), techniques have evolved in response to pitfalls in design. Optimal IPAA design and construction have changed in response to functional outcomes. Nowadays, restorative proctocolectomy with IPAA is the optimal treatment for patients with ulcerative colitis or familial adenomatous polyposis. The J-pouch with stapled anastomosis has become the preferred procedure. Historical configurations and technical pearls, as described in this article, should be considered by surgeons who regularly care for patients requiring ileal pouch surgery.
Keywords: ileal pouch anal anastomosis, restorative proctocolectomy, ileoanal anastomosis, continent ileostomy, optimal pouch design
As proctocolectomy became standard treatment for diseases such as ulcerative colitis (UC) and familial adenomatous polyposis (FAP), surgical innovation sought to improve quality of life for afflicted patients. Early innovation aimed to avoid a permanent conventional stoma. Ileal pouches, originating with the continent ileostomy (CI), were invented to create a reservoir for deferred and controlled evacuation. The restorative proctocolectomy (RPC) with ileal pouch anal anastomosis (IPAA) was first reported as an S-shaped pelvic pouch with mucosectomy and handsewn ileoanal anastomosis.1Additional configurations have been described since, such as W-, D-, and H-pouches. Ultimately, the J-pouch and stapled anastomosis have emerged as the most common technical approach to RPC due to its excellent outcomes and ease of construction. Herein, we described historical context and technical considerations in the optimal pelvic pouch design.
Pre-Pelvic Pouch Outcomes
Permanent Ileostomy
In 1913, Brown first described the ileostomy as a treatment for UC patients intended to provide bowel rest by defunctionalizing the colon. At the time, the procedure was associated with a 30% mortality, likely attributable to the severity of illness in this patient population.2The earliest ileostomy construction involved creation of a skin-level loop. The loop of intestine was subsequently opened with cautery at bedside several days postoperatively allowing for self-maturation of the stoma. Morbidity was extremely high secondary to the resultant partial obstruction from inflammation, pouching difficulty, as well as wound and skin issues. In 1952, Brooke revolutionized the conventional stoma by describing surgical eversion of ileostomy which created a spout away from skin. The innovation of stomal eversion, using a technique of skin grafting and then mucosal eversion, also prevented the subsequent inflammation and stricture which caused obstruction.3Fortunately, this advance in stoma construction, which improved pouching and skin care, coincided with the timing of surgical treatment evolution in UC, as removing the colon and forming an ileostomy demonstrated superiority over defunctionalizing the bowel with ileostomy alone.4In 1959, at the first Bipartite meeting of American Society of Proctology and Section of Proctology of the Royal Society of Medicine, proctocolectomy with permanent ileostomy was described as the gold standard surgical therapy for UC.5The rise of proctocolectomy as definitive surgical therapy led to an era of unprecedented colorectal innovation in order to improve patients' quality of life.
Straight Ileoanal Anastomosis
In an effort to avoid the conventional ileostomy, complete proctocolectomy with ileoanal anastomosis was first described by Nissen in 1933. His report detailed a combined abdominal and sacral approach to create a double loop of ileum joined to the anus in a 12-year-old boy with polyposis. In the initial account, Nissen reported continence after the procedure.6Unfortunately, these results were not replicated with significant success.
Decades later, Ravitch and Sabiston rekindled interest in restorative operations for UC. They initially studied an anal ileostomy with sphincter preservation or “ileoanal anastomosis” in an animal model in 1947.7In a series of 22 procedures, canine mortality was high secondary to pelvic sepsis. Nonetheless, the procedure was subsequently performed successfully in two human patients and reported in 1948.8In response to the frequency and urgency of defecation associated with the procedure, Valiente and Bacon sought a solution to replace the physiologic capacitance provided by the rectum. They devised an experimental reservoir of small intestine using a canine model. Although the procedure provided decreased frequency of bowel movements, the mortality of the dogs was prohibitively high and discouraged its translation to human subjects.9
Continent Ileostomy
The introduction of the CI provided an alternative to conventional ileostomy for patients requiring proctocolectomy who desired control over intestinal continence. CI creation was first described by Nils Kock in 1969 and adopted at centers caring for patients with inflammatory bowel disease during the ensuing decade. Kock's original technique described a U-shaped ileal reservoir with the efferent limb terminating in a skin-level stoma, and became known as the Kock continent reservoir, or “K pouch”10(Fig. 1). The continence of his initial design, which depended on the strength and bulk of the abdominal wall musculature, had its limitations and subsequently resulted in several modifications. His first modification was creation of an antiperistaltic efferent limb, which did not improve function as he hoped.11Next, in 1973, he described the intussuscepted nipple valve,12which provided improved continence to the Kock pouch, albeit adding to the risk of pouch complications. In response to the common complication of valve slippage, Barnett proposed his version of the CI in 1984, adding a “collar” around the outlet to create the Barnett continent ileal reservoir.13The CI enjoyed popularity for a brief period in the 1970s, until Nichols and Parks introduced the concept of intestinal reconstruction with the pelvic pouch, or IPAA.
Fig. 1
The Kock (K) pouch in situ.
Ileal Anal Pouch Design
In the 1950s and 1960s, mucosectomy was described by both Devine and Peck.1415The technique described removal of the diseased rectal mucosa. The remaining muscular wall could then be used for ileoanal anastomosis. Sir Alan Parks built upon this technique by adding a reservoir constructed of ileum that he termed the RPC. In 1976, RPC was first performed in St. Mark's Hospital in London. His original design featured as S-shaped pouch using three limbs of terminal ileum, each 12 to 15 cm in length along with a 2- to 3-cm exit conduit, or efferent limb. In 1978, Parks and Nicholls published the landmark study “Proctocolectomy without ileostomy for the treatment of ulcerative colitis,” which described a series of five patients who has undergone the procedure in the United Kingdom.1Notably, only one patient could evacuate spontaneously. Nonetheless, the procedure quickly became the gold standard operation in UC.
In 1980, Utsunomiya et al introduced the J-pouch configuration in response to the challenges of spontaneous evacuation.16Utsunomiya et al's design modification eliminated the long efferent distal ileal limb to the anus which obviated anal catheterization for pouch evacuation. Furthermore, the J-pouch design afforded significant technical ease in creation. A 1986 symposium reviewed the results of 759 cases and reported 5 to 6 bowel movements per day, nocturnal evacuation in a quarter of patients, anastomotic stricture rate of 10%, and one postoperative death.17Fazio et al further revolutionized the technique at the Cleveland Clinic with the addition of the stapled anastomosis which decreased operative times and standardized a manual anastomosis.18The long rectal cuff described in Parks' and Nicholls' original RPC design was shortened with the introduction of a stapled technique.19Kmiot and Keighley described the safe implementation of a totally stapled RPC in 20 consecutive patients.20Additionally, the ease of creation afforded broader dissemination of the procedure. Most importantly, the stapled anastomosis provided significantly better functional outcomes than the handsewn anastomosis.21
In an effort to improve the reservoir capacity of the J-pouch, Nicholls and Lubowski developed the W-pouch. This design configuration employed four loops of ileum intended to improve the frequency of defecation by increasing the reservoir volume compared to a J-pouch. Although the W-pouch required handsewing of the ileal limbs of the pouch body, it utilized a stapled anal anastomosis intended to eliminate the need for catheterization attributed to the efferent limb of the S-pouch.22Pouch designs of J-, S-, and W-pouch are depicted inFig. 2.
Fig. 2
Comparison of J-, S-, and W- (left to right) pouch configurations.
Comparison of Pouch Outcomes by Technique
J- versus W- versus S-Pouch
In search of the ideal pouch design, a randomized trial compared the increased capacity of the W-pouch to the simplified technique of the J-pouch. Initially, the increased volume of the W-pouch afforded an advantage of decreased 24-hour and daytime bowel movement frequency. However, by end of the 9-year follow-up period, function of the W- and J-pouch designs had equilibrated. Given no difference in long-term quality of life outcomes, the authors concluded that the efficiency, standardization, and teachability of the J-technique made it the ideal pouch design.23
A large meta-analysis of 1,519 patients compared the outcomes of J-, S-, and W-pouches across 18 studies.24The study compared postoperative complications and functional outcomes. There were no significant differences in pouch failure or complications such as leak, stricture, or pelvic sepsis. Functionally, the three pouch types demonstrated similar rates of leakage and incontinence. The J-pouch demonstrated higher frequency of bowel movements and greater use of antidiarrheal medications. Both W- and S-pouch demonstrated difficulty evacuating, requiring intubation. Thus, J-pouch demonstrated an advantage over the other designs. Though the J-pouch has become the preferred technique, S- and W-pouches should remain recognized as they may have a role in some patient-specific situations, such as to achieve reach by adding length or in reoperative pouch surgery.
Handsewn versus Stapled
A meta-analysis of 21 studies with 4,183 patients compared handsewn versus stapled IPAA.25The majority (80%) of patients had a J-pouch. There were no differences in postoperative complications between the two groups. Bowel movement frequency and antidiarrheal medication use were similar; however, incontinence and nocturnal seepage, reflected in lower anorectal manometry metrics, were greater in the handsewn group. Importantly, there was no difference in quality of life or rates of dysplasia in the anal transition zone (ATZ). Additional work has demonstrated safety of preserving the ATZ with infrequent development of cancer.26
A large retrospective analysis compared outcomes following handsewn versus stapled IPAA in 3,109 patients from a single institution.21Anastomotic stricture, pelvic sepsis, bowel obstruction, and pouch failure were greater in the handsewn group. Frequency and urgency of bowel movements were similar, while incontinence and nocturnal seepage were higher in the handsewn group. Authors with significant expertise in pelvic pouch construction propose the continued implementation of the handsewn technique for special circ*mstances such as for dysplasia or cancer in the lower third of the rectum, FAP with significant rectal involvement, failed stapled technique, or in reoperative IPAA surgery.27
Other Pouch Designs and Their Benefits
Other innovative configurations such as D- and H-pouch (Fig. 3) have been described in response to standard pitfalls of the more common designs. In response to the risk of a tip of J leak, surgeons at Wuhan Hospital developed a D-shaped modification. This technique uses a circular stapler along with a linear stapler to incorporate the tip of J staple line into the pouch body, creating a D-pouch. The authors have been able to demonstrate safety and feasibility of this design. Their series reported no increase in operative time and no leaks reported in 43 patients over a median follow-up period of 46 months.28
Fig. 3
D- (left) and H- (right) pouch designs.
The H-pouch was originally described in 1984 by Fonkalsrud in a series of 49 patients as an isoperistaltic ileal reservoir measuring 20 to 30 cm in length using an endorectal pull-through with an ileoanal anastamosis.29Unfortunately, the H-pouch was severely limited by efferent limb stenosis.30Although this technique was largely abandoned as the J design was adopted, a modern adaptation has been employed in pouch salvage. The H-pouch has been described as a last resort for pouch salvage from a single surgeon's experience in five patients over a 4-year period at a high-volume pouch practice. The alternative configuration is employed when it is technically feasible to create an ileal pouch but mesenteric length is inadequate for a tension-free anastomosis.31Though pouch salvage has been demonstrated as a safe and feasible option for pouch failure at experienced referral centers,32the senior author of this article has never utilized the aforementioned alternative configurations in over 100 redo pouch operations.
Benefits and Pitfalls of Pouch Design
Nipple Valve Slippage in Continent Ileostomy Pouches
Each pouch design has unique limitations and complications. In the earliest ileal pouch design, Kock struggled with a method to create continence. The original pouch design incorrectly hypothesized that the rectus abdominis musculature would provide significant pressure to close the exit conduit. In a later modification, Kock created the intussuscepted nipple valve that provided a solution and also became the “Achilles heel” of this procedure. The valve successfully provided continence; however, it remained prone to slippage leading to the most frequently seen complications of the procedure, namely difficult intubation and incontinence. Additionally, the valve created a higher incidence of pouch fistula.11
Efferent Limb Syndrome in S-Pouch
The main pitfall of the S-pouch is the long efferent limb. Parks' initial design configuration of the IPAA provided an S-shaped pouch with a long efferent spout, which created the specific risk of outlet obstruction termed “efferent limb syndrome.” The efferent limb of the S-pouch follows the anorectal angle and makes pouch evacuation difficult.30Ideally, the exit conduit should be kept short, around 2 cm in length, in order to avoid emptying issues and need for anal catheterization of the S-pouch.
Pouch Rectal Anastomosis
Similar to an efferent limb of excessive length, a long rectal cuff also follows the anorectal angle.30The widespread implementation of laparoscopic pouch surgery predisposes to the risk of a long rectal cuff, leading to a pouch rectal anastomosis rather than anal anastomosis. This technical limitation further predisposes the patient to kinking and obstruction of the pouch outflow tract, and it may ultimately lead to pouch failure requiring revisional pouch surgery.33
Tip of J Leak
A specific complication described from the standard construction of the J-pouch occurs at the residual stapled end of the terminal ileum, described as a “tip of J leak.” This most commonly presents in delayed fashion and symptoms may be indolent. The leak is clinically significant and almost never resolves spontaneously. Importantly, this complication frequently results in successful pouch retention through drainage or salvage surgery when recognized.34Consideration of the tip of J leak is prudent at the index pouch creation. The efferent limb length must be sufficient for excision in case of a leak from the stapled end of the terminal ileum. This allows the tip of J leak to be surgically corrected by simply firing a stapler to excise the leaking staple line. Without sufficient length of the terminal ileal limb, a tip of J leak may lead to pouch excision and recreation of a new ileal pouch.
Where to Place the Mesentery
Most technical descriptions of ileal pouch construction focus primarily on techniques for optimizing pouch reach based on the limitations of the superior mesenteric artery. These techniques also have implications for reoperative pouch surgery. Anterior (rather than posterior) positioning of the mesentery is a technique used to improve pouch reach to the anal canal for anastomosis.35The implications of this technique are of particular importance in reoperative pouch surgery. Positioning of the mesentery anteriorly may add 1 or 2 cm necessary length for a tension-free anastomosis; however, the technique positions the ileal serosa posteriorly in contact with the presacral fascia.36Thus, anterior mesenteric positioning may increase the risk of presacral bleeding during dissection for redo pouch surgery as the surgeon seeks to avoid serosal damage to the pouch.
Conclusion
The history of pelvic pouch surgery is rooted in surgical innovation to improve quality of life in patients requiring surgical extirpation of the colon and rectum. From the early straight ileoanal anastomosis to the CI to the modern IPAA, techniques have evolved in response to pitfalls in design. Optimal IPAA design and construction in the modern era have continued to evolve in response to functional outcomes. Nowadays, RPC with IPAA is the optimal treatment for patients with UC or FAP and J-pouch with stapled anastomosis has shown superior outcomes. Other configurations and technical pearls should be considered for individual patients and by experienced pouch surgeons.
Acknowledgments
Original artwork for this manuscript was designed and created by Reagan Stevens, Medical Illustrator, Department of Surgery, University Hospitals.
Footnotes
Conflict of Interest None declared.
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