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An Audit of Restorative Proctocolectomy

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An Audit of Restorative Proctocolectomy 680 Gut1993;34:680-684 An audit ofrestorative proctocolectomy Gut: first published as 10.1136/gut.34.5.680 on 1 May 1993. Downloaded from M R B Keighley, S Grobler, I Bain Abstract (most being of the double limb J variety) at the A total of 168 restorative proctocolectomies dentate line. This procedure resulted in con- have been performed without mortality during siderable damage to the sphincter and was the past nine years. Morbidity from pelvic replaced by a technique of abdominal muco- sepsis (12%), ileoanal stricture (15%), and sectomy3 and sutured ileoanastomosis for the pouch related fistulas (16%) have become less next 58 operations. With an intra-anal sutured with increasing experience of the operation. ileoanal anastomosis, mesenteric vascular Pouch excision, which occurred in 30% of the division was required to deliver the apex of the first 50 patients was undertaken in only 4% in pouch to the dentate line in 24 of the first 76 the last 68 patients. Despite this, intestinal (32%) cases. With increasing confidence of low obstruction (18%) continues to complicate the sutured anastomosis, loop ileostomy has been operation. We have abandoned restorative dispensed with in selected cases (well nourished proctocolectomy after failed ileorectal anasto- patients with no steroid medication and with no mosis in patients with slow transit constipation technical difficulties in the construction of the as half have now requested pouch excision anastomosis). By 1988 we had begun to adopt the because of poor results. Failure to identify double stapling technique for ileoanal anasto- Crohn's disease continues to influence the mosis (anal transection with a transverse linear outcome: in 10 patients now known to have stapler: RL30 (Ethicon) and the end to end Crohn's disease six developed post operative circular stapler with detachable anvil: CEEA fistulas, three have required pouch excision. (Autosuture)), incorporating a stapling tech- Sexual impairment has occurred in three male nique (linear staple cutter PLC 75 (Ehicon)) for patients (4%). Ten women had children after pouch construction.4 In most cases the ileoanal operation, eight uncomplicated vaginal anastomosis lies at the top of the anal columns deliveries occurred without impaired con- and hence the anal transition zone is retained; tinence. Seven ofnine patients over 60 years of however, in patients with polyposis we usually age have had a successful outcome. Our data perform a mucosectomy and a sutured anasto- http://gut.bmj.com/ also indicate that the operation may be justified mosis at the denate line. After a trial of loop in distal disease if urgency is socially incon- ileostomy in totally stapled restorative procto- venient. Frequency of defecation is usually colectomy5 loop ileostomy is now only used in less than three per 24 hours in patients with selected cases (four in the last 18 cases after familial adenomatous polyposis but remains closure of the trial). Rectal excision was origin- variable in those with ulcerative colitis. ally performed keeping close to the bowel and (Gut 1993; 34: 680-684) preserving the superior haemorrhoidal vessels on September 30, 2021 by guest. Protected copyright. (n=29). Thereafter all rectal excisions have included the mesorectum, care being taken at the Restorative proctocolectomy is a useful opera- pelvic brim to identify and preserve the pelvic tion for ulcerative colitis, familial adenomatous nerves and not to enter Dennonvilliers fascia polyposis, and some diseases where colonic during the anterior rectal dissection. function is severely disturbed. The aim of the operation is to ablate the diseased bowel while preserving normal function of the anal Results sphincter.'2 PATIENTS We have analysed our results chronologically Methods into three groups; the first and second 50 cases and the last 68. We fully accept that there have EVOLUTION OF STANDARD TECHNIQUE been changes in technique during this time, as We have used restorative proctocolectomy for described earlier, and as Table 1 shows, in all nine years, initially with a modest annual opera- sutured ileoanal anastomosis some form of tion rate but as confidence has grown and the mucosectomy was performed. The variable use indications for the operation seemed to have ofloop ileostomy is shown. expanded, so the frequency of operation has Most patients (n= 123) were operated on for Department of Surgery, increased (1984, 4; 1985, 9; 1986, 16; 1987, 21; presumed ulcerative colitis but 10 (8%) are now Queen Elizabeth Hospital, Birmingham 1988, 24; 1989, 22; 1990, 24; 1991, 30; so far in known to have Crohn's disease and a further 10 M R B Keighley 1992, 18). Indications for restorative procto- (8%) have certain features ofCrohn's disease and S Grobler colectomy now include not only ulcerative colitis have been labelled indeterminate colitis. Twenty I Bain and familial adenomatous polyposis but high six patients have had a restorative proctocolec- Correspondence to: adenomatous Professor M R B Keighley, grade dysplasia, megacolon constipation, and tomy for familial polyposis of Department of Surgery, certain cases of distal colitis. whom 20 had a synchronous proctocolectomy Queen Elizabeth Hospital, construction and four of these Birmingham B15 2TN. In the first 18 cases the lower third of the and pouch only an muco- a There Accepted for publication rectum was retained and extensive anal patients had covering loop ileostomy. 6 October 1992 sectomy was performed with a sutured pouch were eight patients who had a previous subtotal An audit ofrestorative proctocolectomy 681 TABLE I Change in morbidity with experience: comparison ofgroups this figure has now fallen to 25% in the last 68 operations. There were three important early First 50 Second 50 Last 68 (1984-7) (1988-90) (1990-) complications - namely, infarction of the pouch pelvic bleeding and pelvic sepsis (n=6), (n=6), Gut: first published as 10.1136/gut.34.5.680 on 1 May 1993. Downloaded from Age (median (range)) (y) 32(11-78) 36(16-68) 34(21-78) Age over 60 2 2 5 (n=21). These complications often coexisted Diagnosis: and with the exception of pelvic sepsis, their Ulcerative colitis (n= 103) 33 27 43 Probable Crohn's disease (n= 10) 3 3 4 incidence has not fallen with increased experi- Possible Crohn's disease (n= 10) 4 3 3 ence with the operation. There were three Familial adenomatous polyposis (n=26) 5 7 14 Constipation (failed ileorectal anastomosis) (n=8) 3 3 2 diabetic patients, in the series, and two of them Megacolon and megarectum (n= 10) 2 7 1 had severe sepsis after operation. Although Dysplasia and polyps (n= 1) 0 0 1 Operation: pouch ischaemia was in the past associated with Statured ileoanal anastomosis* (anal mucosectony) 50(18) 15 (0) 4 (0) radical mesenteric vascular division, this Stapled ileoanal anastomosis 0 35 64 Loop ileostomy 45 19 28 complication is still seen. Two recent cases were from malrotation ofthe pouch and another from *The remainder had abdominal mucosectomy. mesenteric vein thrombosis complicating pelvic sepsis. colectomy and ileorectal anastomosis for slow transit constipation who had developed recur- Late morbidity rent difficulty with defecation that necessitated Late complications included stenosis of the large doses of laxatives to control secondary ileoanal anastomosis (n=25, 15%). This event constipation. These eight were treated by seems to be less frequent after the use of stapled restorative proctocolectomy. Similarly, there anastomosis at the top of the anal column (8% were 10 patients with longstanding acquired compared with sutured ileoanal anastomosis megacolon and megarectum with normal ileal 22%). function and acceptable anal sphincter activity Intestinal obstruction that necessitated admis- who have been treated by restorative procto- sion to hospital occurred in 31 (18%) patients. colectomy. The double stapling technique was Episodes of intestinal obstruction usually occur- never applicable in these cases because of the red in the first year of operation but in seven widely dilated and thick walled anus; hence a patients admission to hospital with obstruction hand sewn ileoanal anastomosis was required. occurred after the first 12 months. In 14 patients There were seven patients over the age of 60 operative intervention was necessary for relief of who have had a restorative proctocolectomy, one obstruction and in six of these 10 to 50 cm of ofwhom had longstanding polyps and high grade small bowel required resection, either because of http://gut.bmj.com/ dysplasia; the rest had ulcerative colitis. operative damage (n=3) or infarction from the obstruction (n=3). The frequency ofobstruction seems to have remained constant throughout the COMPLICATIONS series even though there has been a tendency to use loop ilesostomy more sparingly with increas- Mortality ing experience. There has been no operative mortality but two Twenty seven fistulas occurred after opera- on September 30, 2021 by guest. Protected copyright. late deaths have occurred; one patient had a fatal tion. Fistulas either presented early (n= 13), in motorcycle accident and a further patient who which case they usually resulted from a break- suffered chronic small bowel obstruction after down of an ileoanal anastomosis or a suture line pouch surgery developed fatal septicaemia after deshiscence in the pouch to the abdominal wall, pouch excision seven years after the original perineum, or vagina (two cases that were later operation (Table II). proved to have Crohn's disease). Alternatively fistulas have presented later after operation (n= 14) due to unrecognised Crohn's disease Early morbidity (n=4), chronic obstruction at the ileoanal Table II shows the details of morbidity. Over anastomosis (n=3), from a stitch sinus (n=l), half of all patients developed a clinically import- or from possible reactivation of latent crypto- antcomplication in thefirst 100 operations (52%); glandular infections (n=6). Table III shows the anatomical varieties of fistulas, their relation to the underlying bowel disorder, and outcome. Fortunately this complication seems to have TABLE II Changes in morbidity with experience occurred less often with increasing experience.
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