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Laparoscopic Surgery and Ulcerative colitis

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17/03/2006

Ulcerative Colitis affects the lining of the large bowel, which becomes inflamed and bleeds. Excess mucus production leads to watery diarrhoea, frequency and urgency.  UC affects the large bowel and starts in the rectum spreading upwards.  Most people respond to medicine.  In about 30% the inflammation affects the entire large bowel.  If medical therapy doesn't work urgent surgery becomes necessary.  The choice of operation will be made in discussion with your surgeon, but will depend upon your disease and to some extent your choice.

Reasons for surgery
Acute colitis
. In this situation the inflammation is so severe that the patient rapidly becomes ill.  The diarrhoea leads to loss of protein, water and salt which results in malnutrition, weight loss, anaemia, dehydration and germs entering the bloodstream from the bowel.  Eventually the bowel will perforate and lead to peritonitis and death.  If rapid improvement is not achieved, colectomy is indicated.

Chronic colitis. In the majority the inflammation just smoulders on and it becomes clear that medical treatment is not working.  The patient presents with ill health, anaemia, severe symptoms, and involvement of other organs e.g. joints, skin, and eyes. There is also a risk of malignancy (10% after 20 years).

Choice of operation

Acute colitis.  The aim is to get the patient better with the least procedure necessary.  The standard approach is to remove the colon through a large midline incision (shown here) and create an ileostomy leaving the rectum and anal sphincter behind.  Depending upon how severe things are the surgeons will decide to close the rectum or bring it up to the surface as another stoma or mucus fistula.  

BLA
have the largest UK and European experience of undertaking laparoscopic subtotal colectomy.
 
Chronic colitis. The same operation may be advised in these patients if they are on high dose steroids.  With recovery these can be stopped and any subsequent operation carried out with the patient in the best possible condition.  

The possibilities include proctocolectomy and permanent ileostomy or the more elaborate restorative ileo-anal pouch.  In the latter the bowel is removed down to the anal sphincter.  The last 50 cms of small bowel is created into a reservoir or pouch and sutured to the top of the anus.  As this operation requires a lot of sutures, most surgeons would defunct ion the pouch with a temporary ileostomy.  If a check x-ray at 4 weeks shows no leak from any of the suture lines the ileostomy can be closed.  For open surgery the average stay is about 14 days and is limited by the time it takes the e patient to learn how to handle their ileostomy. 

Bristol Laparoscopic Associates
have the largest UK experience of laparoscopic restorative proctocolectomy for ulcerative colitis and FAP (familial adenomatous polyposis) 





Proctocolectomy specimens extracted through the ileostomy site and laid out over the abdomen; all carried out using only a 12mm umbilical port and 12mm & 5mm ports in the right iliac fossal 














Stapled J Pouch fashioned outside the abdominal cavity and then returned via the ileostomy site.  The pouch is then joined to the anal canal using a stapler introduced through the anus.








 





A loop-ileostomy is then created to defunction the pouch; pelvic drain brought out of a 5mm port site.  the drain is removed the following morning.  Note the final cosmmesis.











Patient discharged 3-5 days later with little more than an ileostomy!


What is the difference between the open and laparoscopic J-pouch procedures?

The standard open procedure is performed through a long midline incision.  In the laparoscopic approach we use 3-4 small incisions measuring 1cm (x2) and 5mm (x1-2).  Towards the end of the laparoscopic procedure, the incision directly above the pubic bone is lengthened (approx 4 inches) to allow easier division of the lower rectum and removal of the large intestine and creattion of the pouch.  In slim patients, especialy females, we usually able to remove the bowel and create the pouch utilising the ileostomy site.

What are the advantages of a laparoscopic operation?

The advantages include decreased post-operative pain, shortened recovery time, and better cosmetic result. Studies also suggest a lower rate of adhesions after laparoscopic surgery, which may result in a lower risk for post-operative bowel obstruction. 

This photograph (unstaged) shows a proctocolectomy & ileoanal pouch patient sitting in the recovery ward <20 minutes after completion of the surgery.  She was discharged 3 days later!

How is a laparoscopic J-pouch procedure done?

You will be admitted to hospital on the morning of surgery.  Do not eat or drink any milky products for the 6 hours prior to surgery.  Please drink water up to 1 hours.  We will give you a carbohydrate drink when you arrive on the ward.

The anaesthetist will employ a "one off" spinal injection and a general anaesthetic.  You will be catheterised untill the spinal anaesthetic wears off.    

We utilise three small incisions, each no bigger than 1cm, for the camera and operating instruments.  Throughout the operation we instill carbon dioxide into your abdominal cavity to give us a "working space".  First we detach the large intestine from the back of the abdominal cavity, called the retroperitoneum and divide the blood vessels supplying the large intestine.  After freeing up the entire large intestine  we turn our attention to mobilising the rectum all the way down to the anus.  Care is taken not to injure the nerves in the pelvis and so minimise any post-operative changes in sexual function.  We divide the rectum within 2 cm of the top of the anus using a stapler. 

We are now ready to remove the large intestine from the abdomen.  In female patients with a wide pelvis we usually remove the bowel through the small hole used to site the temporary ileostomy (see above).  In men we occasionally need to enlarge one of the incisions located just above the pubic bone in a side to side to direction for approximately 6 cms.  We are able to remove the large intestine through this incision and divide it where it connects to the small intestine. 

We can now construct the J-pouch (see above) in the standard fashion as has been done for years in open surgery.  Care is taken to construct an adequate sized pouch, which can be brought down to the anus without excessive pulling on the blood supply.  The J-pouch is then joined to the anus using a surgical stapling instrument; the double staple technique.

There is a different technique that involves stripping off the inner lining of the rectum (the mucosa) and joining the J-pouch to the anus using sutures.  This is termed a mucosectomy and is the prfered method for patients with FAP.  Advocates of the mucosectomy technique feel that it removes slightly more lining of the lower rectum/upper anal canal compared to the double staple technique.  Advocates of the double staple technique feel that it may improve long-term function in terms of anal sensation and continence.  Neither technique is clearly superior to the other. Both have potential drawbacks and pitfalls, and both are appropriate for individual patients.

Having completed the anastomosis, we construct the temporary ileostomy, which will divert the small bowel content from the J-pouch and the anastomosis.  This reduces the risk of pelvic infection and allows the J-pouch to heal with minimal scarring for improved long-term function.  For selected patients, we sometimes do not perform an ileostomy.  The ileostomy is brought out through one of the laparoscopic incisions. At this point the operation is complete.

Most patients are in the hospital for about 3-5 days.  Some of that time is used to learn how to take care of the ileostomy.  Patients are discharged home when they are tolerating food and are judged able to care for their ileostomy. 

The ileostomy is closed at a second operation 4-12 weeks later.  In general we arrange for a gastrograffin enema to be performed prior to closing the ileostomy to be certain that there is no problem (a leak) with the J-pouch. 

The final cosmetic results (see left and below) are spectacular.  The scar is little more than one would expect following an appendicectomy! 

The majority of surgeons perform open J-pouch procedures using a full length midline incision. 


We have been performing laparoscopic colo-rectal surgery since 1994 and performed our first laparoscopic J-pouch in 1997.  We are convinced that there are significant benefits to our laparoscopic patients, including reduced postoperative pain, faster return to normal function, and improved cosmetic results. 


Recently published experience from the Cleveland and Mayo Clinics in the USA comparing their laparoscopic J-pouch patients to open surgery patients confirm that there are significant benefits to the patient with the laparoscopic approach while maintaining equivalent J-pouch function.





We also have a large experience of performing a laparoscopic proctectomy and ileoanal pouch in patients who have had a previous open colectomy and ileostomy (see photo to left; note the full length incision of the previous surgery)!  These operations are more difficult to perform (previous adhesions) and take a little longer to carry out.  The patients however, notice the difference and some are in a position to be discharged home after 48hrs!

No surgical procedure is free from complications.  Blockage of the bowel from adhesions occurs in 10% of open operations and usually occurs early.  It may settle or require an operation.   People often have problems with the ileostomy - narrows, retracts, prolapses or develops a hernia.  Pouch failure or need to remove the pouch is reported in 5-10% in the first year rising to 15% over the next 5 years.  This is usually due to chronic sepsis or poor function.  5-10% is an accepted rate for anastomotic breakdown which can lead to pelvic sepsis.  The pouch itself can also become inflamed (10-20%) leading to diarrhoea, bleeding, ill health and fever.  Pouchitis can respond to antibiotics.  Other problems include difficulties with emptying.

Other long term complications include infrequent sexual dysfunction including impotence (<1%) and retrograde ejaculation (<3%) in men, and pain with intercourse (~5%) or stool leakage during intercourse (~2%) in women.

Infrequently, the surgeon will find that the ileum is too short to be connected safely to the anus, and it is impossible to create a J-pouch with good function; in those cases, a permanent ileostomy will be required.



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SPIRE Hospital, Bristol. 
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Contact: Claire Trenberth - 0117 9804051
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