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Center for Colon and Rectal Surgery
Ileoanal Pouch

This is the procedure of choice for ulcerative colitis and familial polyposis coli, as it allows for excision of all diseased bowel and preserves the mechanisms of continence. Though not completely normal, the patient with an ileoanal pouch has satisfactory anal continence. There is a significant risk of complications, but the majority of these are acceptable. Success is largely dependent on the skill and experience of the operating team - this is one instance where the more one does, the better the result.

Ulcerative colitis
Familial polyposis

Anal incontinence

Poor risk: shock, sepsis, malnutrition
Rectal cancer/metastases
Psychiatric problems
Employment situation i.e. neurosurgeon

ULCERATIVE COLITIS - Surgical Alternatives
- Total proctocolectomy
- Continent Ileostomy (Kock Pouch)
- Abdominal colectomy and ileorectal anastomosis
- Ileoanal Pouch/Reservoir

1983 - 1991

203 patients - since the 90's the Calgary group has performed over 2,000 ileoanal pouch operations.

Male 64% (128)
Female 36% (71)

Age range 15 to 57 years (mean 32 y)

Ulcerative colitis 93%
Familial polyposis 7%

Two 83%
Three 17%

Elective 80%
Urgent 19%
Emergent 1%

Pouch type
S - 88.7%
J - 11.3%

Average hospital stay
After pouch - 11 days
After ileo closure - 8 days

Mean time between pouch and ileostomy closure - 10 weeks

COMPLICATIONS - Cumulative Risk
Small bowel obstruction - 24.6% (50)
- Requiring surgery - 8.4% (17)
Anastomotic sepsis - 10.4% (21)
Anal stricture - 14.3% (29)
Abdominal sepsis - 3.0% (6)
Pouch leak - 1.0% (2)
Pouchitis - 21.3% (43)
Failure - 7.4% (15)

Crohn's 3 patients
Pouchitis 2 patients
Poor function 5 patients
Anastomotic complications 5 patients

Length of follow-up - 36 months average
BM 6.5/24 hours, 1.5/night

At present, I have been involved in over 500 Ileoanal Pouch procedures. My complication rate and failure rate have dropped as my experience increased. The sepsis rate has decreased to under 3% overall, and the failure rate has decreased to about 3%. This is mostly because of increasing experience in the procedure. It is also because the procedure has changed in the past 15 years.

The mucosectomy is not routinely done now. Mucosectomy results in permanent damage to the anal sphincter which leads to fecal soiling and incontinence. I now staple the ileal pouch to the rectum and preserve a little transitional zone above the dentate line. This avoids stretch injury to the sphincter muscle and that transitional zone plays an important role in continence improving anal sensation and discrimination.

Since my early days in Canada, my length of hospital stay has also dropped. After the Ileoanal Pouch, the average length of stay is 7 days. This is for open surgery. Most of the cases are now done laparoscopically assisted so the average length of stay is much less.
Ileostomy Closure is done through the ileostomy site, so laparoscopy is not necessary and does not decrease the length of stay which averages 3 days.

This surgery is highly technical and demanding. The clinical results are dependent on the skill of the surgeon doing this procedure. The surgeons with the largest experience have the lowest complication rate, so this is not a surgery that should be performed by the occasional operator.
Unfortunately I still see an occasional general surgeon perform this surgery because he/she saw a few in training. The unfortunate patient is at a greater risk for a poor outcome.

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