Ileostomy Reversal for a Two-Stage Laparoscopic Proctocolectomy with Ileoanal J-Pouch for Ulcerative Colitis

Abstract

This video describes a technique for an ileostomy reversal, which was performed as a second-stage procedure for a total proctocolectomy with ileoanal J-pouch for medically-refractory ulcerative colitis. In this procedure, we start by incising around the ileostomy near the junction of the skin and bowel mucosa. To mobilize the intestine within the abdominal wall, we use electrocautery dissection through the subcutaneous tissues to the level of the fascia. The fascial opening is extended to complete the mobilization of the intestine. Stay sutures are then placed between the loops of intestine at the planned site of the anastomosis, and ILA staplers are used to create a side-to-side functional end-to-end anastomosis. The abdominal fascia is then closed with running sutures, the wound is washed with antiseptic, and the skin is brought together with vertical mattresses.

Case Overview

The patient is a 29-year-old female with medically-refractory ulcerative colitis (UC). She had attempted multiple trials of various medications with continued colitis and symptoms that reduced her quality of life. Therefore, she elected to proceed with a laparoscopic proctocolectomy with ileoanal J-pouch as definitive management for her UC. This procedure was performed in a two-stage approach, in which a diverting loop ileostomy was placed during the first stage to protect the ileoanal anastomosis to allow for adequate healing and leak prevention. The patient tolerated the first operation well and had no issues with the management of her ileostomy. Given her excellent recovery, she was brought to the operating room for the reversal of her diverting loop ileostomy. Prior to the ileostomy reversal, a contrast enema confirmed a widely patent ileoanal anastomosis without a leak. 

The indications for diverting loop ileostomy are focused on the recovery from the first operation, particularly the quality of the ileoanal anastomosis. Complications that may preclude or delay reversal include evidence of anastomotic breakdown, stricturing that results in obstruction of fecal flow, pouchitis or fistulae, active infection, or severe malnutrition.¹ In preparation for surgery, patients should be evaluated with a physical exam, including a thorough perineal and digital rectal exam to evaluate for issues involving the anastomosis. Some practitioners may also use contrast enemas and endoscopy as adjuncts to evaluate the anastomosis prior to reversal.²

Background

UC is a subtype of inflammatory bowel disease (IBD) characterized by epithelial and submucosal inflammation that starts distally in the rectum and ascends within the colon. In the United States, UC affects nearly 1 in 200 adults over the age of 18, with a rising incidence.³ Symptoms are variable depending on disease severity and may include cramping, nausea, diarrhea, bloody stools, and weight loss. In rare cases, the disease may progress to toxic megacolon, a life-threatening condition in which profound inflammation of the colon results in loss of tissue integrity, bacterial translocation, and potentially perforation.⁴ Treatment of this condition requires urgent colon resection for prevention of sepsis. After 8–10 years of disease, the risk of non-adenomatous colorectal cancer significantly increases, and annual colonoscopy with random biopsies is recommended.⁵

First-line therapy for UC involves medical management, which has historically included enteral salicylates. In recent years, an armamentarium of biologic therapies has been developed targeting various components of the immune system that have been implicated in UC pathogenesis.⁶ Despite improved medical therapies, a subset of patients will still require surgery for the management of their UC. Indications for surgery include medically-refractory disease, development of dysplasia or invasive cancer, or development of toxic megacolon or perforation.

The indication for surgery in this patient was the medically-refractory disease. Given her suitable health, she underwent complete resection of the involved tissue, including both the colon and rectum. It is common to protect an ileoanal J-pouch anastomosis with a diverting loop ileostomy based on the risk of a leak.

Focused History of the Patient

The patient is a 29-year-old female with a history of medically-refractory ulcerative colitis. Her other medical history is unremarkable. She has no prior abdominal surgical history. Her last colonoscopy showed no evidence of malignancy. She has an American Society of Anesthesiologist score (ASA) of 2 and her body mass index (BMI) is within a normal range.

Physical Exam

The patient had an unremarkable physical exam. In the office, she presented in no apparent distress with normal vital signs. She had a normal body habitus. Her abdominal exam was unremarkable with a pink, patent, and perfused ostomy. There was no evidence of abdominal wall hernias or tenderness to palpation. Her abdomen was soft and non-distended.

Imaging

A gastrografin enema was performed prior to undergoing ileostomy reversal, which showed no evidence of leak or obstruction. 

Natural History

The pathogenesis of UC is defined by inflammation of the rectum and colon. The majority of patients will have a relapsing-remitting course with periodic flares, though up to 15% of patients will present with severe disease involving the majority of the colon.⁷ One-third of patients will experience proximal progression of their disease within 10 years, and up to 15% of patients will require surgical intervention within 10 years after a diagnosis of UC.⁸ Risk factors for UC include genetic predisposition, environmental factors, and altered immune responses. Over 200 risk loci have been identified from genome-wide association studies (GWAS), including genes related to immune and gut barrier function.⁹ Auto-antibodies have been described in a small subset of UC cases.¹⁰ Chronic inflammatory signaling predisposes rectal and colonic epithelia to progressive genetic dysregulation, leading to non-adenomatous dysplasia and invasive cancer, with the risk increasing after 8–10 years of the disease.

Options for Treatment

The decision to undergo surgical resection of the colon and rectum for UC requires thoughtful consideration by the patient in conjunction with a team that includes a surgeon and a gastroenterologist. In the case of medically-refractory disease, the patient will need to assess the risk-to-benefit ratio of undergoing an operation vs. the quality of life with poor symptom control. Regarding the choice of operation, the standard of care is to remove all involved tissue, including the entire rectum and colon. Therefore, the recommended operation is total proctocolectomy. This operation can be performed laparoscopically at most major medical centers. There is also a decision regarding reconstruction, if any, of the alimentary tract. The ileoanal J-pouch (IPAA) technique is commonly performed, though in rare cases, an end ileostomy without reconstruction may be pursued. IPAA surgery is usually carried out in either two or three stages. In the case of this patient, a two-stage approach was pursued in which the J-pouch was transiently protected by fecal diversion with a loop ileostomy. In the absence of complications with the J-pouch, it is rare to not reverse the ostomy, which can have its own long-term complications including kidney injury, electrolyte abnormalities, and stoma issues.

Rationale for Treatment

The goals of this operation were to reverse the ileostomy and resume normal alimentary function for the patient.

Special Considerations

There are no additional special considerations.

Discussion

As we have shown in this video, the main procedural steps for this operation are as follows: 

1. Skin incision and dissection of the ostomy down to the level of the abdominal wall fascia.
2. Opening of the fascia and mobilization of the ostomy, freeing up two free ends for an anastomosis.
3. Side-to-side functional end-to-end stapled anastomosis of the ileum.
4. Primary closure of the fascia.
5. Closure of the skin.

This technique allows for an efficient approach to ileostomy reversal.

There are multiple accepted technical variations for the ileostomy reversal procedure. In order of sequence, these may include the skin incision (circular vs. tapered), creation of the anastomosis (hand-sewn vs. stapled), closure of the abdominal wall fascia (primary vs. mesh), and wound management (purse-string vs. skin closure).^11,12 Both hand-sewn and stapled anastomotic techniques have similar morbidity and mortality in retrospective analyses.¹³ Although primary closure of the abdominal wall fascia has been the standard of care, recent evidence suggests that retromuscular placement of synthetic mesh at the time of ostomy closure significantly reduces subsequent hernia formation without increased wound complications.¹⁴ Further studies are needed to better clarify the role of mesh for ileostomy reversal. Finally, a recent meta-analysis evaluated purse-string vs. linear wound closure after ileostomy reversal, and it was observed that a purse-string closure was associated with significantly reduced infection rates.¹¹

Patient Outcome Statistics from Procedure

• Operative time: Approximately 40 minutes
• Estimated blood loss: 5 ml
• Fluids: 1000 ml crystalloid
• Length of stay: Discharged from hospital to home without services on postoperative day 1
• Morbidity: No complications
• Final pathology: Ileostomy tissue 

Equipment

• 15-blade scalpel
• Electrocautery
• DeBakey forceps
• Adson forceps
• Abdominal wall hand-held retractor
• Schnidt clamp
• 3-0 and 2-0 silk ties
• Metzenbaum scissors
• ILA stapler
• 0-Vicryl suture for fascial closure
• 3-0 nylon for skin closure

Disclosures

Nothing to disclose.

Statement of Consent

The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online.

Acknowledgments

We would like to thank the surgical staff and anesthesia team for their assistance in this operation.