Total colectomy with ileo-endomuscular pull-through in the treatment of ulcerative colitis in children

Construction of an ileal reservoir in patients with a previous straight endorectal ileal pull-through

A decade has passed since Martin and associates presented the first series of endorectal ileal pull-through (PT) procedures with straight ileoanal anastomosis for treatment of ulcerative colitis and polyposis. During the ensuing years, several medical centers have reported their results using the PT. Although some children have experienced good results, the majority of adults and children have had severe problems associated with high stool frequency, urgency, and incontinence. Between 1977 and 1987, 12 patients underwent colectomy and straight PT for ulcerative colitis or familial polyposis under the direction of a single surgeon. In this group, the average number of stools varied from six to 45 movements per 24 hours (mean, 18). In seven patients, high stool frequency (mean, 24 per 24 hours), partial fecal incontinence, and urgency that led to moderate to severe limitation in physical, social, work, and sexual activities made it necessary to convert the straight PT to an ileal reservoir. For each of these patients, the ileal PT segment was separated from the rectal muscle cuff, a lateral isoperistaltic reservoir was constructed, and the ileoanal anastomosis was re-established in a one-stage operation. One additional patient decided to return to a conventional ileostomy. All seven patients who underwent conversion to a PT with reservoir had no major complications, and each improved markedly in their clinical status. Daytime stool frequency was reduced by a mean of approximately 50%, whereas nocturnal frequency was decreased by a mean of 60%. Incontinence and fecal urgency were relieved significantly. In conclusion, for patients who develop problems with a straight PT procedure and who desire to avoid a permanent ileostomy, conversion to a PT with a lateral ileal reservoir is a valuable alternative with low risk and a high likelihood of success.

Pull-through with isolated jejunal loop for ulcerative colitis

Total colectomy with endorectal mucosectomy and ileal pull-through to preserve fecal continence is well known for ulcerative colitis. A female patient developed severe ulcerative colitis at 5 years of age and had an emergency subtotal colectomy and ileostomy at 7 years of age. The rectum was preserved. At 9 years of age rectal mucosectomy and a pull-through using isolated jejunal loop were performed. Postoperatively she was treated with ano-rectal physiotherapy and balloon dilatations of the new rectum. Six months later the ileostomy was closed. Two and a half years after her operation she has 2-4 soft bowel movements daily, perfect diurnal control with occasional night soiling. A pull-through using an isolated loop of jejunum leaves intact a good functioning ileostomy. The blood supply to the jejunum is better than the terminal ileum. Bacterial contamination with jejunum is less than with ileum. There is no need for a reservoir; if the pull-through fails valuable terminal ileum is not lost.

The critical level for preservation of continence in the ileoanal anastomosis

Mucosal proctectomy with ileoanal anastomosis was performed for 90 patients with ulcerative colitis or polyposis over the past 18 years. In three, the anastomosis was at the dentate line. All three had varying degrees of soilage necessitating permanent ileostomy in one. For 12 patients with the anastomosis 1.0 cm proximal to the top of the columns, all were totally continent, but six experienced recurrent disease. For 75 in the third group, the anastomosis was at the top of the columns. Five await ileostomy closure. Of the other 70, none experienced recurrent disease and three have mild nighttime soilage, two of which are less than 1 year following operation. We recommend that the transitional epithelium of the anorectal columns be preserved.

Endorectal ileal pull-through for ulcerative colitis and polyposis in children

The marked reluctance to leaving a permanent ileostomy in a child is understandable; too often, however, before surgical therapy is accepted, the patient is permitted to decline to a hopeless state from which restoration is virtually impossible without operation. Endorectal ileal pull-through provides an attractive alternative. From 1972 to 1982 at Children's Hospital, G. Gaslini Institute, Genoa, nine patients with ulcerative colitis and eight patients with familial polyposis received this operation. Results are encouraging and support the more frequent use of this alternative.

The lateral reservoir technique of ileal endorectal pull-through for ulcerative colitis and familial polyposis in children

Total abdominal colectomy and endorectal ileal pull-through have been widely used in children as a definitive continence-preserving procedure for ulcerative colitis (UC) and familial polyposis (FP). Controversy exists in regards to the results achieved with the various techniques utilized to accomplish this procedure, including straight ileal pull-through, pull-through with balloon dilatation of the lower ileal segment, and the construction of a variety of ileal reservoirs: S-shaped, J-shaped, or lateral. We have utilized the two-stage lateral reservoir approach advocated by Fonkalsrud et al, on a total of 12 patients, aged 1 to 17 years, including ten patients with UC and two with FP. Twelve patients have undergone stage 1 and seven of these stage 2. Numerous complications of stage 1 occurred early in the series, including breakdown of the ileoanal anastomosis, 3 patients; cuff abscess, 2 patients; postoperative intestinal obstruction, 2 patients; and intraabdominal abscess, 1 patient. All have fully recovered. The last six stage 1 procedures have been without complications. Five of the seven stage 2 patients are now well, continent, and having four to six controlled bowel movements a day 1 to 2 years postoperatively. Two patients are using small amounts of Immodium and Metamucil. One patient has developed marked dilatation of the pouch at 8 months postoperatively with episodic "pouchitis" requiring operative revision and diversion. One stage 2 patient suffered numerous complications including spontaneous perforation of the reservoir 2 months postoperatively, eventually leading to re-creation of a permanent ileostomy and removal of the pouch. Five patients await further treatment. The lateral reservoir technique is capable of producing a satisfied and continent patient; however, the potential technical problems and early complications are significant. The occurrence of delayed "pouchitis" is worrisome. Although the initial results with the lateral reservoir technique appear encouraging, further longterm evaluation is necessary.

Preservation of anorectal continence following total colectomy

The search for continence in the surgical management of ulcerative colitis has resulted in the evolution of a method that has yielded gratifying results in the last 18 patients. The disease process is removed; all patients are continent; they have no postoperative perineal excoriation; the frequency of stools is not excessive and the patients are returning to work or to school within three weeks following ileostomy closure. Their ages were eight to 52 years. The procedure consists of a total of colectomy with mucosal proctectomy, ileoanal anastomosis and construction of a terminal ileal, pelvic reservoir. A proximal ileostomy diverts the fecal stream until healing is complete. The authors are now recommending the operation be considered for patients of all ages who require surgery for chronic ulcerative colitis as well as polyposis.