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A surgical
alternative to the standard ostomy
that eliminates the need to wear a pouch on the abdomen is effective in children
with severe colitis, according to clinicians at the Cleveland Clinic Foundation
(CCF). Their conclusions, which were published in the summer 1996 edition of
Inflammatory Bowel Diseases, were based on a study of 91 patients--all the
children who had undergone ileal pouch-anal anastomosis (IPAA) at CCF between
1982 and 1992.
The goal of IPAA is to preserve the pathway from the rectum to the anus,
allowing the patient to defecate normally. The surgeon performs a colectomy
(removal of the patient's colon and rectum), but salvages the anal muscles.
Next, he constructs a new rectum by making a pouch out of a portion of the small
intestine and attaching it to the anus. This internal pouch can be constructed
in several ways (e.g., J pouch, S pouch). Like the standard ileostomy, IPAA is a
cure for ulcerative colitis.
IPAA usually is performed in two stages. During the first stage, the surgeon
creates a temporary ileostomy in order to prevent stool from passing to the
pouch. This allows the pouch to heal. Six to eight weeks later, the ileostomy is
closed, and gastrointestinal continuity is restored. The procedure has been
refined over the years, and is now widely performed in people of all ages.
Study Results
All of the children (whose median age at diagnosis was 14.2 years) in the CCF
study had suffered from severe symptoms that did not respond to medical therapy.
The clinicians reviewed each case to determine whether complications occurred
after surgery, and when these problems began. A total of 30 early complications
(occurring within 30 days after pouch construction) were documented in 21
patients. The most common early complication was small bowel obstruction.
Fifty-seven late complications (occurring at least 30 days after pouch
construction) were noted in 34 children. Pouchitis
(inflammation of the pouch) was the most common complication in this group,
followed by perineal infection and anastomotic stricture (a narrowing at the
site where the pouch is attached to the anus). The latter occurred primarily in
children who had S pouches. No other relationship between pouch type and
complications was indicated. Similarly, the child's age at the time the
operation was performed did not appear to play a role in the development of late
complications.
In most cases, complications responded to medical therapy. However, 24 children
required additional surgery for complications at some point between the initial
colectomy and the final surgery. In four cases, the pouch had to be removed due
to persistent infection. (Pouch failure occurs in 8-10% of all people who
undergo IPAA. When this happens, the IPAA is converted to a standard ileostomy.)
Of the 78 CCF patients who were asked to evaluate their quality of life after
IPAA, 73 (94%) said that they were very satisfied with the results of the
operation. Following surgery, the children experienced a median number of four
bowel movements per day and one per night. Daytime continence was complete in
86% of the children; 72% did not experience any soiling at night.
In short, the authors conclude that "IPAA is an effective surgical
procedure... and results in a relatively normal pattern of defecation."
While complications can occur, IPAA may be a viable option for children who are
seriously ill and whose symptoms cannot be controlled by medication.
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