Technical Considerations in Performing Total Colectomy and Soave Endorectal Anastomosis for Ulcerative Colitis By L e s t e r W. Martin and C l a u d e L e C o u l t r e 9 Total colectomy, mucosal proctectomy, and ileoanal endorectal anastomosis have been successful in 17 of 19 children with chronic ulcerative colitis. No significant complications were encountered in our recent g cases. The technique of the operation as it is now performed in our institution is described. INDEX WORDS: Ulcerative colitis; endorectal anastomosis; Soave operation,
we reported our 10-yr experience with S INCE total colectomy and mucosal proctectomy with preservation of continence in ulcerative colitis, ~ numerous requests have been received for further specific details of operative management. We have now completed the operation on 19 patients over a period of 11 yr. Initially, multiple complications were encountered. As additional experience has been gained, problems have decreased to a point such that the last 9 patients have recovered free of significant complications. Prior to operation, the patient must be in positive nitrogen balance. This may be accomplished by one of two methods: preoperative total parenteral alimentation or performance of an initial subtotal colectomy and ileostomy, with deferral of the endorectal pull-through until a later date. It is essential that the rectal mucosa be free of gross disease at the time of operation. This generally requires a period of intensive medical m a n a g e m e n t by total parenteral alimentation, systemic steroids, rectal steroids, no oral feedings, sulfasalazine (Azulfidine), and, in certain instances, systemic broad-spectrum antibiotics.
From the Pediatric Surgical Service, Children's Hospital and the Division of Pediatric Surgery, Department of Surgery, College of Medicine, University of Cincinnati, Cincinnati, Ohio. Presented before the 9th Annual Meeting of the American Pediatric Surgical Association, Hot Springs, Virginia, May 3 4 , 1978. Address reprint requests to Lester W. Martin, M.D., Children's Hospital, 240 Bethesda Avenue, Cincinnati, Ohio 45229. 9 1978 by Grune & Stratton, Inc. 0022-3468/78/1307-0037501.00/0
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Usually a period of 4-6 wk of this regimen is required to prepare the rectum for operation. Just prior to operation, after the patient is anesthetized, a sigmoidoscopic examination is performed. If gross active disease is visible, the operation should not be attempted. If the mucosa appears to be free of grsoss disease, a large rectal tube is inserted to be used later during the operation for intraoperative colonic irrigations. The patient is then placed in a supine position with the legs flat on the operating table. This position facilitates dissection deep within the pelvis. If the patient has an ileostomy, it is closed surgically, the instruments are discarded, and the abdomen is again prepared and draped, with all members of the team changing gowns and gloves. The abdomen is opened through a long left paramedian incision. A constrictive tape is placed snugly about the sigmoid colon, and the rectosigmoid is thoroughly irrigated through the inlying rectal tube by an assistant. The abdominal colon is then mobilized, and its blood supply is ligated and divided. A circumferential incision is made through the muscular wall of the colon just above the peritoneal reflexion. Dissection is then continued downward, separating the muscular wall of the rectum from the mucosa. Many small vessels are encountered, and they are best fulgurated before they are divided or disrupted. This portion of the operation usually requires 2-3 hr of careful dissection, and it is important not to Perforate the mucosa. The mucosal cylinder is dissected free as far inferiorly as can be accomplished. A second ligature is then placed about the sigmoid colon distal to the previous one, and the colon is transected between the two ligatures. The terminal ileum is then divided between anastomotic clamps, and the colon is passed from the operative field. The terminal ileum is closed with multiple interrupted inverting sutures without contamination of the operative field, The mesentery of the terminal ileum is then inspected and incised in such a fashion as to provide sufficient length for the ileum to reach the anus and yet preserve an adequate blood supply. The surgeon then proceeds to the perineal Journal of Pediatric Surgery, Vol. 13, No. 6D (December), 1978
ULCERATIVE COLITIS
portion of the operation, with one assistant remaining at the abdominal field. The legs of the patient are elevated to the lithotomy position. The anus is gently dilated, and the rectal mucosa previously mobilized from above is everted and delivered outside the anus. The entire perineal field is then thoroughly prepared and draped. The rectal mucosa is then transected with electrocautery 1.0 cm above the mocuotaneous junction, and the terminal ileum is drawn down through the rectal canal, which has been preserved intact but denuded of mucosa. A single Penrose drain is placed between the external wall of the ileum and the muscular cuff of rectum and is brought out through a stab wound posterior to the anus. A row of absorbable sutures is placed between the seromuscular layer of the end of the ileum and the muscular wall of the rectum just above the transected mucosa. This circumferential layer of deep sutures is placed and tied in an effort to create a watertight seal and prevent subsequent retrograde fecal contamination of the denuded rectal cuff. The sutures in the end of the ileum are then removed, and the full thickness of ileum is sutured in an end-to-end fashion to the transected anorectal mucosa, again using interrupted absorbable sutures. The patient's legs are then returned to the operating table. The members of the surgical team from the perineal portion of the procedure change gowns and gloves and return to the abdominal portion of the operation. A diverting loop ileostomy is then established through a separate opening in the right lower abdomen. The wall of the ileum is sutured to the peritoneum and the rectus fascia, but the ileostomy is not opened until the working incision has been closed and sealed with collodion. A Turnbull diverting loop ileostomy has been most satisfactory for our patients. An adherent ileostomy bag is applied before the patient leaves the operating room. Following operation, parenteral alimentation is continued until the patient is able to take adequate nourishment by mouth. Systemic steroids are gradually decreased, then discontinued. The ileostomy is closed 3-6 mo later following complete healing of the rectal anastomosis. At the time of ileostomy closure in 1 patient (3 mo following colectomy) the wall of the ileum
763
could be bluntly dissected from all layers of the abdominal wall with a finger or knife handle, indicating the poor healing encountered in patients with chronic ulcerative colitis who are receiving high-dosage steroid therapy. This emphasizes the importance of strict adherence to the principles outlined above and the need for deferring ileostomy closure until the patient has fully recovered. Complete avoidance of contamination during the operation is essential. Blood loss must be accurately measured and replaced. Broad-spectrum systemic antibiotics are employed liberally beginning 1 hr prior to operation. RESULTS
Our experience with 19 patients confirms that it is possible to perform a total colectomy and yet preserve anorectal continence. There have been no deaths. Early in our experience, pelvic sepsis was responsible for two failures, one of which proved to be misdiagnosed Crohn's colitis. Both have permanent ileostomies. One patient is awaiting ileostomy closure. They other 16 have recovered and have satisfactory results. All patients have had frequent watery stools, and several have experienced perianal excoriation for several weeks following ileostomy closure. As long as 6-12 mo have been required for adaptation, but all have complete control. Significant complications developed in the first 10 patients before we adopted the 1 mo of preoperative total parenteral nutrition. Cuff abscesses developed in 3 patients before we began to drain the rectal cuff. Pelvic infection developed in 3 patients when the operation was performed in the presence of active rectal disease and without proximal diversion. The five wound infections followed perforation of the rectal mucosa during the dissection from above. Four of the 5 patients had had what we would now consider inadequate colonic irrigations prior to beginning the dissection. Nine recent patients recovered with no significant complications. DISCUSSION
Ulcerative colitis is primarily a mucosal disease. Crypt abscesses, however, may develop and progress to secondary infection within deeper layers of the bowel wall, sometimes to the
764
extent of perforation. Broad-spectrum antibiotics are therefore of value in preoperative preparation of the patient with advanced disease. The teenage patient is often reluctant to accept a permanent ileostomy and will generally agree to operation at an earlier stage of the disease now that continence can be preserved. For the older patient who is the sole support of a family, the one-stage total colectomy, proctectomy, and establishment of a permanent ileostomy will, most likely, return him to employment at a much earlier date. For the pediatric patient, however, certain unknowns in the future, including courtship, marriage, and participation in sports, are significant considerations. In advanced stages of the disease, the opera-
MARTIN AND LECOULTRE
tion is more difficult to perform, and the likelihood of complications is greater. We are often asked what to do in the event that gross rectal disease cannot be reversed by parenteral alimentation and other adjunctive measures. We have not encountered this situation in our own patients, but it would appear logical to perform a subtotal colectomy with ileostomy and preservation of the rectum and plan the endorectal anastomosis for some future date after the rectal disease has become quiescent. REFERENCE
1. Martin LW, LeCoultre C, Schubert WK: Total colectomy and mucosal proctectomy with preservation of continence in ulcerative colitis. Ann Surg 186:477-480, 1977
we reported our 10-yr experience with S INCE total colectomy and mucosal proctectomy with preservation of continence in ulcerative colitis, ~ numerous requests have been received for further specific details of operative management. We have now completed the operation on 19 patients over a period of 11 yr. Initially, multiple complications were encountered. As additional experience has been gained, problems have decreased to a point such that the last 9 patients have recovered free of significant complications. Prior to operation, the patient must be in positive nitrogen balance. This may be accomplished by one of two methods: preoperative total parenteral alimentation or performance of an initial subtotal colectomy and ileostomy, with deferral of the endorectal pull-through until a later date. It is essential that the rectal mucosa be free of gross disease at the time of operation. This generally requires a period of intensive medical m a n a g e m e n t by total parenteral alimentation, systemic steroids, rectal steroids, no oral feedings, sulfasalazine (Azulfidine), and, in certain instances, systemic broad-spectrum antibiotics.
From the Pediatric Surgical Service, Children's Hospital and the Division of Pediatric Surgery, Department of Surgery, College of Medicine, University of Cincinnati, Cincinnati, Ohio. Presented before the 9th Annual Meeting of the American Pediatric Surgical Association, Hot Springs, Virginia, May 3 4 , 1978. Address reprint requests to Lester W. Martin, M.D., Children's Hospital, 240 Bethesda Avenue, Cincinnati, Ohio 45229. 9 1978 by Grune & Stratton, Inc. 0022-3468/78/1307-0037501.00/0
762
Usually a period of 4-6 wk of this regimen is required to prepare the rectum for operation. Just prior to operation, after the patient is anesthetized, a sigmoidoscopic examination is performed. If gross active disease is visible, the operation should not be attempted. If the mucosa appears to be free of grsoss disease, a large rectal tube is inserted to be used later during the operation for intraoperative colonic irrigations. The patient is then placed in a supine position with the legs flat on the operating table. This position facilitates dissection deep within the pelvis. If the patient has an ileostomy, it is closed surgically, the instruments are discarded, and the abdomen is again prepared and draped, with all members of the team changing gowns and gloves. The abdomen is opened through a long left paramedian incision. A constrictive tape is placed snugly about the sigmoid colon, and the rectosigmoid is thoroughly irrigated through the inlying rectal tube by an assistant. The abdominal colon is then mobilized, and its blood supply is ligated and divided. A circumferential incision is made through the muscular wall of the colon just above the peritoneal reflexion. Dissection is then continued downward, separating the muscular wall of the rectum from the mucosa. Many small vessels are encountered, and they are best fulgurated before they are divided or disrupted. This portion of the operation usually requires 2-3 hr of careful dissection, and it is important not to Perforate the mucosa. The mucosal cylinder is dissected free as far inferiorly as can be accomplished. A second ligature is then placed about the sigmoid colon distal to the previous one, and the colon is transected between the two ligatures. The terminal ileum is then divided between anastomotic clamps, and the colon is passed from the operative field. The terminal ileum is closed with multiple interrupted inverting sutures without contamination of the operative field, The mesentery of the terminal ileum is then inspected and incised in such a fashion as to provide sufficient length for the ileum to reach the anus and yet preserve an adequate blood supply. The surgeon then proceeds to the perineal Journal of Pediatric Surgery, Vol. 13, No. 6D (December), 1978
ULCERATIVE COLITIS
portion of the operation, with one assistant remaining at the abdominal field. The legs of the patient are elevated to the lithotomy position. The anus is gently dilated, and the rectal mucosa previously mobilized from above is everted and delivered outside the anus. The entire perineal field is then thoroughly prepared and draped. The rectal mucosa is then transected with electrocautery 1.0 cm above the mocuotaneous junction, and the terminal ileum is drawn down through the rectal canal, which has been preserved intact but denuded of mucosa. A single Penrose drain is placed between the external wall of the ileum and the muscular cuff of rectum and is brought out through a stab wound posterior to the anus. A row of absorbable sutures is placed between the seromuscular layer of the end of the ileum and the muscular wall of the rectum just above the transected mucosa. This circumferential layer of deep sutures is placed and tied in an effort to create a watertight seal and prevent subsequent retrograde fecal contamination of the denuded rectal cuff. The sutures in the end of the ileum are then removed, and the full thickness of ileum is sutured in an end-to-end fashion to the transected anorectal mucosa, again using interrupted absorbable sutures. The patient's legs are then returned to the operating table. The members of the surgical team from the perineal portion of the procedure change gowns and gloves and return to the abdominal portion of the operation. A diverting loop ileostomy is then established through a separate opening in the right lower abdomen. The wall of the ileum is sutured to the peritoneum and the rectus fascia, but the ileostomy is not opened until the working incision has been closed and sealed with collodion. A Turnbull diverting loop ileostomy has been most satisfactory for our patients. An adherent ileostomy bag is applied before the patient leaves the operating room. Following operation, parenteral alimentation is continued until the patient is able to take adequate nourishment by mouth. Systemic steroids are gradually decreased, then discontinued. The ileostomy is closed 3-6 mo later following complete healing of the rectal anastomosis. At the time of ileostomy closure in 1 patient (3 mo following colectomy) the wall of the ileum
763
could be bluntly dissected from all layers of the abdominal wall with a finger or knife handle, indicating the poor healing encountered in patients with chronic ulcerative colitis who are receiving high-dosage steroid therapy. This emphasizes the importance of strict adherence to the principles outlined above and the need for deferring ileostomy closure until the patient has fully recovered. Complete avoidance of contamination during the operation is essential. Blood loss must be accurately measured and replaced. Broad-spectrum systemic antibiotics are employed liberally beginning 1 hr prior to operation. RESULTS
Our experience with 19 patients confirms that it is possible to perform a total colectomy and yet preserve anorectal continence. There have been no deaths. Early in our experience, pelvic sepsis was responsible for two failures, one of which proved to be misdiagnosed Crohn's colitis. Both have permanent ileostomies. One patient is awaiting ileostomy closure. They other 16 have recovered and have satisfactory results. All patients have had frequent watery stools, and several have experienced perianal excoriation for several weeks following ileostomy closure. As long as 6-12 mo have been required for adaptation, but all have complete control. Significant complications developed in the first 10 patients before we adopted the 1 mo of preoperative total parenteral nutrition. Cuff abscesses developed in 3 patients before we began to drain the rectal cuff. Pelvic infection developed in 3 patients when the operation was performed in the presence of active rectal disease and without proximal diversion. The five wound infections followed perforation of the rectal mucosa during the dissection from above. Four of the 5 patients had had what we would now consider inadequate colonic irrigations prior to beginning the dissection. Nine recent patients recovered with no significant complications. DISCUSSION
Ulcerative colitis is primarily a mucosal disease. Crypt abscesses, however, may develop and progress to secondary infection within deeper layers of the bowel wall, sometimes to the
764
extent of perforation. Broad-spectrum antibiotics are therefore of value in preoperative preparation of the patient with advanced disease. The teenage patient is often reluctant to accept a permanent ileostomy and will generally agree to operation at an earlier stage of the disease now that continence can be preserved. For the older patient who is the sole support of a family, the one-stage total colectomy, proctectomy, and establishment of a permanent ileostomy will, most likely, return him to employment at a much earlier date. For the pediatric patient, however, certain unknowns in the future, including courtship, marriage, and participation in sports, are significant considerations. In advanced stages of the disease, the opera-
MARTIN AND LECOULTRE
tion is more difficult to perform, and the likelihood of complications is greater. We are often asked what to do in the event that gross rectal disease cannot be reversed by parenteral alimentation and other adjunctive measures. We have not encountered this situation in our own patients, but it would appear logical to perform a subtotal colectomy with ileostomy and preservation of the rectum and plan the endorectal anastomosis for some future date after the rectal disease has become quiescent. REFERENCE
1. Martin LW, LeCoultre C, Schubert WK: Total colectomy and mucosal proctectomy with preservation of continence in ulcerative colitis. Ann Surg 186:477-480, 1977
