| Abstract|| |
Introduction: Inflammatory bowel disease and Familial Adenomatous Polyposis (FAP) are relatively uncommon in Gulf Arabs. Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) is a surgical method for treating patients with mucosal ulcerative colitis (MUC) and FAP. This paper documents a small experience with this operation in Saudi Arabia. Methods: The charts of all patients who had either MUC or FAP and in whom an IPAA had been performed were identified and were examined in order to determine patient demographics, timing and staging of operation, operative and long term morbidity and mortality and pouch function. Results: Thirty patients underwent IPAA. There were 16 males. 29 pouches were J-pouches. 1 patient was lost to follow up. Surgery was performed for fulminating MUC in 9 patients, failed medical treatment in 12, FAP in 7 and megacolon in 2. An emergency-three stage IPAA was performed in 10 patients. 3 patients received perioperative TPN. 17 were on steroid medication. 12 developed transient anastomotic stricture. 8 developed small bowel obstruction during follow up but none needed further surgery. 1 patient developed 'pouchitis'. Two pouches were removed. The mean daily and nocturnal bowel frequency was 6 and 2 motions per day. 6 patients suffered nocturnal leakage. Conclusion: The operation of restorative proctocolectomy can be performed safely, for the few patients who needed the operation in Saudi Arabia.
Keywords: Mucosal ulcerative colitis, Familial Adenomatous Polyposis, restorative proctocolectomy
|How to cite this article:|
Isbister WH. Restorative proctocolectomy - a nine year experience at the King Faisal specialist hospital. Saudi J Gastroenterol 2000;6:147-52
Inflammatory bowel disease is relatively uncommon in Arabs of the Gulf region  . Between 1975 and 1994 101 Gulf Arabs were managed at the KFSH with either MUC, Crohns disease or indeterminate colitis. Of these 101 patients, 67 were thought to have MUC and of these 14 were managed surgically  . Restorative proctocolectomy with ileal pouch-anal anastomosis is now the accepted alternative to the older operation of pan proctocolectomy with end ileostomy for patients requiring surgery for both MUC and FAP. This paper documents our experience with restorative proctocolectomy at the KFSH in patients with both MUC and FAP over a nine year period.
| Materials and Methods|| |
All patients who had either MUC or FAP and in whom an IPAA had been performed were identified from the Department of Surgery's colorectal database. The charts of the identified patients were examined in order to determine patient demographics, timing and staging of operation, operative and long term morbidity and mortality and pouch function.
Patients with fulminating disease, poor nutritional status and those on high doses of streoids were managed by three stage IPAA (first stage-colectomy and end ileostomy; second stage-construction of pouch and loop ileostomy; third stage-ileostomy closure). All pouches except one (see below), were J-pouches with limb lengths of approximately 20 cm. All j-pouch anal anastomoses were double stapled  , using a 3M PI-55 linear stapler (United States Surgical Corporation, Connecticut) to close the anal stump and an Autosuture premium plus 31mm. EEA (United States Surgical Corporation, Connecticut) stapler to close the pouch anal anastomosis. All pouches were 'covered' by loop ileostomies which were closed following radiological confirmation of IPAA integrity. Following stoma closure patients were first seen after one month and then three monthly for the first year. After six monthly review in the second year patients entered a yearly follow up program.
| Results|| |
Between April 1990 and March 1999 30 patients underwent IPAA at the KFSH [Table - 1]. There were 16 males (av. age 36 yr.) and 14 females (av. age 31yr.). There were 29 J-pouches and one S-pouch in a patient in whom ischaemia of a portion of the constructed J-pouch developed prior to IPAA. In this patient the J-pouch was taken down and a S-pouch was constructed. One patient was lost to follow up after one year. Fulminating MUC was the reason for surgery in 9 patients and a further 12 patients were offered surgery because of failed medical treatment [Table - 2]. The average age of the 21 patients with MUC was 30 years. Seven patients had FAP (av. age 38 yr.) and two patients who were brothers aged 14 and 19 years had megacolon secondary to neuronal intestinal dysfunction.
The overall mean duration of disease prior to surgery was 70 months. The average disease duration in patients with MUC was 33.4 months whereas patients with FAP had had polyps for much longer (172 mo.). One patient had had a failed attempt at IPAA at another hospital and had had an end ileostomy for over a year prior to referral. One young girl with refractile MUC was initially offered colectomy and ileorectal anastomosis as a temporising measure but the disease proved refractory and the patient successfully underwent IPAA. One patient suffered massive DVT during a fulminating attack of MUC, had a caval umbrella inserted and then underwent three stage IPAA. Three patients received perioperative TPN and 12 patients required perioperative blood transfusion. Three stage-emergency, IPAA was performed in 10 patients, the remaining 20 patients underwent routine two stage IPAA. 17 patients were on steroid medication at the time of IPAA.
Twelve patients developed transient anastomotic stricture which responded to anal dilatation prior to stoma closure [Table - 3]. No patient was found to have radiological evidence of anastomotic failure/leak prior to stoma closure although the patient in whom a J-pouch had failed was found to have a small anastomotic sinus following stoma closure. Eight patients developed signs of small bowel obstruction during follow up but no patient needed further surgery. One patient developed stomal obstruction following ingestion of a kilogram of raw grapes. One patient developed signs of 'pouchitis' which were controlled with oral metronidazole.
Two pouches were removed. One patient suffered perineal fissures and frequent bowel movements despite constipating medications for five years before fmally requesting an ileostomy. This patient was finally diagnosed to have Crohns disease and is now well two years after pouch excision. The second patient who developed a wound dehiscence following pouch construction was never `happy' following ileostomy closure. Hee lost in excess of 15kg. weight and requested, following consultation overseas, at which time no cause for his problems was found, removal of his pouch 20 months after it's construction. Histological examination of the removed pouch failed to reveal any abnormality but the patient began to regain weight and now five years following pouch removal the patient is very well with his ileostomy.
One patient with FAP had already developed an invasive cancer before restorative proctocolectomy was performed, a splenic flexure tumour with nodal involvement was reported histologically and the patient died two years following IPAA from metastatic liver disease.
The mean number of daily bowel movements per patient was 6 and the mean number of nocturnal bowel actions was 2. Patients operated upon for MUC seemed to have slightly more frequent pouch activity (day/night 6/2) compared to the FAP patients with J-pouches (4.7/0.4). Overall six patients complained of nocturnal leakage (5 MUC, 1 J-pouch FAP).
| Discussion|| |
It is now nearly quarter of a century since Parks described the operation of restorative proctocolectomy  . Since his first paper there have been many large institutional series of patients having variations of the operation ,,,,,,, . Whilst the present series is rather small by these standards, it nevertheless represents the first account of restorative proctocolectomy performed in the Kingdom of Saudi Arabia.
Mucosal ulcerative colitis and FAP are relatively uncommon in the Kingdom (1, personal observation) and the incidence of MUC in Arabs is known to be lower than it is the wese  . In a previous report from the KFSH it was found that only 67 Gulf Arabs were managed with MUC at the hospital during an 18 year period  . There is no data relating to the incidence or management of FAP in the Kingdom. Few centres in the Kingdom have patients in whom restorative proctocolectomy is indicated but as the Kingdom becomes more `westernised' it might be expected that the incidence of MUC will rise and the need for such surgery in some of these patients at least will increase. It is timely, thus, to document our early experience with one of the surgical alternatives for treating these patients, restorative proctocolectomy. Since the establishment of the colorectal unit at the KFSH in 1990 thirty patients have undergone this operation at the hospital and these patients form the basis of the present study.
In comparison with reports from overseas ,,,,,,, , one centre has now reported over 1000 restorative proctocolectomies  , and as indicated above our study is small and so the power of the data reported and thus it's statistical significance is weak. Statistical comparisons would thus seem to be inappropriate but numerically, at least, our data with regard to morbidity and mortality is very similar to that reported in the literature ,,,,,,, .
At the Cleveland Clinic only six percent of patients having restorative proctocolectomy were operated upon for FAP  whereas in Riyadh 23% of our patients suffered from this condition. This difference probably reflects an evolution in the surgical management of FAP away from restorative proctocolectomy and the increasing awareness of lower FAP patient satisfaction with restorative proctocolectomy .
Saudi patients with both inflammatory bowel disease  and FAP tend to be delayed in their referral for surgery and one of our patients with FAP had already developed invasive colonic cancer before being seen at KFSH. It is probable that these delays result from a generalised medical lack of awareness of the two diseases  and also their rarity in the Kingdom. Poor patient compliance may be another reason for late referral and we have not been able to get many of the siblings of index patients to attend for screening far less agree to surgery.
Two patients satisfactorily underwent restorative proctocolectomy for megacolon and in carefully selected patients it appears to be the operation of choice , .
Small bowel obstruction is relatively common following restorative proctocolectomy (16-25%) and between 7-33% of these patients may require further surgery to relieve the obstruction , . None of our patients needed further surgery although 27% presented with transient obstruction. All patients were advised to take particular care when eating citrus fruits and `coleslaw' but despite this advice several seemed to develop bolus obstruction, including an ileostomy obstruction secondary to grape ingestion which resolved nonoperatively.
None of our patients died during the thirty day post operative period but one patient with FAP did die two years following surgery from metastatic disease. The postoperative mortality rates for restorative proctocolectomy in the literature vary between zero and one percent , . No patient developed a pouch-vaginal fistula  and this finding and the KFSH mortality data may simply be a function of the small number of operations performed.
Two of our patients (7%) developed pouchitis (frequency, blood in stools, histological evidence of inflammation) during follow up. One patient was managed successfully with metronidazole  but the other did not respond fully and ultimately had his pouch removed. This patient had Crohns disease and although this possibility was raised at the time of the colectomy (based on macroscopic findings) the histological report was in favour of MUC and the patient was insistent that he avoid a stoma. It was interesting to see how well he became following stoma reconstruction and pouch removal and this possibly suggests that some patients may be unnecessarily worried about life with a stoma. Pouchitis seemed to be more common in other series (15-23%) ,, and pouch removal rates in other series range from 3-7% , . The misdiagnosis of Crohns disease may be as high as 4% ,, .
No patients in this series were operated upon because mucosal biopsy had shown dysplasia in an otherwise healthy colon . For this reason no patients underwent serial pouch biopsy postoperatively. Forty percent of our patients did develop a pouch anal stricture  which resolved with gentle dilatation. None of the patients however were found to have anastomotic leaks or pelvic sepsis  . Pelvic sepsis has been reported in between 5-7% of patients , and may be one of the causes of stricture formation. Other causes of pouch anal anastomotic stricture include the presence of an ileostomy, anastomotic dehiscence and the use of a small (25mm.) stapler  . A 14% stricture rate was reported in hand sewn anastomoses compared to a 40% stricture rate in stapled anastomoses  .
In our patients who presented with fulminating disease or those on high doses of steroids we elected to perform three stage restorative proctocolectomy. It seems that this policy may be too cautious because it has recently been shown  that there are no differences in complication rates for patients having restorative proctocolectomy on either `high' (>20mg. prednisone/day) or `low' dose steroids (<20 mg. prednisone/day). It has also been shown that two stage operations may be safely performed in patients with fulminating disease .
Temporary loop ileostomies were rotated through 180 degrees if this could be performed without tension in order to place the afferent loop in the most dependant position. This technique sometimes resulted in the loop stomata being positioned more proximally than it would have been without rotation. Two stomata retracted but otherwise there were no major problems with the technique. It has recently been suggested that the rotation is unnecessary and that it may predispose to stricture formation  . We have not observed this complication but do not now rotate the loop.
It has been suggested that the three criteria for a `good' restorative proctocolectomy are a compliant reservoir, a strong sensitive sphincter and normal reflex co-ordination of the reservoir complex  . Our rather long reservoirs (20 cm.), stapled `pouch anal' anastomoses, about lcm. above the dentate line  , and the absence of any identified pouch or pelvic sepsis probably accounted for our reasonably good functional results. Twenty percent of our patients admitted to having an episodic nocturnal soiling and this is similar to the frequency of soiling (13-30%) reported from other series , . The mean daily stool frequency in our patients was six times per day and this has been reported to vary between 4 to 6 times per day in other series , . Two of our patients have
successfully delivered normal full term babies per vaginum  . There did not seem to be any functional differences between patients undergoing restorative proctocolectomy for MUC or FAR.
| Conclusion|| |
The operation of restorative proctocolectomy can be performed safely, for the few patients needing the operation in Saudi Arabia  Morbidity and mortality rates were, comparable to those reported from centres performing the operation with much greater frequency ,,,,,,, . Our commonest complication was transient IPAA stricture which settled with gentle digital dilatation.
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William H Isbister
Consultant Colorectal Surgeon, Department of Surgery, (MBC-40), P.O. Box 3354, Riyadh 11211
[Table - 1], [Table - 2], [Table - 3]