Anorectal: Restorative Proctocolectomy with Ileal Pouch-Anal Anastomosis (RPC-IPAA)

Definitions

• Restorative Proctocolectomy – Complete Colon & Rectum Resection Sparing the Anus for Reconstruction
• Ileal Pouch-Anal Anastomosis – Ileum Loop Folded onto Itself Creating a Pouch for Anastomosis
  • Pouch Allows Reservoir to Decrease Bowel Movement Frequency
• Often Done as a Two-Stage Procedure with Initial Diverting Loop Ileostomy

Possible Candidates

• Inflammatory Bowel Disease without Rectal Involvement Refractory to Medical Management
  • Generally Used in Ulcerative Colitis but Not for Crohn’s Disease
• Familial Adenomatous Polyposis (FAP)
• Severe Colonic Inertia Refractory to Medical Therapy (Ileorectal Anastomosis Preferred)

Contraindications

• Absolute:
  • Severe Fecal Incontinence
  • Low Rectal CA Involving Sphincters
  • Perianal Crohn’s Disease
• Relative:
  • Morbid Obesity
  • Low Rectal CA with Neoadjuvant Tx
  • Non-Perianal Crohn’s Disease
  • Prior Extensive Small Bowel Resection

Ileal Pouch Types

• J-Pouch (2-Limbs)
  • Preferred Type
  • Length: 15-20 cm
• Rare Alternative Types:
  • S-Pouch (3-Limbs)
  • W-Pouch (4-Limbs)

Techniques to Decrease Tension or Ensure Reach

• Division of Ileum Flush with Cecum
• Complete Mobilization of Small Intestine to the Third Portion of Duodenum
• Full Adhesiolysis
• Transverse-Stepladder Relaxing Incisions Over the Mesentery Under Tension Along SMA Vessels

Pouchitis

• Most Common Long-Term Complication (23-59%)
  • Higher-Risk if Resection Due to Ulcerative Colitis
• Infectious Pouchitis
  • Cause: Inflammation of Pouch from Infection
    • Postoperative Microbiome of Pouch Transitions from Ileum-Like to Colon-Like
    • No Specific Pathogens Have Been Consistently Implicated
  • Sx: Diarrhea, Bloody Stools, Pain & Fever
  • Tx: Oral ABX (Ciprofloxacin #1, Metronidazole or Tinidazole)
    • Consider Biopsy to Rule Out Chron’s Disease
• Diversion/Disuse Pouchitis
  • *See Large Intestine: Diversion Colitis
  • Cause: Inflammation of Pouch from Diversion by Loop Ileostomy Due to Deficiency of SCFA’s
  • Preferred Tx: Surgical Reanastomosis
  • If Unable to Reanastomose: SCFA Enema
    • Consider Topical Anti-Inflammatory (5-ASA/Steroids)