Ileostomy Reversal for a Two-Stage Laparoscopic Proctocolectomy with Ileoanal J-Pouch for Ulcerative Colitis
Table of Contents
This video describes a technique for an ileostomy reversal, which was performed as a second-stage procedure for a total proctocolectomy with ileoanal J-pouch for medically-refractory ulcerative colitis. In this procedure, we start by incising around the ileostomy near the junction of the skin and bowel mucosa. To mobilize the intestine within the abdominal wall, we use electrocautery dissection through the subcutaneous tissues to the level of the fascia. The fascial opening is extended to complete the mobilization of the intestine. Stay sutures are then placed between the loops of intestine at the planned site of the anastomosis, and ILA staplers are used to create a side-to-side functional end-to-end anastomosis. The abdominal fascia is then closed with running sutures, the wound is washed with antiseptic, and the skin is brought together with vertical mattresses.
The patient is a 29-year-old female with medically-refractory ulcerative colitis (UC). She had attempted multiple trials of various medications with continued colitis and symptoms that reduced her quality of life. Therefore, she elected to proceed with a laparoscopic proctocolectomy with ileoanal J-pouch as definitive management for her UC. This procedure was performed in a two-stage approach, in which a diverting loop ileostomy was placed during the first stage to protect the ileoanal anastomosis to allow for adequate healing and leak prevention. The patient tolerated the first operation well and had no issues with the management of her ileostomy. Given her excellent recovery, she was brought to the operating room for the reversal of her diverting loop ileostomy. Prior to the ileostomy reversal, a contrast enema confirmed a widely patent ileoanal anastomosis without a leak.
The indications for diverting loop ileostomy are focused on the recovery from the first operation, particularly the quality of the ileoanal anastomosis. Complications that may preclude or delay reversal include evidence of anastomotic breakdown, stricturing that results in obstruction of fecal flow, pouchitis or fistulae, active infection, or severe malnutrition.1 In preparation for surgery, patients should be evaluated with a physical exam, including a thorough perineal and digital rectal exam to evaluate for issues involving the anastomosis. Some practitioners may also use contrast enemas and endoscopy as adjuncts to evaluate the anastomosis prior to reversal.2
UC is a subtype of inflammatory bowel disease (IBD) characterized by epithelial and submucosal inflammation that starts distally in the rectum and ascends within the colon. In the United States, UC affects nearly 1 in 200 adults over the age of 18, with a rising incidence.3 Symptoms are variable depending on disease severity and may include cramping, nausea, diarrhea, bloody stools, and weight loss. In rare cases, the disease may progress to toxic megacolon, a life-threatening condition in which profound inflammation of the colon results in loss of tissue integrity, bacterial translocation, and potentially perforation.4 Treatment of this condition requires urgent colon resection for prevention of sepsis. After 8–10 years of disease, the risk of non-adenomatous colorectal cancer significantly increases, and annual colonoscopy with random biopsies is recommended.5
First-line therapy for UC involves medical management, which has historically included enteral salicylates. In recent years, an armamentarium of biologic therapies has been developed targeting various components of the immune system that have been implicated in UC pathogenesis.6 Despite improved medical therapies, a subset of patients will still require surgery for the management of their UC. Indications for surgery include medically-refractory disease, development of dysplasia or invasive cancer, or development of toxic megacolon or perforation.
The indication for surgery in this patient was the medically-refractory disease. Given her suitable health, she underwent complete resection of the involved tissue, including both the colon and rectum. It is common to protect an ileoanal J-pouch anastomosis with a diverting loop ileostomy based on the risk of a leak.
The patient is a 29-year-old female with a history of medically-refractory ulcerative colitis. Her other medical history is unremarkable. She has no prior abdominal surgical history. Her last colonoscopy showed no evidence of malignancy. She has an American Society of Anesthesiologist score (ASA) of 2 and her body mass index (BMI) is within a normal range.
The patient had an unremarkable physical exam. In the office, she presented in no apparent distress with normal vital signs. She had a normal body habitus. Her abdominal exam was unremarkable with a pink, patent, and perfused ostomy. There was no evidence of abdominal wall hernias or tenderness to palpation. Her abdomen was soft and non-distended.
A gastrografin enema was performed prior to undergoing ileostomy reversal, which showed no evidence of leak or obstruction.
The pathogenesis of UC is defined by inflammation of the rectum and colon. The majority of patients will have a relapsing-remitting course with periodic flares, though up to 15% of patients will present with severe disease involving the majority of the colon.7 One-third of patients will experience proximal progression of their disease within 10 years, and up to 15% of patients will require surgical intervention within 10 years after a diagnosis of UC.8 Risk factors for UC include genetic predisposition, environmental factors, and altered immune responses. Over 200 risk loci have been identified from genome-wide association studies (GWAS), including genes related to immune and gut barrier function.9 Auto-antibodies have been described in a small subset of UC cases.10 Chronic inflammatory signaling predisposes rectal and colonic epithelia to progressive genetic dysregulation, leading to non-adenomatous dysplasia and invasive cancer, with the risk increasing after 8–10 years of the disease.
The decision to undergo surgical resection of the colon and rectum for UC requires thoughtful consideration by the patient in conjunction with a team that includes a surgeon and a gastroenterologist. In the case of medically-refractory disease, the patient will need to assess the risk-to-benefit ratio of undergoing an operation vs. the quality of life with poor symptom control. Regarding the choice of operation, the standard of care is to remove all involved tissue, including the entire rectum and colon. Therefore, the recommended operation is total proctocolectomy. This operation can be performed laparoscopically at most major medical centers. There is also a decision regarding reconstruction, if any, of the alimentary tract. The ileoanal J-pouch (IPAA) technique is commonly performed, though in rare cases, an end ileostomy without reconstruction may be pursued. IPAA surgery is usually carried out in either two or three stages. In the case of this patient, a two-stage approach was pursued in which the J-pouch was transiently protected by fecal diversion with a loop ileostomy. In the absence of complications with the J-pouch, it is rare to not reverse the ostomy, which can have its own long-term complications including kidney injury, electrolyte abnormalities, and stoma issues.
The goals of this operation were to reverse the ileostomy and resume normal alimentary function for the patient.
There are no additional special considerations.
As we have shown in this video, the main procedural steps for this operation are as follows:
- Skin incision and dissection of the ostomy down to the level of the abdominal wall fascia.
- Opening of the fascia and mobilization of the ostomy, freeing up two free ends for an anastomosis.
- Side-to-side functional end-to-end stapled anastomosis of the ileum.
- Primary closure of the fascia.
- Closure of the skin.
This technique allows for an efficient approach to ileostomy reversal.
There are multiple accepted technical variations for the ileostomy reversal procedure. In order of sequence, these may include the skin incision (circular vs. tapered), creation of the anastomosis (hand-sewn vs. stapled), closure of the abdominal wall fascia (primary vs. mesh), and wound management (purse-string vs. skin closure).11,12 Both hand-sewn and stapled anastomotic techniques have similar morbidity and mortality in retrospective analyses.13 Although primary closure of the abdominal wall fascia has been the standard of care, recent evidence suggests that retromuscular placement of synthetic mesh at the time of ostomy closure significantly reduces subsequent hernia formation without increased wound complications.14 Further studies are needed to better clarify the role of mesh for ileostomy reversal. Finally, a recent meta-analysis evaluated purse-string vs. linear wound closure after ileostomy reversal, and it was observed that a purse-string closure was associated with significantly reduced infection rates.11
- Operative time: Approximately 40 minutes
- Estimated blood loss: 5 ml
- Fluids: 1000 ml crystalloid
- Length of stay: Discharged from hospital to home without services on postoperative day 1
- Morbidity: No complications
- Final pathology: Ileostomy tissue
- 15-blade scalpel
- DeBakey forceps
- Adson forceps
- Abdominal wall hand-held retractor
- Schnidt clamp
- 3-0 and 2-0 silk ties
- Metzenbaum scissors
- ILA stapler
- 0-Vicryl suture for fascial closure
- 3-0 nylon for skin closure
Nothing to disclose.
The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online.
We would like to thank the surgical staff and anesthesia team for their assistance in this operation.
- Ng KS, Gonsalves SJ, Sagar PM. Ileal-anal pouches: A review of its history, indications, and complications. World J Gastroenterol 2019;25:4320-42. https://doi.org/10.3748/wjg.v25.i31.4320.
- Sherman KL, Wexner SD. Considerations in Stoma Reversal. Clin Colon Rectal Surg 2017;30:172-7. https://doi.org/10.1055/s-0037-1598157.
- Ye Y, Manne S, Treem WR, Bennett D. Prevalence of Inflammatory Bowel Disease in Pediatric and Adult Populations: Recent Estimates From Large National Databases in the United States, 2007-2016. Inflamm Bowel Dis 2020;26:619-25. https://doi.org/10.1093/ibd/izz182.
- Autenrieth DM, Baumgart DC. Toxic megacolon. Inflamm Bowel Dis 2012;18:584-91. https://doi.org/10.1002/ibd.21847.
- Ullman TA, Itzkowitz SH. Intestinal inflammation and cancer. Gastroenterology 2011;140:1807-16. https://doi.org/10.1053/j.gastro.2011.01.057.
- Singh S, Fumery M, Sandborn WJ, Murad MH. Systematic review with network meta-analysis: first- and second-line pharmacotherapy for moderate-severe ulcerative colitis. Aliment Pharmacol Ther 2018;47:162-75. https://doi.org/10.1111/apt.14422.
- Dignass A, Eliakim R, Magro F, Maaser C, Chowers Y, Geboes K, Mantzaris G, Reinisch W, Colombel JF, Vermeire S, Travis S, Lindsay JO, Van Assche G. Second European evidence-based consensus on the diagnosis and management of ulcerative colitis part 1: definitions and diagnosis. J Crohns Colitis 2012;6:965-90. https://doi.org/10.1016/j.crohns.2012.09.003.
- Frolkis AD, Dykeman J, Negron ME, Debruyn J, Jette N, Fiest KM, Frolkis T, Barkema HW, Rioux KP, Panaccione R, Ghosh S, Wiebe S, Kaplan GG. Risk of surgery for inflammatory bowel diseases has decreased over time: a systematic review and meta-analysis of population-based studies. Gastroenterology 2013;145:996-1006. https://doi.org/10.1053/j.gastro.2013.07.041.
- Ungaro R, Mehandru S, Allen PB, Peyrin-Biroulet L, Colombel JF. Ulcerative colitis. Lancet 2017;389:1756-70. https://doi.org/10.1016/S0140-6736(16)32126-2.
- Geng X, Biancone L, Dai HH, Lin JJ, Yoshizaki N, Dasgupta A, Pallone F, Das KM. Tropomyosin isoforms in intestinal mucosa: production of autoantibodies to tropomyosin isoforms in ulcerative colitis. Gastroenterology 1998;114:912-22. https://doi.org/10.1016/s0016-5085(98)70310-5.
- Gachabayov M, Lee H, Chudner A, Dyatlov A, Zhang N, Bergamaschi R. Purse-string vs. linear skin closure at loop ileostomy reversal: a systematic review and meta-analysis. Tech Coloproctol 2019;23:207-20. https://doi.org/10.1007/s10151-019-01952-9.
- Luglio G, Terracciano F, Giglio MC, Sacco M, Peltrini R, Sollazzo V, Spadarella E, Bucci C, De Palma GD, Bucci L. Ileostomy reversal with handsewn techniques. Short-term outcomes in a teaching hospital. Int J Colorectal Dis 2017;32:113-8. https://doi.org/10.1007/s00384-016-2645-z.
- Markides GA, Wijetunga I, McMahon M, Gupta P, Subramanian A, Anwar S. Reversal of loop ileostomy under an Enhanced Recovery Programme - Is the stapled anastomosis technique still better than the handsewn technique? Int J Surg 2015;23:41-5. https://doi.org/10.1016/j.ijsu.2015.09.039.
- Warren JA, Beffa LR, Carbonell AM, Cull J, Sinopoli B, Ewing JA, McFadden C, Crockett J, Cobb WS. Prophylactic placement of permanent synthetic mesh at the time of ostomy closure prevents formation of incisional hernias. Surgery 2018;163:839-46. https://doi.org/10.1016/j.surg.2017.09.041.
Cite this article
Erstad DJ, Hodin R. Ileostomy reversal for a two-stage laparoscopic proctocolectomy with ileoanal j-pouch for ulcerative colitis. J Med Insight. 2022;2022(298). doi:10.24296/jomi/298.
Table of Contents
- Prepare Fascia
- Close Fascia
- Inject Local Anesthetic
- Final Check for Hemostasis
- Close Skin
So this is a 29-year-old female who had a long history of medically refractory ulcerative colitis. And about 3 months ago, we did a laparoscopic proctocolectomy with ileoanal J-pouch reconstruction, and now she's here for ileostomy reversal. Before the reversal, I always do a gastrografin enema, which is shown here. Here's the side view, lateral view I should say, and the J-pouch fills up nicely. There's no evidence of leak. The contrast goes all the way back to the ileostomy bag. So, no obstruction. So, we're now going to go ahead and do her ileostomy reversal.
Okay, hold on. All right, stop. It's easier to stop and then… And can we have Adsons, please, and a Schnidt? So we're going to keep this towel for dirty stuff, I'm going to leave that here, just so we're... All right, and I have a dirty table I set up. Okay, but this is all going to be dirty right there. Okay. Okay. Can I get a step please? Schnidt, please? Yup, let's get any red spots. Careful that's the bowel right there. Oh - here, we'll just go here. Just to make sure, out there first and then… Now, this is - yep. Do you have a couple Allises please?
When do you want me to start sort of working my way towards the edge of bowel? Yeah, you can start doing this right - you can sort of see. Do you have a DeBakey, Deb? Mm hmm. Going to be right there - yep. Why don't you take that? And then we'll go like that. Okay. Okay, so now, I would say let's see how - yeah, I just wanna get a sense of how freed up it is or not. So you can, if it's easy, that's fine. There's some space there, but that won't want to come around and start - you want to go that direction? Sure. Like… free it up there. Do you have a Rich, Deb? Mm hmm. So I can feel the edge of the bowels right there, so we're going to just be careful and get… Hold on. Yeah. There it is. So we're going to want two firings of the 100 GIA. Yeah. Let's just get this right there, you can see the line. Yeah. If you grab it - grab the fascia and just pull it away a little bit. Yeah, there you go, yeah. That's the last little bit, I think. And then we should be freed up. Okay, nice. So now we have two beautiful loops of bowel. Very easy.
So what we're gonna do is just put one in each side. Why don't you open this up a little bit with a Bovie? Just because the stapler goes in easier. Sometimes it gets a little fibrotic here where the skin is. We're going to take this off anyway, so it doesn't really matter. So that's one limb. And then the other one is like that so just open that up a little. And then we'll take the GIA separately, one at a time. Yeah. So this way it just goes in easily. Okay, so let's see. Let's do - do you see the… Let's see here, yeah, that's fine, there we go. Like in there and just, that's that, and I'll hold it like that. And then the other one, just follow the curve. Mm hmm. Yeah, can we get a 3-0 silk pop-off? So, I would say just with your hands, forget the forceps and just with your hands, just push up so that we get a nice apposition. The mesentery is safely underneath, you want to just put your finger below, you can just confirm that, yup. It's good, yeah. And we'll go all the way - okay, yep. And then we'll take a 3-0 silk. We'll just put a stitch in the crotch. Mm hmm. Needle back. So I'm going to fire this. We're going to take another load of the GIA. This is dirty.
So while we're waiting I'm just going to look inside. I don't see any bleeding. That looks good, and then we're going to offset these, right? So we don't have crossing staple lines. So we'll kind of go like that. Mm hmm. Okay, and then I always feel the lumen, which is nice down to… Do you want it together now? Mm hmm. That's fine, so you can feel it goes right down to there. So, that should be fine just like that. Even down a little bit more just - closer to me, yep. Because it's plenty big - yep. Okay, so this is going to be a specimen: ileostomy site. We'll take a scissors for the silk. And then, okay so now this is the specimen, and then all of this is going to be dirty.
So we're going to - yeah, go around and around just to reinforce this staple line and - good. Should I run it? Yeah, run it - yeah, pull it through a little bit so I can - scissors, please. Oh go ahead, keep it pretty close together. And forceps to me, please. Can I get a sponge? Mm hmm. Do we have some other 3-0 silk pop-offs? Yeah. Yeah, we may just put a couple more in along the… So here just make sure you get into nice healthy bowel there, you see it? Yeah, I'm going to bring it up right here. Yeah, yep. Let me just see something if this dunks eas- if it dunks easily, we could do it this way, just to - yeah, I think it's better, go ahead. I'm going to just keep that down for a minute, just so that corner's not stick- oh - push it in. Oh, you should be closer to - well, okay. Go, go - put it down, go ahead and pull it. Do one more time? Yeah, just go to here. Mm hmm. Okay, you can do maybe a - Do you have a SNaP to do like an instrument tie here, this? And I'll take a wet sponge, please. Okay, so that looks good. So, once again we have a nice wide anastomosis there. You feel it, right? Yeah, that feels good. Yep, another 3-0 silk. We'll just put maybe a couple of Lemberts in here to… So - you can just go like that without grabbing the bowel, if you just… Mm hmm. Mm hmm. Okay, so that looks good - scissors please. And then, the other side you can't really get at. I'm not gonna start causing too much trauma, so let's see if we'll get it back in, try to do this without much trauma to the bowel. We have to push a little bit, but I'm careful about the anastomosis. This one goes in pretty easily, that's good. And - there's actually no adhesions at all around there because with the laparoscopy we did a Pfannenstiel, but there's nothing around there at all. That's great. Wet sponge, please.
Mm hmm. We want to get down to the nice white fascia. So, 0 Vicryl on the fascia. We need two of them and then the 4-0 nylons - I'm sorry, 3-0 nylons for the skin. Yeah, okay. So you can start off closer just so it's - yeah. So you hold it like that. Okay, hold on. And then we can look and kind of get a sense of what direction we should close the fascia. So, if we look at it, let's see, that's fine. It kind of looks almost like diagonal that way is going to come together the best way, like this is an apex. Yeah, I agree. Right? You see what I'm saying? Okay, so let's do 0 Vicryl, actually if you hold like this, I'll do it from this end. And Bonneys, please.
Okay, you can just take that off, it's fine. Just put the retractor in just to expose it, yeah. Getting nice bites into that healthy fascia out there. I want to go - yeah. Do you have the other 0 Vicryl? Yes. Yeah, so that feels good. We'll go like that. Scissors, please. And a couple more of, you know, a couple extra, okay. So this elliptical incision, you know, gives you pretty good exposure. I mean that's the advantage, I think. As opposed to just staying right on the mucocutaneous junction with a small circular incision and closing it that way. Nice exposure and you get a nice closure of the skin, usually it heals up pretty well, the transverse scar. Pull them both up tighter, okay, scissors. Can I have some Betadine to pour in, please? Okay, that looks good. We're going to do a little bit of antisepsis that there's not great scientific proof, but I think it seems to work well. Can we have saline now, please? Suction. I want to get rid of all the… And we'll do the local anesthesia next, and then we'll close the skin. Sponge, please. So let's take the local anesthesia. I'll take the retractor and expose it for you.
We'll get sort of the fascia, all around, and then we'll also get the subcutaneous. So this is 0.5% Marcaine diluted so it's 0.25% total, which means you should be able to use 1 cc/kg Probably around 60 total would be the most. More superficial there. Do you have more local, please? I do. And then more irrigation. Irrigation, please. That's fine, and a dry lap, and then we'll take the 3-0 nylons.
Let's check for hemostasis. Nope, we're all done. The last thing we want is a wound hematoma in this field.
So, we'll do some… Nylon? We'll do some vertical mattress. We'll try to keep them as loose as possible. Because with the post-op swelling, it's almost always too tight. I usually leave these in a minimum of 2 weeks, even up to 3 weeks since there's some tension on the skin closure, you know, since we've done the elliptical sort of removed skin, there's going to be some tension, so I leave the stitches in a pretty long time. Can I get a clean sponge, please? So, what kind of diet do you want to give her? I think for her, let's just start her out with clears and see how she does. Yeah, that's fine. So remember, she's a J-pouch patient, no colon, the expectation is that she'll start moving her bowels within 24 hours. Mm hmm. Very rare to not be within 24 hours, that would be a sign of maybe a problem like obstruction or something. So - and I would say typically they stay in the hospital either 1 or 2 nights - depends how they're doing in terms of, you know, bowel movements and diet. I keep in touch with these patients pretty closely, especially over the course of the first month or two, in terms of their bowel function. With a J-pouch, there's sort of an adaptation phase I would say, the first 3 to 6 months for some patients, it can be difficult with frequent loose stools. Not everyone, but - so, and then usually by about 6 months, they're kind of reached kind of a steady... Do you want one more? One more and that will be good. And then I generally do an initial post-op pouchoscopy on these patients at - yeah, keep it loose now, go ahead - at 6 months or so, take a look on the inside, just make sure everything is healthy and normal. Then after that, it depends on their history. If they have a long history of ulcerative colitis, they, you know, there's still some risk of dysplasia, malignancy, although very very low risk. So, they get either annual or maybe every 2 year pouchoscopy exams with biopsies of the rectal cuff and the J-pouch.