Restorative procedures in colonic crohn disease

Abstract

Surgical management for refractory Crohn colitis often involves creation of a temporary or permanent stoma. Traditionally, the procedure of choice has been a total proctocolectomy with permanent ileostomy. However, restorative procedures that help to avoid a permanent stoma are being used with more frequency. In this article, the authors will address these procedures, including colocolonic anastomosis, ileorectal anastomosis, ileal pouch rectal anastomosis, and ileal pouch anal anastomosis. Factors that may influence one's decision to perform these procedures, such as patient age and nutritional status, medical comorbidities, sphincter function, desire to avoid a permanent ostomy, and prior medical therapy, will be discussed. Functional outcomes regarding these procedures will also be described. One should keep in mind that surgery does not cure Crohn disease and that postoperative long-term management is essential in preventing progression or recurrence of disease.

Keywords: Crohn colitis; ileal pouch anal anastomosis; ileal pouch rectal anastomosis; ileorectal anastomosis; restorative surgery.

Fig. 1

Sutured ileorectal anastomosis. (A) The mesenteric side of the ileorectal anastomosis is made with interrupted vertical mattress 3-0 absorbable sutures. The deep layer of the mattress stitch is full thickness; the superficial layer includes the mucosa and submucosa only. (B) The antimesenteric side of the anastomosis is made with interrupted, 3-0, absorbable sutures that include the serosa and muscle layers resulting in inversion of the mucosa when the suture is tied. (C) The antimesenteric side is reinforced with interrupted full thickness or Lembert-style, interrupted, 3-0, nonabsorbable sutures. (D) A Cheatle slit is sometimes required to create a more equitable size match between the ileum and rectum. (Reprinted with permission from Cleveland Clinic Center for Medical Art & Photography © 2012. All Rights Reserved.)

Fig. 2

Ileal pouch rectal anastomosis. The ileal pouch measures ∼10 cm and can be made with a single fire of a 100-mm linear stapler. The pouch rectal anastomosis is typically made with a 29- or 33-mm circular stapler. (Reprinted with permission from Cleveland Clinic Center for Medical Art & Photography © 2012. All Rights Reserved.)

Fig. 3

(A) Stapled Ileal pouch anal anastomosis. The ileal pouch is made to measure 15 to 20 cm in length. Two fires of a 100-mm linear stapler are often used to make the ileal pouch. The IPAA is typically made with a 29-mm circular stapler. (B) Ileal pouch anal anastomosis with defunctioning loop ileostomy. (C) Sutured ileal pouch anal anastomosis. (Reprinted with permission from Cleveland Clinic Center for Medical Art & Photography © 2012. All Rights Reserved.)

Fig. 4

Subtotal colectomy with end ileostomy and subcuticular implantation of the sigmoid stump. The shaded portion of colon is removed. The stapled sigmoid stump is secured to the rectus fascia in a manner that leaves the staple line in the subcutaneous tissue. (Reprinted with permission from Cleveland Clinic Center for Medical Art & Photography © 2012. All Rights Reserved.)