Brooke Ileostomy Research Articles

Biological effects of a reservoir at the end of the small bowel.

AbstractSubstitution of the anorectum by a reservoir fashioned from the distal ileum can achieve the highly desirable goal of enteric continence after proctocolectomy and, not surprisingly, appears to enhance significantly the patient's quality of life. The potential price to be paid for this advance relates largely to uncertainties concerning the absence of the usual barriers to coloileal reflux and the presence of a stagnant, fecal pouch at the end of the small intestine. Moreover, positive experiences with conventional incontinent ileostomies over many years dictate that the Brooke ileostomy still remains the standard against which all other procedures must be judged. In the majority of patients, the presence of an ileal reservoir does not appear to have major adverse consequences; fecal volumes, fat excretion, overall gut function, and general health appear to be well maintained for the 10–15 years that patients with continent ileostomies have been followed. The follow‐up for ileo‐anal anastomoses is somewhat shorter. The pouches develop a fecal flora and mucosal histology is altered but, in most, no adverse sequelae have been noted. Nonspecific inflammation (“pouchitis”) occurs and is sometimes of major clinical significance, especially when also associated with systemic symptoms. The etiology of these conditions is unknown but bacterial overgrowth is suspected since antimicrobial therapy is often curative.

The J ileal pouch-anal anastomosis.

AbstractThe experience at the Mayo Clinic, Rochester, Minnesota, U.S.A., with abdominal colectomy, mucosal proctectomy, and ileo‐anal anastomosis is now approaching 600 patients. The procedure is safe and, with careful timing and selection of patients, can be performed with minimal mortality. Postoperative morbidity, however, is still considerable, even in the most experienced hands. Increasing experience with the procedure has been shown to be associated with a continuing decline in the incidence of postoperative complications, and a defunctioning ileostomy is still a necessity in the majority of patients.Long‐term functional results of the procedure are satisfactory and have been shown to improve both with the experience of the operator and with the passage of time after surgery. Patient acceptance remains the ultimate sanction, and it appears that the majority of patients are satisfied with their outcome after ileo‐anal anastomosis, with only very few being prepared to consider an alternative. The operation appears to provide a superior quality of life relative to that expected after proctocolectomy and Brooke ileostomy.Not all patients with chronic ulcerative colitis or adenomatosis coli are potential candidates for this procedure, however. The problems of age, obesity, indeterminate colitis and Crohn's disease, co‐existing colorectal neoplasia, technical difficulties at the time of the operation, and the wishes of the patient all must be taken into consideration when assessing the optimal operation in a particular situation. Proctocolectomy with Brooke ileostomy or continent ileostomy and total abdominal colectomy with ileo‐rectal anastomosis both still have roles in the management of diseases such as chronic ulcerative colitis and adenomatosis coli. For a patient who is young, relatively fit, and well motivated and in whom there is little or no doubt about the diagnosis, ileo‐anal anastomosis must be considered as the possible treatment of choice. Increasing experience with the procedure and improvements in functional results seem to be confirming this position.

Experience with the straight endorectal pullthrough for the management of ulcerative colitis and familial polyposis in children and adults.

The first significant experience with the straight endorectal pullthrough for the management of ulcerative colitis was presented before the American Surgical Association in 1977 by Lester Martin. Since then the operation with or without modification has been used extensively. High stool frequencies in some series led to disenchantment with the straight anastomosis and to the development of various reservoir procedures to increase rectal capacity and thereby reduce frequency. As a result, no large series of straight pullthroughs is available for comparison with the reservoir modifications. Between September 1977 and September 1986, 72 children and adults, 61 with ulcerative colitis and 11 with familial polyposis, underwent endorectal pullthrough (ERPT) and straight ileoanal anastomosis under the overall direction of a single surgeon (AGC). Sixty patients have undergone ileostomy closure and form the basis of this study. Mean age at operation was 22.7 years (range 4-48 yr), and duration of active disease averaged 6 years. One-half of the patients underwent total abdominal colectomy with ERPT as a primary procedure. There were 11 cases of adhesive bowel obstruction following ERPT, and in six patients in the series permanent revision to a Brooke ileostomy was required. One patient died of hepatic failure in the late postoperative period. Follow-up has ranged from 3 months to 9 years. Mean stool frequency for the group as a whole at 3, 6, 12, 24, and 36 months was 11.8, 11.2, 9.6, 9.0, and 8.3 per 24 hours, respectively. Daytime continence was achieved in all patients. Occasional nocturnal soiling occurred in 11.1% of patients at 1 year. Stool frequency and continence were also analyzed by age group above and below 18 years and above and below 30 years. There were no statistically significant differences between these groups. The authors conclude from this study that ERPT with straight ileoanal anastomosis remains an appropriate alternative for children and adults with ulcerative colitis or familial polyposis and compares favorably with the more complicated ERPT involving a reservoir.

Sphincter-Sparing Operations for Chronic Ulcerative Colitis

Traditionally, proctocolectomy and Brooke ileostomy has been offered to patients with chronic ulcerative colitis requiring an operation for therapeutic or prophylactic indications. The functional results of this approach were good but the patients were incontinent. Our hypothesis has been that by facilitating control of enteric content, the quality of life after proctocolectomy would be enhanced. Ideally, an operation which provides such control should not only excise all diseased and potentially diseased bowel, but should preserve the anal continence mechanism. The aim of this report is to detail how a new sphincter-sparing operation, ileal pouch-anal anastomosis, may fulfill these ideal criteria, while the more traditional continence-preserving approach of ileorectal anastomosis may not. Finally, the current and future role of ileorectal anastomosis is assessed in light of the recent introduction of ileal pouch-anal anastomosis.

Continent Ileostomy and Ileoanal Procedures

It is fortunate today that several alternatives are available for reconstruction of the intestinal tract when proctocolectomy is required in the management of inflammatory diseases of the colon or multiple neoplastic diseases. The Brooke ileostomy proves to be very satisfactory and is acceptable to the majority of patients but does require the continual wearing of an appliance. For patients with chronic ulcerative colitis and a poorly functioning anal sphincter or one that is diseased, a continent ileostomy is the preferred procedure. However, in patients with a normally functioning anal sphincter, an ileoanal anastomosis, most often with a "J" pouch, is the first alternative procedure to be considered because evacuation following this operation is through the normal route and requires no equipment. For patients with granulomatous colitis (Crohn's disease), it seems best to consider only the Brooke type of ileostomy because of the risk of recurrent inflammatory disease involving the ileum. However, for colonic ulcerative colitis and familial polyposis, either the continent ileostomy or the ileoanal anastomosis is the preferred procedure to be considered. Dozois has reviewed in detail the technical aspects of the various surgical procedures, the indications for their use, the results that can be expected, and the comments of many of the contributors to the advances in the management of patients requiring proctocolectomy and one method or another of re-establishing a means for bowel evacuation. With the various alternatives that are available today and the excellent results that can be expected when patients are properly selected, more patients with diseases of the colon and rectum requiring proctocolectomy can be offered the benefits of surgical treatment, returning them to society and improving their quality of life.

Achieving Enteric Continence: Principles and Applications

Continence may be defined broadly as the ability to defer the passage of enteric content voluntarily to a socially acceptable time and place. In health, continence is provided by the anorectum; several factors interplay to achieve control. When the colon and rectum are removed because of intractable inflammatory bowel disease, a Brooke ileostomy that is incontinent of stool and gas is traditionally constructed, and control of the stoma is provided by an external appliance. Although the functional results after a Brooke ileostomy are good, we believe that restoration of continence would enhance the quality of life. The methods by which continence is restored surgically have undergone evolutionary changes based on an expanding knowledge of the principles of continence gained in the laboratory. In this report, we detail the current status of our understanding of anorectal continence mechanisms and of the principles of ileal continence, in order to examine how "ileo-anal" continence has been achieved in patients who require proctocolectomy.

Temporary ileostomy for ileal pouch-anal anastomosis. Function and complications.

The function and complications associated with temporary ileostomies were reviewed in patients undergoing ileal pouch-anal anastomosis. A series of 180 patients had temporary ileostomies established (157 loop, 23 Brooke). Patients with incomplete fecal diversion had a significantly higher incidence of pouch-anal anastomotic complications (44 percent) than did those with complete diversion (14 percent). Patients with loop ileostomies were more likely than patients with Brooke ileostomies to develop technique-related complications (18 percent vs. 13 percent) and peristomal irritation (54 percent vs. 26 percent). The most frequent complications after take-down of the ileostomy were transient bowel obstruction (13 percent) and peritonitis (7 percent). These complications could not be related to the type of stoma used or the interval to closure. Temporary diversion of a pouch-anal anastomosis decreased the incidence of anastomotic complications. These ileostomies, however, are associated with a significant risk of complications, which can be minimized by meticulous surgical technique.

Restorative Proctocolectomy and Ileal Reservoir

The operation consisting of abdominal colectomy, proximal proctectomy, distal mucosal proctectomy, and ileal pouch-anal anastomosis eliminates colorectal mucosal disease, restores transanal defecation, and avoids the need for a permanent abdominal stoma and the wearing of an external appliance. During the 4-year period from January 1981 through December 1984, 369 such operations were done at the Mayo Clinic for either ulcerative colitis (in 336 patients) or polyposis coli (in 33 patients). None of the patients died in the immediate postoperative period. Follow-up data for the initial 188 patients showed the following complications: anastomotic stricture in 12%, pelvic sepsis in 11%, obstruction of the small intestine in 9%, and reservoir ileitis in 7%. A permanent stoma had to be established in 5% of patients. All patients could defecate spontaneously, and 95% had satisfactory continence for stools and gas. This operation seems safe and effective and provides a quality of life superior to that seen after the conventional Brooke ileostomy.

Alternatives to ileostomy after colectomy for inflammatory bowel disease.

Proctocolectomy and Brooke ileostomy have long been the standard surgical procedure for patients with refractory ulcerative colitis or colonic Crohn's disease. Ileorectal anastomosis, ileoanal anastomosis, the continent ileostomy, and the continent ostomy valve are now being used in selected patients as options to the Brooke ileostomy. The indications for and advantages of these procedures and their potential disadvantages and contraindications are discussed in this chapter.

The improved quality of life with the Kock continent ileostomy.

The conventional Brooke ileostomy is performed far more frequently than the Kock continent ileostomy. To determine the relative satisfaction with these operations, patients whose Brooke ileostomy had been converted to a Kock pouch were questioned about changes in their life-styles. Data were obtained from 80 patients who had worn an external appliance from 4 months to 33 years before the change-over to a Kock pouch. Improvement was reported in social activities (96.2%), athletic endeavors (87.5%), and sexual relations (76.2%). Patients spent less time caring for the stoma (92.5%) and wore street and beach attire with greater ease (97.5%). An average reduction of 75% was noted in ileostomy maintenance costs. The overall patient satisfaction with the Kock pouch was 98.7% despite an appreciable incidence of pouchitis and revisional operations. In our experience, the readier acceptance by patients of a continent internal reservoir over an external fecal-filled appliance has led to the performance of proctocolectomies for ulcerative colitis at an earlier stage of the disease.

Ileoanal reservoir: functional results and management.

Restorative proctocolectomy with ileoanal reservoir is an alternative to Brooke ileostomy. This study of 56 patients emphasizes functional results and management of the loop ileostomy, transient incontinence, frequency of bowel function, constipation, perianal skin, and psychosocial issues.

RECTAL MUCOSECTOMY AND ILEO-ANAL ANASTOMOSIS (RMIAA) IN YOUNG PATIENTS: LONG-TERM FOLLOW-UP

RMIAA with straight pull-through was done after colectomy in 47 patients for chronic ulcerative colitis (CUC) or familial polyposis (FP). All patients have been followed closely to permit continued assessment of this surgical technique. 30 of the 47 patients have been followed prospectively for >12 months after RMIAA by sending a detailed questionnaire every 6 months and yearly visits. Stool frequency is in the Table: Gross incontinence and perianal irritation were unusual (<2 pts/ yr). All patients learned to discriminate stool from flatus and many did not use medications (6/19 at 12 mos, 4/10 at 48 mos). CBC, liver function tests, Vitamin B12 and stool fat were normal when checked. All patients were satisfied (50% very satisfied) at 48 mos (2 pts not satisfied at 12 mos). Conclusion: RMIAA is well tolerated by young patients and may be a good alternative to Brooke ileostomy in CUC or FP. The frequency of stooling decreases gradually with time. *Some patients gave more than 1 qualification.

The temporary intestinal stoma?

Various operative circumstances dictate temporary total diversion of the small intestine. Among these are severe peritonitis, multiple suture lines, fistulas, questionable vascular integrity, and an ileoanal anastomosis. The operative procedure is largely identical to creating a permanent Brooke ileostomy. The distal end of the intestine is closed and sutured in a side-to-side orientation to the proximal intestine just inside the peritoneal exit. A tube is left in the distal intestine for subsequent radiologic study. A major merit of this variation is the ease with which intestinal continuity can be restored. Because the two segments of intestine are tacked together, they are easily retrieved through a small circumstomal incision, and a side-to-side anastomosis can be constructed.

A continent ileostomy device.

The feasibility of achieving fecal continence by mechanical occlusion of an end-ileostomy is explored. Accordingly, progressive stomal occlusion with an indwelling occluding device was evaluated in four healthy patients with Brooke ileostomies. Pre-occlusion clinical and physiologic tests were done, including fat balance, intestinal transit time, ileal motility and absorption, ileal compliance, ileal radiography, and ileoscopy. Progressive stomal occlusion was then employed until periods of occlusion of 5 to 8 hours were achieved after 10 to 16 weeks. Pre-occlusion tests were then repeated. Patients mastered use of the occluding device rapidly, and the device achieved reliable stomal continence in each patient. Whereas ileal capacity was small initially, intermittent occlusion resulted in a large, capacious ileal reservoir. Fasting ileal motility was increased slightly by stomal occlusion, although intestinal transit during feeding was not altered. Also, ileal absorption of glucose, electrolytes, vitamin B-12, and fat were not changed, and ileal mucosa at the site of occlusion remained intact endoscopically. The authors concluded that chronic intermittent occlusion of a Brooke ileostomy with an indwelling stomal device achieved enteric continence without impairing intestinal function.

Ileostomy options

The patient requiring ileostomy may have the opportunity to choose from four options. The Brooke ileostomy has afforded thousands of patients a secure, comfortable life. Appliances adhere well, and complications are few. The continent ileostomy or Kock pouch permits a patient to forego the wearing of an appliance. It is about 90 per cent successful but has a significant complication rate. Crohn's disease and physical frailties preclude its use. In "endorectal pull-through," the colon and rectal mucous membrane are removed to cure polyposis or ulcerative colitis. The ileum is led through the rectal muscular cylinder and anastomosed to the anus. The operation is tedious and not uniformly successful. A period of training must follow. It is unfit for people with Crohn's disease. Ileal anastomosis to a rectal segment is simpler but leaves disease behind. It may be used in Crohn's disease but may expose the patient to the hazard of recurrent disease or cancer. We must understand and ask the right questions if we are to give our patients the right answers.

Factors affecting revision rate after continent ileostomy.

Our aim was to determine factors that may predispose to malfunction of a continent ileostomy. Among 299 patients who underwent continent ileostomy and were followed up for at least one year, the need for revision of the ileostomy was compared by sex, age, type of initial operation, and type of revision. Revision was required less often in females, younger patients, and patients undergoing proctocolectomy and continent ileostomy. However, the rate of subsequent revision was similar after the two types of repair (repair of old valve vs construction of new valve). Constructing a continent ileostomy in stages is not necessary; patients undergoing proctocolectomy and continent ileostomy required fewer revisions than did those who had a Brooke ileostomy prior to their continent ileostomy. Moreover, a malfunctioning valve should be revised rather than a new one created; revision was technically simpler and gave comparable results.

The surgical aspects of chronic mucosal inflammatory bowel disease (chronic ulcerative colitis).

The surgical aspects of chronic mucosal inflammatory bowel disease were reviewed by comparing the experience at our institution between two periods, one a decade later than the other (1961-1965 and 1971-1975). The striking findings were a marked decrease in the incidence of carcinoma and toxic megacolon and a marked increase in use of one-stage proctocolectomy with either Brooke ileostomy or Kock pouch. There was, in addition, a corresponding decrease in the operative mortality for elective cases, from 2.4 to 1.3%; yet the operative mortality for emergency cases remained relatively stable at about 25%. The reason for the decrease in the incidence of carcinoma and toxic megacolon appears to be on the basis of selection outside of our institution, in that fewer of these cases are being referred.