R e v e r s e d Figure Six Ileorectostomy *

JAM~S BARRON, M.D. ~:: Detrr,il , .,ll i('higtm

ALTHOUGH great advances have been made in surgical technics for creating an ileostomy by Brooke, Turnbul l and others, there is still objection to surgical procedures which result in establishment of an artificial anus. In ileostomy cases, we are often deal- ing with younger patients, many of whom are on the threshold of their family and professional lives and objection to ileostomy is manifested by the patients, their parents or guardians and their medical advisers. As a resuh, surgery is often deferred until oper- ative intervention becomes quite dangerous oi malignant degeneration has complicated the problem.

Sporadic reports of preservation of the anal canal have appeared in medical litera- ture in relation to the surgical management of ulcerative colitis. Most of these reports showed few promising results. The work of Stanley Aylet t and Lawrence Abel was re- ceived in this country with some skepticism. However, discussions with them here and in London caused me, although reluctantly, to make the decision to attempt to preserve the rectum and anal canal in selected cases.

Aylett 1 emphasized that there should be complete removal of the colon with attach- ment of the ileum to the rectum. He be- lieves that by total colectomy one removes the vast bulk of the disease and leaves the patient in a better position to combat the residual infection in the rectum. He has shown that islands of residual rectal mucosa

Read at the meeting of the American Procto- logic Society, Atlantic City, New Jersey, June 15 to 17, t959.

**Associate Surgeon, Division o[ General Sur- gery, Henry Ford Hospital, Detroit, Michigan.

may survive the disease process and regener- ate to produce a new lining for the rectum. His view is that, provided the patient can overcome the toxemia associated with the condit ion--and in the chronic as well as the acute phases, this toxemia and all its asso- ciated manifestations are severe--the disease will resolve itself. The part that surgery has to play is to help the patient overcome this toxemia. This it can well do by removing the bulk of the source of the toxemia - tha t is, by removal of all o~ the colon with the exception of the rectum. \'Vith the rapid improvement of the patient's general condi- tion which follows such a procedure, the inflammatory changes in the rectum may be resolved so that it is able to carry on its normal function. The experience of Turn- bulls and our experience would tend to confirm Aylett's claims.

The superiority of end-to-end anastomosis in surgical procedures performed on the large and small intestine is well recognized. However, in making an ileorectal anastomo- sis, one must consider that the diseased rec- turn has no peritoneum posterior to it and that there is disparity between the size of the lumen, of the ileum and that of the rectum (Fig. la). There is general accept- ance of the method of making an anastomo- sis in which the side of the i leum is joined to the proximal end of the rectum (Fig. lb). However, there is a possibility of blind loop formation in the free end of the ileum. I~ order to obviate this difficulty, I decided to join the side of the ileum to the proximal end of the rectum and, as an added feature to anastomose the free end of the ileum to the ileum, some six to nine inches above the

452

REVERSED FIGURE SIX I L E O R E C T O S T O M Y 4 , ~

ileorectal anastomosis (Fig. lc). This i felt would provide such advantages as addi- tional storage space and 17etter absorption and, at the same time, eliminate the dis- advantages of the blind pouch (Fig. 2). This procedure was used in cases of muhi- ple polyposis and the good results which I obtained in these patients along with the results which I observed in patients o[ Aylett and Abel, convinced me that I should give this modification of ileorectostomy a trial in cases of ulcerative colitis. 4

t g

d Fro. la. End-to-end anastomosis of i l eum to rec-

tuna. b, Anastomosis of side of i l eum to end of rectum, c. Reversed "Figure 6" ileal loop.

Surgical Technic, Preoperative and Postoperative Management

This loop procedure has been employed in 10 cases of ulcerative colitis and five cases of multiple polyposis. In all but two in- stances, colectomy and anastomosis were performed in one operation. In two pa- tients, the ileostomy was performed first and later the colon was removed and the ileum was attached to the rectum. All of the cases of ulcerative colitis represented the most serious form of the disease and had failed to respond to intensive and prolonged medi- cal treatment. In these patients there was rectal involvement of some degree and all had moderate to severe toxemia. Some had arthritis, iritis, skin lesions, weight loss, fever, severe diarrhea and malnutrition. One patient who had iritis had lost her sight and one had developed malignant dis- ease in the colon. The ages ranged from 15 to 57 years. Unless an acute emergency e~'dsted, tube feeding with natural food was used to improve the patients' nutrit ional status.e, 3. In all cases, a long small P.E. tube was passed through the upper gastro- intestinal tract to the terminal portion of the ileum. This provided much better con- wol of the small intestine and served to allow refeeding of the gastric aspirate until emptying of the stomach was adequate, The ileorectal anastomosis has been placed near the bottom of the cul-de-sac, just at or above the middle valve of Houston. By using the

side of the ileum for the anastomosis, one has ample peritoneal covering for the pos- terior rectal area which, as I have said, lacks peritoneum. In addition, one can readily make the opening in the ileum as large as desired to match the opening into tire rectal stump. As stated earlier, ileorectal anasto- mosis has been made about si:~ to nine inches from the end of the ileum (Fig. 3). To complete the procedure, the end of the ileum was anastomosed to the side of the ileum, as shown in Figure lc and Figure 4. In all cases, a soft Foley catheter was placed in the rectum through the anal opening to serve as a release for pressme that might build up in the anastomotic area. T o ensure adequate drainage this catheter was used for gentle irrigation a few times every' day until the anastomotic area was well healed. One case had a marked rectal stricture prior to surgery but this was gently dilated hefore the operation.

In both Aylett's and Turnbul l ' s series of ileorectostomy cases and in my limited ex- perience, there is evidence that the opera- tion can be done with a low mortality rate. Turnbul l s in a recent communicat ion con- firmed Aylett's contention that the ~ectum and not the sigmoid should be utilized for the anastomosis and he has shown that he has obtained good results on the basis of information gleaned from a short term follow-up.

4 5 4 BARRON

lvfc. 2. Bl ind loop format ion in a case o[ side-to-side anastomosis in the te rmina l por t ion of the i leum. T h i s basic pr inciple is utilized in the loop i leorectostomy.

FIG. 3. i leorectostomy with loop of i leum. Bot tom of loop anas tomosed to recta l s t u m p jus t above per i toneal reflection. T h e arrows point to the anas tomot ic l ine between the loop of i l eum and the rectal s tump .

REVERSED FIGURE SIX ILEORECTOSTOMY 455

\ <. f,, , %

Fro. 4. Loop ileorectostomy. Reversed "Figure 62' Distal segment about 6 to 9 inches long.

All of my patients have gained weight and some have gained as much as 75 pounds. T h e first loop procedure was done for mult iple polyposis in 1956 and the first operat ion of this type was performed for ulcerative colitis in 1957. There have been no deaths in this series and there have been no anastomotic leaks, in three cases, there has been a "flare-up" of the disease in the rectal stump. These cases responded excel- lently and rapidly to tube feeding. 2, 3 How- ever, they had a limited caloric 2ntake at home and had to be readmit ted to the hos- pital on that account. T u b e feeding with liquefied natural food (from 4000 to 7000 calories) daily produced excellent remis- sions and these patients are now in excel-

lent condition nutrit ionally. T w o patients have had successful repai r of previously existing anal fistulae. In all of these cases of loop ileorectostomy, there has been rather definite rectal dilatation and the loops of i leum have become markedly di- lated. In my opinion, the loop has allowed quicker adaptat ion to fewer stools and there has been better absorption. After the first few months , all patients except one have been able to sleep all ~ight wi thout being awaked by the urgency of bowei evacuation. Two patients became somewhat constipated at the end of one year. ~\rater absorbents have been used in most of our cases and have added to comfort and bowel control. One pat ient had fairly severe bleeding f rom

4 5 6 BARRON

and these loops have shown no such tend- ency. On the other hand, they become larger in diameter.

Fro. 5. Reversed "Figure 6" ileal loop anastomosis of ileum to rectal stump. Note peristaltic waves in distal seg~lent o~ ileum and dilatation of lower ileum and rectal stump. (After four months.)

the upper gastro-intestinal tract due to anticoagulant therapy. Another patient had bleeding episodes following abscess forma- tion with rupture into the upper part of the small intestine.

It is my belief that, when an operation is

undertaken as a life-saving procedure in cases of hemorrhage and fulminating stages of the disease, a two-stage o~Jeration should be carried out.

X-ray studies have shown that only a

portion of the fecal stream enters the rectal stmnp and the remainder is carried by peristaltic action into the afferent loop

(Fig. 5). Furthern~ore, x-ray studies and proctoscopic examination have repeatedly revealed dilatation of the entire anasto- motic circle as well as the rectal stump (Fig.

6). In no case has their been any undesirable effect from this arrangement. This dilata-

tion increases rather rapidly and after one year the loop is difficult to identify on

x-rays because of its size (Fig. 6). The loop can be examined readily with the procto- scope. There is no tendency to atrophy in blind loops of the gastro-intestinal tract

Comment

Since we are dealing with a very serious disease in which major surgical procedures are required, I do not infer that these cases have not been difficult. However, the grati- tude of patients and their families and their willingness in increasing numbers to submit to surgery when informed that an attempt will be made to restore continuity of the bowel, cannot fail to stimulate those inter- ested in caring for patients with this disease to continue their efforts.

It will take considerable time and the experience of many surgeons to determine the exact place that this surgical procedure occupies in the management of this serious

Fro. 6. Increasing dilatatim~ o~ the lower ileum and rectal stump at the end of one and one-half years.

REVERSED FIGURE SIX ILEORECTOSTOMY 457

disease. W i t h increased experience, I be-

lieve we will have reason to feel qui te en- couraged and wi th the passage o[ t ime I

believe we will find that the use of ileal loops will provide cer ta in advantages no t

only at the t ime of surgery bu t in the post- operat ive period. T h e possibil i ty of rectal

preservat ion will ahvays at tract m a n y pa-

t ients and it should be possible for the

surgeon to accomplish it in the ear l ier stages

of the disease before it has advanced to the po in t where surgical i n t e rven t ion is hazard-

ous or m a l i g n a n t degenera t ion has occurred.

References 1. Aylett, Stanley: The avoidance of an ileostomy

by ileo-rectal anastomosis. Proc. Roy. Soc. Med. 49: 952, 1956.

2. Barron, James: Preparation of natural foods for tube feeding. Henry Ford Hosp. M. Bull. 4: 18, 1956.

8. Barron, James, J. J. Prendergast and M. W. Jocz: Food pump: New approach to tube feeding. J.A.MA. 161: 621, 1956.

4. iBarron, James: The use o{ jejunal and ileal loops in stomach al~d colon surgery. Henry Ford Hosp. M. Bull. 6: ~28, 1958.

5. TurnbuI1, R. B., Jr.: Surgical management of ulcerative colitis. J.A.M.A. 169: 1025, 1959.