The ileo-anal pullthrough procedure, (also known as the ileal pouch anal anastomosis procedure or IPAA) is an operation for the treatment of ulcerative colitis or familial polyposis which has gained popularity in recent years. IPAA cures these diseases by removing the diseased large bowel.
The operation removes the large bowel and creates a "new rectum". This is done by making a pouch out of the end of the small bowel (ileum), and attaching it to the anal sphincter muscle. This creates a reservoir for the storage of stool, allowing for predicable and controllable bowel movements.
There are several types and names of pouches that can be created. The most common one is the " J pouch". The pouch is made by taking the end of the small intestine and sewing or stapling it into a "J" shape. The pouch is then pulled through the pelvis and sewn to the anal sphincter. That is why it is commonly referred to as the "pullthrough" procedure.
The IPAA is a major operation. It may be performed in one, two, or three stages. When it is performed electively, not as an emergency, it is usually done in two stages. It is less commonly performed in one stage, only if the surgeon feels it is medically and technically safe. If a patient is very sick, on large doses of steroids or other immunosuppressive drugs, or if the operation is performed as an emergency, it may be safer to do IPAA in two or three stages.
Reasons for having the IPAA include:
- Increased risk of cancer
- the presence of dysplasia on colonic biopsies
- Failure of medical management
- colitis not responding to medical management
- Complication from medications
Benefits of this operation include:
- The disease is cured because the large bowel is removed.
- Disease symptoms such as diarrhea and urgency are eliminated.
- You will not have to take medications for the disease.
- Screening colonoscopies/ flex sigmoidoscopies for cancer may no be longer required.
- You will feel better and have more energy.
Ileal Pouch Anal Anastomosis
For purposes of this explanation, IPAA will be explained as an elective operation, involving two stages. Your surgeon will discuss with you whether you will be a candidate for a one, two, or three stage operation.
Before the First Operation:
The first operation involves removing your large intestine and creating the pouch. Prior to having this first operation several tests will be done. Tests that may be necessary include:
- Blood work
- Chest x-ray
- Rectal manometry
- Upper GI X-rays
All patients need to have a colonoscopy performed at UNC Hospitals prior to surgery. This is an exam of the colon where a lighted flexible tube is inserted into the rectum so the inside of the entire large bowel can be visualized. It shows the surgeon the amount of disease in your intestine. You will be given instructions for a bowel prep when the appointment is made for your colonoscopy. During the exam you will be given medicines to sedate and relax you. In addition to the GI endoscopist, the surgeon or an assistant may be in the room during this exam. The surgeon will be given a full report and pictures by the doctor performing the test. This examination is often performed the day before your surgery.
Prior to the operation, you will need to have a pre-operative "work-up." This means that you need to spend time getting the necessary blood work done, tests performed, being interviewed by the anesthesiologist, and having a complete physical examination by a resident physician. This may be performed at a clinic visit if you are a same day surgery patient or done once you are admitted into the hospital the day before your operation. During your interview with the anesthesiologist, several options for post operative pain control will be discussed. If you have further questions about your surgery or financial considerations, the preoperative evaluation is a good time to ask your surgeon or the GI surgery nurse.
Since the first operation usually includes a temporary ileostomy, you will also be seen by an enterstomal therapist (ET) before surgery. This is a nurse who specializes in ostomy or "bag" care. She is an important part of the team. The enterstomal therapist will work with you while you are in the hospital so that you will become comfortable caring for the ileostomy before you leave. The ET nurse will "mark" the best spot on your skin where you will have your temporary ileostomy prior to having the operation. She is also available to show you pictures and answer your questions about the ileostomy.
The First Operation
The first stage of IPAA consists removing the entire colon and the rectum, leaving the anal sphincter intact. The anal sphincter is the muscle which controls your bowel movements. The pouch is constructed out of the end of the small intestine (ileum) and attached to the anal sphincter. At this point you will be cured of your disease.
A temporary diverting ileostomy is brought out through the skin on the right side of your abdomen. You will wear an ostomy appliance or "bag" over the intestine to collect stool. The ileostomy gives the sutures or staples in the newly created pouch time to heal without stool passing over it which reduces the risk of infections or a leak. You will have the ileostomy for at least six weeks. (Note: in a single stage IPAA, the ileostomy is not performed.)
General anesthesia is required for this operation. The anesthesiologist will discuss this with you. Your vital signs will be monitored throughout the operation and during the recovery phase.
Your incision will be from above your umbilicus (navel) to your pubic bone, or it may be a lower abdominal "bikini" incsion. The incision may be closed during the operation or the last layer may be left open to heal from the inside out. You will be taught to care for the incision. If needed, visiting nurse assistance can be arranged, prior to being discharged from the hospital.
After surgery you will have:
- IV lines--to receive fluids and medicines until you start eating (usually 3-5 days)
- Foley catheter--a urine tube to collect urine into a bag, so that an accurate account of your urine can be monitored (3-4 days)
- Jackson-Pratt or JP drain--small drain left in your abdomen to drain residual blood and fluids (1-2 days)
In addition, you may have:
- Nasogastric (NG) tube--a tube that goes through the nose into your stomach, to reduce nausea until bowel function returns (usually 2-3 days)
- Epidural catheter--some patients elect to receive pain management this way. It consists of a thin small tube that is inserted into the back near the spine so that medicines can be injected through it (usually 3-4 days)
- Rectal tube--tube left in your rectal pouch to drain stool while stitches heal (usually 3-4 days)
The length of the operation can vary between 6 to 10 hours. The time depends on your body size and shape, previous surgery and the severity of your disease. You will be taken to the operating room holding area approximately 1 to 1 1/2 hours before your surgery is scheduled to begin. Immediately after surgery, you will be taken to the post anesthesia care unit (PACU), or recovery room for approximately 1 to 2 hours. Because of the length of the surgery and the pre- and post-care involved, you will be out of your room for 12 to 14 hours. Your family will be notified of your condition by the surgeon once the operation is complete. It is best to have your family wait in your room or the surgical waiting area on the 2nd or 4th floor of the Anderson Building. Be sure to ask your surgeon before your operation where your family should wait.
The hospital stay after this operation is usually 5 to 10 days with an average of 6 days. During this time you are monitored closely by the nursing staff. They are specially trained to take care of surgery patients and will assist in your initial recovery. These nurses are experts at pain management and can help you manage your pain. Many health care providers on the team will see you including your surgeon, resident physicians, medical students, the GI surgery service nurse, the enterstomal therapist and hospital support staff.
Patients who do not wish to receive epidural pain management will receive Patient Controlled Analgesia or "PCA" following surgery. This means that a computerized pump will be attached to your IV line, and you will be in control of your pain medicine by pushing a button to give yourself pain medicine as needed. There will be limits to the amount you can get, but it will be enough to keep you comfortable. As with any type of surgery, it is reasonable to expect some amount of pain. This varies with individual patients and depends on your body's response to pain medication.
Following the operation, you will not be allowed to eat solid food for several days. At first you will be permitted to have a few chips of ice to keep your mouth moist. As bowel function returns, a liquid diet will be started and advanced to regular food.
The first day after the operation you will be able to sit in a chair. It is important for you to be out of bed as much as possible after your operation. By the second day you should be walking in the hallways. You will become more active each day.
Rectal drainage following this operation is common. There is usually residual blood and the small intestine continues to secrete water and mucus. You will probably feel the urge to have a bowel movement 5 to 7 days after your operation. This is normal. When you have the urge you should "move your bowels" on the commode.
Although your lifestyle may be altered temporarily by the ileostomy, it should not keep you from doing activities that you enjoy. Everything you did before your operation is possible after the operation. You will be limited as to the amount of lifting and strenuous exercise for a period of time after each operation.
Most people want to return to normal activities (work or school) as soon as possible. Depending on the type of work you do, you may plan to go back to work 3 to 4 weeks after the operation. Most patients go back to work with restrictions on lifting after 4 or 5 weeks. Talk about this with your surgeon.
The Clinic Visit following the Operation
You will be scheduled to come back to clinic 1-2 weeks following discharge after the first operation. At this time you will be given a physical exam by your surgeon and be asked questions about how you have done following the operation. The second stage of IPAA can be discussed and a date decided upon. You can also see the enterstomal therapist at this time as well as other members of the team. The second stage of IPAA will take place sometime after 6 weeks, but usually not before.
The Second Operation
The second operation involves closing the temporary ileostomy. This is called an ileostomy takedown. Before this operation, you will need to have an x-ray of the new pouch, this is called a pouchogram. This involves putting dye into your pouch with a small tube and taking x-rays. This x-ray shows your surgeon how well your pouch has healed. If this test is okay, then the ileostomy takedown can be done. Before the operation you will either come for a clinic appointment to have bloodwork drawn and talk with the anesthesiologist or you will be admitted to the hospital for the operation the next day. Again, this is a good time to ask questions of the team members.
The second operation is usually less involved and takes less time to perform (1 to 3 hours). The goal of the surgery is to sew or staple the two ends of the small intestine together, closing the ileostomy. In most cases an incision is made around the ileostomy and the operation is done through the ileostomy site. Occasionally the surgeon must go back through the main incision. As with the first operation, 1 to 1 1/2 hours before the operation you will be taken down into the holding area of the operating room, and again it may take 1 or 2 hours for post-op care in the recovery room. This means that you will be away from your room for up to 6 hours on the day of the operation. Your family should wait for the surgeon in the family waiting room on the 2nd or 4th floor in the Anderson Building or in your room. You should ask your surgeon where your family should wait.