Proctocolectomy

概述

A proctocolectomy, also called a total proctocolectomy, is surgery to remove the colon and rectum. It may be needed to treat serious disease in the colon and rectum. It also may lower the chances of getting colorectal cancer in people with certain high-risk conditions.

As part of the procedure, your surgeon creates another way for stool to leave the body.

• Your surgeon may create a pouch from the small intestine and connect it to the anus.
• Your surgeon may instead create an opening in the abdomen, called an ileostomy, that lets stool pass from your body without going through your colon or anus.

The anus is not removed in every proctocolectomy. Whether the anus is removed depends on the type of surgery. Ask your surgeon for details about your own surgery.

Types

Depending on the type of surgery, you may pass stool in different ways after surgery.

• Proctocolectomy with J-pouch, also called ileal pouch-anal anastomosis (IPAA). Your surgeon removes your colon and rectum. The surgeon makes a pouch from the end of the small intestine, called the ileum. The surgeon attaches the pouch to the anus. Sometimes a short-term ileostomy is used while the new pouch heals. This procedure also is called restorative proctocolectomy.
• Proctocolectomy with permanent end ileostomy. Your surgeon brings the end of the ileum through an opening in the abdominal wall to make a stoma. Stool leaves the body through the stoma and collects in a pouch worn outside the body.
• Continent ileostomy. Your surgeon creates an internal pouch from the small intestine. The pouch stores stool and empties via a catheter through a stoma in the abdomen rather than the anus. A Kock pouch is one of several types of continent ileostomy.
• Other related procedures. If your surgery is done in stages, you may have a subtotal colectomy first. Subtotal colectomy removes the colon but leaves the rectum. A later surgery to remove the rectum is called a completion proctectomy. You may hear the term "completion proctocolectomy." You also may hear the terms "panproctocolectomy," "pan proctocolectomy" and "subtotal proctocolectomy."

If one of these terms is used, ask which parts of the colon, rectum and anus will be removed.

目的

Your care team may recommend a proctocolectomy when disease affects most or all of the colon and rectum. Surgery also may be recommended when removing these organs can lower a serious cancer risk.

• Ulcerative colitis. Ulcerative colitis is a type of bowel disease. It causes inflammation and sores, called ulcers, in the rectum and colon. Your care team may recommend surgery when medicines no longer manage ulcerative colitis or when the condition causes serious complications. Removing the colon and rectum treats the effects of ulcerative colitis on the bowel.
• Inherited polyposis syndromes. Familial adenomatous polyposis (FAP) is one such inherited condition. It causes many colon and rectal polyps and a high risk of colorectal cancer. MUTYH-associated polyposis (MAP) is another inherited polyposis syndrome. You may have surgery when the number or location of polyps makes them difficult to manage with regular exams and polyp removal. Depending on the condition and how much of the colon and rectum is affected, surgery may involve colectomy or proctocolectomy.
• Crohn's disease. If you have severe Crohn's disease involving the colon and rectum, you may need proctocolectomy. Proctocolectomy does not cure Crohn's disease because the disease also can affect other parts of the digestive tract.
• Cancer or precancerous changes. Your care team may recommend proctocolectomy when tissue needs to be removed because of colorectal cancer or a high risk of cancer. The team also may recommend surgery for severe precancerous cell changes, called high-grade dysplasia.

风险

Proctocolectomy is major surgery. Your risk of complications depends on your health, the disease you have and the type of surgery.

General risks of bowel surgery include:

• Dehydration from an ileostomy.
• Temporary slowing or stopping of stool passage after surgery, called postoperative ileus.
• For men, changes in erections or ejaculation. The risk of erectile dysfunction may increase with age.
• A leak where parts of the bowel or pouch join.
• Pelvic infection or abscess.
• Wound infection.
• Bowel blockage, also called bowel obstruction.
• Narrowing at a surgical connection, called a stricture.
• Bleeding.
• Blood clots in the legs or lungs.
• Injury to nearby organs.
• Scar tissue inside the abdomen that can cause a bowel blockage.
• A atypical connection between body parts, called a fistula.

J-pouch surgery has other possible complications. These include:

• Inflammation of the pouch, also called pouchitis.
• Narrowing where the pouch joins the anus.
• Bowel blockage.
• Fistula.
• Pouch failure.

An ileostomy also has possible complications. These include dehydration, bowel blockage, skin irritation and stoma complications.

• The stoma can become too narrow or sink below the skin.
• It also can stick out more than expected, called a prolapse.
• A bulge, called a parastomal hernia, also can develop.

Pelvic surgery also can affect sexual function or fertility. Some people have trouble becoming pregnant after J-pouch surgery.

Pelvic surgery can cause erection or ejaculation issues or pain with sex. Talk with your surgeon before surgery if fertility or sexual function is important to you.

If the anus is removed, you'll have a surgical wound where the anal opening was closed. You may see informal references to this as "Barbie butt." Healing complications can happen after this surgery, especially in people with Crohn's disease. Your care team explains how to care for the wound.

如何进行准备

Your care team gives you instructions for preparing for proctocolectomy. Preparation depends on the operation and whether an ileostomy has been planned or is done as an emergency surgery.

Before surgery, your care team may ask you to:

• Follow instructions about when to stop eating and drinking before surgery.
• Use a bowel-cleansing solution if your surgeon recommends it.
• Take antibiotics if they are part of your bowel preparation.
• Have a possible stoma site marked before surgery if you may need an ileostomy.
• Meet with an ostomy nurse or another specialized clinician if you may need an ileostomy.
• Ask whether J-pouch surgery is planned as a one-stage, two-stage or three-stage operation.

If fertility is important to you, discuss it before pelvic surgery. Fertility can decrease after IPAA.

If you need urgent or emergency surgery, preparation may be different. Your care team explains what is possible and necessary in your situation.

可能出现的情况

Before the procedure

On the day of surgery, your care team:

• Checks your vital signs.
• Places an IV for fluids and medicines.
• May give you antibiotics before surgery.
• Usually discusses and marks the stoma site if an ileostomy is planned or possible.

You receive general anesthesia for a proctocolectomy. This means you are in a sleeplike state and are not aware of the operation. Ask questions before surgery if any part of the planned operation is unclear to you.

During the procedure

Proctocolectomy often takes several hours, but the exact amount of time depends on the operation. Your surgeon can give you a more specific estimate.

The operation may be done using:

• Laparoscopic surgery. Your surgeon operates through several small cuts using a camera and instruments. Smaller cuts and smaller instruments cause less damage to the body.
• Robotic surgery. Your surgeon may use robotic assistance for some minimally invasive proctocolectomies.
• Open surgery. Your surgeon operates through a cut in the abdomen.

If minimally invasive surgery is an option for you, it may mean less pain and a shorter hospital stay than open surgery. It also may mean smaller scars. It is not an option in every situation.

If you receive a J-pouch, your surgeon removes the colon and rectum. The anus and the muscles that control the anal opening remain. These muscles are called the anal sphincter. Your surgeon makes a pouch from the ileum and connects it to the anus.

Your surgeon may create a short-term ileostomy while the pouch heals. This keeps stool away from the pouch. A temporary ileostomy is not needed for every surgery that is done in stages.

• If your J-pouch surgery is done in two stages, your surgeon creates the J-pouch and a short-term ileostomy during the first operation. After the pouch heals, a second operation closes the ileostomy. Closure often is planned after about 8 to 12 weeks if testing shows that the pouch connection has healed.
• A three-stage approach may be used when it is safer to separate the surgery into smaller steps.
  • First, your surgeon removes the colon and creates an ileostomy while keeping the rectum.
  • Later, your surgeon removes the rectum and connects the J-pouch to the anus.
  • A temporary loop ileostomy keeps stool away from the pouch while it heals.
  • The loop ileostomy is closed in the third operation.

If you are having a permanent end ileostomy, your surgeon brings the end of the ileum through the abdominal wall. This forms the stoma. Stool leaves the body through the stoma into an external pouch, also called an ostomy pouch.

Ask your surgeon to confirm exactly what will be removed during your planned operation.

After the procedure

After surgery, you go to a recovery area while the anesthesia wears off.

• You may have an IV and other temporary tubes or drains. One may be a urinary catheter, a tube that drains urine from the bladder.
• Tell your care team if pain or nausea is not well controlled.

Your care team watches for complications after surgery. Early walking and fluid monitoring are important parts of recovery. Learning how to care for an external pouch and a stoma also is important.

Your care team carefully manages your fluids to avoid giving too much or too little.

You likely will stay in the hospital for several days. The exact stay depends on the operation and your recovery. Your care team encourages you to walk as soon as it is safe.

You gradually begin drinking and eating as your digestive system recovers.

• Drinking enough fluids is especially important after an ileostomy because fluid losses can cause dehydration.
• Eating nutritious foods that provide the energy and protein your body needs also is important for recovery.
• Your care team may recommend fluids with minerals called electrolytes if you are losing a lot of fluid.

If you have an ileostomy, an ostomy nurse or another member of the care team teaches you how to care for it. You learn how to empty and change the ostomy pouch and care for the skin around the stoma. You also learn how to lower the risk of dehydration and recognize complications that need attention.

Recovery continues after you go home.

• There is no single recovery timetable that applies to everyone. Activity restrictions depend on the operation and how you are healing.
• If you have a temporary ileostomy with IPAA, closure often is planned about 8 to 12 weeks later if the pouch has healed.
• Ask your surgical team when you can return to lifting, exercise and other strenuous activity.

Your scars depend on the surgical approach.

• Minimally invasive surgery usually leaves smaller stomach scars than open surgery.
• If the anus is removed, you also have a healing wound where the anal opening was closed.
• Ask your care team what to expect as the wounds heal.

Contact your care team if you have:

• Signs of dehydration.
• A sudden major change in the amount of stool you pass, whether through an ileostomy or during bowel movements.
• Bowel blockage if you have an ileostomy.

结果

Your experience after proctocolectomy varies depending on whether you have a J-pouch, permanent ileostomy or continent ileostomy. Many people return to work, exercise, travel and other usual activities after recovery.

Passing stool with a J-pouch

After a temporary ileostomy is closed, stool passes through the small intestine into the J-pouch and then through the anus.

• You're likely to pass stool more often than you did with a colon and rectum.
• Frequency often improves as the pouch adapts. You may pass stool during the night as well as during the day.
• Studies report high satisfaction with J-pouch surgery.

A J-pouch does not develop ulcerative colitis because the colon and rectum have been removed. But the pouch can become inflamed. This is called pouchitis.

• Typical pouchitis symptoms include increased stool frequency, urgency, lower stomach pain or cramping, and pelvic discomfort.
• Contact your care team if these symptoms develop or your bowel pattern changes suddenly.

Passing stool with a permanent ileostomy

With an end ileostomy, stool leaves through the stoma and goes into an external pouch. Empty the pouch when it is about one-third full. This helps prevent the weight of the collected stool from disrupting the seal.

After recovery and adjustment, your ileostomy usually does not prevent you from bathing, swimming, exercising or traveling. You also can resume sexual activity after recovery, although adapting to a stoma and pouch may take time.

Passing stool with a continent ileostomy

A continent ileostomy stores stool inside an internal pouch made from the small intestine. You empty the pouch by placing a catheter through an abdominal stoma. Unlike a J-pouch, a continent ileostomy does not empty through the anus.

Diet and daily life

There is no single diet for everyone after proctocolectomy. Foods may affect how often you pass stool. It also may affect stool consistency and gas.

• The effects can differ depending on whether you have a J-pouch or ileostomy.
• Early in recovery, your care team may ask you to add new foods gradually.
• Over time, most people learn which foods work best for them.
• Staying hydrated is especially important after an ileostomy.

Sexual function and fertility

You can usually return to sexual activity after recovery. Pelvic surgery or an ostomy may require practical adjustments. Ask your surgical team when it is safe for you to resume sexual activity.

J-pouch and other pelvic operations may reduce fertility for some people. Pelvic surgery also can affect erections, ejaculation or comfort during sex. If you hope to have children in the future, discuss fertility with your care team before surgery.

Long-term follow-up

If you have ulcerative colitis, removing the colon and rectum usually cures the bowel symptoms caused by ulcerative colitis. You may still need follow-up for your J-pouch, ileostomy or complications.

• If you have FAP, you continue to need regular screening after proctocolectomy. Polyps can develop in a surgically created pouch and elsewhere in the digestive tract.
• If you have Crohn's disease, you need ongoing care because proctocolectomy does not cure Crohn's disease. The disease can return in the small intestine after surgery.