Ileoanal pouch

Controversies
1. Timing of surgery
Total colectomy/end ileostomy (suture stump end to abdominal wound) if:
-Diagnostic dilemma of Crohn's disease
-High PNL requirement
-Toxic colitis and megacolon
-Malnutrition

2.Type of pouch
Functional results the same
J pouch easy to consruct
S pouch if difficulty reaching pelvis (2-4cm extra length as anastomosis is done on end of colon)

3.Type of anastomosis
Controversy leaving cuff of 1-2cm of ATZ
cuffitis and malignancy versus poor continence, increase sepsis
(probably favour stapled, but studies equivocal: ?type II error)
Mucosectomy and hand sewn if dysplasia in lower 2/3 of rectum or rectal cancer

4.Omission of ileostomy
May omit if stringent criteria met re nutrition, PNL, tension etc

Preop
Full colonoscopy
Stomal therapist
Bowel prep
Iv ab
Lloyd Davies, Trendelenburg, IDC, compression stockings
Standard proctocolectomy (high ligation if dysplasia or long standing)
Can gain extra length on ileum by dividing ileocolic and scoring mesentery (see photo)
100mm linear cutter to construct J pouch with 15-20cm limbs
Purse string at apical enterotomy
Ensure anal sphincters are not included in anastomosis. Avoid creating iatrogenic pouch-vaginal fistula (traverse initial staple line posteriorly with bum gun trocar

Post-op
Invariably patients will have high ileostomy outputs as stoma is proximal: make pateients aware of dehydration and ask them to avoid high fibre diets
See @ six weeks to arrange contrast enema and do DRE to break down web like stenosis (easier than treating fibrous stenosis later)
If anal transition zone left, need to do pouch endoscopy and ATZ biopsy