Physicians of the Zane Cohen Centre
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Glossary
| Abscess |
a localized collection of pus, contained in a cavity |
| Anal Sphincter |
the muscles surrounding the anus that are able to contract or close the opening/anus |
| Anastomosis |
a union of one structure to another, usually joining one part of end of the bowel to another |
| Anus |
the opening at the end of the rectum through which stool is eliminated from the body |
| Appliance |
the device or pouch worn over the stoma to collect feces or urine |
| Blockage |
obstruction; a "clogging" of the bowel |
| Colitis |
inflammation of the colon (large bowel) |
| Colon |
large bowel or large intestine |
| Colostomy |
a surgically created opening bringing the colon to the surface of the skin |
| Continence |
the ability to keep stool, gas, or urine inside the body voluntarily |
| Cosmesis |
improved or enhanced appearance; in relation to laparoscopic surgery, a decrease in the length of incisions and subsequent scarring |
| Electrolyte |
a substance which conducts electricity when in solution; for dietary purposes, this includes sodium, chloride and potassium |
| Enterostomal Therapy Nurse (ET Nurse) |
a registered nurse specially educated to provide physical and psychological support to patients with stomas, wounds and incontinence |
| Familial Polyposis / FAP |
an inherited disease in which the colon and rectum contain a large number of polyps |
| Feces |
bodily wastes which are discharged through the anus or stomas; stool |
| Fissure |
painful, linear ulcer of groove a the margin of the anus |
| Fistula |
an abnormal passage or communication, usually between 2 internal organs ( e.g. one part of a bowel to a distant part of bowel, or bowel to bladder), or between an organ and the skin surface (enterocutaneous fistula) |
| Ileoanal Anastomosis |
joining the ileum to the anus following removal of the colon and rectum |
| Ileorectal Anastomosis |
joining the ileum to the rectum following removal of the colon |
| Ileostomy |
surgically created opening bringing the ileum to the surface of the skin |
| Impotence |
an inability to achieve and sustain an erection sufficient for sexual intercourse |
| Incontinence |
the inability to control elimination of urine or feces |
| Koch Pouch or Continent Ileostomy |
construction of an internal abdominal pouch or reservoir with a nipple valve following removal of colon, rectum, and anus. The nipple valve serves to hold the feces inside the pouch as it fills, so that no waste matter can escape to the outside of the body between drainage |
| Laparoscopic |
surgery performed through the use of fibre-optic instruments |
| Loop Colostomy |
surgical opening in the colon. A loop of colon is brought through the abdominal wall to form a stoma |
| Mucosa |
the inner lining of the digestive tract and of other organs of the body |
| Mucus |
a lubricating substance produced by the digestive tract |
| Mucus Fistula |
a surgically created opening from a portion of the bowel to the skin that secretes only mucus |
| Ostomate |
person who has an ostomy |
| Ostomy |
a surgically created opening, usually on the abdominal wall, for the drainage of body wastes. Also referred to as a stoma |
| Pelvic Pouch |
an ileoanal reservoir or sac, created from the ileum; also referred to as Parks Pouch, "J" or "S" Pouch |
| Polyp |
an outgrowth from the mucosa of the colon |
| Pouchitis |
an inflammation of the reservoir or pouch (as in Pelvic Pouch or Kock Pouch) |
| Proctocolectomy |
removal of the colon, rectum, and anus with the creation of permanent ileostomy |
| Rectal Cuff |
the portion of the rectum, consisting of sphincter muscle, that is retained after the lining of the rectum is removed |
| Rectum |
the structure at the end of the colon which serves as a storage space |
| Resection |
excision or removal of a portion of an organ or structure |
| Reservoir |
a structure that serves as a storage place |
| Sphincter |
ring-like muscle which opens and closes voluntarily. The sphincter in the anus provides bowel control and the bladder sphincter controls urine |
| Stoma |
an opening; also referred to as an ostomy |
| Stool |
bodily wastes which are discharged through the anus or colostomy / ileostomy stomas. Also referred to as feces |
| Stricture |
an abnormal narrowing of a duct or passage (i.e. bowel) |
| Stricturoplasty | surgically opening a narrowing in the bowel without requiring resection of the narrowed portion |
Surgical Options - Pelvic Pouch
Prior to the 1970's, individuals with ulcerative colitis and certain individuals with familial polyposis who required surgery to treat their disease underwent a total proctocolectomy. This surgery involves removal of the colon, rectum, anus and sphincter muscles and creation of an ileostomy. This operation cured the disease but left the individual with a permanent ileostomy. This procedure is still considered the safest with the least number of risks and long-term complications. The difficulty is in people's acceptance of the ostomy. As a result, surgeons over the years have attempted to develop alternatives to a permanent stoma. In the early 1970's, Professor Koch of Sweden created the Koch Pouch surgery. The colon, rectum, and anus, were removed and an internal abdominal pouch was constructed from small bowel. The construction of a nipple valve within the Koch Pouch produced a continent ileostomy. The concept was wonderful however the long-term complications and re-operation rates were and still are high. Today, this surgery is performed in a very small minority of cases.
In the late 1970's, surgeons in Britain and Japan first introduced the Pelvic Pouch or Ileoanal Reservoir procedure. As a result, the surgical approach to ulcerative colitis and familial polyposis was revolutionized. The pelvic pouch procedure has become the "gold standard" for those individuals who require surgery to treat their disease. The Pelvic Pouch Procedure involves different surgical scenarios depending on the individual's state of health at the time of surgery.
A question most frequently asked is whether the Pelvic Pouch Procedure can be performed laparoscopically. Pelvic pouches are done laparoscopically at Mount Sinai as well as other centres. It appears that those who have had a laparoscopic intestinal procedure do recover from the operation faster than those done with an open procedure. They often are eating sooner after surgery, and are likely to be discharged sooner from hospital and return to work or school after a relatively short convalescence. In addition, since the incisions are smaller, the resulting scars are smaller. While the number of patients treated laparoscopically remain small, the results are encouraging.
Many patients can be considered candidates for laparoscopic surgery. At Mount Sinai, the colorectal surgeons work as a team, offering a laparoscopic approach whenever appropriate. In some instances, such as emergency procedures, it is impossible to arrange for a laparoscopic assessment and the procedure must proceed using the open technique. In a few cases, initial laparoscopy is performed, but the surgeon is unable to complete the operation with the laparoscope and so converts to an open procedure.
The following describes the different surgical scenarios for the Pelvic Pouch Procedure
Scenario One: "One-Stage Surgery"
In patients who are relatively healthy, not actively bleeding or on high doses of steroids, the Pelvic Pouch will be constructed during the first stage. The colon and rectum are removed leaving the anus, the pelvic muscles and nerves. The pouch or reservoir is created using two loops of small intestine (J-shaped pouch). The pouch is anastamosed or joined to the anus using either staples or stitches. To protect the join, a temporary loop ileostomy is made. An opening is made in the abdomen and a loop of small intestine is brought out. The stool passes into an external appliance. Thus no stool passes through the internal pouch initially.
A pouchogram (x-ray of the pouch) is done at six weeks to determine healing. If healing takes place, the second step involves closure of the loop ileostomy and usually occurs at three months. No preparation is required for the X-ray.
The second operation includes closing the openings to the loop ileostomy thus re-establishing bowel continuity. The stool then passes through the small intestine, into the pouch or reservoir, and exits the body through the anus.
Scenario Two: "Two-Stage Surgery"
Stage One
In this scenario, two major procedures are done. In individuals who have been sick with their disease, have been on high dose steroids, actively bleeding, had significant weight loss or in situations where the disease has not been determined, the safest procedure to be done first is a subtotal colectomy. In a subtotal colectomy, the colon to the sigmoid region is removed, leaving the rectum, anus, pelvic muscles and nerves in place. An end ileostomy (opening in the small bowel or ileum), is established with or without a mucous fistula (opening on the abdomen for the passage of mucous or drainage from the rectum) depending on how diseased the rectum is at the time of surgery.
The goal following surgery is to allow the individual to regain weight, strength and energy, to decrease and eventually stop the steroids and then at a later date (three months or longer), proceed with the pelvic pouch.
Stage Two
In the second stage, the remaining sigmoid colon and rectum is removed leaving the anus, the pelvic muscles, and nerves. These are all necessary and important for voluntary control of bowel movements. A pouch or reservoir is created using two loops of small bowel (J-shaped pouch). The pouch is anastamosed or joined to the anus using either staples or stitches. The Pelvic Pouch procedure is usually completed at this second stage without the need for a second ostomy. A rectal tube placed in the pouch at the time of surgery is generally left in place for five to seven days to rest the join or the anastamosis of the pouch to the anus. Stool automatically drains into a bedside drainage bag.
Reconstruction
Reconstruction of the pouch is possible should the first one fail. Some reasons for pouch failure and the need for reconstruction include fistulas between the pouch and the vagina, infections/ abscesses in the pelvis, problems evacuating/emptying the pouch (due to long outlets of the pouch) or strictures. In most cases, the "old" pouch can be reused, but in some, the old pouch must be removed and a new one created.
Surgical Options - Proctocolectomy
The standard option for individuals with ulcerative colitis who require surgery was the Total proctocolectomy and Ileostomy. The advantages are that it can be performed in one stage and relative to the other procedures can be performed with a low complication rate. The major disadvantage is that individuals are left with a permanent ileostomy. However, most individuals adapt well to an ileostomy both physically and psychologically as long as the ileostomy is constructed well. The most common complication is problems related to the ileostomy and perineal wound.
The Total Proctocolectomy is performed fairly frequently but certainly is not as frequent now that the Pelvic Pouch Procedure is available. Once a colectomy and a proctectomy have been performed and the individual is living with an ileostomy, there is virtually no chance in reconnecting or redoing a Pelvic Pouch Procedure. On the other hand, if one has a Pelvic Pouch Procedure and it fails, then one still has the opportunity of having either a conventional ileostomy on a permanent basis or a conversion to a Continent Ileostomy also known as the Koch Pouch.
Ulcerative Colitis
Ulcerative colitis only affects the large intestine or colon. It also only affects the inner lining of the bowel (the mucosa), causing it to ulcerate and bleed. Ulcerative colitis always starts in the rectum and can continue to extend further along the colon in a continuous fashion. It does not "skip" portions of the colon in its progression.
Common symptoms with ulcerative colitis include diarrhea, which can be associated with the loss of blood. Bowel movements may be frequent and associated with urgency and or spasm and cramping. There may be abdominal pain, fever, and weight loss.
Ulcerative colitis usually presents in the early decades of life, but can also have its initial presentation in the fifth or sixth decades of life, and on occasion in the seventh or eighth decades. Incidence of ulcerative colitis is highest in the Scandinavian countries, Great Britain and North America; it is less commonly found in Asia, Africa and South America. The disease also tends to be found amongst individuals of Jewish descent, more specifically Ashkenazi Jews. There is a slightly higher incidence of Ulcerative Colitis in females than in males.