Proctocolectomy

Overview

A proctocolectomy is a surgical procedure designed to remove either a portion or the entirety of your colon and rectum. The colon and rectum constitute segments of the large intestine or large bowel. The large intestine comprises the colon, rectum, and anus, with the colon being the predominant component, often referred to colloquially as the “colon.” If these components are missing, your surgeon may have to establish an alternate route for waste elimination. This could involve procedures such as a colostomy, ileostomy, or creation of an internal ileal pouch (J-pouch).

Your colon is where food waste gradually solidifies into feces. Following the colon, the rectum is a short segment that holds the feces before their expulsion through the anus, creating a continuous digestive tube.

When surgery becomes necessary for an issue within the large intestine, it could involve any part of this continuous structure. Various types of bowel resection surgeries target different segments. Colectomy surgery, for example, entails the removal of a portion or the entirety of the colon. Specifically, a proctocolectomy, where “procto” refers to the rectum, involves removing both the colon and rectum. Conversely, a proctectomy exclusively removes the rectum.

Types of proctocolectomy

• Total Proctocolectomy: The term “total proctocolectomy” refers to the complete removal of both the colon and rectum, leaving no residual parts behind. In this procedure, there is no intestine remaining between the small intestine and the anus. Consequently, your surgeon will need to construct a new pathway for waste elimination.
• Proctocolectomy with Ileostomy: In some cases, a proctocolectomy may involve creating an ileostomy, where the last segment of the small intestine, known as the ileum, is redirected through a new opening in the abdomen. This may be either permanent (referred to as an end ileostomy) or temporary, depending on the individual’s healing process. There may be an opportunity to reconnect the ileum to the anus at a later stage.
• Restorative Proctocolectomy with Ileal-Anal Pouch: For individuals with a healthy ileum and anus, either at the time of the initial surgery or subsequently, a restorative proctocolectomy may be considered. This involves shaping the ileum into a pouch, known as an ileal-anal pouch or J-pouch, which serves as a reservoir for waste similar to the function of the rectum. The surgeon then reconnects this pouch to the anus (ileoanal anastomosis), allowing waste elimination through the natural route.
• Subtotal Proctocolectomy: In contrast to a total proctocolectomy, a subtotal proctocolectomy involves leaving a portion of the colon or rectum intact, typically preserving the colon due to its larger size. One subtype of subtotal proctocolectomy is Hartmann’s procedure, also known as proctosigmoidectomy, which removes the sigmoid colon and all or part of the rectum. Following a subtotal proctocolectomy, if a sufficient portion of your colon remains healthy, there is a potential for safe reconnection to your remaining rectum or anus. The rejoining of the large intestine, known as anastomosis, becomes feasible based on your overall health condition.

During the healing phase after the proctocolectomy, you might require a temporary colostomy to redirect your colon through a new opening in your abdomen. Depending on your recovery progress, there may be an opportunity to close the colostomy through a subsequent surgery. However, in some instances, a permanent colostomy may be necessary.

Reasons for undergoing the procedure

Similar to other forms of bowel resection surgery, a proctocolectomy becomes necessary when a segment of the bowel is significantly diseased, hindering its proper functioning or posing a life-threatening risk.

Proctocolectomy is commonly employed to address conditions such as:

• Inflammatory bowel diseases such as ulcerative colitis and Crohn’s disease.
• Colorectal cancer
• Precancerous conditions such as familial adenomatous polyposis.

Other potential reasons for proctocolectomy include:

• Traumatic injury.
• Tissue death resulting from ischemia (loss of blood flow).
• Complicated diverticulitis.
• Severe constipation.

Risks

Every surgery involves a minimal risk of specific complications, such as anesthesia reactions, injury to neighboring organs, internal bleeding, and infection.

Possible complications of proctocolectomy surgery

• Intestinal obstruction: Post-surgery, scar tissue build up in your abdomen may lead to an intestinal blockage. Your doctor will assist in alleviating this condition.
• Nerve damage: Surgical procedures involving the rectum and anus may occasionally result in nerve damage affecting sexual or urinary function. This can manifest as difficulties with urination, sensitivity and pain during sex for women, or erectile dysfunction in men. Typically, these complications gradually diminish over time.

Possible complications of an ileostomy or colostomy

• Skin irritation: Irritation of the skin around your stoma may occur due to contact with stool, which contains acidic digestive juices from the ileum and upper colon. To prevent stool leakage, using a better-fitting ostomy bag is advisable.
• Stoma retraction or prolapse: Stoma retraction involves the stoma sinking below the skin surface, while stoma prolapse results in the stoma protruding too far. Both situations can pose challenges in securely fitting your ostomy bag to the stoma. If an appropriately fitting bag cannot be found, your surgeon may need to re-site or revise the stoma.
• Phantom rectum: Following the removal of your rectum, you may experience phantom urges for bowel movements. Some find relief by sitting on the toilet when these urges occur, and typically, they diminish over time.

Possible complications of an internal ileal pouch

• Pouchitis: Pouchitis refers to the irritation and inflammation of the ileal pouch, affecting approximately half of ileal pouch recipients. Although the exact causes are not fully understood, they often appear to be linked to the original disease that led to the proctocolectomy, such as colitis or polyposis. Treatment for pouchitis typically involves antibiotics or anti-inflammatory medications.
• Anastomotic leak: An anastomotic leak is a rare occurrence where the reconnection of the intestinal channel during an anastomosis may result in a leak within the body, leading to a potentially severe infection. Surgeons closely monitor for signs of leakage during your hospital stay and follow-up visits post-surgery. If detected, it is treated as an emergency, involving antibiotics and possibly immediate repair.
• Temporary fecal incontinence: Initially, your anal muscles may be weak, and your bowel movements may be frequent. Occasionally, these movements may catch you off guard, and there might be instances where you struggle to control them in time to prevent accidents. Most individuals regain control as their anal muscles strengthen and their ileal pouch expands over time. If needed, medications can assist in regaining control.

Before the procedure

• Several weeks before: In non-emergency situations, you will have the opportunity to engage in discussions with your doctor regarding your proctocolectomy. This pre-surgery phase allows for an exploration of various proctocolectomy options suitable for you, along with an in-depth examination of the associated risks and benefits.
• Two weeks before: In the fortnight leading up to the surgery, you will be requested to reduce or cease any blood-thinning medications you may be on. Additionally, your doctor will recommend maintaining intestinal health by incorporating a diet rich in dietary fiber and ensuring adequate hydration.
• 24 hours before: The day preceding the surgery, your doctor may prescribe a bowel prep to facilitate intestinal clearance. During this period, a clear liquid diet will be advised. Additionally, preventative antibiotics might be prescribed to guard against post-surgery infections.

During the procedure

• Preparation: Upon arrival at the hospital, you will change into a hospital gown. The healthcare team will insert an intravenous (IV) catheter into one of your veins for continuous fluid and medication administration. Subsequently, you will be transported on a gurney to the operating room. The anesthesiologist, collaborating with your surgeon, will administer general anesthesia, and you will be placed on a ventilator to assist with breathing during the procedure.
• Open Surgery vs. Laparoscopic Surgery: Many proctocolectomies are now conducted through minimally invasive laparoscopic or robotic techniques. In contrast to the traditional open surgery that involves a large abdominal incision, the surgeon, with the assistance of a laparoscope, operates through a few small incisions. Laparoscopic surgery is associated with quicker recovery and improved outcomes, although eligibility depends on individual circumstances. More complex or emergent conditions may necessitate open surgery.
• Resection: Once your surgeon gains access to your bowel, the affected segment of your colon and rectum is meticulously removed. If your anus remains unaffected, it will be preserved along with the anal sphincter. Maintaining a functional anal sphincter is crucial if you aim to regain the ability to defecate through your anus in the future.
• Ileostomy/Colostomy: In most cases, whether temporary or permanent, an ileostomy or colostomy is created during the proctocolectomy. This involves redirecting the course of your ileum or remaining colon to a new opening in your abdominal wall. A bag is attached to the external opening (stoma) where waste is expelled.
• Anastomosis: If sufficient healthy colon remains and immediate reconnection is feasible without requiring healing time, an anastomosis may be performed during the same surgery. This entails stitching together the healthy ends of the large intestine, eliminating the need for an ostomy.

After the procedure

The recovery period in the hospital will extend up to a week. During this time, there will be a gradual reintroduction of solid foods, and the return to regular bowel movements. For those with an ostomy, a Wound, Ostomy, Continence Nurse (WOCN) will provide guidance, instructing on the proper management of an ostomy bag and stoma care. Whether the ostomy is temporary or permanent, several months will elapse before discussions about the next phase with the surgeon, which may involve a reversal or the creation of an internal ileal pouch.

Outcome

You will experience no sensations during the surgery, and robust pain medications will be administered postoperatively. Throughout your hospital stay, the doctor will collaborate with you to tailor the medication to ensure your comfort, and you will be provided with a short-term prescription upon discharge.

While complete recovery may span several months, adhering to your doctor’s advice and taking it easy will facilitate a smooth recuperation. It’s normal to feel some soreness when sitting and experience a pull on your incision during coughing or sneezing. Applying pressure with a pillow over the incision site can offer relief.

The majority of individuals undergoing surgery typically achieve full recovery within a couple of months and can resume their usual activities. Many of the surgery’s side effects are temporary.

Adapting to life with an ostomy involves adjustments, but modern ostomy bags are discreet, and there are numerous specialty products available to assist individuals in maintaining a sense of normalcy.

For those in good health, there’s a possibility of undergoing further surgery after several months to proceed with the subsequent stages of their treatment plan. This may involve closure of the ostomy and reconnection of the intestines.

In cases where an internal ileal pouch is being constructed, one or two additional surgeries might be necessary, depending on individual circumstances. Sometimes, there’s a healing period required before the new pouch can be reconnected. While additional surgeries may prolong the process, eventually, individuals will regain their previous bowel habits. The decision regarding additional surgeries will be made collaboratively between you and your healthcare provider based on your overall fitness for the procedures.