Current trends regarding protective ileostomy after restorative proctocolectomy / Tendências atuais sobre ileostomia protetora após proctocolectomia restauradora

The decision to perform a protective ileostomy after ileoanal-pouch anastomosis is controversial, and most of the discussion is based on its advantages and disadvantages. Although a temporary intestinal diversion has been routinely indicated in most patients, this choice is also associated with complications. The present work aims to review the outcomes after restorative proctocolectomy with or without a protective ileostomy in the treatment of ulcerative colitis and polyposis syndromes. Most papers emphasize that diversion protects against anastomosis leaks; consequently, it may prevent pelvic sepsis and pouch failure. Otherwise, a defunctioning ileostomy may cause morbidity such as dehydration, electrolyte imbalance, psychological problems, skin irritation, anastomosis strictures and intestinal obstruction, among others. There are those who believe that the omission of an ileostomy after the confection of ileal pouches should be reserved for selected patients, with quite acceptable results. The selection criteria should include surgeon, patient and procedure features to ensure a good outcome. (AU)

A decisão de realizar ileostomia de proteção após anastomose da bolsa ileal ao canal anal é controversa, sendo a discussão baseada em suas vantagens e desvantagens. Embora a derivação intestinal temporária tenha sido indicada rotineiramente na maioria dos pacientes, essa escolha também está associada a complicações. O presente trabalho teve como objetivo rever os resultados após proctocolectomia restauradora com ou sem ileostomia de proteção no tratamento da colite ulcerativa e síndromes polipoides. Muitos trabalhos enfatizam que a derivação protege contra fístulas anastomóticas; consequentemente, ela pode prevenir sepse pélvica e perda da bolsa. Por outro lado, a derivação por ileostomia pode ser causa de morbidade como desidratação, distúrbios eletrolíticos, problemas psicológicos, lesões dérmicas, estenose de anastomose e obstrução intestinal, entre outras. Há aqueles que acreditam que a omissão de ileostomia após a confecção de bolsa ileal deve ser reservada a pacientes selecionados, obtendo-se resultados aceitáveis. Os critérios de seleção devem incluir características do cirurgião, do paciente e do procedimento na tentativa de se obter bons resultados. (AU)

Risk Factors of Pouch Failure after a Restorative Proctocolectomy

PURPOSE: The aim of this study was to analyze the risk factors of pouch failure after a restorative proctocolectomy. METHODS: A restorative proctocolectomy was performed in 169 patients between November 1989 and May 2007. A retrospective review was done for postoperative complications and follow-up results of pouch failure, and the risk factors of pouch failure were analyzed. Pouch failure was defined as having occurred when a permanent ileostomy was constructed, regardless of pouch removal. The median follow-up was 48 (3~155) months. RESULTS: Among the 169 cases, 86 cases involved ulcerative colitis (UC group), 70 cases involved familial adenomatous polyposis or attenuated adenomatous polyposis coli (FAP group), and the remaining 13 involved hereditary nonpolyposis colorectal cancer or synchronous colon and rectal caner (CRC group). The sex ratios and the incidences of comorbidity were not significantly different between the groups, but the mean ages were. Complications occurred in 61 patients (36.1%): pelvic sepsis (28 cases), pouchitis (23 cases), desmoid tumor (12 cases), wound infection (10 cases), and anastomosis stricture (4 cases). The 5-year cumulative rate of pouch failure was 9.8%. Presence of a desmoid tumor, pelvic sepsis, and anastomosis stricture were risk factors of pouch failure. CONCLUSIONS: The cumulative pouch failure rate after a restorative proctocolectomy was 9.8% for 5 years, and pouch failure was associated with the presence of a desmoid tumor, pelvic sepsis, and anastomosis stricture.