Abstract
PURPOSE: This retrospective study assesses the results of total colectomy and ileorectostomy for inflammatory bowel disease. METHODS: Between January 1974 and December 1990, 90 patients underwent total colectomy and ileorectal anastomosis for chronic ulcerative colitis (n=48) or Crohn's colitis (n=42) at the Mayo Clinic. Patients' records were reviewed retrospectively. Long-term results were assessed by chart reviews and postal questionnaires. Conversion to a permanent ileostomy, with or without proctectomy, was considered a failure of the procedure. The Kaplan-Meier method was used to estimate survivorship free of failure. The log-rank test was used to compare survivorship curves. Ninety-five percent confidence intervals were calculated at selected time points.P values<0.05 were considered to be statistically significant. RESULTS: The main indication for surgery was refractory chronic disease. There were no immediate postoperative deaths. The anastomotic leakage rate was 4.4 percent, and small-bowel obstruction occurred in 15.6 percent. At the time of follow-up (mean, 6.5±4.8 years), 46 patients (58.9 percent) had recurrence or exacerbation of the disease. This was the most common indication for subsequent proctectomy/permanent ileostomy in the follow-up period. There were 8 failures in 48 patients with ulcerative colitis (16.7 percent) and 11 failures in 42 patients with Crohn's disease (26.2 percent), although this difference was not statistically significant. Cumulative probability of having a functioning ileorectal anastomosis at five years was 84.2 percent (95 percent confidence interval, 71–95.9 percent) for ulcerative colitis and 73.8 percent (95 percent confidence interval, 58.6–88.6 percent) for Crohn's disease. In the latter group, females showed a significantly lower cumulative probability of having a functioning ileorectal anastomosis (females, 634 percent; males, 92.3 percent;P =0.04). Crohn's patients 36 years of age or younger also showed a lower probability of success (patients ≤36 years, 57 percent; patients >36 years, 93.8 percent;P =0.03). In the group with chronic ulcerative colitis, younger patients also seemed to require additional surgery more frequently; however, this difference was not statistically significant. Previous duration of symptoms, with mild or moderate disease in a distensible rectum, had no effect on results in either disease group. Functional results were acceptable in 63.6 and 87.5 percent of patients with Crohn's and ulcerative colitis, respectively. Eighty-four percent of ulcerative colitis patients and 91 percent of Crohn's disease patients reported an improvement in their quality of life, and overall, more than 90 percent considered their health status to be better than before surgery. One patient with ulcerative colitis developed carcinoma of the rectal stump 11.5 years after the colectomy and ileorectal anastomosis (cumulative probability of remaining free of cancer, 85.7 percent at 12 years; 95 percent confidence interval, 57.7–100 percent). CONCLUSIONS: These results demonstrate that, in selected patients with a relatively spared rectum and without severe perineal disease, total colectomy and ileorectal anastomosis still remains a viable option to total proctocolectomy with extensive Crohn's colitis. In addition, ileorectal anastomosis, as a sphincter-saving procedure, continues to have a place in the surgical treatment of chronic ulcerative colitis for high-risk or older patients who are not good candidates for ileal pouch-anal anastomosis, when the latter procedure cannot be done because of technical reasons and in the presence of advanced carcinoma concomitant with colitis, when life expectancy is limited.
Similar content being viewed by others
References
Aylett SO. Three hundred cases of diffuse ulcerative colitis treated by total colectomy and ileo-rectal anastomosis. BMJ 1966;1:1001–5.
Cunningham IG. Ileorectal anastomosis-friend or foe? Aust N Z J Surg 1986;56:31–4.
Cooper JC, Jones D, Williams NS. Outcome of colectomy and ileorectal anastomosis in Crohn's disease. Ann R Coll Surg Engl 1986;68:279–82.
Mann CV. Total colectomy and ileorectal anastomosis for ulcerative colitis. World J Surg 1988;12:155–9.
Khubchandani IT, Sandfort MR, Rosen L, Sheets JA, Stasik JJ, Riether RD. Current status of ileorectal anastomosis for inflammatory bowel disease. Dis Colon Rectum 1989;32:400–3.
Jagelman DG. Surgical alternatives for ulcerative colitis. Med Clin North Am 1990;74:155–67.
Harling H, Hegnhoj J, Rasmussen TN, Jarnum S. Fate of the rectum after colectomy and ileostomy for Crohn's colitis. Dis Colon Rectum 1991;34:931–5.
Dozois RR. Surgical treatment of chronic ulcerative colitis. Hepatogastroenterology 1989;36:227–34.
Parc R, Legrand M, Frileux P, Tiret E, Ratelle R. Comparative clinical results of ileal-pouch anal anastomosis and ileorectal anastomosis in ulcerative colitis. Hepatogastroenterology 1989;36:235–9.
Kelly KA. Anal sphincter-saving operations for chronic ulcerative colitis. Am J Surg 1992;163:5–11.
Binderow SR, Wexner SD. Current surgical therapy for mucosal ulcerative colitis. Dis Colon Rectum 1994;37:610–24.
Smith LE. Current status of sphincter-saving operations for chronic ulcerative colitis. South Med J 1985;78:1304–8.
Goldberg SM, Vasilevsky CA. Alternatives to ileostomy in 1986. J Ark Med Soc 1986;83:56–61.
Schoetz DJ Jr, Coller JA, Veindenheimer MC. Alternatives to conventional ileostomy in chronic ulcerative colitis. Surg Clin North Am 1985;65:21–33.
Goligher JC. The long-term results of excisional surgery for primary and recurrent Crohn's disease of the large intestine. Dis Colon Rectum 1985;28:51–5.
Beart RW Jr. Sphincter saving operations for chronic ulcerative colitis. Adv Surg 1990;23:195–210.
Tjandra JJ, Fazio VW. Surgery for Crohn's colitis. Int Surg 1992;77:9–14.
Scammell B, Ambrose NS, Alexander-Williams J, Allan RN, Keighley MR. Recurrent small bowel Crohn's disease is more frequent after subtotal colectomy and ileorectal anastomosis than proctocolectomy. Dis Colon Rectum 1985;28:770–1.
Shorb PE Jr. Surgical therapy for Crohn's disease. Gastroenterol Clin North Am 1989;18:111–28.
Kaplan EL, Meier P. Nonparametric estimation from incomplete observations. J Am Stat Assoc 1958;53:457–81.
Peto R, Peto J. Asymptotically efficient rank invariant procedures (with discussion). J R Statist Soc, Series A 1972;135:185–207.
Weaver RM, Keighley MR. Measurement of rectal capacity in the assessment of patients for colectomy and ileorectal anastomosis in Crohn's colitis. Dis Colon Rectum 1986;29:443–5.
Oakley JR, Jagelman DG, Fazio VW,et al. Complications and quality of life after ileorectal anastomosis for ulcerative colitis. Am J Surg 1985;149:23–30.
Longo WE, Oakley JR, Lavery IC, Church JM, Fazio VW. Outcome of ileorectal anastomosis for Crohn's colitis. Dis Colon Rectum 1992;35:1066–71.
Farnell MB, Van Heerden JA, Beart RW Jr, Weiland LH. Rectal preservation in nonspecific inflammatory disease of the colon. Ann Surg 1980;192:249–53.
Jones PF, Keenan RA. The place of colectomy with ileo-rectal anastomosis in inflammatory bowel disease. Ann Chir Gynecol 1986;75:75–81.
Leijonmarck CE, Lofberg R, Ost A, Hellers G. Long-term results of ileorectal anastomosis in ulcerative colitis in Stockholm County. Dis Colon Rectum 1990;33:195–200.
Ambroze WL Jr, Pemberton JH, Dozois RR. Surgical alternatives to ileostomy or colostomy. Adv Intern Med 1990;35:375–92.
Backer O, Hjortrup A, Kjaergaard J. Evaluation of ileorectal anastomosis for the treatment of ulcerative proctocolitis. J R Soc Med 1988;81:210–1.
Thomas DM, Filipe MI, Smedley FH. Dysplasia and carcinoma in the rectal stump of total colitics who have undergone colectomy and ileo-rectal anastomosis. Histopathology 1989;14:289–98.
Grundfest SF, Fazio VW, Weiss RA,et al. The risk of cancer following colectomy and ileorectal anastomosis for extensive mucosal ulcerative colitis. Ann Surg 1981;193:9–14.
Tonelli F, Bianchini F, Lodovici M, Valanzano R, Caderni G, Dolara P. Mucosal cell proliferation of the rectal stump in ulcerative colitis patients after ileorectal anastomosis. Dis Colon Rectum 1991;34:385–90.
Morson BC, Pang LS. Rectal biopsy as an aid to cancer control in ulcerative colitis. Gut 1967;8:423–34.
Filipe MI, Edwards MR, Ehsanullah M. A prospective study of dysplasia and carcinoma in the rectal biopsies and rectal stump of eight patients following ileorectal anastomosis in ulcerative colitis. Histopathology 1985;9:1139–53.
Stern H, Walfisch S, Mullen B, McLeod R, Cohen Z. Cancer in an ileoanal reservoir: a new late complication? Gut 1990;31:473–5.
Puthu D, Rajan N, Rao R, Rao L, Venugopal P. Carcinoma of the rectal pouch following restorative proctocolectomy: report of a case. Dis Colon Rectum 1992;35:257–60.
O'Connell PR, Pemberton JH, Weiland LH,et al. Does rectal mucosa regenerate after ileoanal anastomosis? Dis Colon Rectum 1987;30:1–5.
Beckwith PS, Wolff BG, Frazee RC. Ileorectostomy in the older patient. Dis Colon Rectum 1992;35:301–4.
Author information
Authors and Affiliations
About this article
Cite this article
Pastore, R.L.O., Wolff, B.G. & Hodge, D. Total abdominal colectomy and ileorectal anastomosis for inflammatory bowel disease. Dis Colon Rectum 40, 1455–1464 (1997). https://doi.org/10.1007/BF02070712
Issue Date:
DOI: https://doi.org/10.1007/BF02070712