Total colectomy, mucosal proctectomy, and J-pouch ileo-anal anastomosis with temporary ileostomy is the standard operation for children with intractable UC or polyposis. A long and often rather tedious operation, it demands patience, meticulous attention to detail, and a commitment to the patient for the foreseeable future. Experience makes one realize there is no shame in sometimes recommending the traditional “three-staged” approach, particularly when faced with the typical UC patient who is malnourished, steroid-dependent and emotionally tenuous, even though it invariably seems to every new generation of pediatric surgeons to be a hopelessly old-fashioned relic of a bygone era. I prefer to do the STC laparoscopically, and, if the proctectomy is being done the same day, I will make a Pfannenstiel incision (with the fascia opened in the midline) to use a hand-assisted approach, which saves time and minimizes blood loss. I then do the mucosal proctectomy and J-pouch procedure through the Pfannenstiel incision.
Getting the ileum to reach the anus can be quite difficult, especially in obese patients. Every surgeon should have a systematic approach, each step of which adds a few centimeters of length, including mobilizing the pedicle all the way up to the pancreas, scoring the mesentery, and dividing superfluous vessels after test clamping. This should all be done before the proctectomy is started! In the rare event that a tension-free anastomosis is impossible, it is best to abort the pull-through, create an ileostomy, and plan to try again in 6 months or so. If the proctectomy is done, placing omentum in the rectal canal will make it easier to find the lumen in the future. Then again, mobilizing too much ileum increases the risk of pouch prolapse, a vastly under-reported complication of this operation.
Pouchitis is the nemesis of the patient with a J-pouch. Interestingly, it almost never occurs in patients with polyposis, suggesting it may in fact be a forme fruste of UC. Patients with recurrent pouchitis should undergo examination under anesthesia to rule out an anastomotic stricture and Crohn’s disease. Daily dietary fiber supplements, probiotics and judicious intermittent use of metronidazole are all part of a regimen that is usually effective in minimizing recurrence.