Proctocolectomy and ileostomy to pouch surgery for ulcerative colitis.

The development of continence-preserving and sphincter-preserving procedures for operation of ulcerative colitis has a long and interesting history. Reported clinical results on the continent ileostomy (Kock pouch) and the pelvic pouch procedure have often been enthusiastic; and when confronted with the options patients have mostly been in no doubt in selecting "the best operation." However, even if the continent ileostomy and subsequently restorative proctocolectomy were great innovations, it is by no means obvious that they should be recommended as the first choice for all patients. For patients old enough to join in a responsible discussion the pros and cons of the various operations available today must first be carefully described and a decision reached that reasonably meets the patient's wishes and that seems to the surgeon to be soundly based. When comparing the postoperative morbidity, long-term outcome, and quality of life assessment of the options, such a decision is in fact far from easy. Thus panproctocolectomy and ileostomy for ulcerative colitis can be considered a comparatively safe, predictable operation that can cure the patient and allow a short hospital stay, a quick recovery, and rehabilitation. It should also enable the patient to be free of hospital supervision after a year or so. Although there is a major change in body image and sexual disturbances may occur, the operation is in fact still the yardstick by which the other options should be compared. Despite the great attraction of rectum- and sphincter-preserving operations, there will always be patients for whom panproctocolectomy and a conventional end-ileostomy is the superior alternative. The ileal pouch operations are technically demanding and should probably best be restricted to specialist centers even in the future. Complications, if they arise, are often serious, and the hospital stay is often counted in weeks. The functional result may be good, but defects in continence are common and sexual dysfunction is a problem for many of these patients. The pouchitis syndrome is a great disappointment, and recent reports on subsequent epithelial dysplasia and even development of cancer are alarming. The long-term results are in this respect still uncertain. Careful patient selection, with full discussion with the patient and his or her family are essential before a decision on a continent ileostomy or a pelvic pouch is reached. Strong motivation toward avoidance of a conventional ileostomy is important. When compared with the imperfect functional results and the high morbidity associated with the pelvic pouch procedure, there is at present a great revival of interest for total colectomy with ileorectal anastomosis. It is still a useful operation and should be seriously considered particularly in the young. The functional results are comparatively good. Sexual function is well preserved. The use of the operation may enable the teenager to regain good health and finish education and family planning. Due to the cancer risk the need for subsequent supervision must be made clear, however. The operation may also be valuable in elderly patients who would be much bothered by an ileostomy and who are unlikely to live long enough for carcinoma to become a problem. The great advantage is that should a failure occur the other options remain.