Proctocolectomy - Indications and Complications

Introduction:

The large intestine is a tube-like, hollow organ responsible for water absorption from food residuals in humans. It has four parts: the cecum, colon, rectum, and anal canal. It also acts as a passage for the waste to pass through the anus. This waste is called stool and gets stored in the rectum. Sometimes, the colon is used interchangeably with the large intestine.

There are various colon diseases, such as colon cancer and colon polyps. Ulcerative colitis is the inflammation of the large intestine. However, there is no complete cure for this condition. Therefore, surgical removal of the colon and rectum is considered the best choice of treatment, which is called proctocolectomy. Proctocolectomy is a two or three-staged procedure that includes ileostomy in the initial stage. A J-shaped pouch is created to carry out the normal excretion process through the anus.

What Is Proctocolectomy?

It is the surgical removal of the colon (the large intestine’s longest part that connects the small intestine and the anus) and rectum (the end part of the colon connected with the anus). It is the standard gold treatment for patients who have ulcerative colitis (an inflammatory bowel disease that causes inflammation in the large intestine's inner lining (submucosa and mucosa).

What Are the Types of Proctocolectomy?

Several types of proctocolectomy are as follows:

1. Total Proctocolectomy: The surgeon will surgically remove the colon, rectum, and anus. There will be no presence of the intestine. The surgeon may make another pathway for the poop to come out.

2. Restorative Proctocolectomy With Ileal Anal Pouch: The doctor will adopt this type of proctocolectomy if the ileum and anus both are in good health. The surgeon will form a J-shaped pouch in the ileum and connect it with the anus. This is done so that the poop can come out.

3. Proctocolectomy With Permanent Ileostomy: This type is adopted due to the presence of complications. The doctor will surgically remove the rectum, anus, and colon and form a J-shaped pouch in the ileum.

4. Subtotal Proctocolectomy: This type is indicated in case of ulcerative colitis. The surgeon will surgically remove the major portion of the colon and rectum, leaving behind some part of them.

What Are the Indications and Contraindications of Proctocolectomy?

The possible indications of proctocolectomy are as follows:

• Inflammatory Bowel Disease: Proctocolectomy is commonly indicated as a treatment method for patients suffering from ulcerative colitis and Crohn’s disease or people who do not respond to treatment like medications. The indications for proctocolectomy are medication intolerance, cancer, dysplasia, and complications like perforation or bleeding.

• Colorectal Cancer: The surgical removal of the colon and rectum is indicated in the case of colorectal cancer. The procedure is advised when the tumor is large enough and invades the surrounding areas.

• Familial Adenomatous Polyposis: In this condition, multiple polyps are present in the colon area. To remove the polyps, proctocolectomy is indicated so that it does not progress to colorectal cancer.

• Complications: Proctocolectomy is indicated in an individual with severe colon and rectal trauma, severe infection, bleeding, and perforation.

• Intractable Symptoms: Symptoms such as constipation and diarrhea will reduce the individual's quality of life.

Contraindications - Contraindications for proctocolectomy include individuals with active perianal infections, those concerned about the risk of sexual dysfunction or infertility, individuals with weak anal sphincter, and those wishing to preserve anal sphincter function.

What Occurs Before Undergoing a Proctocolectomy?

1. Several Weeks Before the Procedure -

• Discuss the proctocolectomy with the doctor.

• Explore different types of proctocolectomy and their risks and benefits.

2. Two Weeks Before Proctocolectomy -

• Reduce or stop blood-thinning medications.

• Maintain intestinal health by consuming fiber-rich foods and staying hydrated.

3. 24 Hours Before Proctocolectomy -

• Undergo a bowel prep to clear out the intestines.

• Follow a clear, liquid diet.

• Possibly receive preventative antibiotics to prevent infection.

What Is the Procedure of Proctocolectomy?

The surgeon will surgically move out the colon and rectum through several surgical approaches. The surgical approaches include laparoscopic surgery, open surgery, and robotic-assisted surgery. The surgeon will prepare the patient and tell them about the whole procedure. The steps of proctocolectomy are as follows:

• Patient Preparation: The patient will be given a hospital gown. The healthcare professional will place an intravenous catheter to introduce fluids and medications.

• Anesthesia: The surgeon will inject an anesthetic solution. Ensure that the patient is unconscious.

• Incision: The surgeon will make a larger incision in the abdomen in case of open surgery. In the case of laparoscopic and robotic-assisted surgery, the doctor will make a smaller incision to insert a camera.

• Mobilization of Internal Structures: The surgeon will mobilize the internal organs like the colon and rectum by preserving the blood vessels and surrounding tissues.

• Resection: The surgeon will surgically take out the affected colon and rectum. Special care should be taken for the anal sphincter because an individual has to poop through the anus.

• Ileostomy or Anastomosis: The steps taken depending on the specific planned procedure are as follows:

  1. Proctocolectomy With Ileal Pouch Anal Anastomosis (IPAA) - Because the colon is removed, the normal process or passage for excretion of the stool cannot occur. Therefore, a J-pouch is created internally to bypass the colon and carry out normal excretion through the anus. It is also called J-pouch surgery. The diseased part of the colon and rectum is removed. A J-shaped pouch is created at the end of the large intestine. Initially, a temporary loop ileostomy is performed to allow the healing of the J-pouch. Once the J-pouch is healed, the temporary ileostomy is closed or reversed. The normal excretion of the stool and other waste takes place through J-pouch.

  2. Proctocolectomy With End Ileostomy - The colon, rectum, and anus of the patient are removed surgically. An end ileostomy is performed, which is permanent and stays for a lifetime.

• Closure and Recovery: The surgeon will close the incision by using sutures. In the abdomen, the temporary drainage tube is placed to drain excess fluid.

• Postoperative Care: It includes pain management, complications monitoring, and overall health.

How Does Stool Pass After a Proctocolectomy?

After a proctocolectomy, the usual path for poop through the intestines and out of the body is changed. Those who have undergone this procedure wonder how to poop without a colon and rectum. The method depends on the type of proctocolectomy one had, which is determined by their condition and the reason for the surgery.

What Measures Are Taken for Proctocolectomy Follow-up Care?

1. Wound Care: The patient will receive instructions from the doctor on how to clean and change the dressing daily.

2. Ostomy Care: The patient will be taught how to empty their ostomy bag several times a day and how to clean the skin around the stoma to prevent irritation.

3. Diet: After leaving the hospital, gradually reintroduce harder foods into the diet. Pay attention to any gastrointestinal symptoms caused by certain foods and avoid them if necessary. Eating smaller, more frequent meals and chewing thoroughly can aid digestion as the bowels recover.

4. Hydration: Staying hydrated is crucial after this procedure. With much of the large intestine removed, the body will not absorb water as efficiently through it. Since the stool from the ileum and upper colon is loose, one will lose more water and electrolytes. Consider supplementing water intake with electrolyte drinks.

What Are the Complications of Proctocolectomy?

The possible complications are:

• Inflammation of the J-pouch.

• Diarrhea.

• Pain in the abdomen.

• Fever.

• Dehydration.

• Fistula formation is an abnormal connection between the structures or organs.

When to Seek Medical Care?

Consult a doctor immediately if signs of an intestinal blockage include constipation, cramps, bloating, and nausea. Indications of internal or external infection (abdominal discomfort, swelling, discharge, and fever) may be present.

Conclusion:

The inflammation of the large intestine (ulcerative colitis) is best treated with proctocolectomy, a surgical procedure to remove the large intestine or colon and the rectum. The proctocolectomy is a two or three-staged procedure that initially includes ileostomy. Next, a J-shaped pouch is created internally to carry out the normal excretion process through the anus. This eliminates the need to create an external opening in the abdomen (stoma) and place a pouch to collect waste.