An ileoproctostomy or an ileostomy? - Forum

Priya

An ileoproctostomy or an ileostomy? - Ärzteforum

Post#1 »

I would like to ask a simple question about your recommendations to the
following patient...( he happens to be my father-in-law). He is an 81 year
old man who is fairly healthy (no chronic illnesses, no meds...one operation
in the past which was a cholecystectomy that resulted in a roux -y- bypass to
his left hepatic bile duct which was injured in the process with no sequelae).
He has a biopsy proven rectosigmoid cancer at 18 cm and was found to have
several other polyps. I have been told several have been removed from the
descending and transverse colon. There remains a 3 cm sessile polyp in his
proximal transverse colon and a very large polypoid one in his cecum which was
biopsied negative but according to the endoscopist looked worrisome. He is
scheduled for a subtotal colectomy. Would you advise him to have an
ileoproctostomy or an ileostomy? I feel I am too biased to give him an
objective opinion. As you would expect, he has chosen the first choice so
far.


User avatar
Surgeon

Re: An ileoproctostomy or an ileostomy? - Ärzteforum

Post#2 »

Ileosigmoidostomy with anastomosis at about 25-35 cm level.

User avatar
A Doctor

Re: An ileoproctostomy or an ileostomy? - Ärzteforum

Post#3 »

I can't see any reason for an ileostomy--why would you NOT do an
ileoproctostomy? If you did a small bowel resection would you reanastomose or
pull out an ostomy? If you did a gastric resection, would you reanastomose or
pull out a gastrostomy? Certainly there is no reason to remove the rectum if
that is what you are asking, in the absence of any rectal disease. If you are
worried about this old wives tale of intractable diarrhea with ileoproctostomy
which I've seen pop up on this list every so often, well I guess you haven't
done many or you would know it is not true.

Proctologist

Re: An ileoproctostomy or an ileostomy? - Ärzteforum

Post#4 »

With all due respect the cancer is at 18 cm in front of the promontory.
The ileorectal anastomosis will have to be at about 12-14 cm. Don't trade
oncology for function unless it is of no consequence.

With such a low ileorectal anastomosis it is likely the patient will have
multiple loose stools. If he is in good condition, has a good sphincter,
no rectal dysmotility, and is prepared to take a chance an IRA might be
good. If it does him no good he will have to accept a new operation
(ileostomy).

For myself I would probably choose the ileostomy. Or ask the surgeons to
spare the colon.

User avatar
Oncologist

Re: An ileoproctostomy or an ileostomy? - Ärzteforum

Post#5 »

The 18 cm' from anal verge mentioned by the endoscopist may at operation
turn to anything between 10-30 cm'- during the scope they push, pull and
distort everything.

So I would operate with the plan to do a ileorectal anatosmosis above the
peritoneal refelction-this will give him 3-5 bowel motions a day.

Now what to do if the lesion is lower -requeiring a lower anastomosis?
it will be possible to spare 3-4 cm' of the cecum - cross stapel it below
the poplyp -and use it for the ceco-rectal anastomosis. A preserved
Ileo-cecal valve will make him function better.

Ileostomy- do not see a reason!

Gaster

Re: An ileoproctostomy or an ileostomy? - Ärzteforum

Post#6 »

I did not appreciate from the review that there was carcinoma at the 18 cm level. I would probably advise an ileostomy.

User avatar
Alalo

Re: An ileoproctostomy or an ileostomy? - Ärzteforum

Post#7 »

Generally person with ileo-rectal anastomosis will have 3-5 loose stools for
the rest of his life. Usually it is well tolerated.
I do not see the reason not to attempt ileo-rectal anastomosis, u nless he is
represantative of AFP family. Then, pelvic pouch -anal anstomosis is
preferable to eliminate mucosa at-risk.

Sojer

Re: An ileoproctostomy or an ileostomy? - Ärzteforum

Post#8 »

The important point is the length of the rectal stump. If it is really low enough so that rectal urgency may be a problem (less than 10cm) adding ileal inflow at that level COULD be a big problem. Despite Erics thoughts that "diarrhoea" is exaggerated, some pts DO have disability, particularly relatives of physicians. I have done double colectomies (Rt and Ant Res) with no regrets, good function on a few older pts., although if the rectal stump is long enough to provide capacitance, I'd go with subtotal ileo-rectal.

User avatar
Doctor Green

Re: An ileoproctostomy or an ileostomy? - Ärzteforum

Post#9 »

If he still has reasonable anorectal function and continence (history,
digital, perhaps a 100-150ml enema test) then I would suggest IRA. If
his continence is already impaired he won't be happy with "loose
stools".

User avatar
A Doctor

Re: An ileoproctostomy or an ileostomy? - Ärzteforum

Post#10 »

I continue to disagree with this idea of some substantial level of
disability fro diarrhea with IRA--I am aware of no studies
documentingt this disability to any significant extent, nor of any
that correlate the lenght of the rectal stump with the probability of
it happening. I've done innumerable low rectal anastomoses of ileum,
including ileoanal pouches over the past 20 years, and have had no
lasting probelems beyond a few weeks from surgery, and even those
that had diarrhea were mild or very short-lived before solid stool
formed--and I can't believe our population here is any different from
elsewhere--I've done handsewn as well as stapled without difference
to my recollection--of course this is anecdotal, but I get the
impression that YOUR claim also is quite anecdotal--so please educate
me, -
What do you mean by "some" patients get diarrhea? What percentage?
For how long postop? How disabling? What percentage have to have an
ileostomy after IRA for disabling diarrhea? What specific length of
rectal stump dictates disabling diarrhea requiring ileostomy? If you
can't answer these questions (as I don't believe you can) then I
would be wary of burdening a patient with a lifelong stoma on the
basis of conjectured hearsay--if you can answer, please provide the
source? Clearly this is one of those areas in which the proper
studies have not been done to provide conclusive answers, in which
case I would propose that the default position should be the standard
one--anastomose rather than stoma, just as you would with the stomach
, small bowel or other parts of the colon, for which there are also
no studies documenting this is better than stoma, but where we have
no question that anastomosis is best!

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