Thoughtful Ileostomy Creation in Patients Undergoing Redo IPAA

Abstract

INTRODUCTION: Redo IPAA is a viable option to maintain intestinal continuity in patients with ileal pouch failure. Most patients with ileal pouch failure are physiologically and psychologically too deconditioned to undergo a 1- or 2-stage redo ileal pouch surgery, so a 3-staged redo ileal pouch surgery is needed. This consists of an initial proximal diverting loop ileostomy for 6 months, followed by redo ileal pouch construction with temporary stoma, and, lastly, stoma closure. The location of the initial diverting ileostomy is paramount, because 40% of cases will require pouch excision and construction of a de novo pouch, and a thoughtfully placed ileostomy will allow construction of a redo pouch without sacrificing any bowel length. In our report, we described our technique to create thoughtful ileostomy in patients who undergo redo IPAA. TECHNIQUE: We create a loop ileostomy ≈20 cm proximal to the existing ileal pouch, from the level of the tip of the J or the proximal inlet of an S-pouch. We call this a thoughtful ileostomy. By doing that, the thoughtful ileostomy site can be used as the apex of the new ileal pouch and become the ileal-anal anastomosis when a de novo ileal pouch needs to be constructed. RESULTS: We created a thoughtful ileostomy in 50 patients in the Inflammatory Bowel Disease Center at New York University Langone Health who either subsequently underwent or will undergo a redo IPAA between September 2016 and March 2019 (laparoscopic, n = 37; open, n = 13). Ten of the laparoscopic cases were preemptively converted to open because of dense adhesions. CONCLUSION: A thoughtful ileostomy is important so as to not sacrifice bowel in patients being prepared for redo ileal pouch surgery. Initial diversion with thoughtful ileostomy 6 months before redo ileal pouch construction also allows patients to be prepared for a major operation both physiologically and psychologically.

Operative, long‐term and quality of life outcomes after salvage of failed re‐do ileal pouch anal anastomosis

“…Patients undergo a diverting loop ileostomy (laparoscopic if feasible) and remain diverted for at least 6 months to enable their recovery physically and mentally before re‐do IPAA construction. The diverting loop ileostomy is placed 20 cm proximal to the J‐pouch inlet; this enables the ostomy aperture to be used as the apex of the new pouch if needed without any further bowel loss [7].…”

Management of the Hostile Abdomen

“…Upstream diversion can cool off a diseased segment of bowel or an area of chronic sepsis, thereby improving the quality of the tissues and increase the patient's quality of health and life prior to full exploration. 22 Creation of a diverting ostomy in a hostile abdomen can be quite tough to achieve. One way to safely attempt this is to access the abdomen in the upper midline or in the left upper quadrant close to the location of the duodenal-jejunal flexure.…”

Management of Anastomotic Leaks in Ileal Pouch Anal Anastomosis for Ulcerative Colitis

“…Schwartzberg et al describe a "thoughtful ileostomy" in which a loop ileostomy is formed approximately 20 cm proximal from the J-pouch edge that then serves as the apex for a new ileal pouch when the redo anastomosis is formed. 21…”