Purpose: To establish the impact of diverting loop ileostomy on
perioperative complications, length of hospitalization, and patient satisfaction
following a stapled ileoanal J pouch procedure for ulcerative colitis or
familial polyposis.
Methods: We reviewed records of a 120 consecutive patients treated with
double stapled ileoanal J pouches for ulcerative colitis (113) or familial
polyposis (7) from 1990 to 1995. Patients in group I (n=54) were treated with
double stapled J pouches and diverting loop ileostomies; 25/54 (46%) of group I
patients had a mucosectomy. As a result of a change in surgical treatment
policy, consecutive patients in group II (n=66) were treated with stapled
ileoanal anastomoses without diverting ileostomy. Six group II patients required
an ileostomy at initial operation because of concern for potential anastomotic
leak; these patients were not included in this review. Quality of life surveys
were sent to all patients with a 67% response rate. Unpaired student's t test
was used for statistical comparison.
Results: Groups I and II were statistically comparable in age (mean 42 vs
37), duration of disease (12 vs 10 years) and indication for operation. However,
fewer group I patients had undergone colectomy prior to the ileoanal procedure
and a larger percentage of them were on greater than 20 milligrams of prednisone
per day (40 vs 21 percent). Average follow-up was 5 vs 3 years for groups I and
II respectively. Number of days hospitalized for the ileoanal procedure was
significantly longer for group I patients (mean 11.4, range 8-26) than group II
patients (mean 10. range 7-18, p<0.05). Group I patients had a longer
duration of operation (3.5 vs 3 hours, p<0.05), and more intraoperative blood
transfusions (0.2 vs 0.02 units, p<0.05). There were no significant
differences between groups I and II in number of early complications exclusive
of ileus (33 vs 18 percent), number of late complications (33 vs 33 percent),
subsequent operations exclusive of ileostomy takedown (0.55 vs 0.50 per
patient). or subsequent hospital days (5.2 vs 3.9). Group I patients had less
postoperative ileus (7 vs 39 percent, p<0.05). Groups I and II had leak rates
of 11% and 5%; and pouch excision rates of 11% and 5% respectively. There were
no differences in survey response rates, frequency of stools, general health
scores, or overall patient satisfaction in those responding to the survey.
Conclusion: Restorative proctocolectomy with double stapled ileoanal
anastomosis without a diverting loop ileostomy is a safe operation. Patients
without ileostomies experienced longer ileus, but with no prolongation of
hospitalization. Patients without diverting ileostomies did not have higher
rates of late complications, pouch excision or dissatisfaction. We conclude that
diverting loop ileostomy is not necessary when performing a restorative
proctocolectomy.
