Retocolectomia total e anastomose íleo-anal com reservatório ileal: experiência de 16 anos

Total rectocolectomy and ileoanal anastomosis with ileal reservoir: experience of 16 years

ARTIGOS ORIGINAIS

Retocolectomia total e anastomose íleo-anal com reservatório ileal - experiência de 16 anos

Total rectocolectomy and ileoanal anastomosis with ileal reservoir - experience of 16 years

Juvenal Ricardo Navarro Góes, TCBC-SP^I; João José Fagundes, TCBC-SP^I; Claudio Saddy Rodrigues Coy^I; Maria de Lourdes Setsuko Ayrizono^II; Raul Raposo de Medeiros, TCBC-SP^III; Luis Sérgio Leonardi, TCBC-SP^IV

^IProfessor Assistente Doutor

^IIMédico do Hospital das Clínicas, Faculdade de Ciências Médicas

^IIIProfessor Associado

^IVProfessor Titular

^{Endereço para correspondência}

RESUMO

O reservatório ileal pélvico tem sido a melhor opção cirúrgica para a retocolite ulcerativa (RCU) e polipose adenomatosa familiar (PAF). Desde 1983 esta técnica vem sendo empregada, e o objetivo deste trabalho é apresentar revisão desta casuística, analisando seus resultados e seus pontos controversos. Setenta e três pacientes, com média de idade de 34,6 (13-63) anos e com predomínio do sexo feminino (42 pacientes, 56,7%) se submeteram ao procedimento para tratamento de RCU (46 pacientes - 63,0%) e PAF(27 - 37,0%). Foram utilizadas as seguintes variantes técnicas: em S, de grande tamanho e ramo eferente longo (oito); em S pequeno e ramo eferente reduzido (22); em "dupla câmara" (20); em J (23). Todos os procedimentos foram seguidos da construção de ileostomia de proteção. De 1993 em diante, todos os pacientes tiveram a arcada do colo direito preservada. Setenta pacientes têm pelo menos um ano de pós-operatório e 61 têm dois anos ou mais com média de 7,01 (1-16) anos. Foram consideradas complicações precoces aquelas que ocorreram até o 30º dia de pós- operatório e tardias, após esse tempo. Resultados funcionais foram analisados após um ano do fechamento da ileostomia. Ocorreram 35 complicações precoces em 22 pacientes e 39 complicações tardias em 35 pacientes. Vinte e cinco pacientes não apresentaram complicações. As principais complicações foram: obstrução intestinal (19,1 %), fistulizações cutâneas, com vagina ou trato urinário (10,9%), isquemia de reservatório (parcial ou total), (9,5%), e ileíte do reservatório (pouchitis) (6,8%). Nove pacientes (12,3%) têm ileostomia funcionante, sendo que sete pacientes têm ainda o reservatório mantido no lugar e dois tiveram-no ressecado. A mortalidade diretamente relacionada ao procedimento foi em dois pacientes, mas outros quatro pacientes evoluíram tardiamente ao óbito, por causas como desnutrição crônica e tumor de cerebelo. Em conclusão, apesar da morbidade e da existência ainda de questões controversas, as perspectivas tardias têm sido animadoras e têm estimulado a indicação deste tipo de procedimento.

Unitermos: Anastomose íleo-anal; Reservatório ileal; Retocolite ulcerativa, tratamento cirúrgico; Polipose adenomatosa familiar, tratamento cirúrgico.

ABSTRACT

The treatment of choice for ulcerative colitis (UC) and familial adenomatous polyposis (FAP) has been the ileoanal anastomosis with ileal reservoir following total rectocolectomy. This procedure has been used since 1983 and the purpose of this study is to review the results of this series and to analyse the controversial points related to the procedure. Seventy- three patients - mean age 34.6 (13-63) years,female 42 patients (56,7%) - were submitted to the procedure to treat UC (46 patients - 63.0%) and FAP (27% -37,0%). The techniques utilized were: large S and long efferent limb (eight); short S and short efferent limb; "two-chamber”(20); J (23). All the procedures performed were protected by loop ileostomy. Since 1993, all colectomy is performed preserving the right colon marginal vascular arcade. Seventy patients have at least one year of postoperative time and 61 have two years or more (mean 7.01 (1-16) years) Early complications were considered when present until the 30th postoperative day and late complications when diagnosed after this time. Functional results were analysed after the first postoperative year following ileostomy closure. Thirty-five early complications occurred for 22 patients and 39 late complications, for 35 patients. Twenty-five patients did not have any complication related to the procedure. The most frequent complications were: intestinal obstruction (19.1%); fistulization (cutaneous, vaginal, or urinary tract) (10.9%), reservoir ischemia (partial or total)(9.5%), and pouchitis (6.8%). Nine patients (12.3%) have working ileostomy: seven with defunctioned reservoir kept in place and two after reservoir excision). Mortality related to the procedure occurred for two patients, however four others died lately by general causes as malnutrition and tumor of the cerebellum. Functional results were analysed in 58 patients and good day and night continence were present for the majority of the patients (95.0% and 90.0%, respectively). Mean daily bowel movements were: min 4.1 and max 5.7 (ranging 1 - 12); mean nightly bowel movements were: min 0.4 and max 1.2 (ranging O - 4). In conclusion, in spite of the morbidity and remaining controversial points, long term fuctional results has lead good expectation with the procedure and has encouraged its indication.

Key words: Ileoanal anastomosis; Ileal reservoir; Ileal pouch; Ileal pouch-anal anastomosis; Ulcerative colitis, surgery; familial adenomatous polyposis, surgery.

Texto completo disponível apenas em PDF.

Full text available only in PDF format.

Recebido em 30/7/99

Aceito para publicação em 06/12/99

Trabalho realizado na Disciplina de Moléstias do Aparelho Digestivo Grupo de Coloproctologia Faculdade de Ciências Médicas - Universidade Estadual de Campinas – UNICAMP.

• 1. Goes JRN, Medeiros RR, Fagundes JJ. Colectomia total, procto- mucosectomia e anastomose íleo-anal com reservatório ileal. Rev Bras Colo-Proct 1984;4(3):138-139.
• 2. Góes JRN, Fagundes JJ, Medeiros RR, et al. Total colectomy, proctomucosectomy and ileal pouch. Analysis of cases with more than one year after ileostomy closure. Dig Dis and Sci 1986; 31 (10)(Suppl.):444-445.
• 3. Parks AG, Nicholls RJ. Proctocolectomy without ileostomy for ulcerative colitis. Br Med J 1978;2:85-8.
• 4. Góes RN, Fagundes JJ, Coy CSR, et al. The two-chamber ileal pelvic reservoir - an alternative design. Dis Colon Rectum 1993;36:403-4.
• 5. Góes RN, Nguyen P, Huang D, et al. Lengthening of the mesentery using the marginal vascular arcade of the right colon as the blood supply to the ileal pouch. Dis Colon Rectum 1995;38:893-5.
• 6. Vasilevsky CA, Rothenberger DA, Goldenberg SM. The ileal S pouch- anal anastomosis. World J Surg 1987;11:742-750.
• 7. Nicholls J, Pescatori M, Motson RW, et al. Restorative proctocolectomy with a three-loop ileal reservoir for ulcerative colitis and familial adenomatous polyposis. Clinical results in 66 patients followed for up to 6 years. Ann Surg 1984;199:383-8.
• 8. Wexner SD, Wong WD, Rothenberger DA, et al. The ileoanal reservoir. Am J Surg 1990;159:178-185.
• 9. Becker JM. Ileal pouch-anal anastomosi: current status and controversies. Surgery 1993; 113 :509-602.
• 10. Fazio VW, Ziv Y Church JM, et al. Ileal pouch-anal anastomoses. Complications and Fuction in 1005 patients. Ann Surg 1995;222: 120- 127.
• 11. Habr-Gama A, Teixeira MG, Brunetti-Netto C,et al. Restorative proctocolectomy with ileo-anal J pouch anastomosis for treatment of ulcerative colitis. Arq Bras Cir Dig 1992;7:72-8.
• 12. Kiss DR Vilarino TC, Almeida MG. Tramento cirúrgico da retocolite ulcerativa e da polipose cólica familiar pela proctocolectomia com anastomose de reservatório ileal em J ao canal anal, com e sem mucosectomia retal. Rev bras Colo-Proct 1991;11:131-41.
• 13. Poggioli G, Marchetti F, Selleri S, et al. Redo pouches: salvaging of failed ileal pouch-anal anastomoses. Dis Colon Rectum 1993; 36: 492-6.
• 14. Foley EF, Schoetz DJ, Roberts PL, et al. Rediversion after ileal popch- anal anastomosis. Causes of failures and predictors of subsequent pouch salvage. Dis Colon Rectum 1995;38:793-8.
• 15. Sagar PM, Dozois RR, Wolff BG. Long-term results of ileal pouch-anal anastomosis in patients with Crohn's disease. Dis Colon Rectum 1996; 39:893-8.
• 16. Smith L, Friend WG, Medwell SJ. The superior mesenteric artery: the critical factor in the pouch pull-through procedure. Dis Colon Rectum 1984; 27:741-4.
• 17. Browning SM, Nivatvongs S. Intraoperative - abandonment of ileal pouch to anal anastomosis. The Mayo Clinic esperience. J Am Coll Surg 1998;186:441-5.
• 18. Chun HK, Smith LE, Orkin BA.Intraoperative reasons for abandoning ileal pouch-anal anastomosis procedures. Dis Colon Rectum 1995; 38:273-5.
• 19. Cherqui D, Valleur P, Perniceni T, et al. Inferior reach of ileal reservoir in ileal anal anastomosis: experimental anatomic and angiographic study. Dis Colon Rectum 1987;30:365-71.
• 20. Thrilby RC. Optimizing results and techniques of mesenteric lengthening in ileal poch-anal anastomosis. Am J Surg 1995;169:499-502.
• 21. Stahlberg D, Gullberg K, Liljeqvist L, et al. Pouchitis following pelvic pouch operation for ulcerative colitis. Dis Colon Rectum 1996; 39:1012-8.
• 22. Goes JRN, Fagundes JJ, Coy CSR, et al. Re-reservatório ileal pélvico. Reconstruçăo e reanastomose de reservatório ileal após insucesso da primeira cirurgia. Rev Bra Colo-Proct 1997;17:117-121.
• 23. MacRae HM, McLeod RS, Cohen Z, et al. Risk factors for pelvic pouch failure. Dis Colon Rectum 1997;40:257-262.
• 24. Schoetz DJ, Coller JA, Veidenheimer MC. Can the pouch be saved? Dis Colon Rectum 1988;31:671-5.
• 25. Galandiuk S, Scott NA, Dozois RR, et al. Ileal pouch-anal anastomosis reoperation for pouch related complications. Ann Surg 1990;212: 446-54.
• 26. Marcello PW, Schoetz DJ, Roberts PL, et al. Evolutionary changes in the pathologic diagnosis after ileoanal pouch procedure. Dis Colon Rectum 1997;40:263-269.
• 27. McIntyre PB, Pemberton JH, Beart RWJr, et al. Double-staple vs. Handsewnileal pouch-anal anaswtomosis in patients with chronic ulcerative colitis. Dis Colon Rectum 1994;37:430-433.
• 28. Kelly KA. Anal sphincter-saving operations for chronic ulcerative colitis. Am J Surg 1992;163:5-11.
• 29. Goes RN, Coy CSR, Amaral CA, et al. Superior mesenteric artery syndrome as a complication of ileal pouch-anal anastomosis. Dis Colon Rectum 1995;38:543-4.
• 30. Deen KI, Hubscher S, Bain I, et al. Histological assessment of the distal doughnut in patients undergoing stapled restorative proctocolectomy with high or low anal transection. Br J Surg 1994;81:900-903.
• 31. Johnston D, Holdsworeth PJ, Nasmyth DG, et al. Preservation of the entire anal canal in conservative proctocolectomy for ulcerative colitis. Br J Surg 1986;73:571-2.
• 32. Luukkonen P, Jarvinen H. Stapled vs. hand-sutured ileoanal anastomosis in restorative proctocolectomy. Arch Surg 1993;128:437-40.
• 33. Seow-Choen A, Tsunoda A, Nicholls RJ. Prospective randomized trial comparing anal function after handsewn ileoanal anastomosis with mucosectomy versus stapled ileoanal anastomosis without mucosectomy in restorative proctocolectomy. Br J Surg 1991 ;78: 430-4.
• 34. Thompson-Fawcett MW, Mortensen NJMcC. Anal transitional zone and columnar cuff in restorative proctocolectomy. Br J Surg 1996; 83:1.047-1.055.
• 35. Tsunoda A, Talbot IC, Nicholls RJ. Incidence of dysplasia in the anorectal mucosa in patients having restorative proctocolectomy. Br J Surg 1990;77:506-508.
• 36. Lavery IC, Sirimarco MT, Ziv Y, et al. Anal canal inflammation after ileal pouch-anal anastomosis. The need for treatment. Dis Colon Rectum 1995;38:803-6.
• 37. Slors JFM, Ponson AE, Taat CW, et al. Risk of residual rectal mucosa after proctocolectomy and ileal pouch anal reconstruction with the double stapling technique. Dis Colon Rectum 1995;38:207-210.
• 38. Sagar PM, Taylor BA. Pelvic ileal reservoirs: the options. Br J Surg 1994;81:325-332.
• 39. Sugarman HJ, Newsome HH, DeCosta G, et al. Stapled ileoanal anastomosis for ulcerative colitis and familial polyposis without a temporary ileostomy. Ann Surg 1991;213:606-17.
• 40. Goes R, Beart RW Jr. Physiology of ileal pouch-anal anastomosis. Current concepts. Dis Colon Rectum 1995:38:996-1005.

Endereço para correspondência:

Juvenal Ricardo Navarro Góes

Rua Antonio Augusto de Almeida 37

13084-070 - Cidade Universitária Campinas - SP

Datas de Publicação

• Publicação nesta coleção
  31 Jul 2009
• Data do Fascículo
  Fev 2000

Histórico

• Aceito
  06 Dez 1999
• Recebido
  30 Jul 1999