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| Surgical Procedures for People With FAP or HNPCC
by Peggy Conrad,
MS, CGC and Jonathan
a person with FAP
(familial adenomatous polyposis) or HNPCC
(hereditary nonpolyposis colorectal cancer), you may
one day need to consider having your large bowel (colon)
removed either to prevent cancer
from developing or to remove a cancer that has already
occurred. While many people assume that removal of the
colon means the loss of bowel control and therefore
the need for a colostomy bag or ileostomy bag (essentially,
a waste collection bag attached to the patient's abdomen)
this is not necessarily the case today. The following
describes the three most common surgical procedures
for removing the colon.
is important to note that the majority of studies on
these procedures have been done with FAP patients. However
these procedures are all also options for patients with
reading to learn about the advantages and disadvantages
of each procedure, but be aware that this article contains
very graphic anatomical and surgical details.
Total Abdominal Colectomy with Ileorectal Anastomosis
abdominal colectomy with ileo-rectal Anastomois
(IRA): The shaded area shows the colon, which
is surgically removed. A surgical attachement
(anastomosis) is then made between the rectum
and the lowest part of the small bowel (the ileum).
Patients are able to have bowel movements through
the rectum and anus, as they did before the surgery.
(called IRA for short) the colon is removed,
but the rectum
is left intact, allowing the small bowel to be attached
directly to it. The procedure usually requires a five-
to seven-day hospital stay. A full recovery with resumption
of all regular activities usually takes from three to
six weeks. The advantages of this procedure include
complications: Although IRA does carry
with it the risk of major complications such
as infection or separation of the connected bowel
sections (which would necessitate further surgery
to repair) they are relatively infrequent,
occurring in only approximately two to three percent
of such cases.
of bowel control:
Because this procedure leaves the rectum in place,
patients retain control over their bowel function.
For many people this is a significant physiological
and psychological advantage. After fully recovering
from the procedure, the average patient will have
three to five soft bowel movements per day, but problems
with bowel control are rare.
what many consider to be this procedure's biggest advantage
the fact that it leaves the rectum intact
is also what accounts for its primary drawback: the
patient remains at risk for developing cancer of the
rectum. For this reason, the National Comprehensive
Cancer Network recommends that post-operative IRA patients
who have FAP continue to be screened via sigmoidoscopy
every six months for at least the first three years
following surgery. After that, patients would follow
an individualized screening regimen, which would be
determined by whether or not they had developed rectal
polyps during this period.
is important to remember that even with continued intensive
screening, studies show that 15 percent of FAP patients
who have had this surgery will develop cancer of the
rectum at some point in the 25 years following the procedure.
IRA procedure is an attractive option for people with
HNPCC who chose to have a colectomy
because their risk of rectal cancer is lower than the
risk for people with FAP.
Proctocoloectomy with Ileal Pouch Anal Anastomosis (IPAA)
proctocolectomy with ileal pouch anal anastomosis
(IPAA): At the time of the initial surgery the
colon, rectum, and part of the anus are removed.
The ileum is then usually cut into two segments
(A and B), and diverted so that it empties through
an ileostomy in the bowel wall. After the lower
part of the ileum heals into an artificial pouch
(C), a second surgery is performed to get rid
of the ileostomy and reconnect the segments of
ileum (A and B). Waste then passes through the
entire ileum and is excreted through the anus.
The ileum is sewn into a pouch (C) that can hold
stool like an artificial rectum after it heals.
this increasingly popular procedure (called IPAA for
short) has been performed since the early to mid-l980s.
In an IPAA, the colon and rectum are removed and a portion
of the small bowel is used to make a pouch that can
store feces and function like an artificial rectum.
Like the IRA, this procedure usually requires a five-
to seven-day hospital stay. However, full recovery generally
takes longer. Patients may not have optimal bowel function
until three to six months after the procedure has been
primary advantage of this technique is that the risk
for both rectal and colon cancer is decreased dramatically
while leaving the patient in control of his or her bowel.
Not surprisingly, however, the procedure carries with
it disadvantages as well:
the IPAA procedure is more complicated and thus technically
more challenging than the IRA procedure, it carries
a greater rate of major complications such as infection,
separation of the connected bowel section, or failure
of the pouch to heal so that it never functions (reported
in approximately three to six percent of IPAA procedures,
as compared to two to three percent of IRA procedures).
To reduce this risk of complications, many surgeons
will insist that a temporary ileostomy be created
until the pouch has healed which means a patient
must wear a waste disposal bag on his or her abdomen
for several months and then undergo a second operation
to have the ileostomy closed.
overall satisfaction: In general, although both
the IRA and IPAA procedures allow patients to retain
control of their bowels, patients are less satisfied
with these functions following IPAA. Compared with
the IRA procedure, IPAA causes more frequent bowel
movements, diarrhea, and episodes of incontinence.
Patients with an IPAA often will have five to eight
bowel movements per day. What's more, as many as 30
percent of patients will also have night time bowel
movements. At least that many will also experience
some form of mild incontinence, such as night time
or day time stool leakage, which requires that a pad
be worn. The pouch can also become inflamed (a problem
called pouchitis), which can increase the amount of
diarrhea. In two to three percent of patients, the
pouch never functions sufficiently in which
case it must be removed, leaving the patient with
risk of polyp formation:
Unfortunately, recent reports have documented cases
in which even IPAA patients have developed polyps
(and thus possibly cancer) at the site where the small
bowel and anus are joined (though this risk is much
lower for patients who have undergone the IPAA procedure
rather than the IRA). Thus, patients may need to continue
to follow some form of screening even after IPAA,
though formal guidelines have not yet been developed.
Many experts recommend that patients still have a
screening examination of the pouch every year.
Proctocolectomy with Permanent Ileostomy
proctocoloectomy with permanant ileostomy: The
shaded area shows the colon, rectum and anus,
which are removed surgically. The "end ileostomy"
shows the lowest part of the small bowel (the
ileum), emptying through an opening in the abdomen.
Patients usually wear an ileostomy bag to collect
waste from the end ileostomy.
involves removing the large bowel (colon and rectum)
and diverting the lowest part of the small bowel (ileum)
through an opening in the abdominal wall so that the
gut can empty its waste into a collection bag. It
what many people still assume all colon cancer surgery
entails. However, although doctors still sometimes perform
this surgery to remove a cancer
if it occurs low in the bowel
rarely use it as a preventive measure (that is, to remove
the colon before cancer has developed). Now that the
IPAA procedure has become available and popular, there
is little reason for patients to have a permanent ileostomy
created unless they have developed a cancer in their
rectum. In that case, it may be impossible to leave
the anus in place and adequately remove the cancer.
If the anus is removed, an IPAA cannot be performed.
who do undergo this surgery lose control of their bowel
function and must thus wear an ileostomy bag 24 hours
a day. This is necessary because the surgery removes
the lower part of the rectum and the sphincter, which
controls the passage of stool through the anus.
many people are understandably squeamish about the prospect
of wearing a permanent ileostomy bag, you should understand
that it's possible to lead a normal, full life after
this procedure, and that there are support groups available
to help you deal with its consequences. After recovery
from the surgery, most patients are quite satisfied
with the ileostomy and there is little long-term impact
on quality of life.
W., R. Dozois, et al. (1992). "Familial adenomatous
polyposis: results following ileal pouch-anal anastomosis
and ileorectostomy." Dis Colon Rectum 35(1):
Church, J. (1996). "Prophylactic colectomy in patients
with hereditary nonpolyposis colorectal cancer." Ann
Med 28(6): 479-82.
Sagar, P. and J. Pemberton (1996). "Operations for familial
adenomatous polyposis." Surgical Oncology Clinics
of North America 5(3): 675-688.
Duijvendijk, P., J. Slors, et al. (1999). "Functional
outcome after colectomy and ileorectal anastomosis compared
with proctocolectomy and ileal pouch-anal anastomosis
in familial adenomatous polyposis." Annals of Surgery
Duijvendijk, P., H. F. Vasen, et al. (1999). "Cumulative
risk of developing polyps or malignancy at the ileal
pouch-anal anastomosis in patients with familial adenomatous
polyposis." J Gastrointest Surg 3(3): 325-330.
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