Preserving Continence Without an Ostomy at Any Cost?

While preserving life is always a physician’s No. 1 priority, improving quality of life is never far behind. This secondary goal often means helping patients with digestive diseases and conditions preserve or regain bowel continence. Research confirms that patients perceive the avoidance of a permanent stoma or ostomy as a measure of good quality of life.

“Advancements in surgical care have made it possible for many patients to achieve bowel continence without a permanent ostomy while minimizing overall disease burden,” says Steven Wexner, MD, PhD, Director of the Ellen Leifer Shulman and Steven Shulman Digestive Disease Center at Cleveland Clinic Florida and Chairman of the Department of Colorectal Surgery. “With each innovation and improved technique, more and more patients can achieve this desired outcome.”

Ostomy trends

Diverticulitis, Crohn’s disease, ulcerative colitis, colorectal cancer and familial adenomatous polyposis (FAP) are some of the most common conditions that could lead to the use of an ostomy to divert stool from the lower part of the digestive tract either temporarily or permanently. Trends in colostomy and ileostomy surgeries provide a picture of evolving care and stoma-avoidance success.

According to the United Ostomy Associations of America (UOAA), nearly one million people in the United States are currently living with an ostomy. While an estimated 100,000 ostomy surgeries are performed annually in the United States, a review of U.S. healthcare data from 1993 to 2014 found a substantial decrease in permanent colostomies and an even larger increase in temporary ileostomies.

“Both trends point to the rise of ‘sphincter-sparing’ colorectal cancer surgeries, which remove the cancer while preserving continuity to the anus without the need for a permanent ostomy,” explains Dr. Wexner. “The use of J-pouch surgery for mucosal ulcerative colitis and familial adenomatous polyposis are other examples of the trend to decrease permanent ostomies.”

Improving the gold standard

For more than four decades, the ileal pouch anal anastomosis (IPAA) has been the standard surgical procedure for treating chronic mucosal ulcerative colitis (MUC), FAP, and some colorectal cancers. Following a total removal of the colon and rectum, the lowest part of the small intestine is formed into a reservoir and connected to the anus to provide for normal waste storage and elimination. The most common form of the IPAA procedure, developed in the 1970s, is the J-pouch.

In 1989, Dr. Wexner and the late David G. Jagelman, MD, at Cleveland Clinic Florida were the first surgeons in North America to perform the double-stapled J-pouch, a modified version that greatly improved outcomes and eventually became the “gold standard.” The same team later became the first in the world to perform laparoscopic J-pouches just two years later, a technique that has become a treatment mainstay.

Laparoscopic reoperative J-pouch surgery

As many as 300,000 people in the United States are now living with a J-pouch, and about 10 to 20% of these patients will experience short or long-term complications that require pouch revision, advancement or excision. These challenging reoperative procedures are typically performed as laparotomy at a small number of referral centers.

More recently, laparoscopic reoperative ileal J-pouch surgery was demonstrated to be feasible and safe with better outcomes than laparotomy, according to a retrospective analysis of a Cleveland Clinic prospective database published in Surgical Endoscopy. Among the noted benefits are shorter length of stay and significantly fewer superficial and deep surgical site infections.

“While an important advancement in care, these operations are technically complicated procedures and only the most experienced, high-volume laparoscopic IPAA surgeons should consider this approach,” notes Dr. Wexner, the senior author of the study.

Advancements in rectal cancer care

Today there are many more sphincter-sparing treatment options for patients with rectal cancer than ever before. These innovative treatments include colonic J-pouch reconstruction following rectal cancer removal and transanal total mesorectal excision (TaTME). Using these techniques, Cleveland Clinic Florida surgeons avoid the need for a permanent colostomy in over a majority of cases while still achieving some of the lowest cancer recurrence rates in the world.

The colonic J-pouch is an alternative to a straight coloanal anastomosis that results in fewer complications and lower bowel frequency for patients. Cleveland Clinic Florida surgeons were the first in North America to use this procedure and went on to demonstrate its superiority in a landmark prospective randomized study.

The team also performs many TaTME procedures, an emerging, minimally invasive technique that allows removal of benign and certain malignant tumors of the rectum without a large abdominal incision. According to colorectal surgeon Dana Sands, MD, who has among the highest single surgeon volumes of TaTME in the world, surgeons can better visualize and remove lower rectum tumors with this natural-orifice technique while maintaining the benefits of a standard laparoscopic procedure.

“With TaTME, we can be very aggressive in not removing the anus, allowing patients to avoid having a permanent colostomy,” Dr. Sands adds. “While we cannot avoid ostomies in all patients, each surgical innovation brings us one step closer.”