By Miriam Komaromy, MD

Reviewed by Peggy Conrad, MS, CGC and Jonathan Terdiman, MD
Last updated August 9, 2000

As 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.

It 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 HNPCC.

Continue 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 (IRA)

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Total 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.

In this procedure (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 the following:

• Few 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.

• Retention 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.

Unfortunately, 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.

It 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.

The 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.

Total Proctocoloectomy with Ileal Pouch Anal Anastomosis (IPAA)

Total 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.

In 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 completed.

The 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:

• More complications: Because 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.

• Lower 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 an ileostomy.

• Residual 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.

Total Proctocolectomy with Permanent Ileostomy

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Total 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.

This older procedure 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 is what many people still assume all colon cancer surgery entails. However, although doctors still sometimes perform this surgery to remove a cancer — particularly if it occurs low in the bowel — they 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.

Patients 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.

While 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.

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References

Ambroze, W., R. Dozois, et al. (1992). "Familial adenomatous polyposis: results following ileal pouch-anal anastomosis and ileorectostomy." Dis Colon Rectum 35(1): 12-15.

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.

Van 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 230(5): 648-654.

Van 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.