What Is Proctocolectomy?

  • Anna Mizerska Masters in Global Health and Biomedical Engineer, Norwegian University of Science and Technology (NTNU), Norway

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Introduction

Colectomy is a surgical procedure aimed at the removal of all or a portion of the colon. The colon, constituting part of the large intestine, is a lengthy tubular organ situated at the end of the digestive tract. Colectomy becomes necessary for the treatment or prevention of diseases and conditions affecting the colon.

Several types of colectomy operations exist, including:

  1. Total colectomy, which entails the complete removal of the colon.
  2. Partial colectomy, also known as subtotal colectomy, involves the removal of a specific segment of the colon.
  3. Hemicolectomy, where either the right or left portion of the colon is removed.
  4. Proctocolectomy, which encompasses the removal of both the colon and rectum.

Colectomy surgery typically involves additional procedures to reconnect the remaining parts of the digestive system, allowing waste to exit the body.1

A proctocolectomy is a surgical procedure involving the removal of part or the entire colon and rectum. The colon and rectum are components of the large intestine, also known as the large bowel. The colon, the most significant part of the large intestine, is responsible for the gradual solidification of food waste into faeces. Connected to the colon, the rectum is a short section that stores faeces before their eventual release through the anus. These components collectively form a continuous tube.

When surgical intervention is necessary due to issues in the large intestine, it may involve different segments along this continuum. Various types of bowel resection surgery may target specific parts. Colectomy surgery, for example, removes a portion or the entirety of the colon. With "procto" referring to the rectum, a proctocolectomy involves the removal of both the colon and rectum. In contrast, a proctectomy specifically removes only the rectum.2

Procedure Details

Before

Several weeks before the scheduled surgery, if it is not deemed an emergency, you will have the opportunity to engage in discussions with your healthcare provider. These discussions will cover various aspects of the upcoming proctocolectomy, including the different types of procedures for which you may be a candidate, as well as an exploration of the associated risks and benefits.

Two weeks before the surgery, it will be recommended that you reduce or discontinue any blood-thinning medications you are currently taking. Additionally, you will receive advice on maintaining the health of your intestines by consuming a diet rich in dietary fibre and ensuring adequate hydration.

Within the 24 hours leading up to the surgery, your healthcare provider may prescribe a bowel preparation regimen to facilitate the clearing of your intestines. During this time, you will be instructed to adhere to a clear liquid diet. In some cases, preventative antibiotics may also be prescribed to guard against potential infections following the surgery.

During

Preparation for surgery

Upon arrival at the hospital, you will change into a hospital gown, and a healthcare team member will insert an intravenous (IV) catheter into one of your veins to provide continuous fluids and medications. Subsequently, you will be wheeled into the operating room on a gurney. The anesthesiologist, collaborating with your surgeon, will administer general anaesthesia to induce sleep, and you will be placed on a ventilator to assist with breathing during the operation.

Open surgery versus laparoscopic surgery

Many proctocolectomies are now conducted through minimally invasive laparoscopic1 or robotic surgery. Instead of the traditional open surgery involving a large abdominal incision, the surgeon operates through a few small incisions with the assistance of a laparoscope and a tiny camera. Laparoscopic surgery is associated with quicker recovery times and improved patient outcomes. However, candidacy depends on the complexity of the condition, and more intricate or emergency situations may necessitate open surgery.

Resection

Once your surgeon has accessed your bowel, they will meticulously remove the affected portion of your colon and rectum. If your anus is unaffected, it will be preserved along with the anal sphincter. Preserving a functioning anal sphincter is crucial for the potential to resume bowel movements through the anus in the future.

Ileostomy/colostomy

During proctocolectomy surgery, whether temporary or permanent, an ileostomy or colostomy is typically created. An ostomy redirects the course of your ileum or remaining colon to a new opening in your abdominal wall. A bag is attached to the outside opening (stoma) of the intestine, where waste, or stool, will exit.

After

The initial phase of recovery involves spending up to a week in the hospital. During this time, you will gradually reintroduce solid foods and resume regular bowel movements. If you have an ostomy, a wound ostomy continence nurse (WOCN) will collaborate with you to provide guidance on living with an ostomy bag and caring for your stoma. Whether the ostomy is temporary or permanent, the discussion about the next step, either a reversal or an internal ileal pouch, will typically occur several months later after the initial surgery.

Risks and  benefits

Colectomy, like any surgical procedure, carries a risk of serious complications. The likelihood of complications is influenced by factors such as your overall health, the specific type of colectomy performed, and the surgical approach chosen by your medical team.

Potential complications of colectomy include:

  1. Bleeding
  2. Formation of blood clots in the legs (deep vein thrombosis) and lungs (pulmonary embolism)
  3. Infection
  4. Injury to adjacent organs near the colon, such as the bladder and small intestines
  5. Tears in the sutures reconnecting the remaining parts of the digestive system.

Post-surgery, you will spend time in the hospital to allow for the healing of your digestive system. Your healthcare team will closely monitor you for any signs of complications, and the duration of your hospital stay will depend on your individual condition and circumstances, typically ranging from a few days to a week.2

Complications of proctocolectomy surgery

  1. Intestinal obstruction: Scar tissue from the surgery may accumulate in the abdomen, leading to an intestinal blockage. Healthcare providers can assist in relieving the obstruction.
  2. Nerve damage: Surgery in the rectum and anus may result in damage to nerves associated with sexual or urinary function. Potential complications include difficulty with urination, sensitivity, and pain during sex for women or erectile dysfunction in men. These complications typically improve over time.
  3. Standard surgery risks: All surgeries carry a low risk of complications, including reactions to anaesthesia, injury to nearby organs, internal bleeding, and infection.

Complications of ileostomy or colostomy

  1. Skin Irritation The skin around the stoma may become irritated due to contact with stool. Using a better-fitting ostomy bag can help prevent stool leakage.
  2. Stoma retraction or prolapse: A retracted stoma sinks below the skin surface, while a prolapsed stoma protrudes too far. These situations can make it challenging to secure the ostomy bag, requiring potential stoma revision.
  3. Phantom rectum: Individuals may experience phantom bowel movement urges after the removal of the rectum, similar to phantom limb syndrome. Sitting on the toilet during these episodes may provide relief, and the sensation usually diminishes over time.

Complications of internal ileal pouch

  1. Pouchitis

Pouchitis involves irritation and inflammation of the ileal pouch, occurring in about half of ileal pouch recipients.The causes are not entirely clear but may be related to the original disease.

Treatment involves antibiotics or anti-inflammatory medications.

  1. Anastomotic leak

 Rarely does the new connection created during surgery leak, causing a serious infection. Surgeons monitor for signs of leakage and treat it as an emergency with antibiotics and potential immediate repair.

3. Temporary fecal incontinence

Weak anal muscles initially may lead to frequent bowel movements that could be difficult to control. Most people regain control as muscles strengthen, but if issues persist, medications can help.1

Recovery and outlook

Recovery and living with ostomy2

Full recovery: most individuals fully recover from the surgery and can resume all normal activities within a couple of months. Many side effects of the surgery are temporary.

Living with an ostomy: adjusting to life with an ostomy is a process, but modern ostomy bags are discreet, and numerous speciality products are available. These innovations assist ostomates in living as normally as possible.

A potential return to surgery: depending on health conditions, some individuals may return to surgery after several months to complete the next steps of their procedures. This may involve closing ostomies and reconnecting intestines.

Internal Ileal pouch construction: for those having an internal ileal pouch constructed, one or two additional surgeries may be necessary, depending on the individual's condition. The new pouch may require time to heal before reconnection.

A longer process, positive outcome https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5139041/3: while additional surgeries may extend the process, the ultimate goal is the restoration of normal bowel function. Collaborating with healthcare providers, decisions about the timing and necessity of additional surgeries are made based on individual fitness and circumstances.

FAQs

Why is a proctocolectomy done?

A proctocolectomy is a form of bowel resection surgery designed to address conditions where a section of the bowel is either too diseased to function effectively or poses a life-threatening risk. Commonly treated conditions with proctocolectomy include:

  1. Inflammatory Bowel Diseases
    • Ulcerative colitis
    • Crohn's disease
  2. Colorectal Cancer and Precancerous Conditions
    • Familial adenomatous polyposis

Other potential reasons for proctocolectomy include:

  1. Tissue Death due to Ischemia
    • Loss of blood flow to the affected tissue
  2. Complicated Diverticulitis
    • Severe inflammation of diverticula (small pouches in the colon)
  3. Traumatic Injury
    • Bowel injury resulting from trauma or accident
  4. Severe Constipation
    • When other treatment options for severe constipation have been ineffective

How do you poop after a proctocolectomy?

A proctocolectomy indeed disrupts the normal pathway of waste through the intestines and out of the anus. How you will manage bowel movements without your colon and rectum depends on the specific type of proctocolectomy you undergo. The choice of procedure is determined by your condition and the underlying reason for the proctocolectomy.1

Is proctocolectomy surgery painful?

During the surgery, you won't feel anything as you'll be under anaesthesia, and you'll receive strong pain medications afterwards. Your healthcare team will tailor your pain medication to ensure your comfort during your hospital stay. Additionally, you'll be provided with a short-term prescription to manage pain at home.

Although complete recovery may take several months, following your healthcare provider's guidance and taking it easy will contribute to your well-being. It's normal to feel sore when sitting, and you may experience a tug on your incision during activities like coughing or sneezing. Using a pillow for support can be helpful in such situations.1

Summary

A proctocolectomy is a significant surgery that involves the removal of a major organ, and it's completely normal to feel overwhelmed by the potential implications. In addition to the physical healing from the surgery, you'll need to adapt to new processes for everyday functions, including eating and bowel movements. However, the surgery may bring relief from the discomforts and inconveniences caused by the underlying disease.

The primary objective of a proctocolectomy is not only to save lives but also to enhance the quality of life for individuals dealing with chronic and progressive diseases. Fortunately, there are various options available for those considering proctocolectomies today. Collaborating with your healthcare provider, you'll choose the type of operation that best suits your condition. After the adjustment period, the aim is for you to resume your life, ideally in improved health and comfort compared to before.1

References

  1. Jani K, Shah A. Laparoscopic total proctocolectomy with ileal pouch-anal anastomosis for ulcerative colitis. J Minim Access Surg. 2015 Jul-Sep;11(3):177-83. doi: 10.4103/0972-9941.140212. PMID: 26195875; PMCID: PMC4499922.
  2. Lichtenstein GR, Cohen R, Yamashita B, Diamond RH. Quality of life after proctocolectomy with ileoanal anastomosis for patients with ulcerative colitis. J Clin Gastroenterol. 2006 Sep;40(8):669-77. doi: 10.1097/00004836-200609000-00002. PMID: 16940876.
  3. Jayarajah U, Samarasekara AM, Samarasekera DN. A study of long-term complications associated with enteral ostomy and their contributory factors. BMC Res Notes. 2016 Dec 5;9(1):500. doi: 10.1186/s13104-016-2304-z. PMID: 27919277; PMCID: PMC5139041.

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This content is purely informational and isn’t medical guidance. It shouldn’t replace professional medical counsel. Always consult your physician regarding treatment risks and benefits. See our editorial standards for more details.

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Anna Mizerska

Masters in Global Health and Biomedical Engineer
Anna is a highly analytical and insightful professional with progressive experience in providing quality services in fast-paced and high-pressure environments. Over the years she has built up extensive knowledge, expertise and transferable skills that translate into writing reliable medical content and articles.

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