lleoanostomy in Ulcerative Colitis (Ravitch Procedure)
By Yoshiyuki Fujiwara, Tetsunosuke Ohizumi,
Goro Kakizaki, and Tetsuro Fujiwara Akita City, Japan
l leoanostomy combined with total colectomy and excision of rectal mucosa was first described in 1948 by Ravitch. j Although this operation would appear to be useful in the treatment of ulcera- tive colitis, since it retains function of the anal sphincter, to our knowledge, only five additional cases have been repor te J of the condition with lesions in the rectum treated by this procedure. We wish to report our experience with a 10-yr-old boy with ulcerative colitis with principal le- sions in the rectum, in whom total colectomy and ileostomy were performed and, in the second stage, i leoanostomy combined with excision of rectal mucosa (by the procedure of Ravitch) was undertaken with a favorable result (Table 1).
The patient had experienced two episodes of bloody stools at age 6 and 9 yr, and was ad- mitted to the hospital at age 10 yr for continuing fulminant rectal bleeding with recurrent ab- dominal cramps, anemia, and fatigue. Ulcerative colitis was diagnosed on X-ray findings with barium enema. Sigmoidoscopy revealed diffuse edema of the rectal mucosa which was noted to be hyperemic, friable, and bled easily. The mucosa at 19-22 cm above the anus was eroded and edematous, and subrnucosal petechiae were also prominent at this level. Surgical treatment was elected because of poor response to corticosteroid therapy and other medical therapy.
First surgical operation. Upon laparotomy performed under general anesthesia, the large in- testine from the cecum to the sigmoid was noted to show diffuse thickening of the wall and absence of haustral markings, and the rectal serosa was very edematous. Total colectomy and ileostomy were performed. After operation, watery stools caused marked skin irritation around the ileal stoma. The stools gradually became formed and the patient was discharged home 3 mo later. Repeated rectoscopic examinations revealed no improvement of congestion, edema, or petechiae in the mucosa of the rectum. The patient was readmitted for reoperation.
Second operation. Laparotomy disclosed the remaining rectum to be markedly edematous and hypervascular. Upon opening the rectum, its mucosa was found to be congested, edematous, and hemorrhagic. After closure of the ileostomy, the rectal mucosa was excised down to near the anus. Then, from a perineal approach, a circular incision was made along the mucocutaneous junction, excising all remaining rectal mucosa. The terminal ileum was pulled through the lumen of the rectum and i leoanostomy performed. The patient continued to have diarrhea for about a month after the operation, causing considerable excoriation of the perineal region. Subsequently, the stools became formed day after day and he was discharged home in good condition 3 mo post- operatively. On 12-mo follow-up examination, the boy appears to have normal bowel function, and attends school.
From this case experience we believe that the surgical treatment by this procedure should be
Table 1. Sphincter-Preserving Ileoanostomy in Patients Requiring Proctocolectomy for Ulcerative Colitis
Age at Age at Method of Author Cases Sex Onset (yr) Operation (yr) Operation
Ravitch 1 1 Male t6 28 Three stages 2 Female 28 36 Two stages
Ekesparre 2 3 Female 3 8 One stage 4 Female 10 15 Two stages 5 Female 4 6 One stage 6 Male 2 9 One stage 7 Female 19 21 Two stages
Present case 8 Male 6 10 Two stages
Journal of Pediatric Surgery, Vol. 10, No. 1 (February), 1975 145