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Page 1: Ileoanostomy in ulcerative colitis (Ravitch procedure)

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 Al though this operation would appear to be useful in the t reatment of ulcera- tive colitis, since it retains function of the anal sphincter, to our knowledge, only five addit ional cases have been r e p o r t e 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 i leostomy 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 cont inuing 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 t reatment 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 a round the ileal s toma. The stools gradually became formed and the patient was discharged home 3 mo later. Repeated rectoscopic examinat ions revealed no improvement of congestion, edema, or petechiae in the mucosa of the rectum. The patient was readmitted for reoperation.

Second operation. Laparo tomy 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 mucocu taneous junct ion, excising all remaining rectal mucosa. The terminal ileum was pulled through the lumen of the rectum and i leoanostomy performed. The patient cont inued to have diarrhea for about a mon th 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 examinat ion, the boy appears to have normal bowel function, and attends school.

From this case experience we believe that the surgical t reatment 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

Page 2: Ileoanostomy in ulcerative colitis (Ravitch procedure)

146 CASE REPORTS

completed in a single stage rather than in two separate stages, since the complications associated with ileostomy cause difficulties in the second-stage operation.

REFERENCES

1. Ravitch MM: Anal ileostomy with sphinc- 2. Ekesparre W: Weitere Erfahrungen mit ter preservation in patients requiring total der chirurgischen Behandlung der Colitis colectomy for benign conditions. Surgery 24: ulcerosa. Z Kinderchir 5:84, 1967 170, 1948


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