Staple For Success

Calcutta doctors develop a surgical 
procedure to cure a deadly ulcer, reports Biplab Das 

Arup Banerjee, a 28-year-old sales executive, had repeated bouts of bloody diarrhoea, which weakened him so much so that he frequently skipped work. Having to rush to the toilet six to eight times a day, he lost weight at an alarming rate. Pale and emaciated, Banerjee was afraid, not only of losing his job but also his life. Worried, he came down to the surgical gastroenterolgy department of Medical College where its head, Prof. Gautam Chatterjee, diagnosed him with ulcerative colitis. The disorder causes ulcers in the colon, the point at which the large and small intestines meet. 

Banerjee was immediately put on a cocktail of drugs and initially he responded well. But six months later, his illness took a turn for the worse. He started having 10 to 12 bloody motions a day and acute abdominal pain. After a colonoscopy (examination of the colon), Chatterjee found that the vicious ulcers peppered with pseudopolyps (islets of malfunctioning cells) had spread all over the rectum as well as colon. Without further delay, Chatterjee decided to perform Totally Stapled Restorative Proctocholectomy (TSRP). This procedure - in which the colon and rectum are totally removed - is one of the most difficult in surgical gastroenterology. 

To make up for the loss of the colon and rectum, Chatterjee's team created a new rectum using the terminal end of the ileum (the last part of the small intestine). The newly formed rectum was joined to the anal canal (the end part of the large intestine). "Within a month, the patient recovered and started gaining weight," wrote Chatterjee and his teammates in a paper that was presented at a conference of the Indian Association of Surgeons held recently at the Medical College. "The patient also showed no bloodletting during motions." Chatterjee was assisted in the surgery by Dr. Sarfaraz Jalil Beig from the general surgery department and Dr. Arka Bandopadhyay from the surgical gastroenterology department. 

"The cause of ulcerative colitis is yet to be pinned down," says Chatterjee. "Evidence shows that first-degree relatives (son of an affected father or mother) of patients are genetically 15 times more prone to the disease." Studies have shown that smoking has a protective effect against ulcerative colitis. However, it can't be prescribed as an effective antidote. 

"When prolonged treatment fails to cure the disease, surgery is the last resort," says Chatterjee. If surgery is delayed, the disease can wreak havoc on vital organs like the liver and eyes. Neglected, it may even turn into colon cancer. "The patient on whom we performed the operation already had an enlarged liver," Chatterjee says. "Though he showed no signs of jaundice and viral infections like hepatitis B and C, he was at risk of developing arthritis and bile duct cancer." Of all the patients of ulcerative colitis, 3.5 per cent run the risk of cancer. If the disease persists for 20 years, the risk of cancer is 12 per cent. 

Before the surgery, Banerjee was counselled that he was going to lose a large part of a vital organ. "This was done to avert any post-operative psychological complication he might have had," says Chatterjee. Banerjee also had a low level of alubumin, a vital blood protein, which aids in the healing of intestines. His rectum was cut 2 cm above the anal canal, using a stapler (titanium clips), a device used to cut and join the ends or sides of intestines. After this, the connection between the small and large intestine was cut. Then, the entire colon was removed including 1 cm of ileum. 

"Two loops (20 cms each) of terminal ileum were used to create a pouch, which looked like the English letter J," says Chatterjee. This is why the newly formed pouch was called a J pouch. "The J pouch will be the new rectum," he adds. The new pouch was joined to the anal canal. Due to use of staplers, the operation was wrapped up in four hours. 

"As the patient could not use the new rectum, ileostomy, an alternative system to drain out undigested food, was the way out," Chatterjee says. Five days after the operation, the patient gulped down solid food. "Twelve weeks after the operation, the patient gained 15 kgs," says Chatterjee. "Three months later, the J pouch healed adequately and started functioning as the new rectum. At this time, the ileostomy was closed." 

"The new rectum (J pouch) quickly adapted to the role of colon," Chatterjee points out. "What is more, the new rectum's mucous membrane (the inner lining) changed from the small intestine to large intestine type." According to Chatterjee, the nerve connections of the anal canal and anal spinchter muscle (a ringlike muscle which closes a passage) were kept intact. So, the patient had no problem in holding stool and air. "Evidence shows that there is 20 per cent chance of developing pouchitis (inflammation of the J pouch) after operation," says Chatterjee. "But antibiotics and calcium supplements can combat the problem." 

So far, Chatterjee and teammates have performed such an operation on 12 other patients. "All of them are leading a normal life," he says. "The J pouch remains active throughout life." But, studies have shown that pouch failure occurs in a small percentage (.5 to 1 per cent) of patients. In case of pouch failure, it is removed and a terminal ileostomy is done.