Epidural analgesia shortens postoperative ileus after ileal pouch-anal canal anastomosis

PURPOSE

A retrospective study was conducted to determine whether epidural analgesia would speed recovery from postoperative ileus in patients undergoing ileal pouch-anal canal anastomosis.

METHODS

Among 85 patients who underwent proctocolectomy with ileal pouch-anal canal anastomosis at the Mayo Medical Center between January 1, 1991 and October 31, 1992, 44 were treated for postoperative pain with continuous infusion of epidural fentanyl citrate supplemented by intravenous morphine on request, while 41 controls were given only systemic morphine sulfate as needed.

RESULTS

The patients in the two groups were matched and similar with regard to preoperative and operative risk factors and postoperative morbidity. No operative mortality occurred. Epidural fentanyl analgesia resulted in less need for nasogastric suction and intravenous fluids, more rapid discharge of fecal content, more rapid return to oral intake, and shorter hospitalization.

CONCLUSION

Epidural analgesia with fentanyl citrate shortened postoperative ileus after proctocolectomy and ileal pouch-anal canal anastomosis.

Clinical and physiological aspects of ileal pouch-anal anastomosis

Proctocolectomy with ileal pouch-anal anastomosis is the surgical treatment of choice for severe chronic ulcerative colitis and familial polyposis coli because the entire colonic mucosa is removed while anal function can be preserved and the necessity for permanent ileostomy is eliminated. Long-term functional results are generally gratifying, as defecation frequency and degree of incontinence are acceptable in most patients. Pouchitis, however, a non-specific inflammation of the ileal reservoir, is a major long-term complication occurring in a considerable number of patients. The etiology of pouchitis is unknown. Since pouchitis occurs more frequently or even exclusively in ulcerative colitis patients it is assumed that pouchitis is a novel manifestation of inflammatory bowel disease. However, bacterial overgrowth in the ileal pouch may also play a pathogenetic role. Chronic inflammation and villous atrophy of varying severity is found in virtually all pouches. Acute inflammatory changes and ulceration are associated with pouchitis.

Functional assessment of ileal pouch-anal anastomotic techniques

BACKGROUND

Recent advances in ileal pouch-anal anastomotic (IPAA) technique include the substitution of a double stapled anastomosis for a mucosectomy and hand-sewn pouch-anal anastomosis, and the use of staples to construct a "J" shaped pouch rather than a hand-sewn "S" pouch in most cases.

METHOD

To determine the impact these technical changes have had on pouch function, 235 IPAA patients with 15 to 155 months of follow-up (mean 70 months) were interviewed by telephone concerning pouch function and quality of life. Categorical responses were then evaluated by contingency table analysis to detect differences between mucosectomy (n = 157) and nonmucosectomy (n = 80) groups, and between J pouch (n = 50), S pouch with mucosectomy (n = 137), and S pouch nonmucosectomy (n = 30) subgroups. An index encompassing nine functional measures was used to quantify the overall impact of technique changes (optimal score 100).

RESULTS

Stool frequency for mucosectomy patients was 7.2 movements/24 hours, compared to 7.1 for nonmucosectomy patients. Elimination of a mucosectomy dramatically reduced nocturnal major incontinence (P < 0.001), nocturnal minor incontinence (P < 0.001), daytime minor incontinence (P = 0.03), and day-time pad use (P = 0.002). Nonmucosectomy patients had a better functional index score than had patients with an S pouch, even when only data from nonmucosectomy patients were analyzed (J = 95.5, S = 91.8, P = 0.009).

CONCLUSIONS

Avoidance of a mucosectomy in the performance of an ileal pouch-anal anastomosis does not influence stool frequency but does significantly improve fecal continence and introduces no detectable morbidity associated with the retained rectal mucosa.

Outcome of early surgical complications following ileoanal pouch operation without diverting ileostomy

BACKGROUND

Many surgeons use a diverting ileostomy routinely following ileoanal pouch operation because they fear that complications may lead to permanent unsatisfactory pouch function or even death. We report the outcome of early surgical complications when ileoanal pouch operation is performed without a diverting ileostomy. We performed 74 consecutive ileoanal pouch operations since ileoanal pouch operations since October 1989 using a transition-zone-sparing stapled J pouch method.

RESULTS

Of the 74 patients, 68 (92%) underwent the operation without a diverting ileostomy. Five of the 68 patients (7.4%) required reoperation within 30 days of operation. Pouch excision was necessary in 2 patients (3%) for reasons not resulting from omitting the diverting ileostomy, and they now have excellent pouch function.

CONCLUSION

Patients who required early reoperation and placement of a temporary diverting ileostomy did not suffer long-term consequences. The fear that early surgical complications following ileoanal pouch operation without diverting ileostomy are permanently detrimental is unjustified.

Fertility and sexual and gynecologic function after ileal pouch-anal anastomosis

PURPOSE

This study was designed to determine the incidence of infertility, gynecologic problems, and sexual dysfunction after ileal pouch-anal anastomosis (IPAA).

METHODS

A questionnaire was sent to 206 females who underwent pouch surgery at a single institution from 1980 through 1991. Response rate was 53 percent (110/206). The computerized registry of the 206 females undergoing IPAA at this institution was reviewed to add additional data.

RESULTS

Mean age at pouch construction was 32 (range, 14-61) years. Mean time from pouch surgery to survey was 49 (range, 1-132) months. Fifty-seven females had 119 children before pouch surgery, and 23 children were born to 19 females after IPAA (5 vaginal deliveries, 18 Cesarean sections). Eighteen females experienced infertility after IPAA. Thirty patients had persistent dyspareunia. Pelvic cysts developed in 15 patients; 11 patients required surgery.

CONCLUSIONS

Although childbirth appears safe, gynecologic problems, such as dyspareunia and formation of pelvic cysts, may be underestimated after IPAA. The effects of IPAA on fertility are still unknown.

Ileal pouch pressures after defecation in continent and incontinent patients

After ileal pouch-anal anastomosis, a pouch/anal canal pressure gradient is present such that mean pressures in the anal canal exceed pressures in the pouch facilitating fecal continence. Such a relationship was not present in incontinent patients.

PURPOSE

Our aim was to evaluate characteristics of pouch pressures dynamically in continent and incontinent patients following ileal pouch-anal anastomosis (IPAA).

METHODS

A multichannel microtransducer catheter was positioned in eight continent patients and nine incontinent patients after IPAA. Twenty-four-hour recordings of pouch pressures and large pressure wave contractions were recorded when patients were awake, asleep, and after evacuation.

RESULTS

When patients were awake, pouch pressures were similar. However, nocturnal pouch pressures were higher in the incontinent group (P < 0.05). Large pressure wave amplitude was higher in incontinent patients when awake and asleep (P < 0.05). Moreover, pouch pressures failed to decline in the incontinent group after evacuation, unlike continent patients.

CONCLUSION

Compared with continent patients, incontinent patients after IPAA had persistently high phasic and basal pouch pressures at night and following pouch evacuation.

Obstructing inflammatory fibroid polyp in pelvic ileal reservoir after restorative proctocolectomy in ulcerative colitis. Report of a case

PURPOSE

This study was designed to describe clinical, endoscopic, and histopathologic features of an inflammatory fibroid polyp occurring in the pelvic ileal reservoir after restorative proctocolectomy in ulcerative colitis.

METHOD

A case report describing the clinical course of such a patient is presented.

RESULTS

Three years postoperatively, the patient developed diarrhea, anemia, weight loss of 10 kg, and symptoms of obstructed defecation. Ileoscopy showed pouchitis and a polypoid tumor filling the pouch. Biopsies revealed chronic inflammation without signs of malignancy. At laparotomy, a 5 cm x 3.5 cm x 3.5 cm submucosal, solid, circumscribed tumor was found within the pouch, and histopathologic examination yielded the diagnosis. The pelvic pouch was resected and replaced by a Brooke ileostomy. During 18 months of follow-up, the course has been uneventful.

CONCLUSION

Inflammatory fibroid polyp is a rare, reactive, non-neoplastic lesion, which, for the first time, is reported in a pelvic ileal reservoir. It may cause pouch dysfunction. It is always benign but may masquerade as a malignant tumor.

Functional outcome in handsewn versus stapled ileal pouch-anal anastomosis

Eighty-eight of 119 patients who underwent ileal pouch-anal anastomosis for ulcerative colitis were evaluated. Forty patients had a handsewn anastomosis (Hs) with mucosectomy, and 48 had a stapled anastomosis (St). In each patient, we evaluated operative, morphologic, functional, and manometric features. The results in the Hs and St groups were similar when the anastomosis was within 1 cm of the dentate line. In particular, there was no correlation between the type of anastomosis and the number of bowel movements in a 24-hour period, the presence of the urge to defecate, and the use of antidiarrheal drugs. Leakage was significantly higher in the Hs group, even when the anastomosis was less than 1 cm from the dentate line. Pouchitis was more frequent in the Hs group, and, within this group, among those with a short distance between the anastomosis and the dentate line. No correlations were found between the presence of columnar epithelium or active colitis in the mucosa below the anastomosis, the functional outcomes, and the incidence of pouchitis.

Transanal mucosectomy. Ileal pouch advancement for anorectal dysplasia or inflammation after restorative proctocolectomy

PURPOSE

Restorative proctocolectomy has gained increasing popularity in the surgical treatment of ulcerative colitis. However, symptomatic proctitis in an excessively long anorectal stump or high-grade dysplasia within the retained anorectal mucosa can pose challenging problems. A corrective operation for these problems is described.

METHODS

A sphincter-preserving perineal approach to mobilize the pouch was described. It allows excision of the inflamed or dysplastic-retained anorectal mucosa, followed by pouch advancement and a neoileoanal anastomosis.

RESULTS

The technique was successfully performed in two patients, one with symptomatic "proctitis" and another with high-grade dysplasia in the anorectal mucosa after a previously stapled ileoanal (distal rectal) anastomosis.

CONCLUSIONS

This report illustrates the relative ease and safety of delayed mucosectomy via a perineal approach, provided that the initially stapled anastomosis is within 3 cm to 4 cm of the dentate line. This technique also obviates the need for complex abdominopelvic surgery after previous restorative proctocolectomy.

Pouch-vaginal fistula after restorative proctocolectomy: aetiology and management

Pouch-vaginal fistula is a rare complication following restorative proctocolectomy. Seven patients who developed such a fistula are presented. Six pouch-vaginal fistulas occurred at the level of the pouch-anal anastomosis and one 3 cm above the anastomosis, level with the posterior vaginal fornix. The anastomosis had been hand-sewn in four patients (following mucosectomy) and stapled in three. Five fistulas presented within the perioperative period (median 16 (range 10-30) days) and two at 186 and 273 days. Treatment was successful in the patients who presented early, and these remain continent with functioning pouches. If not already present (two patients), an ileostomy was raised. Repair was by endovaginal flap advancement, combined with fistulotomy and sphincter repair in two patients. Treatment was unsuccessful in the two patients who presented late; in both the diagnosis was revised to Crohn's disease, necessitating pouch excision.

Follow-up results of hematology data before and after restorative proctocolectomy. Clinical outcome

PURPOSE

This study was designed to investigate the development of anemia during functional ileoanal pouch.

METHODS

Eighty-three patients received an ileoanal pouch between 1980 and 1987. The hematology data deviations among the preoperative period, defunctionalized stage, and after ileal pouch in function were monitored. Aspects studied included serum hemoglobin, iron, folates, vitamin B12, white blood cell, erythrocyte sedimentation rate, pt-B12, and fat absorption. Specimens were collected before colectomy, during ileostomy prior to pouch operation, before loop ileostomy closure, and at 6, 12, 18, 24, and 36 months after loop ileostomy closure.

RESULTS

Two patients developed iron deficiency anemia after 2.5 and 5 years of pouch function: one patient, a vegetarian, had low hemoglobin, iron, and vitamin B12 postoperatively, the other patient developed low iron and hemoglobin 5 years after the operation. Significant elevations of serum hemoglobin, iron, and folates were seen preoperatively vs. postoperatively from 123.46 +/- 2.845 g/l, 10.282 +/- 0.992 mumol/l, and 9.983 +/- 1.308 mmol/l to 138.842 +/- 1.563 g/l (P < 0.0001), 17.544 +/- 1.529 mumol/l (P < 0.0003), and 16.784 +/- 1.757 mmol/l (P < 0.01) (mean +/- SE) of the defunctionalized loop ileostomy. Serum B12 decreased insignificantly. After loop ileostomy closure, at 6 and 36 months of functional ileal pouch-anal anastomosis, the elevations were still significant; serum hemoglobin was P < 0.0001 and P < 0.01, and serum iron was P < 0.001 and P < 0.01, respectively. Vitamin B12 levels decreased insignificantly at six months in controls and significantly (P < 0.01) at 36 months. There was a significant increase of serum folates (P < 0.01 and P < 0.001). Patients with low iron were 50 percent at precolectomy, 23 percent with ileostomy, 16 percent with loop ileostomy, 15 percent at six-month follow-up, and 11 percent at 12-month follow-up. Although only 3 percent and 11 percent of the patients with ileal pouch-anal anastomosis had low serum vitamin B12 values at the 12-month and 36-month follow-up, 31 percent and 36 percent had decreased Schilling tests. Thirty-three percent and 41 percent had decreased 14C-triolein breath tests. In five patients vitamin B12 deficiency began during the first six months of pouch function: in two patients after one year and in one patient after two years. Eight of 83 patients have had substitution therapy with vitamin B12. The therapy was discontinued in three patients after two to four years; these patients developed no further symptoms and had normal Schilling tests in the succeeding 30 months to 46 months. Five patients continue with substitution after 40 months to 68 months. During the functional period, serum erythrocyte sedimentation rate and white blood cells were elevated in some controls on different occasions. Folates were normal throughout the functional period.

CONCLUSION

For predicting hematologic data outcome in patients with functional ileal reservoir, the results justify the necessity for control during both manipulative and functional periods until evaluations are reliable and satisfying.

Problems after ileo-pouch anal anastomosis for ulcerative colitis. How can we prevent it? What can we do?

During the last 10 years (1982-1992) 370 patients have had a pelvic pouch constructed in the Colorectal Unit at the Department of Surgery II, Sahlgrenska Hospital. The complications and the eventual outcome in 307 patients (median follow-up 5.5 years ranging from 1.5 to 11 years) have been analysed. The overall complication rate was 22%. Anastomotic leaks, anal ulcerations or fissures and strictures (13%) and small bowel obstruction (5%) were the most common followed by ileostomy-related complications (2%). Re-laparatomy was required in 10%. Most anastomosis-related complications were successfully managed by prolonged ileostomy diversion combined with local procedures. The anastomotic leaks all proved to be radiologically healed at the time of ileostomy closure. Three of 16 patients who had had radiological leaks developed complications subsequently, but all could be successfully managed. In contrast, 6 of 15 patients in whom clinical leaks healed initially developed complications that eventually resulted in failure. The overall late complication rate was 22%. The most common complications were anastomotic stricturing (4%), small bowel obstruction (5%) and poor pouch function (pelvic pain, high evacuation frequency and other functional imperfections) (6%). Anal abscess, fistula or pouch-vaginal fistula were uncommon, however. While laying open of simple anal fistula and dilation of stenosis during anaesthesia were sometimes successful, re-laparotomy with redo of the pouch-anal anastomosis was needed for successful treatment of grossly fibrotic strictures, complex pouch-vaginal fistulae and poorly functioning pouches.(ABSTRACT TRUNCATED AT 250 WORDS)

Can (neo)rectal evacuation disorders be treated surgically in inflammatory bowel disease?

Besides the well-known perineal and anal manifestations of inflammatory bowel disease (abscess, ulcers, fissures and fistulae) anal stricture can develop in Crohn's disease. Usually anal dilation under general anaesthesia in one or two procedures is recommended as the treatment of choice. In the Leiden University Hospital 4 patients were seen in the period 1988-1993 with an anal stricture based on Crohn's disease after previous attempts at dilation. On physical examination and anal manometry it was judged that dilation in a single procedure was endangering faecal continence. It was decided to treat the patients with "self dilation" by means of custom made dilators over a period of several months. Three patients are very satisfied with the results and no longer have disordered defaecation. The fourth patient has only recently started this form of treatment but is experiencing clinical improvement. Anal stricture at the site of the anastomosis of the efferent limb of an ileal pouch in patients after restorative panproctocolectomy is most often the cause of obstructed defaecation. However, patients with such a pouch can develop obstructed defaecation caused by an efferent limb of the pouch that is compressed or intussuscepted on defaecation. Four patients with such a disorder were treated with a new operation to prevent repeated damage to the anal sphincter. In this operation the pouch was opened at the top and a stapling device was used to fuse the efferent limb with the pouch.(ABSTRACT TRUNCATED AT 250 WORDS)

[Acute inflammation of ileal reservoir after restorative ileoanal anastomosis]

Ileo-anal anastomosis (IAA) is a suitable surgical treatment for selected patients with ulcerative colitis or familial adenomatous polyposis. Acute inflammation of the ileal reservoir (pouchitis) is the most frequent late complication and is characterized by endoscopic and histological changes of acute inflammation similar to ulcerative colitis with abdominal and sometimes systemic symptoms. Between May 1984 and April 1993, 160 patients (103 male and 57 female) aged between 7 and 64 years (mean age 32.6) underwent IAA; twenty of these for familial adenomatous polyposis, 138 for ulcerative colitis and 2 for indeterminate colitis. After a mean follow-up of 41.8 months (range 1-108), 138 patients (86.3%) were symptoms free and twenty-two (16 male and 6 female-13.7%) who underwent IAA for ulcerative colitis, had pouchitis. Clinical, biochemical, endoscopic and histologic findings suggest pouchitis as a chronic recurrent disease similar to inflammatory bowel disease. In conclusion, the etiopathology of this new entity is unknown. Bacterial overgrowth is one of the most popular hypothesis, but the onset of the acute inflammation observed by us only in patients with previous ulcerative colitis and in some cases during the period of protective ileostomy suggests a multifactorial pathogenesis.

Double-blind crossover trial of metronidazole versus placebo in chronic unremitting pouchitis

Metronidazole has been used to treat pouchitis, but there are no controlled data that show it is effective. Chronic unremitting pouchitis is a form of the disorder particularly difficult to manage. Diarrhea is the main symptom of pouchitis, which results from acute inflammation of the mucosa of an ileal reservoir. To test the hypothesis that metronidazole (400 mg thrice daily for seven days) is no better than placebo at reducing stool frequency in chronic unremitting pouchitis, a double-blind placebo-controlled crossover study has been performed. Thirteen patients who had undergone restorative proctocolectomy for ulcerative colitis were studied. The diagnosis of pouchitis was based on clinical, endoscopic, and histological criteria. At entry all patients had symptomatic pouchitis and were passing more than six stools/24 hr or had consistently bloody stools with at least four of six endoscopic criteria of mucosal inflammation. The median frequency of defecation decreased by 3 bowel actions/24 hr (conservative 95% confidence intervals 0-4/24 hr) on metronidazole but increased by a median of 1/24 hr on placebo. The difference between the median number of bowel motions, when treatment with metronidazole was compared to placebo, was 4 motions/24 hr (P < 0.05) in favor of metronidazole. There was no significant change in the endoscopic or histological grade of inflammation, in the serum C-reactive protein level, or symptomatic scores. In a parallel study, metronidazole did not alter stool frequency in asymptomatic patients without pouchitis who had endoscopically normal reservoirs (six polyposis, six colitis).(ABSTRACT TRUNCATED AT 250 WORDS)

[Radiological findings in patients with a J-shaped ileal reservoir]

This study comprised 116 patients with either ulcerative colitis or familial adenomatous polyposis, who were treated from 1983 to 1990. The patients were subjected to total colectomy followed by formation of an ileoanal reservoir (J-pouch). In a retrospective study the radiological findings of the J-pouch and the reservoir related complications are presented and a description of the applied technique for pouchography is given. A total of 513 radiological investigations were performed--median two per patient (range: 1-44). All 116 patients were subjected to pouchography while 59 patients additionally underwent conventional X-ray investigations, 42 patients were referred to ultrasound and ten patients to CT. Fourty-five percent of the patients presented no radiological complications at all. Patients with a normal primary pouchogram showed a significantly lower risk of long term complications related to the pouch. Pouchography was a useful method for excluding pouch pathology before restoring intestinal continuity as well as showing fistulas or cavities. In cases of leakage and especially stenosis and pouchitis pouchography was, however, less reliable. Ultrasound examination combined with CT-scan was beneficial in diagnosing abscesses.

The ileoanal reservoir: an alternative to ileostomy

The ileoanal reservoir, or ileal pouch-anal anastomosis, is a relatively new, innovative surgical approach offering normal sphincter preservation to clients with familial adenomatous polyposis and ulcerative colitis. In most patients, the ileal pouch-anal anastomosis is performed in two stages. In stage one, the ET nurse must address such patient-education issues as an understanding of the surgical procedure, care of the temporary ileostomy, diet and electrolyte balance, care of the perirectal skin, and the restrengthening of bowel control. Stage two ET nursing interventions focus on perianal skin care, use of medications, sphincter reeducation, and prompt recognition of complications. Written instructions offer the best method of providing crucial information succinctly. Patients require significant physical and emotional support throughout the potentially complex, long-term course until an optimal steady state is achieved.

Comparing functional results one year and ten years after ileal pouch-anal anastomosis for chronic ulcerative colitis

Proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the treatment of choice for most patients with chronic ulcerative colitis. Long-term results, however remain undefined; the major concern is that function may deteriorate.

PURPOSE

The aim of this study was to assess functional outcome in a subgroup of patients who have an IPAA for chronic ulcerative colitis for > 10 years.

METHODS

Among 1400 IPAA patients, 75 consecutive subjects (31 females and 44 males; median age 31 at operation) were identified who had the procedure prior to 1982. All patients had functional results recorded 1 year and 10 years following ileostomy closure.

RESULTS

There were four deaths during the follow-up period; none were pouch related. Two patients refused ileostomy closure. Of the remaining 69 patients, there were 8 (11 percent) failures, leaving 61 subjects available for study. Stool frequency (7 +/- 3, mean +/- SD) remained unchanged. Of the 50 subjects with initially excellent daytime continence, 39 (78 percent) remained the same, 10 (20 percent) developed minor incontinence, and 1 developed poor control after 10 years. Four of 10 subjects (40 percent) with initial minor daytime incontinence remained unchanged, 4 (40 percent) improved, and 2 (20 percent) worsened. The one subject with poor control at one year was unchanged. Nocturnal fecal spotting increased over the 10-year period but not significantly (38 percent vs. 52 percent; P = 0.08).

CONCLUSIONS

After IPAA, functional results in terms of stool frequency and rate of fecal incontinence did not deteriorate with time.

Quest for continence: surgery for ulcerative colitis and familial adenomatous polyposis

In the past decade pelvic pouch procedure (restorative proctocolectomy) has become the surgical treatment of choice for ulcerative colitis and most cases of familial adenomatous polyposis. It is an operation that eradicates disease yet restores gastrointestinal continuity and maintains continence.

Is the construction of an ileoanal pouch associated with the development of arthritis?

The construction of an ileoanal pouch in patients who have undergone total colectomy for ulcerative colitis is claimed to be associated with the development of arthritis. The pattern and prevalence of reported musculoskeletal symptoms in the 15 patients with ileoanal pouches attending our hospital was not significantly different to a control group of 60 patients with an ileostomy for inflammatory bowel disease. There was no clinical or serological evidence of arthritis in the eight patients from the study group reporting symptoms. We conclude that the majority of symptoms occurring following pouch construction are not attributable to an inflammatory arthropathy.

[Technical aspects of neorectum: restorative proctocolectomy]

In the last decade, restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) is considered as the procedure of choice in the surgical management of most patients with familial adenomatous polyposis and chronic ulcerative colitis. Beyond the attraction of this operation, which permit to completely remove disease-bearing mucosa, spare the anal sphincter, and avoid a permanent ileostomy, it remains a difficult procedure with not negligible complication rate. Correct operative technique is required: to the purpose, main technical aspects of IPAA are analysed.

Obstruction after ileal pouch-anal anastomosis: a preventable complication?

Small bowel obstruction is a common complication after ileal pouch-anal anastomosis. This review of 460 patients examines the frequency of small bowel obstruction and determines potential risk factors. The leading indication for ileal pouch-anal anastomosis was ulcerative colitis (83 percent). In 142 patients (31 percent), loop ileostomy was rotated 180 degrees to facilitate emptying of the ileostomy. Ninety-four patients (20 percent) had 109 episodes of obstruction. Obstruction occurred after creation of the pouch (40 episodes), closure of the ileostomy (29 episodes), or developed during the subsequent follow-up period (40 episodes). Operative intervention was required in 39 percent of the episodes (7 percent of all patients). At operation, the most common point of obstruction was at closure of the ileostomy (n = 22/42, 52 percent). In 16 of these patients, the ileostomy had been rotated. Multiple risk factors, including age, sex, primary diagnosis, surgeon incidence, pouch type, prior colectomy, steroid usage, stomal rotation, technique of closure of the ileostomy, and prior obstruction, were examined by univariate and multivariate analysis. Of all factors, only stomal rotation was statistically significant (P = 0.0005, chi-squared analysis). Rotation of the loop ileostomy during ileal pouch-anal anastomosis, although an apparent technical refinement, is unnecessary and predisposes to obstruction.

Radiology of the ileal J-pouch-anal anastomosis (IPAA)

Forty-four consecutive patients operated on with ileal J-pouch-anal anastomosis (IPAA) and diverting ileostomy were examined with barium contrast medium of the pouch before closure of the ileostomy. CT was performed in 4 of the patients. The anatomy of the ileal reservoir as well as complications were assessed. As normal postoperative anatomy we found a "blind loop" at the upper part of the reservoir in 29 patients and a contrast lucency at the anastomosis between the anal channel and the pouch in 5 patients. Complications were revealed at barium contrast medium examinations in 13 patients, including stenoses at the anastomosis between the pouch and the anal channel in 8 patients and fistulas in 5 patients. CT was especially valuable in the exact diagnosis and location of a pelvic abscess in 3 patients, none of which was shown at pouchography.

Altered erythrocyte transmembrane transport of sodium and potassium in patients with conventional or reservoir ileostomy

After proctocolectomy, the loss of the colonic absorptive capacity of sodium is compensated for by increased small intestine sodium absorption and renal conservation of Na by enhanced tubular reabsorption. These processes entail increased cellular sodium transport in the enterocytes and in the renal tubular cells. In order to evaluate if there is a general increase in cellular transport of Na after proctocolectomy for inflammatory bowel diseases erythrocyte Na and K contents and the transmembrane Na fluxes were determined in 35 patients with conventional ileostomy, 23 of which were reinvestigated after conversion to continent reservoir ileostomy. A selected group of another 12 patients having high output from their reservoir ileostomy and low urinary Na were studied concomitantly and 33 healthy subjects served as controls. The intracellular Na content did not differ between the groups while the intracellular K levels were higher in patients with conventional or continent ileostomy compared to controls. In addition, the Na influx and the efflux rate constant of Na were both increased after conversion to reservoir ileostomy. Na influx correlated positively with intake and urinary excretion of Na in conventional ileostomy patients. The results suggest that patients with ileostomy have an increased cellular K uptake and that construction of a reservoir ileostomy further alters cell cation transport by increasing the transmembrane Na turnover.

[The prevention of the aorto-mesenteric compression syndrome in interventions for ileoanal anastomoses]

Restorative proctocolectomy with ileal-anal anastomosis can induce a duodenal stenosis due to the compression between superior mesenteric artery (SMA) and aorta when the ileum is pulled-down to the anus stretching the SMA. This situation may require prolonged nasogastric intubation or even surgery. In our experience this occurred in 10% of pts. Aiming to avoid this complication we have performed an intestinal derotation just before ileal-anal anastomosis abolishing any possibility of duodenal compression. Comparing this latter group of patients to those who didn't receive intestinal derotation, we observed a significant reduction of nasogastric tube drainage and of the nasogastric intubation time. We think that intestinal derotation could be effective in preventing SMA syndrome after restorative proctocolectomy and ileal-anal anastomosis.

Chronic pouchitis after ileal pouch-anal anastomosis: responses to butyrate and glutamine suppositories in a pilot study

Nonspecific, idiopathic inflammation of ileal pouch mucosa ("pouchitis") after ileal pouch-anal anastomosis is a common complication of this surgical approach. The epithelium of the pouch is ileal, but variable degrees of colonic metaplasia are natural sequelae of construction of such a pouch. One hypothesis is that pouchitis is caused by a deficiency of epithelial nutrition. Thus, a lack of butyric acid (the principal metabolic fuel of colonocytes) or of glutamine (the main fuel of enterocytes) may develop. In this study, our aims were to determine the concentration of total short-chain fatty acids in random stool samples obtained from patients with an ileal pouch-anal anastomosis with and without pouchitis and to test the therapeutic effects of butyrate and glutamine suppositories on pouchitis. During the study, all conventional therapy for pouchitis was discontinued. For 21 days, 9 patients participated in a butyrate trial, and 10 patients were treated with glutamine. Total concentrations of fecal short-chain fatty acids were significantly less in patients with pouchitis than in those without pouchitis. During treatment, 6 of the 10 patients who received glutamine had no recurrence of symptoms, but only 3 of the 9 patients who received butyrate responded similarly. Hence, further studies of glutamine in the treatment of pouchitis seem warranted.

The ileal pouch operation for ulcerative colitis

Ileal pouch-anal anastomosis cures chronic ulcerative colitis with an acceptable perioperative morbidity and mortality. The great majority of patients achieve satisfactory continence with an excellent quality of life. However, continence is not perfect, and fecal soilage is a troublesome problem for a small number of patients. Moreover, as many as one third of patients develop pouchitis, for which an effective means of long-term prevention or treatment has yet to be developed. Finally, controversial issues such as optimal pouch design or technique of anastomosis will be resolved only when long-term follow-up of randomized trials has been completed.

[The impact of conventional proctocolectomy on sexual function]

Seventy-one women who had a proctocolectomy for ulcerative colitis (n. 41) or Crohn's disease (n. 30) were interviewed in the follow-up clinic for gynaecological problems and fertility. Forty-nine per cent (35/71) of the women had a distressing vaginal discharge after proctocolectomy, compared with 9% before surgery. At the gynaecological examination 45% (32/71) had a heavy vaginal secretion without any signs of an acute vaginal infection. In 68% (30/44) fluid retention in the vagina was associated with a caudally firmly-fixed and dilated posterior vaginal fornix. Twelve per cent (8/66) of the women reported dyspareunia before surgery. After surgery, 27% (18/66) complained of this symptom. Fertility was significantly reduced after surgery since only 37% (10/27) of the women who attempted to become pregnant succeeded within five years follow-up. The corresponding figure before surgery was 72% (39/54). Those who conceived went through pregnancy and parturition without any incident, 6 of 24 delivered by cesarean section. Fifty-seven men who had a proctocolectomy for ulcerative colitis (n.41) or Crohn's disease (n. 30) were interviewed in the follow-up clinic for the presence of sexual disturbances and their incidence was studied. Fifty-seven per cent of elderly patients (above 40 years old) complained of reduced libido and sexual satisfaction. In younger patients (below 40 years old) 33% complained of an impaired quality of sexual life and 22% complained of an impaired sexual satisfaction. However, despite some sexual dysfunction, 56% reported improved sexual life and 67% improved sexual satisfaction. This may be explained by improved general health and increased libido after removal of diseased bowel.(ABSTRACT TRUNCATED AT 250 WORDS)

Patient teaching for an ileoanal reservoir

Creation of an ileoanal reservoir involves a two-stage surgical procedure. Each stage requires extensive patient education. After stage I, the patient must learn to manage an ileostomy, maintain fluid and electrolyte balance, care for perianal skin irritation, implement dietary changes, and reestablish bowel control. Stage II involves reanastomosis of the bowel, and patient education continues with emphasis on bowel reeducation and skin care. Complications can be frequent, but they may be eliminated or at least minimized by educating the patient. Patients having this procedure usually have had a stressful medical history and are highly motivated to return to a normal lifestyle, yet they still need emotional support. Patient education sheets provide a means to summarize the necessary information. Written instructions provide reinforcement for demonstrations and aid in retention of knowledge.

[Pouchitis: acute inflammation in the pelvic ileal reservoir. Diagnostic criteria, frequency, possible etiological factors and treatment]

Pouchitis is a significant long-term complication of restorative proctocolectomy. Pouchitis is characterized by diarrhoea, fever, malaise, abdominal pain and in few a patients a worsening of already present extraintestinal manifestations may occur. The estimated probability of pouchitis occurring within five years is approximately 35%. Standard diagnostic criteria have not yet been established, but clinical symptoms, endoscopic and histological features should be included. The cause of pouchitis is unknown, bacterial over-growth, faecal stasis, oxygen free radicals, secondary and deconjugated bile acids, shortchain fatty acids, gastrointestinal hormones and an immunologically-mediated reaction have all been suggested as possible etiological factors. Metronidazole is the most commonly used treatment and has prompt effect in more than 90% of the patients. Steroids and 5-aminosalicylic acid derivatives also seem to be effective. A diverting ileostomy is necessary in only five to seven percent of the patients, and in less than one percent does pouchitis result in excision of the pouch. Controlled trials with uniform diagnostic criteria are required to assess the effectiveness of the individual regimens.

Fistula complicating restorative proctocolectomy

Twenty-seven patients developed a fistula after 168 restorative proctocolectomies. Thirteen fistulas were enterocutaneous (two with communication to the bladder); their origins were from the pouch (three patients), the ileoanal anastomosis (three), the pouch appendage (three), a previous loop ileostomy (two) and iatrogenic small bowel injury (two). Two patients had Crohn's disease. The pouch was removed in four patients, one of whom died from chronic small bowel obstruction; the remaining nine have satisfactory pouch function after fistula excision. Ten pouch-vaginal fistulas occurred, all from the ileoanal anastomosis; four were extrasphincteric. Four of these patients had underlying Crohn's disease. Only two patients, with Crohn's disease and indeterminate colitis, required pouch excision; the remainder have good pouch function after treatment of the fistula. There were three pouch-perineal fistulas, all from the ileoanal anastomosis; these were successfully managed by seton fistulotomy. There was one pouch-vesical fistula, successfully treated by excision of the fistula and pouch appendage.

Ileal pouch arthritis

The association between arthritis and intestinal inflammation is well established, but the pathogenesis of the inflammatory joint disease remains speculative. We report six patients who developed a polyarthritis following restorative proctocolectomy with an ileal pouch-anal anastomosis (IPAA) for extensive ulcerative colitis between 1983 and 1990. Six patients were identified with no complaint of joint symptoms before surgery. The average time to onset of arthritis following surgery was 8 months (1 week-yr). The typical features were of an acute symmetrical polyarthritis involving the peripheral and axial skeleton. Early morning stiffness was pronounced in two and minimal in the rest. Three patients were treated with a course of prednisolone and remain in remission (1-4 yr). We believe that this is a novel form of arthritis clearly linked to pouch surgery which may provide important clues to the role of gastrointestinal antigens in rheumatic diseases.

Pouch-vaginal fistula

Between January 1976 and June 1991, 161 women underwent restorative proctocolectomy. Seventeen (10.6 per cent) developed pouch-vaginal fistula. There was no difference in the incidence of inflammatory (15 of 141; 10.6 per cent) and non-inflammatory (two of 20; 10 per cent) disease, the severity of colitis or the number of stages in the operation. In 15 patients the fistula involved the ileoanal anastomosis; in two it had possibly occurred at the dentate line. There was no significant difference in the proportion of hand-sewn (ten of 120; 8.3 per cent) and stapled (seven of 41; 17 per cent) ileoanal anastomosis. Of the 17 women, six had pelvic sepsis in the immediate postoperative period and five had an anastomotic complication. There was no case of Crohn's disease. Three patients developed a pouch-vaginal fistula before closure of the ileostomy. The remaining 14 fistulas occurred a median of 7 (range 1-144) months after closure. Five further patients were referred from elsewhere to give a total of 22 for analysis of treatment and outcome. The fistula developed before ileostomy closure in five patients (group 1) and after closure in 17 (group 2). Following treatment, six fistulas had healed with five patients still undergoing treatment. In group 1, three of the five fistulas healed, whereas in group 2 only three of the 17 healed. Eight patients required excision of the pouch. The prognosis appears to be worse when pouch-vaginal fistula occurs after ileostomy closure. The optimal management is not yet established.

Effects of sodium valproate on various intestinal motor functions after ileal J pouch-anal anastomosis

BACKGROUND

We investigate the effects of sodium valproate, a gamma-aminobutyric acid transaminase inhibitor, on the clinico-physiologic state after ileoanal anastomosis.

METHODS

Twelve patients (five with ulcerative colitis and seven with familial adenomatous polyposis coli) were studied in a placebo-controlled trial.

RESULTS

Placebo had no effect, but valproate increased the resting anal pressure by 22.4% and the maximum tolerable pouch volume by 20.7%. It also prolonged pouch emptying by 47.3%, with an associated improvement in stool frequency and incontinence. These results suggested that valproate improved both reservoir continence and sphincter continence.

CONCLUSIONS

Only minimal side effects were noted, so the administration of sodium valproate appears to be a safe and useful adjunct for patients with ileoanal anastomosis in the early postoperative period.

Possible role of the autonomic nervous system in sphincter impairment after restorative proctocolectomy

Peroperative manometry was performed in 12 patients operated on with endoanal proctectomy and a hand-sewn pouch-anal anastomosis and in 12 in whom proctectomy was performed entirely from above, with the ileal pouch stapled to the top of the anal canal. Results from both groups showed that division of the superior rectal artery reduced the median (95 per cent confidence interval (c.i.)) resting anal pressure from 77.5 (69.9-83.3) mmHg to 64.5 (55.2-70.0) mmHg (P < 0.01). Complete rectal mobilization to the pelvic floor decreased resting pressure by an additional 22 per cent, to a median of 50.0 (95 per cent c.i. 40.1-53.5) mmHg (P < 0.01). After completion of anastomosis, irrespective of the operative technique used, a further decline in median pressure to 35.0 (95 per cent c.i. 26.0-47.7) mmHg could be demonstrated (P < 0.05). This study indicates that anal sphincter pressure is reduced to a similar extent after hand-sewn and stapled anastomoses. Injury to the autonomic nervous supply to the anal sphincter mechanism might be the major cause for this reduction.

Long-term results of the ileoanal pouch procedure

Many surgeons consider the ileoanal pouch procedure to be the procedure of choice for patients who require surgery for ulcerative colitis and familial adenomatous polyposis. To determine long-term results, 460 patients (mean +/- SD age, 31 +/- 9 years) who underwent the ileoanal pouch procedure from 1980 through 1991 were prospectively observed by computerized registry. The leading indication for operation was ulcerative colitis (n = 382; 83%). A J-shaped reservoir was created in 434 patients (94%). More than 5 years after ileostomy closure, the mean number of bowel movements was 5.8 +/- 2.2, and 13% of patients had leakage. Most patients (94%) were satisfied with their results. Sixteen patients (3.5%) required recreation of a permanent stoma for pouch failure. Complications (major and minor) occurred in 266 patients (58%) and included obstruction (n = 94; 20%), pouch fistula (n = 26; 6%), anastomotic stricture (n = 40; 9%), anastomosis separation (n = 14; 3%), and pouchitis (n = 83; 18%). Modifications in technique and increased operative experience have significantly decreased the incidence of obstruction (P = .05) and pouch-related complications (P = .004). Despite complications, long-term results are acceptable, and patient satisfaction remains high.

[Examination of the risk factors for infectious urolithiasis formation in patients receiving urinary diversion or urinary reconstruction using intestine--comparison of reservoir and ileal conduit]

Urinary risk factors and preventive factors for infectious calcium (Ca) urolithiasis formation, such as citrate, oxalate, Ca, phosphate, magnesium, and uric acid were examined more than 2 months after performing a urinary reservoir in 12 patients (R group) and ileal conduit in 10 patients (C group). There was no difference in the positive rate of risk factors between the two groups and also no difference in the positive rate of more than two risk factors between the two groups. Although four patients with more than two risk factors in the R group suffered from reservoir stones all of which included Ca-urolithiasis, none in the C group did. In the R group, the incidence of stone formation in patients with 2 or more risk factors was significantly higher than those in patients with 1 or no risk factor. In conclusion, the urinary reservoir operation should not be carried out in patients with more than two risk factors for urolithiasis formation, and urinary risk factors should be examined before reservoir operation.

Previous subtotal colectomy with ileostomy and sigmoidostomy improves the morbidity and early functional results after ileal pouch-anal anastomosis in ulcerative colitis

The aim of this work was to study the effects of previous subtotal colectomy (STC) with ileostomy and sigmoidostomy on the outcome of ileal J-pouch-anal anastomosis (IPAA) in patients with acute ulcerative colitis. Between 1983 and 1991, we conducted a prospective, nonrandomized study of 156 patients who underwent IPAA in our center. Fifty-five patients (34.3 percent) had undergone STC with ileostomy and sigmoidostomy for either severe acute colitis (36.5 percent of cases) or nonresolving acute colitis (63.5 percent) up to six months before IPAA with covering ileostomy. There were no perioperative deaths; six patients (11 percent) developed complications requiring reoperation (three cases of pelvic sepsis, two occlusions, and one stenosis of the ileostomy). IPAA was successfully carried out at a later stage in all cases. The results of IPAA in these patients were compared with those in 78 patients who underwent the classical two-stage IPAA procedure. The rates of pelvic sepsis and postoperative occlusion were lower in the subgroup of patients who underwent the three-step procedure. Three months after closure of the ileostomy, the mean number of daily stools was significantly lower in the patients who had undergone prior STC (5.09 vs. 5.9), but there was no significant difference between the two groups with regard to diurnal and nocturnal continence, the need to wear a pad, discrimination between gas and stools, or the use of antidiarrheal medication. In addition, there was no significant difference at one year in terms of functional parameters. We conclude that STC is a simple and safe procedure for the treatment of a severe attack of colitis and that it does not compromise the results of later IPAA. Because it does not increase the morbidity of subsequent IPAA and is associated with more rapid functional recovery, STC appears to be suitable for the treatment of patients with nonresolving acute colitis before the onset of malnutrition or steroid dependency.

Stapled vs hand-sutured ileoanal anastomosis in restorative proctocolectomy. A prospective, randomized study

A prospective, randomized study of hand-sutured (group 1, n = 19) and double-stapled (group 2, n = 21) ileoanal anastomosis was carried out in 40 consecutive patients during restorative proctocolectomy to compare complications and functional outcome. Eight patients (42%) in group 1 and 12 (57%) in group 2 had one or more complications. Four patients in group 1 and five in group 2 developed pelvic sepsis. One stapled anastomosis had to be converted to a hand-sutured one because of severe anastomotic stricture. Four patients in group 1 and eight in group 2 had no nighttime evacuations 3 months after surgery and seven patients in group 1 and 11 in group 2 had no nighttime evacuations six months after surgery. Mucous leakage occurred in two vs five patients after 6 months in groups 1 and 2, respectively. The mean resting anal pressure decreased 30% in group 1 and 28% in group 2. In conclusion, double-stapled ileoanal anastomosis does not offer any functional or technical advantage over hand-sutured anastomosis, but it does leave some of the disease behind.

Complications and risk factors after ileal pouch-anal anastomosis for ulcerative colitis associated with primary sclerosing cholangitis

OBJECTIVE

This study determined predictive factors for postoperative complications and outcome after ileal pouch-anal anastomosis in patients with ulcerative colitis and primary sclerosing cholangitis.

SUMMARY BACKGROUND DATA

Patients with ulcerative colitis and primary sclerosing cholangitis treated by colectomy and ileostomy are at high risk of troublesome bleeding from peristomal varices.

METHODS

Postoperative complications and outcome were assessed in 40 patients with ulcerative colitis and sclerosing cholangitis who received an ileal pouch-anal anastomosis between January 1981 and February 1990.

RESULTS

Immediate postoperative and remote ileoanal anastomosis-related complications were high but related directly to the severity of liver disease. No patient had perianastomotic anal bleeding.

CONCLUSIONS

In patients with both ulcerative colitis and primary sclerosing cholangitis, ileal pouch-anal anastomosis is safe and is not associated with perianastomotic bleeding.

Evaluation of the inflammatory infiltrate in pouchitis with 111In-labeled granulocytes

BACKGROUND

The aim of this study was to elucidate the inflammatory infiltrate in pouchitis and define the changes following metronidazole therapy.

METHODS

Twenty-seven patients underwent functional grading, sigmoidoscopic and histological scoring, 111In-labeled granulocyte scanning, and 4-day fecal collections for 111In-labeled granulocyte excretion. Six of the patients with pouchitis underwent repeat studies after 1-month treatment with metronidazole, 400 mg three times daily.

RESULTS

The grade of macroscopic inflammation in the pouch mucosa (sigmoidoscopic score) correlated well with the acute histological score (P < 0.0001), chronic histological score (P < 0.001), 4-hour 111In scan (P < 0.001), 24-hour 111In scan (P < 0.001), and with 4-day fecal 111In excretion (P < 0.001). After metronidazole therapy there was decreased inflammatory grade sigmoidoscopically and histologically on the 4- and 24-hour scans and decreased 4-day fecal 111In granulocyte excretion.

CONCLUSIONS

This study confirms that the inflammatory infiltrate in pouchitis is acute or chronic, is characterized by neutrophils, is usually localized to pouch mucosa, and is always decreased after metronidazole therapy.