Estimation of small bowel transit time following colectomy and ileal reservoir construction

Scintigraphic Small Intestinal Transit Time and Defaecography in Patients with J-Pouch

Objective methods for examination of pouch function are warranted for a better understanding of the functional result and treatment of dysfunction. The objective of this study was to evaluate the results of scintigraphic intestinal transit time and defaecography compared to the results of pouch function, mucosal condition and a questionnaire on quality of life (QoL). This cross-sectional study included 21 patients. Scintigraphic transit time and defaecography was determined with the use of Tc-99m. Pouch function was assessed by number of bowel movements, pouch volume, and continence. Pouch mucosal condition was evaluated by endoscopy and histology. Median transit time was 189 min (105-365). Median ejection fraction at defaecography (EF) was 49% (3-77) and 62% (17-98) after first and second defecation. Median pouch volume was 223 mL (100-360). A median daily stool frequency of nine (4-25) was reported and three (14%) patients suffered from daytime incontinence. No patients had symptomatic or endoscopic pouchitis; however, the histology showed unspecific inflammation in 19 (90%) patients. There was no correlation between transit time, evacuation fraction (EF) and pouch function in univariate analysis. However, we found a high body mass index (BMI) and a low bowel movement frequency to be associated with a longer transit time by multivariate analysis. Scintigraphic determination of transit time and defaecography are feasible methods in patients with ileal pouch anal anastomosis, but the clinical relevance is yet doubtful.

Influence of colectomy on hydrogen excretion in breath

INTRODUCTION

Hydrogen breath test is the most commonly used method to analyze carbohydrate absorption and diagnose carbohydrate malabsorption. The result of the H(2) breath test is influenced by different factors, which are mostly related to quantitative or qualitative aspects of colonic flora. A scarcely studied variable is the effect of colonic anatomical integrity on H(2) excretion in breath.

PURPOSE

The present study aims to determine whether loss of colonic integrity reduces H(2) excretion capacity after an oral load of an unabsorbable carbohydrate.

METHODS

An observational study was conducted in three patient groups: controls with preserved colon, patients with partial colectomy, and patients with complete colectomy and ileostomy. H(2) concentration in breath was measured by gas chromatography every 10 min for 3 h after oral lactulose administration.

RESULTS

Twenty-two patients with partial colectomy, 18 controls with preserved colon, and seven patients with ileostomy were included. H(2) excretion after lactulose did not differ between patients with partial colectomy and controls (basal excretion = 8.5 vs 4 ppm; delta increase = 50.0 vs 47.5 ppm; area under the curve = 4,480.0 vs 4,710.5 ppm/min). In contrast, H(2) excretion was significantly lower in the ileostomy group.

CONCLUSIONS

Partial colectomy does not influence the capacity for H(2) excretion after oral unabsorbable carbohydrate administration.

The role of pouch compliance measurement in the management of pouch dysfunction

PURPOSE

Ileal pouch anal anastomosis is an established option for patients who require total proctocolectomy and restoration of bowel continuity. However, the functional results are not always good and low pouch compliance has been suggested as one possible cause. We aimed to review the results of pouch compliance tests over 11 years to assess whether measuring pouch compliance is a useful diagnostic tool to guide management of pouch dysfunction.

METHODS

The results of pouch compliance tests performed between 1996 and 2007 together with the details of symptoms, treatments and outcome were reviewed.

RESULTS

One hundred and forty-one pouch compliance tests were performed. There was no difference in pouch compliance between those with overt pathology (pouchitis, pelvic sepsis or anastomotic stricture) and those with idiopathic pouch dysfunction. In this second group, there was no difference in pouch compliance between patients with and without each of the symptoms of increased defaecatory frequency, incontinence and evacuation difficulties. The results of the compliance testing did not influence the clinical decision making on idiopathic pouch dysfunction (p=0.77) nor diverted pouches (p=0.07).

CONCLUSIONS

Measuring pouch compliance does not offer new information accounting for idiopathic pouch dysfunction and has little influence on the clinical management.

Functional outcome after restorative proctocolectomy in pigs: comparing a novel transverse ileal pouch to the J-pouch and straight ileoanal anastomosis

BACKGROUND

Restorative proctocolectomy followed by an ileoanal J-pouch procedure is the therapy of choice for patients with familial adenomatous polyposis and ulcerative colitis. After low anterior rectal resection, the authors have reported on a novel, less complex pouch configuration, a transverse coloplasty pouch. The aim of the present work was to apply this new design to the ileal pouch construction, to evaluate feasibility, and to measure functional results in comparison with the J-pouch and the straight ileoanal anastomosis using the pig as an animal model.

METHODS

Twenty-three pigs underwent restorative proctocolectomy followed by reconstruction with straight ileoanal anastomosis (IAA; n = 5), J-pouch (n = 7), and a transverse ileal pouch (TIP; n = 11). Pigs were followed for 6 days postoperatively. Peristaltic function was assessed by manometry proximal to the pouch, in the reservoir, and at the level of the ileoanal anastomosis. Functional outcome was monitored by semiquantitative assessment of the general condition of the animals, postoperative feeding habits, and stool frequency and consistency. A Fourier analysis was performed in order to compare peristalsis in the ileal reservoirs. The reservoir volume was measured in situ by triple contrast computed tomography scan with 3D reconstruction.

RESULTS

Seventeen animals survived for 1 week. There was no difference in the general condition or the feeding habits of the groups. A significant number of pigs with the TIP pouch (7/10) had semisolid or formed stools as opposed to liquid stools after J-pouch (6/6) and IAA (4/5; p = 0.01). TIP animals had a lower stool frequency (3.2 +/- 1.14 per day) on day 6 after the operation than pigs with J-pouch, 5.33 +/- 1,03, and IAA, 4.6 +/- 1.82 (p = 0.0036). The in situ volume of the pouches did not differ significantly. The Fourier analysis demonstrated a disruption of peristalsis by the J-pouch and the TIP reconstruction but not after IAA.

CONCLUSION

The function of ileoanal reservoirs after proctocolectomy may result from the disruption of properistaltic waves after pouch formation. The mechanism of peristalsis disruption is independent of the in situ volume of the pouch.

Gastric emptying function after ileal J pouch-anal anastomosis for ulcerative colitis

BACKGROUND

Little is known of the effects on gastric function after ileal J pouch-anal anastomosis (IPAA) for ulcerative colitis. This study aimed to determine whether patients with postoperative high stool frequency after IPAA exhibit impaired gastric function.

METHODS

Gastric emptying time (GET) for a solid diet (rice gruel) with the use of a radioisotope method and for a liquid diet (orange juice) with the use of an acetaminophen method were assessed in 36 patients with ulcerative colitis more than 30 months after closure of protective ileostomy. Patients were divided into 2 groups: 18 patients with stool frequency less than 6 per day (group A) and 18 patients with stool frequency more than 7 per day (group B). GET for solid and liquid diets in groups A and B were compared with those in 18 healthy volunteers (group C). We correlated the time of peak blood concentration of acetaminophen (TPBCA) and both individual stool frequency per day and the length of distal ileum removed.

RESULTS

GET for the solid diet in groups A and B was not altered by IPAA compared with group C. GET for the liquid diet in groups A and B was slower than in group C (P<.0001). GETs for the liquid diet at 60 minutes or more in group A were slower than in group B (P<.0001); TPBCA was longer in group A than in groups B or C (P<.01). There were inverse correlations between TPBCA and individual stool frequency per day and between TPBCA and length of distal ileum removed (P<.001).

CONCLUSIONS

Rapid transit from the stomach of the liquid diet in group B compared with group A may influence high stool frequency after IPAA. Our results suggested that, to obtain an adequate stool frequency after IPAA, the length of distal ileum removal should be less than 15 cm.

Relationship between gastrointestinal transit time and daily stool frequency in patients after Ileal J pouch-anal anastomosis for ulcerative colitis

BACKGROUND

To investigate how the gastrointestinal transit function changes after ileal J pouch-anal anastomosis (IPAA) for ulcerative colitis (UC) and to study whether gastrointestinal transit time (GTT) has an influence on daily stool frequency, we investigated the relationship between GTT and stool frequency per day.

METHODS

Forty patients with UC who had undergone restorative proctocolectomy, with ileostomy closure at least 48 to 120 months (mean 96.3) previously, and who had no preoperative and postoperative complications were recruited. They were divided into two groups on the basis of their stool frequency: 26 patients had a stool frequency of less than 6 times per day (group A: 16 men, 10 women; aged 15 to 59 years old, average 36.6) and 14 patients had a stool frequency of 7 or more times per day (group B: 10 men, 4 women; 24 to 56 years old, average 40.9). The GTTs using a radiopaque marker were studied. Interviews concerning the defecation states were performed at the examination.

RESULTS

High nocturnal stool frequency was significantly noted more in group B than in group A (P <0.001). All cases in group A and 12 cases in group B could discriminate flatus from feces, and there were significant differences between groups A and B (P <0.05). Feeling of stool remaining was significantly noted more in group B than in group A (P <0.01). Stool consistency in group A was harder than that in group B (P <0.001). Patients with soiling were significantly noted more in group B compared with those in group A (P <0.001). Incontinence was detected in only 2 cases in group B. Group A showed a better defecation state than group B. In the GTT study, the GTT was almost the same in groups A and B. The small bowel transit, pouch transit, and whole gut transit times in group B were faster than those of group A (P <0.001). Removal length of the terminal ileum in patients after IPAA: patients in group B (13.8 +/- 3.9 cm) had significantly more ileum removed compared with patients in group A (6.3 +/- 2.4 cm; P <0.001). Regression lines in the relationship between removal length of the terminal ileum and individual stool frequency showed there was a correlation between removal length of the terminal ileum and individual stool frequency per day in direct proportion (r = 0.79, P <0.001). A resection of more ileum, up to 15 cm, plays a role in increased stool frequency.

CONCLUSIONS

The present results suggested that rapid transit of both the small bowel and pouch may lead to a high stool frequency of 7 or more times per day with a poor defecation state after IPAA. It was also pointed out in this study that an important point is a resection of more ileum, up to 15 cm, plays a role in increased stool frequency.

Mouth to pouch transit after restorative proctocolectomy: hydrogen breath analysis correlates with scintigraphy

OBJECTIVES

Fast intestinal transit may be responsible for slow adaptation and unacceptable steady-state function after restorative proctocolectomy. Investigation of GI transit time may be valuable in such a setting. We hypothesized that postprandial hydrogen breath tests may yield transit data that correlate with technetium-labeled meal scintigrams.

METHODS

This study compared intestinal transit after a lactulose and bean meal via the breath hydrogen and scintigraphy methods in 21 ileoanal pouch subjects. The meal consisted of baked beans (425 g), 30 ml (20 g) lactulose syrup, 1 mCi 99mtechnetium sulfur colloid in finely chopped liver and 170 ml tap water. The meal contained 120 Kcal (70% carbohydrate, 18% protein and 12% fat).

RESULTS

Of 21 pouch subjects, 11 (53%) had breath tests and scintigraphy transit studies that differed by 5-21 min. Three of 21 (14%) scintigraphy mouth to pouch transit times were faster than breath test transits by 43-107 min. Seven of 21 (33%) subjects did not have breath test peaks >10 ppm. Mouth to pouch transit for breath hydrogen (104+/-16 min) and scintigraphy (98+/-7 min) tests had significant correlation (r = 0.96, p < 0.0001) among subjects with alveolar hydrogen peaks and accurate scintigrams (n = 11). Scintigrams were five times more expensive than breath tests.

CONCLUSIONS

A peaking hydrogen breath test provides an alternative to scintigraphy for estimating intestinal transit after ileoanal pouch.

Myoelectric and motor activity after proctocolectomy and ileal pouch-anal anastomosis in dogs

BACKGROUND

The aim of this study was to investigate the motor function of the ileoanal pouch and to evaluate its coordination with proximal small-intestine motility.

METHODS

Proctocolectomy and ileal J pouch-anal anastomosis were performed in 12 dogs. Motility was recorded by serosal electrodes and strain gauge transducers.

RESULTS

Transmission of the migrating motor complex (MMC) on the pouch appeared in only 37 of 109 measurements. On the ascending limb there was a constant irregular activity with no MMC detectable. Motility pattern of the pouch did not change postprandially. Spontaneous defecation always appeared independently from MMC transmission without an increase of electrical or mechanical activity or endoluminal pouch pressure.

CONCLUSIONS

Ileal pouch motility is independent from motility patterns of the proximal intestine. Its random contractile activity might provide storage function and make the pouch act as a functional reservoir. Intrinsic pouch motility is not responsible for pouch evacuation under physiologic conditions.

The physiology of ileo-anal pouch function

Even excellent clinical function after ileo-anal pouch construction is associated with a variety of physiological abnormalities. Small bowel intestinal motility is essentially normal but the ileal reservoir serves to markedly suppress the ileal motor response both to progressive distension by intestinal contents and to transmitted myoelectrical complexes. As a result, the healthy pouch can accommodate a large volume of intestinal content before the rising baseline pressure and the appearance of large isolated contraction waves produce an urge to defecate. Evacuation in the normal pouch patient is rapid and highly efficient and is achieved by means of the Valsalva maneuver without any evidence of significant intestinal propulsion. External anal sphincter function is fully preserved but internal anal sphincter function is significantly impaired in the immediate postoperative period. Recovery occurs over the next 6 to 12 months but is often incomplete. Bacterial overgrowth in the pouch and prepouch ileum is almost universal and results in the premature deconjugation of primary bile salts and accumulation of secondary bile salts within the pouch. These produce morphologic changes in the ileal mucosa, and their excretion in pouch effluent gradually depletes the bile salt pool. Anerobic organisms also bind with vitamin B12 and the vitamin B12-intrinsic factor complex, resulting in subtle but measurable reductions in vitamin B12 levels in pouch patients. Finally, anerobic fermentation of mucus and undigested carbohydrate results in excessive quantities of short chain fatty acids within the pouch lumen. The clinical significance of these substances is unclear, but they may have an adverse action on both ileal mucosal and smooth muscle function. In essence, however, the pouch surgeon can maximize the likelihood of good clinical function by constructing a large capacity pouch, by avoiding surgery in patients with clearly deficient anal sphincter mechanisms, and by careful attention to pouch-anal anastomotic technique.

The release of gastric inhibitory peptide, glucagon-like peptide-I, and insulin after oral glucose test in colectomized subjects

BACKGROUND

The physiologic role of the colon as an endocrine organ is not clear. We therefore studied the enteroinsular axis in patients with ulcerative colitis after colectomy.

METHODS

The subjects included 11 patients with a conventional ileostomy, 10 patients with an ileoanal reservoir, and 10 normal controls. The concentrations of glucose, insulin, gastric inhibitory peptide (GIP), and glucagon-like peptide-I (GLP-I) were measured in plasma during an oral glucose test.

RESULTS

The peak level of glucose and peak levels and area under the curve (AUC) of insulin and GIP were higher in patients (P < 0.05). Neither the peak level nor the AUC of GLP-I differed between patients and controls, but time to peak level was four times longer in patients with an ileoanal reservoir (P < 0.05).

CONCLUSION

Colectomy seems to affect the enteroinsular axis, leading to hyperinsulinemia and an impaired glucose tolerance. Moreover, patients with an ileoanal reservoir have a slower GLP-I response after intake of glucose.

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.