Radiology of the continent ileostomy reservoir: II. Findings in patients with late complications

The Association of Coloproctology of Great Britain and Ireland consensus guidelines in surgery for inflammatory bowel disease

AIM

There is a requirement of an expansive and up to date review of surgical management of inflammatory bowel disease (IBD) that can dovetail with the medical guidelines produced by the British Society of Gastroenterology.

METHODS

Surgeons who are members of the ACPGBI with a recognised interest in IBD were invited to contribute various sections of the guidelines. They were directed to produce a procedure based document using literature searches that were systematic, comprehensible, transparent and reproducible. Levels of evidence were graded. An editorial board was convened to ensure consistency of style, presentation and quality. Each author was asked to provide a set of recommendations which were evidence based and unambiguous. These recommendations were submitted to the whole guideline group and scored. They were then refined and submitted to a second vote. Only those that achieved >80% consensus at level 5 (strongly agree) or level 4 (agree) after 2 votes were included in the guidelines.

RESULTS

All aspects of surgical care for IBD have been included along with 157 recommendations for management.

CONCLUSION

These guidelines provide an up to date and evidence based summary of the current surgical knowledge in the management of IBD and will serve as a useful practical text for clinicians performing this type of surgery.

Imaging of the postsurgical small bowel

The small bowel is subject to a variety of surgical interventions for the treatment of a broad spectrum of disease processes. Most operative procedures applied to the small bowel are straightforward techniques encumbered by few complications, whereas other procedures are considerably more complex and can be associated with significant postoperative morbidity. Familiarity with the anatomic alterations related to the various operations is essential, both for evaluation of early postoperative complications and those abnormalities that manifest late in the postoperative course. The surgeon and radiologist should carefully coordinate clinical suspicion with the strengths of the various imaging modalities to optimize postsurgical assessment and provide timely and accurate diagnosis. Enteric anastomoses, the different forms of enterostomy, and the varied constructions of small bowel pouches and reservoirs are each associated with unique anatomy and therefore optimal techniques of assessment. Small bowel contrast studies such as enteroclysis--including its recent modification, CT enteroclysis--and CT imaging represent the primary modalities for imaging of the postoperative bowel and its related abnormalities. Small bowel transplantation continues to progress as a realistic treatment for intestinal failure, and the role of diagnostic imaging in these unique and challenging patients is evolving.

Common surgical procedures

This article illustrates some common surgical procedures. Radiologists and other physicians frequently see patients who have had one or more of these operations. We hope to illustrate with drawings and radiographs the basic purpose of the procedures and the relevant anatomy. This is not intended to illustrate or discuss the actual surgical techniques. Our intention is to illustrate one generally accepted way of performing a given type of surgical procedure. For many of these operations, there may be multiple other techniques to accomplish the same result for the patient. Some of the illustrations and text in this monograph were originally published in Radiologic Guide to Medical Devices and Foreign Bodies, edited by T.B. Hunter and D.G. Bragg, St. Louis: Mosby-Year Book, 1994.

Radiology of the continent ileostomy reservoir: I. Method of examination and normal findings

The aim of the present study is to describe the radiologic methods used to study continent ileostomy reservoirs and to depict the normal radiologic features and variations identified by these procedures. During an 8-year period, 408 double-contrast studies were performed in 261 patients. The present study comprises 170 examinations in 99 patients with normal findings. A high-density barium contrast medium and air were used. Modes variation in the size and shape of the reservoirs was observed. The mucosal pattern of the reservoirs resembled that of the ileum but the folds were slightly wider. The continence-providing valves were 3-5 cm long and had a diameter of 2.5-4.0 cm. The diameter of the afferent ileal segments was usually slightly larger than that of more proximal ileal segments, with an upper limit of approximately 4 cm. The efferent ileal segments generally had a straight course without widening or out-pouches. Retrograde barium double-contrast examination is a satisfactory method for the evaluation of continent ileostomy reservoirs. Here we define the range of normal variations of such reservoirs as seen on retrograde double-contrast radiologic examinations.