The endorectal ileal pouch-anal anastomosis. Current clinical results

Ileal pouch-anal anastomosis-vaginal fistula: a review

BACKGROUND

Fistula between an ileal pouch and the vagina is an uncommon complication of ileal pouch-anal anastomosis. Its optimal management has not been determined because of its low incidence.

METHODS

The literature describing such fistulas was reviewed to determine the incidence, cause, and appropriate investigation and repair of these lesions. A literature search was performed with the PubMed, MEDLINE, and EMBASE databases. Through this search we located English-language articles from 1970 to 2003 on pouch-vaginal fistulas following ileal pouch-anal anastomosis. References from these articles were searched manually for further references.

RESULTS AND CONCLUSION

Pouch-vaginal fistula occurs in 6.3 (range, 3.3-15.8) percent of female patients with an ileal pouch-anal anastomosis. Sepsis and technical factors are the most common contributors. It is the cause of considerable morbidity. Management depends on the level of the fistula, the amount of pelvic scar tissue, and previous treatments. An algorithm for surgical treatment is suggested.

Internal anal sphincter: advances and insights

The internal anal sphincter, the smooth muscle component of the anal sphincter complex, has an ambiguous role in maintaining anal continence. Despite its significant contribution to resting anal canal pressures, even total division of the internal anal sphincter in surgery for anal fistulas may fail to compromise continence in otherwise healthy subjects. However, recently reported abnormalities of the innervation and reflex response of the internal anal sphincter in patients with fecal incontinence indicate its significance in maintaining continence. The advent of sphincter-saving surgery and restorative proctocolectomy has re-emphasized the major contribution of the internal anal sphincter to resting pressure and its significance in preventing fecal leakage. The variable effect of rectal excision on rectoanal inhibitory reflex has led to a reappraisal of the significance of this reflex in discrimination of rectal contents and its impact on anal continence. Electromyographic, manometric, and ultrasonographic evaluation of the internal anal sphincter has provided new insights into its pathophysiology. This article reviews advances in our understanding of internal anal sphincter physiology in health and disease.

Afferent limb obstruction complicating ileal pouch-anal anastomosis

PURPOSE

Small-bowel obstruction is a common complication after ileal pouch-anal anastomosis (IPAA). Acute angulation of the afferent limb at the pouch inlet is the cause of obstruction in a subset of patients requiring laparotomy.

METHODS

Patients were identified from the Lahey Clinic ileoanal pouch registry, a prospective computerized database of all patients who have undergone IPAA since 1980. Records of patients who were identified as having afferent limb obstruction as a cause of bowel obstruction after IPAA were reviewed.

RESULTS

A total of 567 patients had undergone total proctocolectomy and ileoanal J-pouch at time of the study. Of 122 patients with one or more episodes of obstruction after IPAA, 48 required operative intervention. Afferent limb obstruction was identified as the cause of obstruction in six patients (12 percent). The most common presentation was recurrent partial obstruction (4 of 6 patients). Contrast small-bowel series and enemas were suggestive of obstruction in four of six patients, the most consistent radiographic finding being small-bowel dilation to the level of the pouch inlet. All patients underwent laparotomy for unresolved obstruction. Intraoperatively, the afferent limb was found to be adherent posterior to the pouch, causing acute angulation at the pouch inlet. Rather than risk injury to the pouch or its mesentery, the obstruction was bypassed by side-to-side anastomosis of the afferent limb to the pouch (enteroenterostomy) in five of six patients. One patient underwent ileostomy only because of technical considerations. Two patients required re-exploration and pexy of the afferent limb to the pelvic sidewall (pouchopexy) to relieve recurrent afferent limb obstruction.

CONCLUSION

Afferent limb obstruction should be suspected in patients with recurrent obstruction after IPAA. Bypass of the obstructed segment from distal ileum to the pouch is safe and effective treatment. Because of the risk of recurrent afferent limb angulation, concurrent pouchopexy should be considered.

Influence of ileal pouch capacity and anal sphincteric function on the clinical outcome after ileal pouch-anal anastomosis

This study was designed to determine the influence of ileal pouch capacity and anal sphincteric function on the clinical outcome after ileal pouch-anal anastomosis. A total of 24 patients who had undergone ileal pouch-anal anastomosis (J pouch) for ulcerative colitis were studied. The 24-hour stool frequency was found to be inversely correlated with the sensitivity threshold volume (STV), maximal tolerance volume (MTV), and distensibility, but was independent of the maximal resting pressure and maximal squeeze pressure. Patients experiencing nocturnal fecal incontinence had maximal resting pressures that were significantly lower than those of nocturnally continent patients. Among the patients with fecal incontinence, those with frequent soiling had lower resting pressures, STV, and distensibility than the patients with intermittent spotting. In addition, the STV in patients needing nocturnal evacuation were lower than those of patients who did not evacuate after falling asleep. The conclusions are as follows. Both stool frequency and the need for nocturnal pouch evacuation correlated directly with pouch volume. Anal incontinence was more common in patients with low internal sphincteric function. In addition, frequent and gross nocturnal incontinent patients demonstrate a worse function in both the anal sphincter and reservoir than those with intermittent spotting.

The use of an ileostomy connector to diminish the frequency of defecation prior to ileostomy closure in patients with a pelvic pouch

A new method for allowing stool passage into the pelvic pouch before ileostomy closure to verify the defecation state and diminish stool frequency is reported herein. This was accomplished by fitting an ileostomy connector connecting the proximal and distal openings of the diverting loop stoma. The ileostomy connector was initially in place for 6 h a day, the length of time being gradually increased until it was able to be left in for 24 h a day over a 3-month period. The calculated daily frequency of stools decreased from 24 to 6 or 7 times, and the mean daily frequency immediately after ileostomy closure was 6.5 times. Physiological study also showed an improvement, with squeeze pressure increasing from 35 cmH2O to 116 cmH2O and the maximum tolerated volume increasing from 35 ml before, to 90 ml 3 months following the use of an ileostomy connector. Thus, we conclude that an ileostomy connector may be useful to predict postoperative functional outcome and its complications, and to diminish the frequency of defecation before ileostomy closure in patients with a covering loop stoma.

Superior mesenteric artery syndrome as a complication of ileal pouch-anal anastomosis. Report of a case

PURPOSE

Duodenal compression by the superior mesenteric artery following total proctocolectomy and ileal pouch-anal anastomosis is a rare occurrence. Previous surgical treatment involved duodenal division. The aim of this report was to describe a case with such a complication and to discuss an operative alternative.

METHODS

Case report.

RESULTS

Mobilization of the duodenum from its retroperitoneal attachments, without transection and reanastomosis, allowed the free passage of gas through the duodenum and recovery for the patient.

CONCLUSION

This case report suggests that a more conservative approach may be successful in managing this complication.

Fecal incontinence

Fecal incontinence is a common but infrequently reported, imperfectly understood, multifactorial disease with far-reaching socioeconomic and psychological implications. Limited success with somewhat empirical surgical procedures implies that patients should be investigated fully, indications for surgery should be clear, and disability should be serious enough to demand surgical intervention. Dietary adjustments and medical treatment should be tried first. Unwelcome though it is, colostomy may be the ultimate remedy in some patients.

Adenocarcinoma in the rectal segment in familial polyposis coli is not prevented by sulindac therapy

Sulindac, a nonsteroidal anti-inflammatory drug, causes regression of polyps in familial polyposis coli and may prevent new lesions. However, it is not clear whether the effect of sulindac in preventing polyps also applies to carcinoma. This case report describes a patient with familial polyposis coli who developed a carcinoma in a rectal segment after subtotal colectomy and ileorectal anastomosis. She had been treated with 450 mg sulindac daily for 28 months and was free of polyps during the latter 12 months of this period. However, despite intensive endoscopic follow-up, she developed an adenocarcinoma of the rectum. This finding may have important implications for our understanding of the development of colon cancer in familial polyposis coli and the use of sulindac to prevent it. Development of de novo carcinoma in microadenomatous tissue of the rectal mucosa, which bypasses the polyp-cancer sequence, must be considered as a possibility in these patients.

Prospectively evaluating anal sphincter function after ileal pouch-anal canal anastomosis

The decreased anal sphincter pressure that occurs after ileal pouch-anal canal anastomosis (IPAA) has usually been attributed to damage of the internal and sphincter. We hypothesized that the operation damages both the internal and the external anal sphincter. Resting pressure in the anal canal (a function of internal and external sphincters), anal squeeze pressure (a function of external sphincter only), and the rectal-anal inhibitory reflex (involving the internal sphincter) were measured manometrically in 10 patients with ulcerative colitis (4 women and 6 men; mean age, 33 years; range: 20 to 49 years). The patients were studied while awake before IPAA, under general anesthesia with striated muscle blockade just before incision, awake 2 months later before ileostomy takedown, and again under anesthesia with blockade just before takedown. The operation decreased maximum resting anal pressure while awake and during anesthesia with blockade. The decrease was detected in the proximal anal canal but not in the distal anal canal. In addition, the operation impaired anal squeeze pressure and abolished the rectal-anal inhibitory reflex. We conclude that IPAA damages both the internal and the external anal sphincter.

Does the level of stapled ileoanal anastomosis influence physiologic and functional outcome?

PURPOSE

The aim of this investigation was to ascertain how the length of anal canal preserved above the dentate line in stapled end-to-end ileoanal anastomosis influenced late outcome.

METHODS

Two groups, high cuff group and low cuff group of nine subjects with stapled anastomosis, matched for sex, age, pouch configuration, and mean follow-up, representing the highest (median, 2.5 cm) and lowest (median, 0.7 cm) anal cuff lengths in our series, were selected. Physiologic and functional parameters were appraised preoperatively, at the time of ileostomy closure, and at 1, 3, 6, and 12 months after reestablishment of intestinal continuity.

RESULTS

At one year, the drop in mean anal canal resting pressure was 13 percent in the high cuff group (not significant) and 31 percent in the low cuff group (P < 0.05); mean maximum squeezing pressure did not differ significantly from preoperative values in both groups. The mean volume of the ileal pouch was higher in the low cuff group at all insufflation pressures. The rectoanal inhibition reflex reappeared in four high cuff group patients and in none of the low cuff group patients. Mean distention pressure (cm H2O) and volume (ml) eliciting urge sensation were 80 and 360 in the low cuff group compared with 40 and 240 in the high cuff group (P < or = 0.05). Daytime bowel movements and night incontinence were significantly better in the low cuff group. No statistical differences were observed for night stool frequency, daytime incontinence, pad use (day and night), discrimination between gas and feces, ability to defer evacuation, and difficulty in emptying the pouch.

CONCLUSION

Patients with stapled anastomoses and a low rectal cuff length, despite presenting lower anal resting pressure and absence of rectoanal inhibition reflex, had a better functional outcome in terms of continence than those with a high cuff length.

Fecal short-chain fatty acid concentrations and effect on ileal pouch function

Random stool samples were obtained from 14 ileal pouch-anal anastomosis (IPAA) patients 43 +/- 5 (mean +/- SEM) months after surgery, and the concentrations of individual short-chain fatty acids (SCFAs) were determined by gas liquid chromatography. Stool frequency was determined from a diary recorded for 15 days prior to stool sampling. The frequency, amplitude, and duration of phasic contractions (PCs) within the pouch following infusion of a physiologic concentration of SCFAs and normal saline randomly into the pouch of six IPAA patients were determined manometrically. The mean total SCFA concentration after IPAA did not differ significantly from normal stools (83 +/- 20 mM after IPAA vs. 97 +/- 10 mM for controls; P > 0.05). In the IPAA patients, regression analysis demonstrated an inverse relationship between stools per day and total SCFA concentration (r = 0.73; P < 0.001). Moreover, no change in frequency (3.0 +/- 0.9 vs. 3.2 +/- 0.8 PCs/30 minutes), amplitude (26 +/- 5 vs. 25 +/- 4 mmHg), or duration (23 +/- 3 vs. 26 +/- 2 seconds) of PCs was found after SCFA infusion compared with saline control (P > 0.1). These findings demonstrate that SCFAs are present in ileal pouch effluent and that stool frequency may be related to fecal SCFA concentration. Also, the normal contractile response of the terminal ileum to SCFAs does not occur in the ileal pouch.

Complications associated with ileal pouch-anal anastomosis

Seventy-three patients underwent total colectomy, rectal mucosectomy, creation of J or S ileal reservoir, and ileal pouch-anal anastomosis from 1982 to 1989. Mean follow-up was 38 months, with a minimum of 3 months in 15 patients being followed long-term at another institution. Forty-eight (66%) patients had histologically proven ulcerative colitis and 25 (34%) patients had familial polyposis. Thirty-eight J reservoirs and 35 S reservoirs were constructed. There were no perioperative deaths. The failure rate (loss of pouch) was 3%. Thirty-six complications in 34 (47%) patients were reported, 14 (19%) patients required surgery. Bowel obstruction was the most common postoperative complication (16%), followed by pouchitis (15%), and cuff infection (5%). Seventy-eight percent of the complications were associated with the J pouch. Average stool frequency at 1 year was 4 per 24-hour period. Other complications included postoperative pneumonia (1), peroneal nerve palsy (1), and temporary sexual dysfunction (1). Seven of 15 complications requiring surgical intervention occurred in the first 2 years of the study period, illustrating the learning curve associated with the procedure. Blood loss, transfusion requirements, and length of operation were not associated with higher complication rates. Use of the J pouch and experience of the individual surgeon affected morbidity.

A personal experience with 100 consecutive total colectomies and straight ileoanal endorectal pull-throughs for benign disease of the colon and rectum in children and adults

In 1974 total colectomy and ileoanal straight endorectal pull-through (ERPT) were first used at our institution for the definitive management of total colonic Hirschsprung's disease in infants and children. Early success with this operation encouraged us to use this procedure in children and adults with ulcerative colitis and familial polyposis in 1977. Since 1974 we have performed total colectomy and straight ileoanal ERPT on 100 consecutive patients with ulcerative colitis (79), familial polyposis (19), and total colonic Hirschsprung's disease (10). Patients who have undergone a colectomy and ERPT but have not had their temporary ileostomy closed have been excluded from this report. This group of patients represents the only large series of straight ERPTs available for comparison with the various reservoir modifications that have been reported. All operations were performed under the direction of the author. The mean age at surgery was 20.6 +/- 9.8 years, with a range of 1 to 48 years. Forty-six patients were younger than 18 years at the time of operation. All patients with ulcerative colitis and familial polyposis underwent a temporary loop ileostomy with total abdominal colectomy with ERPT; the 10 infants and children with Hirschsprung's disease underwent the total colectomy and ERPT without a back-up ileostomy. There were two deaths in this series, one from fulminate hepatic failure in the late postoperative period and the other from multiple bowel fistulas and sepsis in a teenager with Crohn's disease, in whom the initial diagnosis was ulcerative colitis. Follow-up has ranged from 3 months to 15 years. There were 13 cases of adhesive bowel obstruction, seven of which required an enterolysis. Pelvic sepsis occurred in three patients, two of whom required operative drainage. Two women developed rectovaginal fistulas, which healed with temporary diversion. Minor wound infections occurred in five patients. There were no anastomotic leaks, nor were any cases of pouchitis encountered. In five patients permanent conversion to a Brooke ileostomy was required. Mean stool frequency 3 years after surgery was 7.7 per 24 hours. Daytime continence was achieved in all patients. Occasional nocturnal soiling occurred in 11.1% of patients at 1 year and was absent by 3 years. Neither age nor diagnosis (ulcerative colitis versus familial polyposis) affected stool frequency.(ABSTRACT TRUNCATED AT 400 WORDS)

Bile composition after total proctocolectomy with interposed jejunal segment as neorectum

Changes of bile composition in gallbladder bile and serum chemistries were investigated in nine dogs after proctocolectomy and ileoanal anastomosis, using an interposed jejunal segment as a neorectum. A significant decrease in cholic acid and an increase in deoxycholic acid were observed 24 weeks after the operation, although there was no significant change of total bile acid and phospholipids in the bile. Concentration of cholesterol and cholesterol saturation index in bile increased after total proctocolectomy. Although serum triglyceride levels became lower compared with the nontreated control group, concentrations of total protein, serum cholesterol, total lipids, blood sugar, and electrolytes showed no significant difference. This operative procedure apparently did not impair intestinal absorption of bile acid, but did increase the biliary cholesterol saturation index.

New approach to surgical treatment of ulcerative colitis and polyposis coli without pelvic pouch. Experimental study in dogs

A new method for the surgical treatment of ulcerative colitis and polyposis coli is described. Instead of preparing a pelvic pouch, the natural rectal pouch stripped of the diseased mucosa was used experimentally in dogs. The undisturbed muscular cuff of the rectum (12 cm from the anal verge) was covered by healthy vascularized mucosa of small bowel in such a manner that the dog could use its rectum as usual before surgery. The results are encouraging. The rectal reservoir is spared, with its sensitivity, continence and motor activity covered by healthy mucosa. The dogs thrived.

Multivariate analysis of factors influencing the results of restorative proctocolectomy

Univariate and multivariate analyses have been used to assess the influence of 14 variables on the results of 65 consecutive ileoanal pouch procedures over 5 years. There were nine failures requiring intubation, ileostomy or pouch excision. There was a significant association between failure and pelvic sepsis (P less than 0.05, n = 8), endoanal mucosectomy (P less than 0.05, n = 7), preservation of a long rectal cuff (P less than 0.05, n = 5) and lack of experience with the operation (P less than 0.05, n = 8). Of 49 patients with preoperative evidence of ulcerative colitis, three are now known to have Crohn's disease. Functional outcome was significantly impaired in patients who developed pelvic sepsis (P less than 0.01) or a postoperative fistula (P less than 0.05), and who had an endoanal mucosectomy (P less than 0.05). Success with ileoanal pouch reconstruction increases with experience. Avoidance of sepsis is associated with a lower failure rate, improved functional results and reduced hospital stay. Preliminary colectomy is also advised to exclude Crohn's disease if the diagnosis is in question.

Postoperative adaptation of the small intestine after total colectomy and J-pouch-anal anastomosis

Twelve patients who underwent total colectomy and J-pouch-anal anastomosis were followed up to 3 years after surgery to evaluate the functional and morphologic changes of the small-bowel reservoir. Intestinal absorption was impaired for lactose in 18 percent, for D-xylose in 27 percent, and for 75SeHCAT in 83 percent. Morphologic changes in ileal-pouch specimens consisted of a marked flattening of the villi and augmentation in crypt number and length. The number of Paneth's cells was increased compared with normal ileum. Parameters, indicating neorectal function such as stool frequency, pouch volume, and intestinal transit, improved in time during the postoperative course. Because of impaired small-bowel function, which is not restricted to the pouch reservoir, the ileum acquires progressive colonic capacities in accordance with its morphologic transformation to a colonic type mucosa. None of our patients developed clinical malabsorption requiring regular therapeutic substitution beyond a well-balanced diet due to these morphologic and functional changes and postoperative acceptance was good or excellent in all but one case.

Anal and ileal pouch manometric measurements before ileostomy closure are related to functional outcome after ileal pouch-anal anastomosis

Anal canal length, and canal resting and squeeze pressures, ileal pouch capacity and pouch compliance were measured in 104 patients after ileal pouch-anal anastomosis but before ileostomy closure. The intention was to determine if such parameters were associated with late functional outcome after re-establishment of intestinal continuity. Functional outcome in terms of stool frequency (day and night), incontinence (day and night), perianal pad use, perianal skin irritation, and the use of constipating agents was assessed for all 104 patients 1 year or more (median 438 days) after ileostomy closure. A low mean anal sphincter resting pressure before ileostomy closure was associated with subsequent nocturnal incontinence (P less than 0.05) and, to a lesser extent, the need to use constipating agents (P = 0.08). Pouch compliance if low before ileostomy closure was associated with an increased frequency of nocturnal stool frequency after 1 year (P less than 0.05). Anal canal length, and sphincter squeeze pressure and pouch capacity before ileostomy closure were not related to subsequent functional outcome in these patients.

Sulindac for polyposis of the colon

The effect of sulindac, a nonsteroid antiinflammatory drug, on colon polyposis has been evaluated in seven patients after subtotal colectomy and ileoproctostomy and in four patients with intact colons. The patients all had Gardner's syndrome or familial polyposis coli. All polyps were eliminated, except for a few that arose in the rectal mucosa and the anal canal. No cancers developed in these patients on follow-up.

Straight ileoanal anastomosis with preserved anal mucosa for ulcerative colitis and familial polyposis

Thirty-two patients were treated with colectomy, mucosal proctectomy, and straight ileoanal anastomosis. Mucosal dissection was performed from the abdominal side, and an anal mucosal brim of 1-2 cm was preserved. Diverting ileostomy was not used, and four patients developed anastomotic leak with pelvic sepsis. Three patients had take-down of the anastomosis for reasons related to the operative method. The remaining patients are all completely continent day and night and have a median stool frequency of 6/24 h 1 year after the operation. The frequency was significantly higher in patients with ulcerative colitis (UC) than in patients with familial polyposis (FP). No dysplasia, ulceration, or stricture formation was found in the preserved mucosa in the UC patients. Regrowth of polyps in the mucosal brim occurred in 10 of 13 FP patients, with atypia in 1. The FP patients had more late complications attributed to extracolonic manifestations of the FP disease.

Prospective randomized trial to compare the stapled double lumen pouch and the sutured quadruple pouch for restorative proctocolectomy

Thirty-three consecutive patients having restorative proctocolectomy since April 1986 were randomly allocated to reconstruction using a stapled J pouch (n = 18) or a sutured W pouch (n = 15). There were no deaths, but one patient required pouch excision for ischaemia (J). One patient developed a leak from the pouch necessitating loop ileostomy (J) and one patient had a low pouch vaginal fistula successfully treated by a seton (W). There were no other major complications. Median (range) operative time was 200 min (165-290) for J pouch and 255 min (220-330) for the W pouch (P less than 0.05). In 24 patients followed up for more than 4 months after restoring intestinal continuity, median frequency of defaecation over 24 h was 4 (3-6) for the J pouch and 4 (3-6) for the W pouch. There was no incontinence, urgency or soiling. These results indicate that the quicker J pouch provides identical functional results to the larger W pouch in this series of patients.

Physiological parameters influencing function in restorative proctocolectomy and ileo-pouch-anal anastomosis

Ileo-pouch-anal function has been assessed in 30 patients after restorative proctocolectomy and compared with age- and sex-matched controls. Median resting anal canal pressure was only 42 cmH2O (7-113 cmH2O) compared with 100 cmH2O (46-114 cmH2O) in controls (P less than 0.005). Maximum squeeze anal pressures were also significantly lower in pouch patients: 87 cmH2O (25-180 cmH2O) than controls: 143 cmH2O (114-171 cmH2O) (P less than 0.01). The recto-anal inhibitory reflex was absent in all pouch patients but was present in all controls. Maximum pouch or ileal pressures exceeded resting anal canal pressures in three patients. Median volume at first leak during saline infusion was 320 ml (60 ml-no leak) in pouch patients whereas the majority of controls had no leakage (median, none; 450 ml-no leak; P less than 0.05). Threshold pouch sensation (median, 50 ml (0-250 ml] did not differ from rectal sensation in controls (50 ml (0-180 ml] but pouches were less compliant than a normal rectum, median 6.8 ml/cmH2O (2.1-17 ml/cmH2O) and 11.6 ml/cmH2O (4.7-16.2 ml/cmH2O) respectively (P less than 0.05). In patients who had an episode of pelvic sepsis (n = 8) the average number of abnormal physiological indices per patient was 3.8, compared with 1.3 in those with no sepsis (P less than 0.05). There was no difference in the number of abnormalities per patient with a J pouch (2.0; n = 19) or a W pouch (1.9; n = 11).

Gracilis muscle repair of rectovaginal fistula after restorative proctocolectomy. Report of two cases

Gracilis muscle interposition flaps have been used to treat two patients with rectovaginal fistulas. The fistulas occurred following restorative proctocolectomy with a J-shaped ileal reservoir and ileoanal anastomosis. Attempts at local repair of the fistulas had failed. A diverting loop ileostomy was constructed simultaneously. Anterior sphincteroplasty was performed in one patient for associated incontinence. Excellent results were achieved in both patients. The fistulas have healed, and intestinal continuity has been re-established. This procedure can be useful to salvage a pelvic pouch complicated by a rectovaginal fistula.

Operative treatment of ulcerative colitis: conventional proctectomy with Brooke ileostomy versus mucosal proctectomy with ileoanal anastomosis

Fifty-four patients with ulcerative colitis were operated on during a 3-year period; 35 had conventional proctectomy and Brooke ileostomy, and 19 had mucosal proctectomy, performed from the abdominal side, leaving 1-2 cm of the distal anal mucosa, and a straight ileoanal anastomosis (IAA) without diverting ileostomy. There were no operative deaths. In the ileostomy group 19 (54%) of the patients had a total of 38 reoperations: 10 laparotomies and 28 revisions of a perineal sinus. Three (16%) of the IAA patients had a total of five reoperations: four laparotomies and one closure of a loop ileostomy. All IAA patients had perfect continence day and night and a median stool frequency of 7.5/24 h 1 year after the operation. Ileostomy patients had significantly longer time out of work, and more urinary, sexual, and social dysfunctions than the IAA patients. After 2-3 years' follow-up study, all differences in results are greatly in favour of the ileoanal procedure.

Experience with the straight endorectal pullthrough for the management of ulcerative colitis and familial polyposis in children and adults

The first significant experience with the straight endorectal pullthrough for the management of ulcerative colitis was presented before the American Surgical Association in 1977 by Lester Martin. Since then the operation with or without modification has been used extensively. High stool frequencies in some series led to disenchantment with the straight anastomosis and to the development of various reservoir procedures to increase rectal capacity and thereby reduce frequency. As a result, no large series of straight pullthroughs is available for comparison with the reservoir modifications. Between September 1977 and September 1986, 72 children and adults, 61 with ulcerative colitis and 11 with familial polyposis, underwent endorectal pullthrough (ERPT) and straight ileoanal anastomosis under the overall direction of a single surgeon (AGC). Sixty patients have undergone ileostomy closure and form the basis of this study. Mean age at operation was 22.7 years (range 4-48 yr), and duration of active disease averaged 6 years. One-half of the patients underwent total abdominal colectomy with ERPT as a primary procedure. There were 11 cases of adhesive bowel obstruction following ERPT, and in six patients in the series permanent revision to a Brooke ileostomy was required. One patient died of hepatic failure in the late postoperative period. Follow-up has ranged from 3 months to 9 years. Mean stool frequency for the group as a whole at 3, 6, 12, 24, and 36 months was 11.8, 11.2, 9.6, 9.0, and 8.3 per 24 hours, respectively. Daytime continence was achieved in all patients. Occasional nocturnal soiling occurred in 11.1% of patients at 1 year. Stool frequency and continence were also analyzed by age group above and below 18 years and above and below 30 years. There were no statistically significant differences between these groups. The authors conclude from this study that ERPT with straight ileoanal anastomosis remains an appropriate alternative for children and adults with ulcerative colitis or familial polyposis and compares favorably with the more complicated ERPT involving a reservoir.

Superior mesenteric artery syndrome following ileal J-pouch anal anastomosis. An iatrogenic cause of early postoperative obstruction

This is the first case report of the superior mesenteric artery syndrome developing in a patient following total proctocolectomy and ileal J-pouch anal anastomosis. In addition, this is the first demonstration of this syndrome using abdominal CT scan. A 22-year-old veteran underwent total proctocolectomy for left-sided ulcerative colitis because of failure of medical therapy. At operation an ileal J-pouch anal anastomosis was constructed. Following operation, the patient developed an intestinal obstruction. Abdominal CT scan demonstrated scant retroperitoneal fatty tissue, massive dilatation of the duodenum proximal to the midline, and tapered narrowing of the duodenum between the superior mesenteric artery and aorta. These findings indicated superior mesenteric artery syndrome: arteriomesenteric obstruction of the duodenum. Based on the experience of this case, the authors believe that compression of the duodenum by the superior mesenteric artery may be a common but unsuspected cause of prolonged postoperative ileus or early postoperative obstruction following ileal pouch anal anastomosis.

Surgery for ulcerative colitis

Ileal pouch-anal anastomosis is a relatively new surgical alternative to conventional ileostomy in patients with chronic ulcerative colitis. The rationale for the operation is that the disease is cured by the colectomy, proximal proctectomy, and distal endorectal mucosal resection, but enteric continence is maintained because the anal sphincters are preserved and the reservoir capacity is restored by incorporating an ileal pouch. This article describes the criteria for selecting appropriate patients, the surgical technique, the short- and long-term clinical results, and the physiologic consequences of the operation. The possible implications of this new procedure on the future management of patients with chronic ulcerative colitis are also presented.

Physiology of ileoanal anastomosis with ileal reservoir for ulcerative colitis and adenomatosis coli

A physiologic and metabolic assessment was carried out on eight patients six months after total proctocolectomy with ileal reservoir for ulcerative colitis and familial adenomatosis coli. All patients were continent and able to defecate spontaneously, stool frequency ranging from two to five per 24 hours. Anal sphincter resting pressures (35 +/- 14 mmHg) and squeeze pressures (88 +/- 24.2 mmHg) were similar to those of a healthy population, with the exception of one patient's complaint of nocturnal mucous leakage per anus. Biopsies of the ileal mucosa of the reservoirs showed a mild inflammation in seven patients; in one a subtotal villous atrophy (plus glandular pattern) was found. Anthropometric measurements, lymphocyte counts, hemoglobin, albumin, transferrin, iron, B12, and folate were normal in all. In the majority of patients there was no evidence of bacterial overgrowth. Vitamin B12 absorption was reduced slightly in only one patient. Lipid absorption (as judged by the 14C-Triolein breath test) was abnormal in three patients. Fecal clearance of alpha 1 antitrypsin as protein losses index was abnormal in three patients. Bile acid malabsorption was the most important ileal dysfunction observed in the patients.

Perforation of terminal ileal appendage of J-pelvic ileal reservoir

If, during restorative proctocolectomy, the most distal segment of the terminal ileum is not incorporated into the reservoir during J-pouch construction, it will remain as an appendage and may twist upon itself and obstruct. Two cases in which this resulted in significant complications are described.

Determinants of stool frequency after ileal pouch-anal anastomosis

The aim of our study was to determine whether ileal pouch motility and evacuability and the 24 hour fecal output influence stool frequency after ileal pouch-anal anastomosis. In 23 patients, at a mean of 24 months postoperatively (range 22 to 26 months), ileal pouch motility was measured using an intraluminal bag and pressure-sensitive catheters. The pattern and efficiency of ileal pouch emptying was determined scintigraphically. A 24 hour stool collection was made and the stool output and stool frequency recorded. The volume of ileal pouch distention at which large amplitude propulsive waves appeared (the threshold volume) correlated closely with stool frequency. The larger the threshold volume, the fewer the stools per 24 hours (correlation coefficient -0.70; p less than 0.01). Also, the greater the 24 hour stool output, the greater the stool frequency (correlation coefficient 0.79, p less than 0.001). In contrast, the efficiency of ileal pouch evacuation was less strongly related to stool frequency (correlation coefficient -0.41, p = 0.05). We conclude that ileal pouch motility and stool output are major determinants of stool frequency after ileal pouch-anal anastomosis. Inefficient pouch emptying is less commonly associated with frequent bowel movements.

Achieving enteric continence: principles and applications

Continence may be defined broadly as the ability to defer the passage of enteric content voluntarily to a socially acceptable time and place. In health, continence is provided by the anorectum; several factors interplay to achieve control. When the colon and rectum are removed because of intractable inflammatory bowel disease, a Brooke ileostomy that is incontinent of stool and gas is traditionally constructed, and control of the stoma is provided by an external appliance. Although the functional results after a Brooke ileostomy are good, we believe that restoration of continence would enhance the quality of life. The methods by which continence is restored surgically have undergone evolutionary changes based on an expanding knowledge of the principles of continence gained in the laboratory. In this report, we detail the current status of our understanding of anorectal continence mechanisms and of the principles of ileal continence, in order to examine how "ileo-anal" continence has been achieved in patients who require proctocolectomy.

Anal continence following Soave procedure. Analysis of results in 100 patients

The Soave procedure is an increasingly popular procedure for the definitive therapy of patients with ulcerative colitis. The authors present their experience with 100 patients in whom total proctocolectomy, rectal mucosal stripping, and ileoanal anastomosis (generally using an S-pouch) were carried out. The physiological and anatomical basis of continence is presented, and anastomosis at the top of the columns of Morgagni is recommended. Of the 100 patients in whom this procedure was performed, there was no mortality either in-hospital or later. Of the 12 patients in whom the anastomosis was done 1 cm above the top of the columns (and thus columnar epithelium was retained), six have recurrent anorectal disease, but all are continent both day and night. Three patients in whom the anastomosis was done at the dentate line have had difficulty with continence; two are now continent, but one, after being totally incontinent for 4 years, has required a permanent ileostomy. Of the 69 patients in whom the anastomosis was done at the top of the columns of Morgagni, five are incontinent at night only and two have seepage during both day and night. Thus, if the anastomosis is done at the level recommended, namely, at the top of the columns of Morgagni, retaining no columnar epithelium and anastomosing the ileal pouch to transitional epithelium (which the authors believe not to be subject to the disease of ulcerative colitis), daytime continence will be achieved in 97% and total day and night continence in 90%. The evidence presented suggests that a properly done pull-through procedure with ileoanal anastomosis is the procedure of choice for ulcerative colitis.

Comparison of the function of triplicated and duplicated pelvic ileal reservoirs after mucosal proctectomy and ileo-anal anastomosis for ulcerative colitis and adenomatous polyposis

Among 39 consecutive patients who underwent colectomy, mucosal proctectomy and ileo-anal anastomosis, a triplicated pelvic ileal pouch was constructed in 17, and a duplicated pouch in 22 patients. There was no mortality, but complications such as anastomotic dehiscence and pelvic sepsis led to removal of the pouch in seven patients (18 per cent). The functioning of the pouch and anal sphincter was assessed in 31 patients 6 months, and in 22 patients 12 months after closure of the diverting ileostomy. By 6 months, all patients were either completely continent or experienced only minor leakage and defaecation could be deferred for more than 15 min by 81 per cent of patients and flatus distinguished from faeces by 90 per cent of patients. No significant differences between triplicated and duplicated pouches were discernible at 6 months. At 12 months defaecation was significantly less frequent (P less than 0.05) in patients with triplicated pouches (median, 5 times in 24 h) than in patients with duplicated pouches (7 times in 24 h). All patients with triplicated pouches and all except one with duplicated pouches were able to defaecate spontaneously, without needing to intubate the reservoir. Thus, provided the early postoperative problems can be overcome, most patients achieve good anal function after mucosal proctectomy combined with a pelvic ileal reservoir. No evidence was found in this study that the functional results of duplicated pouches were superior to those of triplicated pouches; in fact, the triplicated pouches proved to be slightly superior.

Twenty year experience with familial polyposis coli in Cape Town

Forty-nine patients undergoing surgery for familial polyposis coli (FPC) over a twenty year period are presented. Forty-three patients underwent total colectomy with ileorectal anastomosis (TC + IRA) and five patients subsequently developed a rectal carcinoma. The incidence of rectal carcinoma following TC + IRA appears to increase with time. There were significant postoperative complications secondary to adhesive obstruction and desmoid tumour recurrence. Upper gastrointestinal pathology has been detected by endoscopy in only one of nine patients, but the importance of upper gastrointestinal pathology is now appreciated. The problem of screening a widely distributed and closely knit community has been considerable. TC + IRA remains the operation of choice for the majority of patients with FPC, but a total colectomy with ileal reservoir and ileo-anal anastomosis is appropriate in some cases.

Restorative proctocolectomy. Clinical results and manometric findings with long and short rectal cuffs

Clinical results and manometric findings were compared in 82 patients following restorative proctocolectomy. There were 41 patients with long rectal cuffs measuring 8 to 10 cm. There were 39 J-shaped pouches and 2 S-shaped pouches in this group. Forty-one patients had short rectal cuffs measuring 2 to 3 cm. There were 28 J-shaped pouches and 13 S-shaped pouches in this group. Anal manometry was performed in ten patients with long rectal cuffs and in ten patients with short rectal cuffs matched for age, sex, and stool frequency. Postoperative complications were significantly greater in patients with long rectal cuffs. Functional results and manometric findings were similar. No patient demonstrated a normal rectoanal inhibitory reflex. The data in this study suggest that a short rectal cuff can be used safely for restorative proctocolectomy with satisfactory results. A normal rectoanal inhibitory reflex may be absent after restorative proctocolectomy, and this does not interfere with the attainment of continence.

The pelvic ileal reservoir. An experimental comparison of the 3-loop and 2-loop systems

In an experimental study the function of the 3-loop (Parks) pelvic ileal reservoir was compared with that of the 2-loop (Utsunomiya) reservoir. Both types achieved satisfactory degrees of continence and evacuation when tested in the defunctioned state. Following restoration of intestinal continuity, the stools of dogs with 3-loop pouches were usually liquid (69 percent) compared to the more formed stools (72 percent) in the 2-loop group, P less than 0.001. At postmortem the reservoirs of the 3-loop group were found to have undergone much greater dilatation (P less than 0.05). These findings suggest that construction of the 3-loop (Parks) pelvic reservoir may lead to retention with overflow if catheterization is not used. It is not clear whether the superior function of the 2-loop pouch is attributable to better motor function or the absence of an efferent limb which allows it to be placed deep in the pelvis.

Ultrasonic mucosal proctectomy without endorectal pull-through

The surgical treatment of patients with familial polyposis coli and ulcerative colitis often requires removal of the rectum. Abdominoperineal resection, however, has a substantial morbidity. Ultrasonic fragmentation allows complete removal of the distal rectal mucosa with preservation of the surrounding muscularis. Ten adult mongrel dogs underwent ultrasonic mucosal proctectomy with resection of the proximal rectum and end colostomy. Two months later, the animals were sacrificed and the remaining rectum was removed and examined. The rectal remnant had shrunk and there was fibrous healing of the muscular wall with obliteration of the lumen. There was no mucosal regeneration. Ultrasonic mucosal proctectomy appears to achieve the same results as abdominoperineal resection of the rectum without the morbidity of the perineal dissection. This procedure may be useful in those patients where removal of the rectum is necessary for benign disease and endorectal pull-through is not indicated.

Ileoanal anastomosis 24 years after total proctocolectomy for ulcerative colitis

The efficacy of constructing an ileal pouch in association with an ileoanal anastomosis after mucosal proctectomy has been well established. Ordinarily, the pouch is fashioned at the time of mucosal proctectomy. This report describes a patient whose end ileostomy was successfully converted to a J-pouch 24 years after intersphincteric resection of his rectum for ulcerative colitis. Postoperative anal manometric data are presented, and the potential for applying this operation to other patients who have had previous intersphincteric rectal resections is discussed.

The ParkS S ileal pouch and anal anastomosis after colectomy and mucosal proctectomy

Attention to detail is crucial to the success of the operation described. Surgeons contemplating performing it should first be experts in pelvic surgery and are advised to personally observe and participate in the procedure performed by surgeons currently experienced in this technique.

Mechanisms of rectal continence. Lessons from the ileoanal procedure

To clarify mechanisms of rectal continence, we evaluated 34 patients who had straight or J-pouch ileoanal anastomosis. This evaluation included pressures, anal inhibitory reflex, neorectal capacity, neorectal compliance, and the ability to discriminate stool from gas. Both groups of patients had satisfactory anal sphincter resting pressures and neorectal capacities, and all could discriminate stool from gas despite the absence of any rectal mucosa. We conclude that normal rectal mucosa is not necessary to be able to discriminate stool from gas; a long rectal muscular cuff is not necessary for rectal sensation; essentially normal sphincter function is preserved, and this procedure does not normally fail because of inadequate sphincter function or the absence of the anal inhibitory reflex; and in the presence of normal sphincter function, continence is not dependent on the presence of normal mucosa or the anal inhibitory reflex but correlates with reservoir capacity and compliance as well as with the frequency and strength of intrinsic bowel contractions.