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PubMed1994

Recovery of the internal anal sphincter and continence after restorative proctocolectomy.

The internal anal sphincter (IAS) was assessed prospectively using electromyography and manometry in 66 patients (48 men) undergoing restorative proctocolectomy to determine its role in the gradual return of continence. Twenty-nine patients received a J pouch and 37 a W reservoir. Some 38 pouches (J, ten; W, 28) were hand-sewn (mucosal proctectomy with endoanal anastomosis) and 28 (J, 19; W, nine) stapled (end-to-end pouch-anal anastomosis 1 cm above the dentate line). Twelve patients underwent a one-stage procedure (all J pouches), while the remainder had a covering loop ileostomy. Each patient was reassessed immediately after restorative proctocolectomy and again at 7 days, 1 month, 4 months, 9 months and 18 months after pouch formation. Internal sphincter electromyographic activity was greatly reduced after pouch-anal anastomosis (median preoperative frequency 0.51 Hz versus immediate postoperative frequency 0.21 Hz, P < 0.003) and gradually recovered from 4 months after surgery. At 18 months, measurements of IAS function had not fully recovered to preoperative values (median frequency 0.31 Hz; P < 0.03). Resting anal pressures (median preoperative value 99 cmH2O) decreased by over 50 per cent after surgery (median immediate postoperative resting pressure 44 cmH2O) and recovered gradually but incompletely (median pressure at 18 months 63 cmH2O). Eleven patients reported leakage in the follow-up period. The median (range) resting pressure in these patients (54 (40-71) cmH2O) was not significantly different at 9 months from that of those who were continent either before or after operation (59 (46-68) cmH2O). Prolonged recordings in patients with faecal leakage revealed evidence of high-pressure pouch waves that overwhelmed anal sphincter pressures and coincided with leakage. These episodes were most common during sleep, when anal sphincter activity was reduced.

Adolescent↗

PubMed2002

One-stage laparoscopic restorative proctocolectomy: an alternative to the conventional approach?

PURPOSE: There is significant concern in the current literature over the safety of laparoscopic techniques in removal of the entire colon and rectum. The purpose of this study was to examine the results of a one-stage laparoscopic-assisted restorative proctocolectomy in patients with mucosal ulcerative colitis and familial adenomatous polyposis in a single institution experience. METHODS: All patients who underwent laparoscopic-assisted one-stage restorative proctocolectomy (29 mucosal ulcerative colitis; 3 familial adenomatous polyposis) over a 24-month period were followed up prospectively for short-term and long-term complications and functional outcome. RESULTS: There were 32 patients (17 males), with a median age of 32 years (range, 16-29 years). There were no conversions to open surgery. There were two intraoperative complications, an inconsequential rectal perforation during mobilization and one staple line misfire. There were 11 postoperative complications: 3 obstruction/ileus, 2 pouchitis, 2 wound infections, 2 strictures, 1 pelvic abscess, and 1 pouch leak (at the top of the "J"). Three patients required reoperation (1 temporary ileostomy, 1 lysis of adhesions, and 1 transpouch drainage). The median number of bowel movements was seven per day (range, 2-15). CONCLUSION: A one-stage laparoscopic-assisted restorative proctocolectomy can be performed effectively and safely. Given that techniques in laparoscopic large-bowel surgery are still evolving rapidly, the role of this operation in the surgical treatment of patients with mucosal ulcerative colitis and familial adenomatous polyposis is likely to expand in the near future.

Adenomatous Polyposis Coli↗

PubMed1996

Prospective study of the incidence, timing and treatment of pouchitis in 104 consecutive patients after restorative proctocolectomy.

OBJECTIVE: To determine the incidence timing and effectiveness of treatment of symptomatic pouchitis following restorative proctocolectomy with ileal J-pouch anal anastomosis. DESIGN: A cohort analytical study. SETTING: University hospitals, a tertiary referral center; all subjects entered into the study followed up for a minimum of 12 months (mean follow-up, 40 months). PATIENTS: One hundred four consecutive patients undergoing restorative proctocolectomy with ileal J-pouch anal anastomosis for either ulcerative colitis (n = 97) or familial adenomatous polyposis (n = 7) between June 1986 and December 1994. INTERVENTIONS: Patients with symptomatic pouchitis were treated with either oral metronidazole or ciprofloxacin. OUTCOMES: Diagnosis of pouchitis was determined by clinical symptoms and confirmed with endoscopy. Response to oral antibodies was determined by resolution of symptoms. RESULTS: Fifty-two patients (50%) experience at lest 1 episode of pouchitis. The first episode of pouchitis occurred within the first 12 months after restoration of intestinal continuity in 56% of the cases. In 2 patients it occurred after 30 months. Response to antibiotic treatment was 96%. Two thirds of patients had multiple episodes. Chronic pouchitis occurred in 6 patients, necessitating pouch removal in 2. CONCLUSIONS: The incidence of pouchitis after ileal J-pouch anal anastomosis is approximately 50% with two thirds of these patients having multiple episodes. Chronic pouchitis occurs in a minority of patients. In chronic pouchitis, the risk of pouch loss is substantial.

Adenomatous Polyposis Coli↗

PubMed1995

Long-term results of restorative proctocolectomy for ulcerative colitis.

To study the long-term effects of restorative proctocolectomy with J-pouch for ulcerative colitis 100 consecutive patients were examined a mean of 5.6 years after ileal pouch-anal anastomosis (IPAA). Seventy-three percent of patients were on steroids and 22% had a preceding severe attack of colitis before IPAA. The overall early and late complication rates were 40% and 33%, respectively. Failure rate was 5% and all failures requiring pouch excision occurred within the first three postoperative years. Pouchitis (36%) was the commonest late complication. A preceding severe attack of colitis was an important prognostic sign of late anastomotic complications, troublesome incontinence and ultimate failure. The daily mean stool frequency varied from 4.5 to 6.9. After a short learning period continence-stabilised and minor incontinence was common (57%). The majority of patients (72%) were either very satisfied or had no problems in daily activities after IPAA. Ten patients were dissatisfied after surgery due to obvious medical reasons in most of them.

Adolescent↗

PubMed2006

Anatomic extent of colitis and disease severity are not predictors of pouchitis after restorative proctocolectomy for mucosal ulcerative colitis.

BACKGROUND: Pouchitis is a common complication following restorative proctocolectomy with ileal pouch anal anastomosis (RPC-IPAA) for mucosal ulcerative colitis (MUC). The aim of this study was to determine if perioperative anatomic extent and severity of disease are predictors of pouchitis. METHODS: All consecutive patients who underwent RPC-IPAA for MUC between 1988 and 2002 were retrospectively studied. Pouchitis was classified as acute, recurrent or refractory. Colectomy specimen slides were histopathologically evaluated by a single blinded pathologist (MB), who assessed extent and severity of disease. RESULTS: Of 112 patients assessed, 70 (62.5%) had some form of pouchitis at a median follow-up of 38 months (range, 1-204 months). No association was found between the extent or severity of disease and subsequent development of acute or chronic pouchitis. A positive correlation was found between the histopathologic score and the occurrence of clinical pouchitis (p=0.014). The presence of colonic metaplasia in the pouch biopsy was significantly correlated with a histopathologic diagnosis of pouchitis (p<0.0001, r=-0.449). CONCLUSIONS: Following RPC for MUC, the extent and severity of disease do not predict the subsequent development of pouchitis.

Adolescent↗

PubMed2006

Surgical management of pouch-vaginal fistula after restorative proctocolectomy.

BACKGROUND: Pouch-vaginal fistula (PVF) is a devastating complication after restorative proctocolectomy with ileal pouch anal anastomosis (IPAA). The aim of this study was to evaluate the surgical management of PVF. METHODS: After Institutional Review Board approval, all patients treated for PVF between 1988 and 2003 were retrospectively reviewed. Success of treatment was defined as the complete absence of symptoms or no radiologic evidence of fistula. RESULTS: The study included 23 female patients; indications for IPAA were mucosal ulcerative colitis in 20 (87%), indeterminate colitis in 1 (4.3%), and familial adenomatous polyposis in 2 (8.7%) patients. Seven patients with mucosal ulcerative colitis were postoperatively diagnosed with Crohn's disease. Mean time interval from initial IPAA to development of symptomatic fistula was 17.2 months. Mean number of surgical treatments was 2.2. Overall, success was achieved in 17 (73.9%) patients at a mean followup of 52.3 months. Fistulas in patients with Crohn's disease occurred relatively late after IPAA (p = 0.015) and required a median of three (p = 0.001) surgical procedures, compared with patients without Crohn's disease. Pelvic sepsis after original IPAA occurred in eight (35.8%) patients, four (50%) of whom ultimately required pouch excision. CONCLUSIONS: Fecal diversion and local procedures are effective in the majority of patients with PVF after IPAA. Patients with Crohn's disease tend to have a delayed onset of fistula occurrence and require more extensive surgical management. Pelvic sepsis can be a predictive factor of poor outcomes.

Adolescent↗

PubMed2004

Fertility is reduced after restorative proctocolectomy with ileal pouch anal anastomosis: a study of 300 patients.

BACKGROUND: Restorative proctocolectomy and ileal pouch anal anastomosis (RP/IPAA) has become the gold standard surgical therapy for the majority of patients with mucosal ulcerative colitis and familial adenomatous polyposis. The aims of this study were to evaluate the fertility rates before and after RP/IPAA, to compare them with the reproductive data of the general United States population, and to determine surgical parameters that might influence subsequent fertility. METHODS: Three hundred women of reproductive age who underwent RP/IPAA between 1983 and 2001 completed a mailed questionnaire regarding their reproductive function before and after the procedure. Additional information was obtained from the pelvic pouch database. The reproductive information was compared to age-matched historical control subjects from the United States general population. The associations between changes in fertility and surgical parameters were also investigated. RESULTS: The median (25th, 75th percentile) age at surgery was 28 (24, 33) years. Out of 300 women, 206 attempted to conceive. Before operation, 48 (38%) of 127 patients were unsuccessful after 1 year of unprotected intercourse, whereas after operation, 76 (56%) of 135 patients were unsuccessful. This infertility rate was higher after operation than before (P <.001). For the subgroup of 56 women who tried to get pregnant both before and after operation, the infertility rate was higher after operation than before (69% vs 46%; P=.005). Also, a higher percentage of these patients who had an intraoperative transfusion were infertile after operation compared to patients who did not have an intraoperative transfusion (54% vs 21%; P=.023). CONCLUSIONS: There was an increase in the infertility rate after RP/IPAA. Intraoperative blood transfusion had a negative impact on the fertility rate after operation in patients who tried to conceive both before and after RP/IPAA.

Adolescent↗

PubMed1997

Evolutive study of the functional results after restorative proctocolectomy for ulcerative colitis.

AIM: Evolutive study of the functional results after restorative proctocolectomy for ulcerative colitis. PATIENTS AND METHODS: Prospective study in 24 patients with an ileoanal "J" pouch (n = 8: mucosectomy and hand-sewn anastomosis; n = 16: stapled anastomosis without mucosectomy). A clinical survey was carried out during two evolutive follow-ups of the functional pouch (medians: 14.5 and 39.0 months) as well as an anorectal manometry study during the preoperative period and in two follow-ups after the creation of the pouch (medians: 6.0 and 35.5 months). RESULTS: The mean frequency of defecation per 24 hours and per night was significantly reduced in the first follow-up (5.5 [24 h]; p < 0.003 and 1.0 [per night]; p < 0.009) compared with the postoperative period (7.9 [24 h] and 1.4 [per night]), with no significant changes in the second follow-up (5.5 [24 h] and 0.9 [per night]). At the same time, it has been significantly lower in patients with stapled anastomosis in the different evolutive follow-ups. One patient (4.2%) had major fecal incontinence in the two evolutive follow-ups and 7 (29.2%) and 6 (25%) patients had minor incontinence in the first and second follow-up respectively. The mean maximum resting anal pressure in the first follow-up was significantly lower (p = 0.002) in patients with mucosectomy than the values observed in patients with stapled anastomosis (35.4 vs 68.0 mmHg). In the second follow-up increased significantly (p = 0.046) only in patients with mucosectomy (55.1 mmHg). Recto-anal inhibitory reflex was present in 2 (10%) and 9 (45%) patients in the first and second follow-up respectively. CONCLUSIONS: The functional results improve significantly with the follow-up time, fundamentally during the first year of the functional pouch.

Adult↗

PubMed1998

[Indications for restorative proctocolectomy in systemic colorectal diseases (ulcerative colitis and familial adenomatous polyposis coli)].

Restorative proctocolectomy is now the procedure of choice for patients suffering from ulcerative colitis (UC) and familial adenomatous polyposis coli (FAP). The majority of patients with UC require surgery for failure or development of side effects of medical therapy. Other indications include dysplasia, carcinoma and complications from either medical therapy or the disease, such as massive bleeding or perforation. In the adolescent patient, resection may be necessary owing to growth retardation. In patients with FAP the 100% risk of developing colorectal carcinoma can be avoided only by proctocolectomy. Crohn's colitis and carcinoma of the lower rectum represent absolute contraindications. A relative contraindication exists in indeterminate colitis, patients with poor sphincter function, mesenteric desmoids, obesity and an age above 65 years.

Adenomatous Polyposis Coli↗

PubMed2003

A new operative technique for restorative proctocolectomy: the endorectal pull-through combined with a double-stapled ileo-anal anastomosis.

BACKGROUND: In children, restorative proctocolectomy is usually accomplished by a rectal mucosectomy followed by a hand-sewn ileo-anal anastomosis+/-ileal pouch. In certain patients, a hand-sewn anastomosis can be technically difficult. This led us to develop a new technique that combines endorectal mucosectomy with a double-stapled ileo-anal anastomosis. METHODS: After colectomy, an ileal J-pouch is constructed. The head of the circular stapler is placed in the apex of the pouch and secured. An endorectal mucosectomy is completed from the abdomen to approximately 1.5 cm above the dentate line. The rectal mucosal/submucosal tube is everted onto the perineum. A transverse stapler is positioned 1.5 cm above the dentate line on the perineum and fired. The circular stapler is inserted transanally and the trocar advanced through the transverse staple line until the head and anvil are mated and then fired. A loop ileostomy is constructed. RESULTS: Thirteen patients, with a mean age of 12.3 years, have undergone endorectal mucosectomy with a double-stapled anastomosis without major complication. The operative time averaged 280+/-70 minutes. The mean 24-hour stool frequency, with 9 months' follow-up, was 6.8+/-3.2, of which 1+/-0.7 were at night. CONCLUSIONS: The combination of endorectal mucosectomy with a double-stapled anastomosis is a new approach for patients requiring restorative proctocolectomy. In our early experience, this technique was completed with a low complication rate and excellent functional results.

Adolescent↗

PubMed2005

Multimedia article. Laparoscopic restorative proctocolectomy for ulcerative colitis.

BACKGROUND: With increasing experience, laparoscopic techniques have been applied even to extended colorectal operations as restorative proctocolectomy for ulcerative colitis and familial adenomatous polyposis. METHODS: A 36-year-old woman with a 7-year history of ulcerative colitis was transferred for elective surgery 6 weeks after an episode of toxic megacolon treated conservatively. The procedure was performed in modified lithotomy position using six trocars. After initial medial transection of the three main vascular pedicles of the ileocolic and middle colic vessels and the inferior mesenteric artery and vein, the colon was dissected free laterally, from the sigmoid orally toward the ileum. Special consideration was necessary for dissection of the omentum. The rectum was mobilized down to the pelvic floor in two steps, starting at the level of the promontory and the upper rectal stalks. It was transected at the level of the dentate line. Through a Pfannenstiel incision, the bowel was extracted. After transection of the ileum and removal of the specimen, a J-pouch was created. The anastomosis was completed laparoscopically using a double-stapling technique. Finally, a diverting loop ileostomy was created. RESULTS: A total of 13 patients underwent surgery. The medium age of these patients was 25.5 years (range, 19-57 years). There was no conversion to an open procedure. The median length of hospital stay was 11.5 days (range, 7-107 days). Four patients experienced major complications, including one case each of pouch failure after arterial occlusion, pouch-vaginal fistula, infected hematoma, and intraabdominal abscess formation. There was no postoperative mortality. CONCLUSIONS: For restorative proctocolectomy, laparoscopic techniques proved to be safe and feasible. With further experience, they may have the potential to become an appealing alternative to open surgery.

Adult↗

PubMed1994

Anorectal function after restorative proctocolectomy and low anterior resection with coloanal anastomosis.

Anorectal manometry and electromyography were studied in 17 patients before and after restorative proctocolectomy with stapled pouch-anal anastomosis, in ten patients before and after low anterior resection with stapled coloanal anastomosis, and in 35 normal controls. More than 80 per cent of patients in both groups developed abnormal oscillation of anal pressure after operation (amplitude 15-60 (median 25) cmH2O, frequency 4-10 (median 8) per min) and showed no anal relaxation in response to intermittent neorectal distension. All patients lost discriminative rectal sensation and none could perceive a normal desire to defaecate. Patients with postoperative soiling had a greater amplitude of anal pressure oscillation and lower minimum basal pressure, although those who underwent coloanal anastomosis had a greater risk of incontinence because of large asynchronous oscillations in neorectal pressure. The common pathophysiological features after restorative proctocolectomy and coloanal anastomosis probably relate to damage to the autonomic and enteric nerve supplies. The presence of an unstable internal anal sphincter may be an important cause of postoperative nocturnal incontinence.

Adult↗

PubMed1988

Clinical and functional results after restorative proctocolectomy.

Of 84 patients who underwent restorative proctocolectomy with an ileoanal reservoir in 21 Italian departments of surgery, 51 had ulcerative colitis, 32 familial polyposis and 1 intractable constipation. Follow-up information is available for all 58 patients who had their ileostomy closed, the length of follow-up ranging between 2 and 78 months. There were no operative deaths. A failure rate (i.e. excision of the pouch) of 3 per cent was observed. Sepsis was the most common postoperative complication, and was most often related to ileoanal anastomosis dehiscence (15 per cent), followed by small-bowel obstruction requiring laparotomy (10 per cent). Clinical 'pouchitis' occurred in 14 per cent of patients after ileostomy closure. The average frequency of defaecation was four motions per 24 h; evacuation was spontaneous in all patients and only 5 per cent complained of troublesome faecal soiling while 34 per cent had occasional incontinence to flatus and mucus. Patients with a short or absent rectal cuff had a lower rate of incontinence (30 versus 48 per cent, difference not statistically significant) without any increase in the frequency of genito-urinary disorders. None of the two most used reservoirs, the J (n = 40) and S pouch (n = 17) showed significant superiority in terms of bowel frequency and continence. Incontinence was more likely in patients whose ileostomy closure had been delayed for more than one year.

Adenomatous Polyposis Coli↗

PubMed2001

[Laparoscopic restorative proctocolectomy in ulcerative colitis and colonic polyps].

With increasing experience, laparoscopic techniques have been applied even to extended colorectal operations as restorative proctocolectomy in ulcerative colitis and familial adenomatous polyposis. After initial medial transection of the three main vascular pedicles, the colon is dissected free laterally, from the sigmoid orally towards the ileum. The rectum is mobilized down to the pelvic floor. Over a Pfannenstiel incision, the bowel is extracted and the pouch is created. The anastomosis is completed in double-stapling technique. At two departments, 27 patients have been operated on. The median time of operation was 320 min (180-540). The median length of hospital stay was 8.1 days. There was no postoperative mortality. The complication rate was similar to conventional surgery at the same institutions. Three patients had to be re-operated on, two for ileal obstruction close to the pouch, one patient for bleeding from the pouch. In restorative proctocolectomy, laparoscopic techniques prove to be safely feasible. They have the potential to become an appealing alternative to open surgery.

Adenomatous Polyposis Coli↗

PubMed2001

Restorative proctocolectomy.

The development and refinement of pelvic pouch surgery now allows the excision of a diseased colon while maintaining transanal faecal continence. The success of restorative proctocolectomy is largely dependent on careful patient selection combined with meticulous surgical technique. The authors discuss the main indications for restorative proctocolectomy and describe the surgical procedure.

Humans↗

PubMed1994

Ulcerative colitis and coexisting colorectal cancer: recurrence rate after restorative proctocolectomy.

BACKGROUND: The association between mucosal ulcerative colitis (MUC) and adenocarcinoma is well established. METHODS: Records of patients who had undergone restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) from 1983 through 1992 were examined. Of these, 604 had MUC and 27 (4.3%) had MUC with coexisting cancer. Patients were surveyed annually for recurrent disease. Pouch function and quality of life were evaluated with a questionnaire and physical examination. RESULTS: The duration of disease was longer (p = 0.001) in patients with cancer (16.1 +/- 8.0 years) than in those without cancer (9.1 +/- 7.1 years), although the mean age at diagnosis of MUC was the same. Of the 27 patients, 20 had colon cancer and seven had rectal cancer. Multicentricity was found in seven (25.9%) patients. Using the TNM staging classification, 14 patients (51.8%) had stage 1 cancer, eight (29.6%) had stage 2, four (14.8%) had stage 3, and one (3.8%) had stage 4. The patient with stage 4 cancer died 5 months after surgery and was excluded from the follow-up analysis. During a mean follow-up time of 4.3 +/- 2.6 years, cancer recurred in two of the remaining 26 patients (7.7%). In one patient, a local recurrence was found 8 months after surgery, and distant metastases were found in the other patient 35 months after surgery. Both recurrences were in patients with colon cancer. Two of the 26 patients died; one death was related to cancer recurrence (3.8%). Pouch function is good to excellent in all surviving patients. CONCLUSIONS: Restorative proctocolectomy for patients with MUC and coexisting colorectal cancer can be performed with a favorable prognosis and function. It is appropriate for curative intent, given that an adequate margin without tumor is obtained.

Adolescent↗

PubMed2001

Surgical treatment of severe colonic inertia with restorative proctocolectomy.

Patients with severe constipation due to colonic inertia who remain symptomatic after extensive medical therapy or partial colonic resection have occasionally been treated with ileostomy as a last resort. The hospital records of five patients with persistent symptomatic idiopathic colonic inertia were reviewed. Each of the patients had undergone extensive medical management, and eventually four underwent one or more colonic resections to relieve the recurrent abdominal distention and pain. Three of the patients eventually received a distal ileostomy, which functioned well. Anorectal manometric studies were within normal range for each of the five patients. Restorative proctocolectomy (J pouch) was therefore performed for each. With a mean follow-up of 42 months after restorative proctocolectomy each of the five patients was relieved of constipation and small bowel distention. The average number of bowel movements per 24 hours at 6 months was 4.8. All patients were able to discriminate flatus from stool, could hold back for up to 1.5 hours after the initial urge to defecate, and had total daytime continence. Each returned to work or school within 3 months, and each reported greater satisfaction with bowel function than with the ileostomy. Restorative proctocolectomy with a J pouch provides a satisfactory option for the management of patients with persistent abdominal distention and pain due to idiopathic colonic inertia.

Adolescent↗

PubMed2005

Restorative proctocolectomy and ileal pouch-anal anastomosis for ulcerative colitis after liver transplant for primary sclerosing cholangitis: case report and review of literature.

Primary sclerosing cholangitis (PSC) is present in 5 per cent of patients with ulcerative colitis (UC). Conversely, as many as 90 per cent of patients with PSC have been found to have UC. The accepted treatment for advanced PSC is orthotopic liver transplant, and the treatment of ulcerative colitis with concomitant PSC is restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA). A small number of studies have shown that there is an increased risk of pouchitis in UC patients with PSC after ileal pouch-anal anastomosis. We report a case of a 45-year-old male who underwent a two-stage restorative proctocolectomy with IPAA after previous orthotopic liver transplant for PSC. We have reviewed the available literature concerning restorative proctocolectomy after liver transplantation, giving special attention to postoperative complications and subsequent development of pouchitis. It is important to be aware of the possibility of increased risk for development of pouchitis and to follow these patients closely to prevent complications.

Anal Canal↗