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PubMed2005

Stapled restorative proctocolectomy in children with refractory ulcerative colitis.

OBJECTIVE: The aim of this study was to review the results after stapled restorative proctocolectomy among children with refractory ulcerative colitis. PATIENTS AND METHODS: Clinical records of 16 consecutive children with refractory ulcerative pancolitis undergoing colectomy and stapled straight ileoanal anastomosis at a median age of 8.3 years (range, 3.1-14.9 years) were reviewed. Periodical clinical examinations and endoscopies with biopsies above (terminal ileum) and below (columnar cuff) the anastomosis were carried out during follow-up. Median follow-up after bowel restoration lasted 5.3 years (range, 1.2-9.6 years). RESULTS: Two major complications occurred (12.5%), 1 episode of sepsis treated conservatively and 1 bowel perforation proximal to the anastomosis treated with a temporary diverting ileostomy. All the anastomoses were functional at the end of the study. The columnar cuff averaged 2.6 cm in length and presented signs of persistent inflammation (cuffitis) in 94% of children. Inflammation responded poorly to any medical treatment but was symptomatic in 1 case only. Ileal inflammation was detected endoscopically in 31% of patients and histologically in 62.5%. No case of dysplasia or cancer was recorded. At final follow-up, children had an average of 7.1 +/- 3.1 bowel movements per day; full daytime and nighttime continence were achieved in 87.5% and 62.5% of cases, respectively. A severe inflammation of the columnar cuff was associated with an increased risk of nighttime incontinence. CONCLUSIONS: Stapled ileoanal anastomosis in children with pancolitis is associated with low morbidity. Refractory cuffitis persists in almost all patients but is mostly asymptomatic, although it could be associated with nighttime incontinence.

Adolescent↗

PubMed1985

Quality of life after restorative proctocolectomy with pelvic ileal reservoir.

Fifty-five patients who had undergone restorative proctocolectomy with a pelvic ileal reservoir between 3 and 82 months previously were sent a detailed questionnaire to assess their quality of life. All patients had experienced an ileostomy at some time. Fifty-one (94 per cent) returned completed questionnaires. The average frequency of evacuation from the reservoir was four times per 24 hours. Antidiarrhoeal medication was required by 14 (27.4 per cent). Continence was normal in 32 (62.7 per cent) and only 3 (5.9 per cent) had troublesome faecal leakage. Twenty-two (43.1 per cent) evacuated stool spontaneously, while 24 (47.1 per cent) needed to catheterize the reservoir for each evacuation. Four patients who had had the reservoir removed were added to the 51 responders to give a total number of 55 whose quality of life was considered in this study. The reservoir was preferred to an ileostomy with regard to confidence (87 per cent), cleanliness (89 per cent), sexual self-image (87 per cent), social (85 per cent) and sport activity (87 per cent), and ease of carrying out work (84 per cent). The overall preference was 87 per cent. Thirty-four (66.7 per cent) felt there was no significant disadvantage associated with the reservoir, while 10 (19.6 per cent) saw the long convalescent period and 9 (17.6 per cent) the requirement for catheterization as drawbacks.

Adult↗

PubMed1989

The clinical and functional outcome after restorative proctocolectomy. A prospective study in 100 patients.

One hundred consecutive patients treated by restorative proctocolectomy with construction of an ileo-anal anastomosis and a J-shaped (n = 90) or an S-shaped ileal reservoir were studied prospectively to evaluate postoperative complications and functional outcome and to search for factors that might influence results. There were no deaths. Postoperative complications requiring surgery were pelvic sepsis (3 patients), pouch-related fistula (2), peritonitis following ileostomy closure (3) and small bowel obstruction (6), with an overall relaparotomy rate of 14%. The cumulative risk of pouchitis was 30% at 2 years. The average stool frequency decreased gradually, stabilizing at about five evacuations/24 h after 1 year. At that time 9% of patients still had greater than or equal to 7 day-time evacuations and 40% had night evacuations (greater than 1/week). These parameters did not improve further with time. Mucous soiling, a frequent problem initially, also diminished with time, occurring in 30% of patients at 1 year. At 2 years, however, this mucous leak occurred in only 20%, suggesting that improvement of continence can be expected to occur even beyond one year. Despite defects in function patient satisfaction was generally excellent. So far only three patients have preferred conversion to an ileostomy. To establish which factors might influence the functional results a specially designed scoring system, combining all functional variables, was used. It was shown that results deteriorated with increasing age and that elderly women tended to have a poorer result than elderly men. Sex, previous parity or postoperative complications appeared not to affect the functional outcome. Male sexual disturbances occurred in 8%.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗

PubMed1983

Restorative proctocolectomy with ileal reservoir and ileoanal anastomosis.

An initial experience with a technique of restorative proctocolectomy utilizing a rectal mucosectomy, total colectomy, and ileal reservoir (Parks S-pouch) with ileoanal anastomosis for patients with ulcerative colitis and familial polyposis is presented. Although there were no deaths, significant morbidity did occur and was attributed to the use of a temporary loop ileostomy which may not be necessary. Early functional results are promising and to date, patient satisfaction is very high.

Adolescent↗

PubMed2003

A study of the complications and pelvic visceral function after restorative proctocolectomy and W pouch construction.

OBJECTIVE: Aspects of ileal pouch surgery remain controversial. The authors' single practice experience of 107 operations illustrates many of them. It was hoped that its study would contribute usefully to the debate. PATIENTS AND METHODS: Details of all 107 restorative proctocolectomies carried out since the operation was started in Gloucester in 1984 until the study period ended have been kept prospectively. All patients had proctectomy by mesorectal dissection, and 106 had W pouch restoration. Four suffered functional failure requiring reversion to ileostomy and three patients have died. The remaining 99 were sent a questionnaire concerning pelvic visceral function and evidence of pouchitis. Records of all but one of the patients have been reviewed. RESULTS: Surgical morbidity was low with neither chronic pelvic sepsis, pouch related fistula, pouch haemorrhage nor pouch ischaemia. Mucosectomised patients had similar bowel control to the stapled group. The policy change from routine to selective protective ileostomy proved satisfactory. W pouch function was found to be comparable to that reported from major J pouch series, although anti-diarrhoeal usage was reduced, and was not influenced by either gender, age or time since surgery. CONCLUSION: None of the following reasonably intuitive assumptions seem supported by our findings: that mesorectal excision necessarily poses a greater danger to pelvic visceral function than close rectal dissection, that the greater capacity of W pouches will be reflected in markedly less frequency, that mucosectomy would impair anal control, or that a defunctioning ileostomy is a mandatory precaution. Pouch frequency is less if wind can be passed separately; otherwise functional outcome seems determined by other, non-technical, factors.

Adenomatous Polyposis Coli↗

PubMed1987

Discrimination is not impaired by excision of the anal transition zone after restorative proctocolectomy.

Anal sensation has been assessed using a constant current stimulator in 21 patients after restorative proctocolectomy (15 J pouch, 6 W pouch). The anal transition zone (ATZ) has been excised in 15 patients but preserved in 6. Results were compared with 14 age- and sex-matched patients with ulcerative colitis (UC) and 14 controls. Median threshold values in the lower, mid and upper zones of the anal canal in pouch patients were: 6.8 mA, greater than 15.0 mA and greater than 15.0 mA respectively compared with 3.9 mA (P less than 0.01), 5.7 mA (P less than 0.01) and 11.4 mA (P less than 0.01) in UC and 3.5 mA (P less than 0.01), 4.2 mA (P less than 0.01) and 11.4 mA (P less than 0.01) in controls. The mid and upper zone threshold anal sensation was significantly lower when the ATZ had not been removed and except in the lower zone did not differ from UC or controls (median threshold sensations when ATZ was preserved were: lower zone, 5.8 mA; mid zone, 5.5 mA; upper zone, 7.5 mA). Paired studies in eight patients showed that excision of the ATZ was associated with a significant impairment in anal sensation (mid zone: 5.7 versus greater than 15.0 mA, P less than 0.05; upper zone: 7.5 versus greater than 15.0 mA, P less than 0.05) whereas no change in anal sensation was recorded when the ATZ was preserved. Despite these physiological changes, no clinical benefit could be identified in patients in whom the ATZ was preserved. Discrimination was normal in all except one patient. The incidence of soiling, nocturnal incontinence and failure to defer defaecation for more than 1 h was recorded in 3/15 patients (20 per cent) whose ATZ had been removed, compared with 1/6 patients (17 per cent) in whom the ATZ had been preserved. We conclude that excision of the ATZ does not eliminate the ability to discriminate and does not increase the risk of impaired continence after ileo-pouch anal anastomosis.

Adolescent↗

PubMed1989

Evaluation of ileal W pouch-anal anastomosis for restorative proctocolectomy.

Clinical defaecatory function, neorectoanal manometry and pouchography were assessed in 16 patients treated by restorative proctocolectomy with ileal W-reservoir. The duration after ileostomy closure was 6 to 28 months (mean 17 months). There were no operative deaths and no failures where the reservoir had to be removed. Partial anastomotic dehiscence occurred in one patient, and intestinal obstruction requiring laparotomy in two. Anastomotic stricture, which could be corrected easily by dilatation, occurred in three patients. Daily stool frequency was 4.3 +/- 1.2 at 6 months after ileostomy closure, 3.8 +/- 1.2 at 12 months, and 3.3 +/- 1.0 at 24 months. The clinical score for neorectal function gradually and steadily improved with time as well as daily stool frequency. In the manometric and pouchographic studies, mean anal canal length (3.4 +2- 0.6 cm), mean maximal anal sphincter resting pressure (57.1 +/- 9.7 cm water) and mean maximal reservoir resting pressure (4.3 +/- 2.0 cm water) tended to be less than normal controls but not significantly so. Neorectoanal inhibitory reflex disappeared completely or was greatly decreased in all patients. However, all were capable of spontaneously controlled defaecation. There was an inverse linear relationship between daily stool frequency and maximal tolerated reservoir volume (p less than 0.01). There were inverse linear relationships also between daily stool frequency and horizontal diameter of the reservoir measured on pouchography (p less than 0.05), and daily stool frequency and dilatation ratio of the reservoir (p less than 0.01). From these results, we conclude that a large and wide reservoir allows better defaecatory function.

Adenomatous Polyposis Coli↗

PubMed1988

Restorative proctocolectomy with J reservoir in the treatment of ulcerative colitis.

The results of 16 cases of restorative proctocolectomy with J-pouch and ileoanal anastomosis performed for ulcerative colitis, associated with polyposis in one, and for diffuse polyposis in the last one, are reported. Satisfactory functional results as for continence, number of daily bowel movements and with moderate nocturnal leakage in a single patient, were obtained. The anal sphincter function, assessed manometrically about one year after surgery was shown to be normal in all cases except for the loss of sphincteric and inhibitory reflex. In spite of the still debated problems, it is concluded that this procedure based on the absence of operative mortality, acceptable morbidity and satisfactory long-term results, is the treatment of choice in surgery of ulcerative colitis with severe rectal lesions or dysplasia and of familial polyposis with carpeting rectum and/or cancer.

Adenomatous Polyposis Coli↗

PubMed1990

Anal manometry with microtransducer technique before and after restorative proctocolectomy. Sphincter function and clinical correlations.

Anal manometry, with microtransducer technique, was performed in 55 patients after restorative proctocolectomy. Forty-two patients were followed regularly from before surgery until 12 months after surgery, and 23 patients until 24 months of function. Postoperatively, sphincter function was severely impaired. At 12 months, the mean height was less than 60 percent, mean area less than 50 percent, and mean length less than 90 percent of the preoperative values of the high pressure zone. There was no improvement between 12 and 24 months. Mean maximal squeeze pressure was restored at 12 months. Rectoanal inhibitory reflex was constantly present preoperatively, but in only 4 of 30 patients, postoperatively. Those patients with preoperative resting pressure 100 cm H2O or greater had significantly higher resting tones at 12 months than those with less than 100 cm H2O. Patients with 5 or fewer bowel movements every 24 hours had significantly higher resting tones than those with more than 6 movements every 24 hours (66 vs. 45 cm H2O). Patients with deferral 60 minutes or greater had significantly higher resting pressures than those with deferral less than 30 minutes (65 vs. 44 cm H2O). No correlation was found between resting pressure and state of continence.

Adult↗

PubMed1986

An assessment of inflammation in the reservoir after restorative proctocolectomy with ileoanal ileal reservoir.

The significance of inflammation of the mucosa of the ileal reservoir after restorative proctocolectomy is not known although in some cases it appears to be associated with symptoms when the condition has been referred to as pouchitis. This investigation has aimed to determined the prevalence of inflammation, to define pouchitis and to examine some factors which might be related to inflammation. Mucosal biopsies from the ileal reservoir were studied in 90 patients at up to 62 months after closure of the ileostomy. A histological grading system (0-6) was used to assess the severity of inflammation. Some degree of chronic and acute inflammation was found in 87% and 30% of cases respectively. The prevalence of a grade of 4 or more was 23% and 3.5%. There was a correlation between severity of chronic and acute inflammation. Severe histological acute inflammation (grade 4-6) was associated with sigmoidoscopic features of inflammation and with increased frequency of defaecation. Of 55 patients sigmoidoscoped by one clinician, 6 (11%) had pouchitis which was characterised by macroscopic inflammation of the reservoir, diarrhoea and a histological grade of 4 or more. The severity of chronic inflammation was not related to frequency of defaecation. Histological inflammation could not be correlated with the type of reservoir, residual volume after evacuation of a known volume of stool substitute introduced per anum into the reservoir or compliance of the reservoir. Acute inflammation was significantly more severe in patients with ulcerative colitis than in those with familial adenomatous polyposis.

Adenomatous Polyposis Coli↗

PubMed1987

Restorative proctocolectomy with ileal reservoir and ileoanal anastomosis: a clinico-physiological study.

The results of nine patients undergoing restorative proctocolectomy with ileal reservoir are presented. Mean frequency of defaecation per 24 h is 5.8. The reservoir was removed in one patient. Continence was normal in six patients and two had minor soiling. Manometry was normal in all except one with minor soiling and electromyography showed no features of sphincter denervation.

Adult↗

PubMed1988

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).

Anal Canal↗

PubMed1990

Incidence of dysplasia in the anorectal mucosa in patients having restorative proctocolectomy.

The incidence of dysplasia in the mucosal strippings from the anorectal stump was studied in 132 patients treated by restorative proctocolectomy with ileal reservoir for ulcerative colitis and familial adenomatosis. The anorectal mucosa was stripped from the level of division of the gut tube to the dentate line. Of 118 patients with ulcerative colitis, 12 (10.2 per cent) had dysplasia in some part of the large bowel. Mucosal strippings were examined histologically in 118 cases, of which only three (2.5 per cent) showed dysplasia. There was a correlation between dysplasia and the presence of carcinoma and the duration of the disease in the operative specimen of colon and rectum and also in the anorectal mucosal specimen although the number of patients with carcinoma (eight cases) in this analysis was small. All 14 patients with familial adenomatous polyposis showed large bowel mucosal dysplasia in the operative specimen which was severe in six cases. Anorectal mucosal strippings were examined in these patients and 12 showed dysplasia which was severe in three.

Adenomatous Polyposis Coli↗

PubMed2001

Histological and macroscopic changes in the pelvic pouch: long-term follow up after restorative proctocolectomy for ulcerative colitis (UC).

OBJECTIVE: Our aim was to evaluate macroscopic and histological (inflammatory) changes in ileal pouch mucosa after restorative proctocolectomy with J-pouch-ileoanal anastomosis for UC during long-term follow up. PATIENTS AND METHODS: Thirty-six (56%) out of 64 consecutive patients operated at our Institute during 1985-90 underwent endoscopy of the reservoir in the years 1994 and 1998. Functional outcome and macroscopic changes were recorded and histological samples taken from the three levels of the pelvic pouch. Acute and chronic inflammation were graded in accordance with a well-established histopathologic scoring system. RESULTS: The functional outcome was unchanged in 26 (72%), became worse in eight (22%) and better in two (6%) cases during follow up. The number of macroscopic changes increased during follow up and there was a tendency for them to become more common in the distal pouch. Microscopic acute and chronic inflammation decreased during follow up. There were more severe inflammatory changes in the distal pouch. Both acute and chronic inflammatory scores were higher through the reservoir in the cases of chronic pouchitis. Chronic pouchitis occurred more often in males. CONCLUSION: Macroscopic and inflammatory changes in the pelvic pouch seem to have separate progress during long-term follow up. In chronic pouchitis both acute and chronic inflammation are pronounced and spread over the entire pelvic pouch mucosa.

Journal Article↗

PubMed1981

Restorative proctocolectomy with ileal reservoir: a pathophysiological assessment.

A metabolic and physiological assessment was carried out in 14 patients who had undergone restorative proctocolectomy with ileal reservoir more than six months previously. The haemoglobin was normal in all but one and plasma electrolytes and serum albumin, calcium, phosphorus, and red cell folate estimations were normal in all. Five patients had low serum iron levels of whom one had an iron deficiency anaemia. The 24 hour faecal fat output was normal in all patients and there was no case of vitamin B12 malabsorption as judged by the Schilling test, although four patients had marginally low values. These were not associated with increased bacterial counts in the faeces within the reservoir and there was no evidence to support a diagnosis of stagnant loop syndrome. Inflammation of the reservoir mucosa was, however, associated with higher counts of aerobic bacteria than in cases where inflammation was absent. Subtotal villous atrophy or inflammation was seen in biopsies of the reservoir in six patients. The mean faecal output per 24 hours was 659 +/- 259 g and the mean reservoir volume was 330 +/- 78 ml. Mean resting anal canal pressure was significantly lower in patients with a mucous leakage per anum than in those without, while manometry of the reservoir showed no alteration of pressure over a period of one hour before and after a meal. A positive rectosphincteric reflex was observed in nine patients.

Adult↗

PubMedDate not supplied

[Two stage videoassisted restorative proctocolectomy. Early experience of 12 cases].

AIM OF THE STUDY: This study reports our early experience in two-stage video assisted restorative proctocolectomy (RPC). PATIENTS AND METHODS: From May 1999 to May 2003, 12 video assisted RPCs were performed (mucosal ulcerative colitis: n = 11; familial adenomatous polyposis: n = 1). These patients were matched for age, gender, body mass index and indication for surgery, with 12 patients who underwent RPC by laparotomy (open group). RESULTS: Median operative time was significantly longer in the video assisted RPC group (400 min; range: 360-490) vs open group (300 min; range: 210-390) (P = 0.003). A conversion in midline laparotomy (under the umbilicus) was necessary in 3/12 patients (25%) in the video assisted RPC group. Return to bowel function and oral intake occurred two days earlier after video assisted RPC (respectively, P = 0.009 and P = 0.0001) but length of stay was not significantly shorter in this group. A complication occurred in 3/12 patients (25%) in both groups, which lead to a reoperation in one patient in the open group (ns). CONCLUSION: Two-stage videoassisted RPC is feasible at the cost of a lengthening of operative time, Nevertheless postoperative results after video assisted RPC are comparable to those obtained after RPC by laparotomy.

Adenomatous Polyposis Coli↗

PubMed1988

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.

Adult↗

PubMed1983

[Restorative proctocolectomy with an ileal pouch. Functional and biochemical results].

A metabolic and functional assessment was carried out in 7 patients, who had undergone a restorative proctocolectomy with pelvic ileal pouch (Parks S-Pouch) between 8 and 38 months previously. The average follow-up was 22,5 months. The symptoms which led to the operation were in all patients ulcerative colitis. The mean faecal output per 24 h was 425.7 +/- 104 g, and the mean reservoir volume 233.5 +/- 102.3 ml. Within 24 h the average number of bowel movements has been 4.5 +/- 1.05 (range 3 to 6). One of the patients only uses a catheter for the evacuation. Two patients reported a degree of mucous leakage. The motility of the reservoir and of the anal canal showed the following pressures: In the pouch a medium pressure of 20.4 +/- 6.35 cm H2O was ascertained. The mean resting pressure in the anal canal was 88.88 +/- 20.9 cm H2O, mean voluntary contraction pressures were 211.8 +/- 42.2 cm H2O. The anal canal showed a length of 2.94 +/- 0.29 cm. In patients with mucous leakage the resting anal canal and maximal voluntary contraction pressures were no different to those who had mucous leakage and those who had not. A positive rectosphincteric reflex was observed in five patients. The absorption of vitamin B12 was reduced in two patients, one of them had a pathological D-Xylose Test. The other parameters like potassium, sodium, calcium, magnesium, iron, zinc phosphorus, TIBC, Transferin, Haemopexin, Folate and immunoglobulins were in all patients completely normal. The mean concentration of aerobic microorganisms was 7.18 +/- 1.33 log 10/g and for anaerobic 9.07 +/- 1.07; there was no evidence of a stagnant loop syndrome. Histological examination of the reservoir mucosa showed no evidence of superficial ulceration and crypt abscesses; an uncharacteristic inflammation of the ileum mucosa was proved in 6 patients. No cellular dysplasia, fibrosis, or progressive atrophy was seen in the present biopsies. In relation to the bladder and sexual function (one of the seven patients is a child) there were no problems.

Adult↗