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PubMed1985

Restorative proctocolectomy with ileal reservoir for ulcerative colitis and familial adenomatous polyposis: a comparison of three reservoir designs.

One hundred and four patients were treated by restorative proctocolectomy with ileal reservoir for ulcerative colitis and familial polyposis. Three different designs of reservoir were used (triple loop 68, double loop 13, quadruple loop 23). There were no postoperative deaths but six (5.8 per cent) had the reservoir removed. Rates for pelvic sepsis were 25, 15 and 13 per cent, and for intestinal obstruction requiring laparotomy 14.7,0 and 8.6 per cent. Function was assessed in 88 patients (58, 12 and 18) after mean intervals from closure of the ileostomy of 23.7, 12.7 and 4.5 months. Frequency of defaecation per 24 h was 3.7 +/- 1.6, 5.5 +/- 1.6 and 4.1 +/- 1.3, being significantly greater for double loop reservoirs; night evacuation was more prevalent in the same group (26, 58 and 22 per cent). Significantly fewer patients with triple than with double loop reservoirs required antidiarrhoeal medication (19 and 58 per cent). Normal continence occurred in 67, 75 and 89 per cent of patients in the three groups. All patients with double or quadruple loop reservoirs defaecated spontaneously while only 41 per cent with triple loop reservoirs did so. Mean intra-operative reservoir volumes were 177 +/- 64, 172 +/- 58 and 325 +/- 37 ml and volumes after closure of the ileostomy were 416 +/- 176, 197 +/- 69 and 322 +/- 33 ml respectively. Double loop reservoirs were significantly smaller than the other two designs after ileostomy closure. There was an inverse relationship between reservoir volumes and frequency. A quadruple loop reservoir directly connected to the anal sphincter preserved spontaneous evacuation and resulted in function similar to that obtained with the triple loop reservoir.

Colectomy↗
PubMed1990

Ambulatory anorectal physiology in patients following restorative proctocolectomy for ulcerative colitis: comparison with normal controls.

The purpose of this study was to determine the manometric activity of ileoanal W pouch reservoirs following restorative proctocolectomy for ulcerative colitis and to compare the results with normal controls. Thirty-one studies were carried out; there were 15 controls (median age 52 years (range 29-80 years), 10 men, 5 women) and 16 pouch patients (median age 40 years (range 28-52 years), 13 men, 3 women). Mid-anal sphincter pressure and 'rectal' pressure were measured with a microtransducer catheter. The signals were digitalized and recorded in a portable electronic memory for later computer display and analysis. The system allowed the study of patients with minimal constraints while fully ambulant. The frequency of sampling (rectal pressure greater than or equal to sphincter pressure), sensation of flatus present and flatus being passed were 7(1-41), 3(1-7) and 1(0-3.5) per hour in the normal controls and 0(0-3), 0(0-1) and 0(0-1) respectively per hour in the pouch patients (P less than 0.001). Compared with the highly dynamic nature of the anorectum in normal subjects the patients with a pouch had very little activity. The sensation of pouch filling and the desire to defaecate were noted on 12 occasions and in six were associated with a rise in pouch pressure greater than 20 mmHg. One patient had nocturnal soiling and this was the only patient in whom frequent pouch contractions were noted. The results suggest that ileoanal pouch motility is usually quiescent and that incontinence in this group may be related to increased pouch activity.

Adult↗
PubMed1987

Restorative proctocolectomy with ileal reservoir: pathological and histochemical study of mucosal biopsy specimens.

Mucosal biopsy specimens from the ileal reservoirs of 92 patients who had undergone restorative proctocolectomy (12 with familial adenomatous polyposis, 78 with ulcerative colitis, and two with functional bowel disease) were studied. Chronic inflammation was found in almost all, as was villous atrophy of varying severity. Other changes included pyloric metaplasia and mucosal prolapse. Acute inflammatory changes and ulceration were less common but, when present, corresponded to the clinical condition of "pouchitis". A grading system was devised to score acute and chronic inflammatory changes. There was a significant increase in acute inflammatory scores in ulcerative colitis compared with those in familial adenomatous polyposis, and pouchitis was present only in patients who had had ulcerative colitis; the morphological features of pouchitis are similar to those seen in the colorectal mucosa in ulcerative colitis. Histochemical studies of mucin in the reservoirs of mucosa showed that there may have been a change from small intestinal mucin to colonic mucin.

Biopsy↗
PubMed1984

Restorative proctocolectomy with a three-loop ileal reservoir for ulcerative colitis and familial adenomatous polyposis. Clinical results in 66 patients followed for up to 6 years.

The results of restorative proctocolectomy with a three-loop ileal reservoir were reviewed. Of 66 patients treated between 1976 and 1982, 52 had ulcerative colitis and 14 had familial adenomatous polyposis. The temporary ileostomy was closed between 2 and 78 months previously in 63 cases. Of these, three patients had had the reservoir removed and two were lost to follow-up. One other patient was subsequently found to have Crohn's disease. Function was assessed in 55 patients who had undergone closure of the ileostomy more than 8 weeks previously. Mean frequency of defecation was 3.7 per 24 hours (range 1-9.5) and 11 patients (20%) were taking antidiarrheal medication. Spontaneous defecation occurred in 22 patients (40%) while 29 (52.7%) had to use a catheter passed per anum. Four patients defecated spontaneously but sometimes used a catheter. Continence was normal in 36 (65.4%) and minor leakage once every 2 to 3 days occurred at night in 16 (29.1%). Three patients (5.4%) had some soiling during day and night. Troublesome perianal soreness (five patients, 9.1%) necessitated a defunctioning ileostomy in one. Fifty-four of the 55 patients assessed preferred their quality of life to that with an ileostomy.

Adult↗
PubMed1991

Prospective randomized trial comparing anal function after hand sewn ileoanal anastomosis with mucosectomy versus stapled ileoanal anastomosis without mucosectomy in restorative proctocolectomy.

A prospective randomized trial was performed to compare complications and function after hand sewn ileoanal anastomosis with mucosectomy (group A) with stapled ileoanal anastomosis without mucosectomy (group B) during restorative proctocolectomy. Thirty-two age- and sex-matched consecutive patients under the care of one surgeon were randomized. The median duration of anal dilatation while making the anastomosis was 19 min (range 14-33 min) and 1 min (range 0-39 min) in groups A and B respectively (P less than 0.005). The median level of the anastomosis was at the dentate line (range 0-0.5 cm) in group A and 2 cm above the dentate line (range 0.2-4.0 cm) in group B (P less than 0.005). Seven patients in group A and 11 in group B had at least one postoperative complication (n.s.). One patient in group A and four in group B developed an anastomotic stricture requiring dilatation (n.s.). One patient in group B had the reservoir removed. Function was assessed at a median of 11 months (range 7-15 months) after ileostomy closure in 14 patients in group A, and at a median of 12 months (range 5-17 months) in 14 patients in group B. Median frequency of defaecation per 24 h was 4 in both groups (group A, range 2-7; group B, range 2-10). Night evacuation (greater than once per week) occurred in seven patients in each group. All patients in both groups could delay the desire to defaecate by more than 30 min. Eleven patients in group A and 12 in group B had normal continence. Evidence to date favours a full mucosectomy. Function is not vitiated by this technique and surgical removal of the disease is more complete.

Adult↗
PubMed1991

Correlation between laboratory findings and clinical outcome after restorative proctocolectomy: serial studies in 20 patients with end-to-end pouch-anal anastomosis.

Clinical function and anorectal physiological function were assessed and correlated in 20 patients with ulcerative colitis before restorative proctocolectomy and 3, 7, and 12 months after operation. The entire anal sphincter was preserved by means of a stapled pouch-anal anastomosis. Before operation, the median resting anal pressure was 79 cmH2O (interquartile range 70-89 cmH2O), the rectoanal inhibitory reflex was present in all patients and anorectal 'sampling' was noted in 16 of 20 patients. Three months after operation, resting anal pressure was 68 cmH2O (range 50-87 cmH2O) (P less than 0.001), the reflex was present in only three patients (P less than 0.001) and sampling was observed in one patient. After 7 months, resting anal pressure was 76 cmH2O (range 64-89 cmH2O), the reflex was present in 11 patients and sampling was observed in nine patients. At 12 months, resting anal pressure was 84 cmH2O (range 66-94 cmH2O), the reflex was present in 19 patients and sampling was observed in 17 patients. The compliance and capacity of the reservoir increased significantly. Ability to discriminate flatus from faeces was associated with return of the rectoanal reflex and sampling.

Adaptation, Physiological↗
PubMed1990

Single lumen ileum with myectomy: a possible alternative to the pelvic reservoir in restorative proctocolectomy.

An alternative procedure to construction of a pelvic ileal reservoir was assessed which avoids the need for a pouch, while providing an adequate rectal substitute and good continence. Thirty-six female adult beagles were allotted randomly to undergo total colectomy with (a) ileo-anal anastomosis alone, (b) ileo-anal anastomosis with two 15 cm myectomies, (c) ileo-anal anastomosis and myectomy with an ileo-ileal valve, or (d) ileo-anal anastomosis with a duplicated J pouch. The animals were studied before operation and at 4-weekly intervals for 20 weeks after operation. Mortality rates were similar. Ileal compliance was increased significantly by myectomy from 0.64 ml/mmHg (median, interquartile range 0.49-0.78) after ileo-anal anastomosis alone to 1.65 mmHg (1.16-1.93), P less than 0.01, an increase which was maintained. Ileal capacity was also increased both by myectomy and by the J pouch: ileo-anal anastomosis = 85 ml (75-100 ml), ileo-anal anastomosis and myectomy = 139 ml (116-156 ml), ileo-anal anastomosis and myectomy and ileo-ileal valve = 125 ml (range 85-145 ml), ileo-anal anastomosis and J pouch = 130 ml (range 75-165 ml) (P less than 0.01). Bowel function in the other three groups was markedly superior to ileo-anal anastomosis alone. Mean transit time was significantly less after ileo-anal anastomosis, 5.2 h (2.6-8.2 h) than after both ileo-anal anastomosis and myectomy, 10.5 h (9.6-13.9 h), P less than 0.05 and ileo-anal anastomosis and J pouch, 11.0 h (8.4-13.0 h), P less than 0.05, but addition of an ileo-ileal valve did not produce a further increase in transit time, 12.9 h (range 10.5-14.5 h), P = n.s.. Myectomy of single lumen ileum may be a useful alternative to a pelvic ileal reservoir in restorative proctocolectomy.

Anal Canal↗
PubMed1999

Restorative proctocolectomy in children with ulcerative colitis utilizing rectal mucosectomy with or without diverting ileostomy.

BACKGROUND: Controversies continue concerning the best way to perform restorative proctectomy (RP) for ulcerative colitis (UC). Can rectal mucosectomy and hand-sewn ileoanal anastomosis (IAA) withstand the challenge posed by extrarectal dissection with a double-stapled technique and no mucosectomy? Is a diverting ileostomy mandatory after RP? METHODS: The authors describe 30 consecutive children with UC who underwent RP with rectal mucosectomy and hand-sewn IAA. The authors assess the results and compare the first 14 patients (group 1) treated with temporary diverting ileostomies with the next 16 consecutive patients (group 2) without diverting ileostomies. RESULTS: The average age (13.8 years in group 1 v 10.4 in group 2), duration of illness before resection (3.2 years in group 1 v 1.5 in group 2), and gender breakdown (10 of 14 were girls in group 1, 10 of 16 were girls in group 2) were similar between the two groups. Outcome was not significantly different between the two groups. Average bowel movements per 24-hour period was 5.5 in group 1 and 4.2 in Group 2. Occasional nighttime staining occurred in two patients in group 1 and five in group 2. No one suffered daytime staining in group 1, and one patient had occasional daytime staining in group 2. Average quality of life (on a scale of 0 to 5) as assessed by the patients or parents was 4.4 in group 1 and 4.9 in group 2. There were 10 total complications in group 1. One child required a permanent stoma for ileoanal separation. Two patients required reoperations for complications caused by the diverting ileostomy. The single instance of peritonitis was in group 1 caused by anastomotic leak after ileostomy closure. There were five total complications in group 2, of which, two required temporary stomas for ileoanal separations. CONCLUSIONS: RP with rectal mucosectomy and hand-sewn IAA in children with UC provides good functional results. Peritonitis did not occur in the absence of diversion. Eliminating routine diverting ileostomy avoids the considerable complications and morbidity from the stoma and its closure.

Adolescent↗
PubMed1986

Restorative proctocolectomy and ileal reservoir.

The operation consisting of abdominal colectomy, proximal proctectomy, distal mucosal proctectomy, and ileal pouch-anal anastomosis eliminates colorectal mucosal disease, restores transanal defecation, and avoids the need for a permanent abdominal stoma and the wearing of an external appliance. During the 4-year period from January 1981 through December 1984, 369 such operations were done at the Mayo Clinic for either ulcerative colitis (in 336 patients) or polyposis coli (in 33 patients). None of the patients died in the immediate postoperative period. Follow-up data for the initial 188 patients showed the following complications: anastomotic stricture in 12%, pelvic sepsis in 11%, obstruction of the small intestine in 9%, and reservoir ileitis in 7%. A permanent stoma had to be established in 5% of patients. All patients could defecate spontaneously, and 95% had satisfactory continence for stools and gas. This operation seems safe and effective and provides a quality of life superior to that seen after the conventional Brooke ileostomy.

Adult↗
PubMed1987

Abdominal mucosectomy reduces the incidence of soiling and sphincter damage after restorative proctocolectomy and J-pouch.

Thirty-two ileoanal J-pouch procedures have been performed by the author between 1983 and 1986. Two pouches have been excised, one has been defunctioned for diarrhea, and seven patients either have not had their ileostomy closed or have not been followed for more than four months after restoration of intestinal continuity. Of the remaining 22 patients, 12 early operations involved endoanal mucosectomy while in the ten most recent procedures, the rectum and anal mucosa have been excised from the abdomen. Incidence of complications between the methods of mucosal excision were comparable apart from cuff abscess (n = 5) which only occur after endoanal muscosectomy. Functional results were identical apart from the incidence of soiling which occurred in six of 12 patients after endoanal mucosectomy but in only one of ten patients after abdominal mucosectomy. Resting anal canal pressures fell significantly after endoanal mucosectomy (87 to 60cm H20, P less than 0.05) but not after abdominal mucosectomy (82 to 81 cm H20). These differences may be due to the duration and extent of anal retraction, which was 72 minutes after endoanal mucosectomy but only 18 minutes after abdominal mucosectomy. Abdominal mucosectomy appears to cause less sphincter damage and soiling than conventional endoanal excision.

Anal Canal↗
PubMed1987

Restorative proctocolectomy: the four loop (W) reservoir.

The four loop (W) reservoir was developed with the aim of improving the functional results of the J reservoir and to avoid the need for catheterization often seen with the S reservoir. It is no more difficult to construct and results in better function. Sixty-four patients have undergone the procedure. There were no deaths. Mean hospital stay (including ileostomy closure) was 24 +/- 8 days. The reservoir has been removed in one patient (one week postoperatively) who was found to have a Dukes' B rectal carcinoma. Function has been assessed in 51 patients (mean follow-up 18.6 +/- 8.9 months). Frequency of defaecation per 24 h is 3.3 +/- 1.0 (range 1-8) with night evacuation in 14 per cent. Antidiarrhoeal medication is required by 20 per cent of patients. Continence is normal in 92 per cent, and 8 per cent have minor leakage. All patients defaecate spontaneously.

Adenomatous Polyposis Coli↗
PubMed1989

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.

Adult↗
PubMed1990

Surgical correction of the efferent ileal limb for disordered defaecation following restorative proctocolectomy with the S ileal reservoir.

The S ileal reservoir has been superseded in this unit but 76 patients had this operation between 1976 and 1983. Forty-one (54 per cent) patients had to catheterize the reservoir to evacuate faeces and this was primarily due to the long efferent ileal limb. In six patients, the need to catheterize and other problems with defaecation were such that surgical correction of the efferent ileal limb was undertaken. These six patients are reported. Presenting features were the need to catheterize the reservoir, difficulty in catheterizing, faecal incontinence, stenosis of the efferent ileal limb and transanal prolapse of the efferent ileal limb. All patients had an excessively long efferent ileal limb of 8 cm or more which was resected and reanastomosed to the anal canal. The resection was performed endoanally in three patients but was successful in only one. In the two patients in whom endoanal excision was unsuccessful and in the remaining three resection of at least 5 cm was performed transabdominally with endoanal reanastomosis. Three of these five patients were converted from catheterizing the reservoir to spontaneous evacuation, but two patients still needed to catheterize. All six patients benefited in terms of the need for, or frequency of, catheterization, or by improvement in continence. Excessive length of the efferent limb of an S ileal reservoir may cause unsatisfactory defaecation, which may be improved by partial resection. The transabdominal route is recommended for the resection, with endoanal reanastomosis. This surgery is potentially problematic and, although no anastomotic leakage was encountered, a covering loop ileostomy is recommended.

Adult↗