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PubMed1993

Pouch-vaginal fistula.

Between January 1976 and June 1991, 161 women underwent restorative proctocolectomy. Seventeen (10.6 per cent) developed pouch-vaginal fistula. There was no difference in the incidence of inflammatory (15 of 141; 10.6 per cent) and non-inflammatory (two of 20; 10 per cent) disease, the severity of colitis or the number of stages in the operation. In 15 patients the fistula involved the ileoanal anastomosis; in two it had possibly occurred at the dentate line. There was no significant difference in the proportion of hand-sewn (ten of 120; 8.3 per cent) and stapled (seven of 41; 17 per cent) ileoanal anastomosis. Of the 17 women, six had pelvic sepsis in the immediate postoperative period and five had an anastomotic complication. There was no case of Crohn's disease. Three patients developed a pouch-vaginal fistula before closure of the ileostomy. The remaining 14 fistulas occurred a median of 7 (range 1-144) months after closure. Five further patients were referred from elsewhere to give a total of 22 for analysis of treatment and outcome. The fistula developed before ileostomy closure in five patients (group 1) and after closure in 17 (group 2). Following treatment, six fistulas had healed with five patients still undergoing treatment. In group 1, three of the five fistulas healed, whereas in group 2 only three of the 17 healed. Eight patients required excision of the pouch. The prognosis appears to be worse when pouch-vaginal fistula occurs after ileostomy closure. The optimal management is not yet established.

Colitis, Ulcerative↗

PubMed1994

Pelvic ileal reservoirs: the options.

Restorative proctocolectomy has become an established surgical option for patients with chronic ulcerative colitis and familial adenomatous polyposis. However, despite a large number of different reservoir designs there is so far no acknowledged ideal configuration. This paper reviews the advantages and disadvantages of the different types of pelvic ileal reservoir so far studied.

Adenomatous Polyposis Coli↗

PubMed1995

Butyrate metabolism in the terminal ileal mucosa of patients with ulcerative colitis.

The rate of oxidation of butyrate, glutamine and glucose was investigated in terminal ileal mucosal biopsy samples from nine patients with ulcerative colitis undergoing restorative proctocolectomy and from 12 patients undergoing laparotomy for reasons other than ulcerative colitis. Substrate oxidation was assayed using a radiolabelled isotope technique. Butyrate was the preferred fuel substrate, followed by glutamine and then glucose (median (95 per cent confidence interval) 567 (262-894), 63 (35-123) and 8.1 (5.1-18) pmol micrograms-1 h-1 respectively; P < 0.01, Mann-Whitney U test) in normal terminal ileal mucosa. The patients with ulcerative colitis had a significantly reduced rate of butyrate oxidation compared with the control group (194 (81-321) versus 567 (262-894) pmol micrograms-1 h-1, P < 0.05). Normal terminal ileal mucosa oxidized butyrate in greater quantities than glucose and glutamine. Ulcerative colitic terminal ileal mucosa exhibited an impaired rate of butyrate oxidation.

Adolescent↗

PubMed2006

Effect of vaginal delivery on long-term pouch function.

BACKGROUND: The optimal method of childbirth for women with a restorative proctocolectomy (RP) has yet to be determined. Little is known about long-term ileal pouch function after vaginal delivery, especially when childbirth occurred before RP. The aim of this study was to evaluate the effect of vaginal delivery before or after RP on long-term pouch function. METHODS: All 267 women who underwent RP between January 1985 and November 2004 were invited to participate. Functional outcome was assessed by colorectal functional outcome questionnaire, and patients were asked about their pregnancies and risk factors for obstetric injury. Linear regression analysis was performed to study potential risk factors for poor pouch function. RESULTS: The response rate was 82.6 per cent. Median follow-up after pouch surgery was 7.2 (range 1.0-19.7) years. One hundred patients had at least one delivery. Fifty-two (60 per cent) of the 86 patients who attempted a vaginal delivery had an increased risk of obstetric injury according to predefined risk factors. In these patients ageing and longer follow-up were significant risk factors for impaired incontinence. CONCLUSION: Women who had RP and vaginal delivery with a high risk of obstetric injury had impaired continence with ageing and longer follow-up. Patients with RP should be informed about the considerable risk of vaginal delivery on long-term ileal pouch function.

Adult↗

PubMed2002

Mucin expression in the ileoanal reservoir reflects incomplete mucosal adaptation.

Restorative proctocolectomy is regarded as a standard surgical procedure for patients who require a proctocolectomy for ulcerative colitis and familial adenomatous polyposis. The ileal mucosa undergoes colonic phenotypic change with time, but the extent and relevance of these changes to the long-term safety of the ileoanal pouch are unclear. The aim of this study was to study the mucin biology of this adaptive process in order to assess its extent and possible impact on pouch safety. Ileoanal pouch biopsies from a cohort of patients and normal ileal and colonic controls were subjected to histological, biochemical, histochemical, and immunohistochemical mucin analysis. Mucin sulphation and sialic acid O-acetylation were studied as parameters of colonic phenotypic change. Fifty-one patients, 16 ileal, and 22 colonic controls were studied. Seventy per cent of biopsies retained villous mucosal architecture, with no cases of dysplasia detected. Ileoanal pouch mucosal sulphation and sialic acid O-acetylation did not reach colonic levels, thus indicating limited evidence for a more colonic phenotype. The data from this study suggest that colonic phenotypic change within the ileoanal reservoir is incomplete, with no cases of dysplasia detected. The degree of phenotypic change is less than in previous studies, which may support, but not prove, our hypothesis that there may be a process of reversion to an ileal type mucosa in the ileoanal reservoir with time.

Adaptation, Physiological↗

PubMed1994

Does laparoscopic-assisted ileal pouch anal anastomosis reduce the length of hospitalization?

Previous data have suggested that laparoscopic colon and rectal surgery may shorten the length of hospitalization. These claims have been attributed to a reduction of the length of ileus. The definition of "ileus" is variable and in all cases is subjective. In this study it was defined as the length of time until the patient passed flatus or stool without nausea, vomiting or abdominal distention. This prospective study was undertaken to compare the duration of ileus and of hospitalization after laparoscopic-assisted (LAC) and standard laparotomy (SC). After restorative proctocolectomy with an ileal-pouch anal anastomosis (IPAA) in both sets of patients. Twenty-two patients underwent LAC and 20 age, sex, and diagnosis-matched controls underwent SC. Mucosal ulcerative colitis (MUC) was the diagnosis in 16 LAC and in 15 SC patients while polyposis was the diagnosis in 6 LAC and in 5 SC patients. The mean time to resolution of postoperative ileus was 4.2 (4-11) days in the LAC group and 3.3 (2-5) days in the SC group. Hospital discharge was similar in each group occurring at a mean of 8.7 (7-13) days after LAC and 8.9 (6-18) days after SC. Neither the length of time for ileus resolution nor the length of hospitalization were reduced in the LAC group. Laparoscopic-assisted IPAA conferred none of the theoretical advantages associated with other laparoscopic procedures.

Adolescent↗

PubMed1994

Loop ileostomy fixation: a simple technique to minimise the risk of stomal volvulus.

Turnbull's "loop" ileostomies is a routinely performed procedure in the management of a variety of colorectal problems. Mechanical and functional complications occur with both permanent and temporary ileostomies, however they are more common with the loop than with the end (Brooke) variety. With the advent of restorative proctocolectomy with pouch formation, and the documented benefit of simultaneous temporary faecal diversion, the incidence of such complications will rise. Bowel obstruction, requiring laparotomy in the interval before stoma closure, is more commonly associated with the loop ileostomy. A loop stoma is routinely brought out directly through the abdominal wall, with little or no fixation or closure of the lateral space. However, anti-mesenteric fixation, as described here, minimises the risk of volvulus by widening the attachment of the adjacent ileum to the parities, creating a broader fulcrum. Since adopting this simple technique, we report no complications in over 30 loop ileostomies, "fixed" by this technique and followed up for a minimum of 4 years. Where applicable, no difficulty was encountered with stoma closure, either by a transverse single layer serosubmucosal technique, or as a minimal resection with end to end anastomosis (sewn or stapled), following bowel mobilisation. This technique should minimise the frequency of obstructive events, and we recommend it's routine use.

Adolescent↗

PubMed1995

A case of pneumatosis coli managed by restorative proctectomy and ileal pouch-anal anastomosis.

Pneumatosis coli is a rare condition in which gas filled cysts occur in the wall of the intestines. Most symptomatic patients can be managed conservatively but those who fail medical management or who develop bowel obstruction will require surgery. Surgery usually involves a limited colectomy with a potential for recurrence. We describe a case of pneumatosis coli managed successfully by restorative proctocolectomy and ileal pouch-anal anastomosis.

Anastomosis, Surgical↗

PubMed1994

Ambulatory pouch and anal motility in patients with ileo-anal reservoirs.

Twelve patients were studied for a median of 18 hours (range 8.5-21.5 hr) by continuous, ambulatory, simultaneous pouch and anal manometry 10-85 months after restorative proctocolectomy. Two main patterns of motility were observed: (1) Large isolated contractions up to 68 cm H2O in amplitude and up to 67 seconds in duration were present in ten patients. These were often associated with the urge to defaecate and were more frequent before defaecation than after but did not appear to be associated with expulsion of faeces from the pouch. In two patients atypical large isolated contractions up to 378 cm H2O in amplitude were observed. (2) Rhythmic contractions at a frequency of 7-11 per minute and amplitude of 24-330 cm H2O, occurred for a duration of 18 seconds to 18 minutes in six patients. In the other six patients this motility pattern was not seen. Of the 12 patients nine were considered to have good function (five or less bowel actions per 24 hours) and three poor function (ten or more bowel actions per 24 hours). Rhythmic activity was the predominant motility pattern in all three with poor function whereas large isolated contractions predominated in those with good function, although there was considerable overlap in the types of motility observed between patients with good and poor function. Mean pouch pressure tended to be higher in patients with poor function than in those with good function both throughout the entire recording and during sleep. In a number of patients simultaneous anal recordings revealed the presence of slow waves and falls in pressure, some of which were associated with a simultaneous rise in pouch pressure.

Adult↗

PubMed1994

A method for predicting the volume of an ileo-anal pouch.

Functional outcome following restorative proctocolectomy depends, in part, on the volume of the pouch. This study investigates the relationship between the length of ileum and volume of saline required to distend the ileum to a set pressure, and the possibility of predicting the volume of an ileoanal pouch using these measurements. Measurements were made on the ileum of 8 mongrel dogs. There was a linear relationship between the length of ileum and volume of saline infused to produce an intraluminal pressure of 20 mmHg (r = 0.94-0.99). However, the capacity of ileum varied widely from animal to animal (100 cc of saline filled 15.5 cm to 43 cm of ileum). Twenty-four pouches (15J, 9S) were constructed from segments of ileum of known capacity. The capacity of a J pouch was 1.71 +/- 0.11 times greater than the capacity of the original length of bowel and an S pouch had a capacity 2.14 +/- 0.25 times greater. These changes in capacity are similar to a theoretical calculation of change in volume of ileum after pouch construction. This technique is a simple, quick method of predicting the volume of an ileo-anal pouch which will be useful in a clinical trial to compare function of pouches of different volumes.

Animals↗

PubMed1996

Comparison of relative risks of urinary stone formation after surgery for ulcerative colitis: conventional ileostomy vs. J-pouch. A comparative study.

PURPOSE: Urinary stone formation is a widely recognized complication o f inflammatory bowel disease and the surgical management of these conditions. Previously the fecal volume and chemistry after restorative proctocolectomy with J-pouch were found to be similar to conventional panproctocolectomy with permanent ileostomy. The purpose of this study was to investigate whether the relative risks of urinary stone formation were less following J-pouch than following conventional ileostomy. METHODS: The risk of urinary stone formation was determined from the chemical composition of two consecutive 24-hour urine samples in 13 patients with well-functioning ileostomies, 15 patients with well-functioning J-pouches, and 17 control volunteers. RESULTS: Compared with controls, ileostomy and J-pouch patients had significantly lowered urinary volumes and pH, higher concentrations of calcium and oxalate, and an increased risk of forming uric acid stones. In addition there was an increased risk of forming calcium stones in the conventional ileostomy group. This risk was found not to be present in the J-pouch group. CONCLUSIONS: The risks of forming uric acid stones are high for both ileostomy and J-pouch patients, but our results suggest that there will be a reduction in calcium stone formation after J-pouch.

Adult↗

PubMed1994

Coordinated activity of the new "rectum" and anal sphincter after sphincter-saving resection of the rectum for colitis or carcinoma.

PURPOSE: The aim of this study was to determine whether coordinated activity exists across a stapled enteroanal anastomosis. METHODS: Twenty-nine patients were studied for a median of one year after complete excision of the rectum and stapled enteroanal anastomosis; 12 patients underwent low anterior resection with coloanal anastomosis for carcinoma, and 17 patients underwent restorative proctocolectomy with ileoanal anastomosis. RESULTS: Maximum anal resting pressures were slightly lower after coloanal anastomosis than after ileoanal anastomosis [median range, 56 (11-60) cm H2O, cf 69 (40-107) cm H2O, P = NS]. During distention of the neorectum, anal sphincter pressures at 2.5, 1.5, and 0.5 cm from the anal verge were significantly lower after coloanal anastomosis compared with after ileoanal anastomosis (P < 0.01 at each station). The volume of neorectal distention required to produce maximal inhibition of the anal sphincter was significantly less after coloanal anastomosis at 50 (range, 20-60) ml of air than after ileoanal anastomosis at 240 (range, 100-420) ml of air (P < 0.01). Minor fecal leakage and urgency of bowel action were significantly more common after coloanal anastomosis (P < 0.01). CONCLUSION: Alterations in the dynamic response of the anal sphincter to distention of the neorectum may explain why the clinical results were better after ileal pouch-anal anastomosis than after coloanal anastomosis.

Adult↗

PubMed1996

Selective preservation of the anal transition zone in ileoanal pouch procedures.

PURPOSE: A prospective trial was conducted to evaluate use of certain preoperative criteria in the choice of operative technique for ileal pouch-anal anastomosis (IPAA). Handsewn vs. stapled anastomotic techniques were compared as was preservation vs. excision of the anal transition zone (ATZ). METHODS: Over an 18-month period, 40 consecutive patients underwent restorative proctocolectomy with IPAA for ulcerative colitis (31 cases) or familial adenomatous polyposis (9 cases). In 28 patients, ATZ was completely excised, by either a transanal mucosectomy with handsewn anastomosis (Group I, 13 cases) or by double-stapled technique (Group II, 15 cases). The ATZ was preserved and the anastomosis was double-stapled in colitis patients with suboptimum sphincter function and/or greater than 50 years of age in the absence of dysplasia or severe distal proctitis (Group III, 12 cases). RESULTS: Groups I and II patients were homogeneous in their preoperative variables and had equivalent functional outcome. Group III patients were older (P = 0.0001), with weaker preoperative anal sphincter resting tone (P = 0.024). Compared with Groups I and II, patients in Group III had significantly greater 24-hour stool frequency (P = 0.0056), daytime stool frequency (P = 0.0125), and incidence of daytime fecal seepage (P = 0.007). There was no significant difference in other outcome variables in Group III patients. There was no difference in morbidity in the three groups. CONCLUSIONS: Transanal mucosectomy with handsewn anastomosis provided early functional results equivalent to low anal transection with double-stapled IPAA in younger patients with excellent preoperative sphincter function. A double-stapled technique with preservation of the ATZ may be reserved for older patients, with poorer anal sphincter function, at minimum dysplasia/cancer risk, to optimize continence figures.

Adenomatous Polyposis Coli↗

PubMed1995

Rectal mucosectomy in the treatment of giant rectal villous tumors.

PURPOSE: Rectal mucosectomy, a technique adapted from restorative proctocolectomy, has been used to treat large rectal villous tumors. We compared morbidity, tumor control, and functional outcome following rectal mucosectomy with the results of more conventional transanal excision and piecemeal snaring and fulguration in patients with large rectal villous tumors. METHODS: We retrospectively reviewed the charts of inpatients who had undergone transanal surgery for villous tumors. RESULTS: Between 1983 and 1993, rectal mucosectomy, transanal excision, and snaring and fulguration were performed, respectively, in 12, 26, and 23 patients with large rectal villous tumors. Tumors treated by rectal mucosectomy had a larger mean diameter (8.5 cm) than those treated by transanal excision or snaring and fulguration (4.5 cm and 4.2 cm, respectively; P < 0.0001, analysis of variance). After a mean follow-up of 47 months, incidence of tumor persistence was 17 percent following rectal mucosectomy, 20 percent following transanal excision, and 40 percent following snaring and fulguration (P = 0.04, chi-squared). Tumor recurrence was 8 percent after rectal mucosectomy compared with 36 and 44 percent, respectively, after transanal excision (P = 0.09, chi-squared) and snaring and fulguration (P = 0.04, chi-squared). Clinically significant postoperative bleeding did not occur after rectal mucosectomy; 17 percent of patients had persistent mild incontinence. CONCLUSIONS: Rectal mucosectomy for villous tumors, a new application of an established technique, is safe and associated with low rates of tumor persistence and recurrence. Rectal mucosectomy may result in mild incontinence and should be reserved for large or circumferential lesions. For smaller lesions, transanal excision results are more reliable tumor eradication than snaring and fulguration.

Adenoma, Villous↗

PubMed1996

Effect of systemic steroids on ileal pouch-anal anastomosis in patients with ulcerative colitis.

BACKGROUND: Long-term steroid therapy predisposes to postsurgical complications, especially in patients with inflammatory bowel disease. PURPOSE: This study was undertaken to determine incidence of early septic complications after ileal pouch-anal anastomosis (IPAA) in patients who are undergoing prolonged steroid therapy. METHODS: We reviewed charts of 692 patients undergoing restorative proctocolectomy and IPAA to treat ulcerative colitis. Incidence of early (within 30 days) septic complications and sepsis-related reoperations, in patients who were having high-dose (>20 mg of prednisone per day) and low-dose steroid therapy (<20 mg of prednisone per day) for more than one month before surgery, was compared with patients who were not receiving steroid therapy. Follow-up included an annual questionnaire and physical examination. RESULTS: Patients without steroid dose data recorded were excluded (n = 21). Of the 671 remaining patients, 310 received no steroids, 169 received low-dose steroids, and 192 received high-dose steroids. These three groups were similar in gender composition, age at surgery, types of anastomosis (stapled or handsewn), and incidence of diabetes mellitus, peripheral vascular disease, and obesity. Early septic complications were found in 18 (6 percent), 14 (8 percent), and 12 (6 percent) patients without steroid therapy, those having low-dose steroid therapy, and those having high-dose steroid therapy (P = 0.57), respectively. Sepsis- related reoperation rate (P = 0.73) and number of sepsis-related pouch excisions (P = 0.79) did not differ between groups. In patients undergoing IPAA without ileostomy, early septic complications were found in one (3.8 percent), two (20 percent), and five (50 percent) patients without steroid treatment, low-dose steroid therapy, and high-dose steroid therapy (P = 0.004), respectively. CONCLUSION: In patients who are undergoing IPAA with diversion for ulcerative colitis, prolonged systemic steroid therapy before surgery is not associated with increased septic complications.

Adolescent↗

PubMed1996

Pouch polyposis after ileal pouch-anal anastomosis for familial adenomatous polyposis: report of a case.

PURPOSE: A case of a patient with familial adenomatous polyposis (FAP) is reported, in whom adenomas developed in an ileal pelvic pouch six years after it was made. This case is reported to serve as a warning that restorative proctocolectomy, a relatively recent addition to surgical options for FAP, does not remove the risk of metachronous intestinal neoplasia; it merely defers it. METHODS: Case of a patient with pouch polyposis was reviewed, and patient was prospectively studied after three months of sulindac therapy. RESULTS: Polyps not removed at first examination became much less prominent. Literature review reveals only one study of adenomas in pelvic pouches, with 7 cases of 38. CONCLUSION: Proctocolectomy and ileal pouch-anal anastomosis does not cure FAP, and multiple polyps can occur in the ileal pouch.

Adenoma↗

PubMedDate not supplied

Results of the double stapling procedure in pelvic surgery.

The double stapling technique for rectal reconstruction after resection involves closing the lower rectal segment with a linear stapler and performing the anastomosis using a circular stapler across the linear staple row. The purpose of this report is to review the results of double stapling, present our experience, and draw conclusions from the material available. We have utilized the double stapling technique in 80 patients for primary anastomoses and in 11 patients for secondary anastomoses following Hartmann procedures. Twenty-one anastomoses were at or near the dentate line. Fifty-six patients had rectal carcinoma, 29 patients had diverticulitis, 3 patients had carcinoma of the ovary, and 1 patient each had traumatic rectal perforation, volvulus, or rectal prolapse. Complications in the total 91 patients included 3 anastomotic leaks (3.3%), 1 postoperative hemoperitoneum (1.1%), and 3 strictures (3.3%). No anastomosis was protected by diverting colostomy. There were no operative deaths. Of 43 patients with cancer available for follow-up, 4 patients have developed local recurrence. The technique has been modified for ileoanal anastomosis during abdominal restorative proctocolectomy for ulcerative colitis and familial polyposis and early results are favorable. The double stapling technique provides a safe method for rectal reconstruction at or near the dentate line and offers the following advantages over other stapler techniques: (1) It eliminates the frustrating distal pursestring; (2) The rectal segment is not opened, minimizing contamination; and (3) It avoids gathering the sometimes generous circumference of the rectum on a pursestring thus allowing a more precise distal donut.

Anal Canal↗

PubMedDate not supplied

The results of pouch surgery after ileo-anal anastomosis for inflammatory bowel disease: the manometric assessment of pouch continence and its reservoir function.

Anal sphincter function after restorative proctocolectomy has mainly been investigated by anal manometry. A significant decrease of basal pressure up to 45%, has been recorded postoperatively, possibly due to sphincter stretch during endoanal mucosectomy. Both abdominal mucosectomy and anastomosis at the level of the anorectal ring have been reported to prevent anal sphincter damage and lead to better continence. The striated sphincter is not significantly affected by the surgical procedure. Pouch-anal inhibitory reflex is partly maintained in the presence of a rectal cuff which leaves the ganglionic plexus unaltered; a satisfactory continence is also retained in the absence of the reflex when the rectum is totally excised. Pouch capacity, compliance and motility have been investigated by endoluminal balloon and probes. Pouch emptying has been studied by a "porridge" test, by a semi-solid medium labelled with technetium-99, and by other methods. A more effective storage function is achieved by large capacity reservoirs which lower the bowel frequency. The motor response to pouch distension, to a meal, and to pharmacological stimuli is usually counteracted by sphincter contraction. Ileal hypermotility may lead to fecal leakage mainly in the presence of weak sphincters. Poor pouch emptying may be related to an anal stricture.

Adolescent↗