Anal and neorectal function after ileal pouch-anal anastomosis.

Bowel function varies markedly among patients with colectomy and ileal pouch-anal anastomosis. Little is known of the mechanisms controlling fecal continence and frequency of defecation after operation. The aim of this study was to determine which features of the anal sphincter and neorectum accounted for the variation in clinical outcome. Twenty patients were studied 4 to 35 months after operation and compared to 12 healthy volunteers. Despite several patients exhibiting impaired fecal continence, anal sphincteric length and pressures and ileal pouch capacity and distensibility were similar in patients and controls. Patients with poor results, however, had rapid filling of their ileal pouch, which resulted in early onset of high amplitude propulsive pressure waves in the pouch. As these waves became more frequent, defecation resulted. Patients with poor results also were not able to empty adequately their pouch. The poorer the completeness of evacuation, the more frequent the defecation (r = 0.62, p less than 0.01). The authors conclude that rapid pouch filling and impaired pouch evacuation can lead to increased stool frequency in patients after ileal pouch-anal anastomosis.     

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

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

Determinants of stool frequency after ileal pouch-anal anastomosis

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

Proctocolectomy with jejunal pouch-distal rectal anastomosis: An alternative to ileal pouch reconstruction

The aim of this study was to determine whether a jejunal pouch would have a lower resting pressure, be more distensible, and have more interdigestive migrating myoelectric complexes and less fecal bacterial overgrowth than would an ileal pouch after proctocolectomy and pouch-distal rectal anastomosis. In six conscious dogs with a jejunal pouch-distal rectal anastomosis and six with an ileal pouch-distal rectal anastomosis (controls), pouch distensibility and motility were measured using a barostat and perfused pressure-sensitive catheters passed per anum, pouch electrical activity was recorded using chronically implanted electrodes, and the number of bacteria per gram of stool was assessed by culture. Dogs with a jejunal pouch had lower resting pouch pressures, more distensible pouches, faster frequencies of pacesetter potentials in the pouch, more phase 3 intervals of the interdigesive migrating myoelectric complex reaching the pouch, but similar numbers and types of bacteria in their stools compared to the dogs with an ileal pouch. We concluded that jejunal pouches have a lower resting pressure, are more distensible, have more cleansing contractions, but a similar fecal flora compared to ileal pouches. A jejunal pouch has features that make it an attractive alternative to an ileal pouch for pouch-distal rectal or pouch-anal canal anastomosis after proctocolectomy. Supported by the Mayo Foundation, Tohoku University, and the Nigro grant. Presented at the Thirty-Eighth Annual Meeting of The Society for Surgery of the Alimentary Tract, Washington, D.C., May 11–14, 1997. An abstract of this work was published in Gastroenterology 112:A1478, 1997.     

A clinico-physiological comparison of ileal pouch-anal and straight ileoanal anastomoses

The ileal pouch-anal anastomosis improves clinical results after colectomy and mucosal proctectomy compared to the straight ileoanal anastomosis. The question was what physiologic changes brought about by the pouch led to the improvement. Among 124 patients who had had ileoanal anastomosis, 25 volunteered for a detailed clinicophysiologic evaluation. Fourteen had had the ileal pouch-anal operation a mean of 8 months previously, and 11 had the straight ileoanal operation a mean of 25 months previously. Both groups of patients had satisfactory anal sphincter resting pressures (mean +/- SEM, pouch = 68 +/- 8 cm H2O, straight = 65 +/- 9 cm H2O, p greater than 0.05) and neorectal capacities (pouch = 278 +/- 26 ml, straight = 233 +/- 36 ml, p less than 0.05), and all could evacuate spontaneously. However, the pouch patients had a more distensible neorectum (delta V/delta P pouch = 9.5 +/- 1.3 ml/cm H2O, straight = 4.9 +/- 0.9 ml/cm H2O, p less than 0.05) and smaller amplitude neorectal contractions (pouch = 36 +/- 5 cm H2O, straight = 90 +/- 13 cm H2O; p less than 0.05). We concluded that the pouch-anal anastomosis increased the distensibility of the neorectum and decreased its propulsive drive, and so improved clinical results.     

Anal sphincter-saving operations for chronic ulcerative colitis.

Three anal sphincter-saving operations--ileorectostomy, ileal pouch-anal anastomosis, and ileal pouch-distal rectal anastomosis--are currently being used in the surgical treatment of chronic ulcerative colitis. All three operations remove the disease, or most of it, and yet they maintain transanal defecation, reasonable fecal continence, and a satisfactory quality of life. All three avoid permanent abdominal ileostomy. Ileorectostomy is the easiest to perform, but it leaves residual disease in the remaining rectum and proximal anal canal that may cause symptoms and that may predispose the patient to cancer. In contrast, ileal pouch-anal anastomosis, although a more technically demanding procedure, totally eradicates the colitis. Its main drawbacks--frequent stooling, nocturnal fecal spotting, and pouchitis--are usually satisfactorily treated with loperamide hydrochloride and metronidazole. Ileal pouch-distal rectal anastomosis is somewhat easier to perform than ileal pouch-anal anastomosis and may result in less nocturnal fecal spotting. Like ileorectostomy, however, the operation leaves residual disease in the distal rectum and proximal anal canal. Considering all of these factors, the ileal pouch-anal operation is preferred today for most patients who require surgery for chronic ulcerative colitis.     

Late functional adaptation after colectomy, mucosal proctectomy, and ileal pouch-anal anastomosis

Ileal pouch-anal anastomosis (IPAA) is currently an alternative to proctocolectomy and ileostomy for patients with ulcerative colitis or familial polyposis. Some studies have suggested significant anal sphincter damage after mucosal proctectomy. Our aim was to assess prospectively late sphincter function after IPAA. In 250 patients, anorectal pressures were assessed with a pneumohydraulic perfused catheter manometry system. Each patient underwent colectomy, mucosal proctectomy, ileoanal anastomosis of a 15 cm ileal J-pouch, and loop ileostomy. Eight weeks after IPAA, anal manometry was repeated, and the ileostomy was closed. Manometry was repeated at yearly intervals. A decline in resting tone of the anal sphincter occurred early after IPAA with a gradual recovery toward control. External sphincter squeeze after pressures were not affected by IPAA and steadily increased to 8 years after operation. During this time, a progressive increase in J-pouch capacity was noted, and 24-hour stool frequency declined from 7.9 +/- 0.3 stools to 6.5 +/- 0.3 stools (p less than 0.05). We conclude that mucosal proctectomy results in internal anal sphincter trauma but is associated with long-term sphincter recovery, coupled with a significant improvement in external sphincter capacity, ileal pouch volume, and stool frequency.     

Quality of life after Brooke ileostomy and ileal pouch-anal anastomosis. Comparison of performance status.

Although the clinical results of Brooke ileostomy are good, patients are permanently incontinent of stool and gas. Alternative operations designed to restore enteric continence, such as ileal pouch-anal anastomosis, must not only be as safe and effective as Brooke ileostomy, but should provide an improved quality of life in order to establish long-term acceptability. Ileal pouch-anal anastomosis has been performed safely and good functional results have been reported. The quality of life after ileal pouch-anal anastomosis, however, has not been documented. Two hundred ninety-eight ileal pouch patients and 406 Brooke ileostomy patients who had the operations performed for chronic ulcerative colitis or familial adenomatous polyposis formed the basis of the study. After adjusting for age, diagnosis, and reoperation rate, logistic regression analysis of performance scores in seven different categories was used to discriminate between operations. Median follow-up was longer in Brooke ileostomy patients than in ileal pouch patients (104 months vs. 47 months, respectively), and Brooke ileostomy patients were slightly older (38 years vs. 32 years). A great majority of patients in each group were satisfied (93% Brooke ileostomy; 95% ileal pouch-anal anastomosis). Thirty-nine per cent of Brooke ileostomy patients, however, desired a change in the type of ileostomy they had. At 47 months, ileal pouch patients had a median of 5 stools per day and 1 at night, 77% did not experience any daytime incontinence, while 22% reported occasional spotting. In each performance category, the performance score discriminated between operations, with the probability of having had an ileal pouch-anal anastomosis operation increasing with improvement in performance scores (p less than 0.05). We concluded that after ileal pouch-anal anastomosis, patients experienced significant advantages in performing daily activities compared to patients with Brooke ileostomy and thus may experience a better quality of life. These results help further to establish ileal pouch-anal anastomosis as a safe, attractive, and valid alternative to Brooke ileostomy.     

Physiologic determinants of nocturnal incontinence after ileal pouch-anal anastomosis

The goals of the ileal pouch-anal anastomosis (IPAA) operation are the construction of a fecal reservoir and the preservation of anal function, without compromising continence. Some of the patients are incontinent at night. The aim of our study was to identify the mechanisms responsible for nocturnal incontinence. We analyzed patients undergoing IPAA for ulcerative colitis, who underwent anorectal tests between 1993 and 1995. All patients were subjected to pull-through manometry and pelvic floor function studies, and 33 patients underwent overnight ambulatory manometry. Among 44 patients (27 men and 17 women), 22 had complete continence, whereas 22 had nocturnal incontinence. Mean age was 40±1 years. There were no differences with regard to sex, age, stool consistency, and ability to differentiate gas from stool between groups; only stool frequency was lower in the continent group (median [range] 6 [3 to 10] vs. 8 [5 to 25] stools/24 hours;P=0.011). Resting and squeezing anal canal pressure did not differ (P=0.42 andP=0.73, respectively). Resting, squeezing, and defecating anorectal angle, percentage of pouch evacuation, and perineal descent, all measured scintigraphically, did not differ between groups (allP>0.05). Ambulatory manometry showed that the mean anal canal pressure was higher in continent patients compared to incontinent patients, both during awake (88±11 vs. 62±8;P=0.032) and sleep (81±14 vs. 49±9;P=0.029) periods. The motility index was similar (awake,P=0.88; sleep,P=0.95), as was the number of episodes where the pouch pressure was greater than the anal canal pressure (P=0.28). In otherwise continent patients after IPAA, the combination of high stool frequency and low basal anal canal pressure may be related to nocturanal incontinence. Moreover, standard anorectal physiology tests cannot identify these subtle differences. Supported in part by the Crohn's and Colitis Foundation of America, Inc. Presented at the Thirty-Seventh Annual Meeting of The Society for Surgery of the Alimentary Tract, San Francisco, Calif., May 19–22, 1996.     

Factors affecting the bowel function after proctocolectomy and ileal J pouch-anal anastomosis for ulcerative colitis

The aim was to study determinants of postoperative bowel function after restorative proctocolectomy for ulcerative colitis. Medical records of patients who underwent proctocolectomy with ileal J pouch-anal anastomosis (IPAA) in two- or three-stage operations and whose status of defecation was known via a questionnaire were retrospectively reviewed. Bowel function, including stool frequency, stool consistency, and degree of nighttime soiling, was correlated with age at the time of surgery, time after ileostomy closure, mean resting anal pressure, longitudinal length of ileal J pouch, and duration of fecal diversion by using univariate and multivariate analyses. Stool frequency decreased significantly with time after ileostomy closure in both univariate and multivariate analyses. Stool frequency tended to be less in patients having a long J pouch, but the correlation was not significant (P=0.071) in univariate analysis. Nighttime soiling ameliorated with time after ileostomy closure in multivariate, but not univariate, analysis. Deterioration of nighttime soiling was seen in patients whose duration for fecal diversion was long, both in univariate (P=0.068) and multivariate (P=0.052) analyses. Stool consistency was related to none of the five factors investigated. These results indicate that as the time after surgery increases, stool frequency decreases and nighttime soiling ameliorates. Delaying ileostomy closure because of anticipated postoperative incontinence does not significantly alter postoperative continence.     

Function after ileal pouch and stapled pouch-anal anastomosis for ulcerative colitis

Fourteen patients with ulcerative colitis underwent formation of an S ileal pouch and construction of a stapled pouch-anal anastomosis by a modified technique, which eliminated the use of purse-string sutures. Eleven have had their covering ileostomies closed. Anal manometry performed before and a median of 9 months after ileostomy closure showed significant impairment of internal anal sphincter function. Night evacuation was significantly reduced in the stapled group compared with a similar group of patients who had undergone S ileal pouch formation, mucosal proctectomy and manual transanal anastomosis, but this was the only parameter of function to show a difference. A stapled pouch-anal anastomosis may be superior to the conventional procedure but it still may lead to internal anal sphincter damage which cannot be due to mucosectomy or prolonged anal retraction.     

Randomized prospective trial comparing ileal pouch-anal anastomosis performed by excising the anal mucosa to ileal pouch-anal anastomosis performed by preserving the anal mucosa.

OBJECTIVE: The purpose of the study is to compare the results of ileal pouch-anal anastomosis (IPAA) in patients in whom the anal mucosa is excised by handsewn techniques to those in whom the mucosa is preserved using stapling techniques. SUMMARY BACKGROUND DATA: Ileal pouch-anal anastomosis is the operation of choice for patients with chronic ulcerative colitis requiring proctocolectomy. Controversy exists over whether preserving the transitional mucosa of the anal canal improves outcomes. METHODS: Forty-one patients (23 men, 18 women) were randomized to either endorectal mucosectomy and handsewn IPAA or to double-stapled IPAA, which spared the anal transition zone. All patients were diverted for 2 to 3 months. Nine patients were excluded. Preoperative functional status was assessed by questionnaire and anal manometry. Twenty-four patients underwent more extensive physiologic evaluation, including scintigraphic anopouch angle studies and pudendel never terminal motor latency a mean of 6 months after surgery. Quality of life similarly was estimated before surgery and after surgery. Univariate analysis using Wilcoxon test was used to assess differences between groups. RESULTS: The two groups were identical demographically. Overall outcomes in both groups were good. Thirty-three percent of patients who underwent the handsewn technique and 35% of patients who underwent the double-stapled technique experienced a postoperative complication. Resting anal canal pressures were higher in the patients who underwent the stapled technique, but other physiologic parameters were similar between groups. Night-time fecal incontinence occurred less frequently in the stapled group but not significantly. The number of stools per 24 hours decreased from preoperative values in both groups. After IPAA, quality of life improved promptly in both groups. CONCLUSIONS: Stapled IPAA, which preserves the mucosa of the anal transition zone, confers no apparent early advantage in terms of decreased stool frequency or fewer episodes of fecal incontinence compared to handsewn IPAA, which excises the mucosa. Higher resting pressures in the stapled group coupled with a trend toward less night-time incontinence, however, may portend better function in the stapled group over time. Both operations are safe and result in rapid and profound improvement in quality of life.     

Perioperative resting pressure predicts long-term postoperative function after ileal pouch-anal anastomosis

The purpose of this study was to determine whether perioperative manometry is useful in predicting long-term functional status after ileal pouch-anal anastomosis (IPAA). Prospectively collected perioperative anal manometry data from 1439 patients undergoing IPAA from 1986 to 2000 were compared to postoperative functional status at various time intervals from 6 months to 8 years after IPAA. A validated questionnaire was used to obtain information regarding restrictions of diet, work, social and sexual activity, urgency, fecal seepage or incontinence, energy level, satisfaction with surgery, and quality of life. The presence of seepage and the degree of incontinence were compared to the patient’s perceived quality of life, health, energy level, and satisfaction with surgery. Low (<40 mm Hg) pre- and postoperative resting pressures were associated with increased seepage, pad use, and incontinence. Patients with low resting pressures also reported diminished quality of life, health, energy level, and satisfaction with surgery. There was a significant association (P < 0.001) between seepage and degree of incontinence and quality of health, quality of life, energy level, and level of satisfaction with surgery. Perioperative resting anal sphincter pressures greater than 40 mm Hg are associated with significantly better function and quality of life after ileal IPAA. Improved functional outcome is associated with better quality-of-life outcomes. Low preoperative resting pressures do not preclude successful outcome after IPAA. Presented at the Forty-Second Annual Meeting of The Society for Surgery of the Alimentary Tract, Atlanta, Georgia, May 20–23, 2001 (oral presentation).     

Ileal pouch-anal anastomosis for chronic ulcerative colitis. Long-term results.

The aim of this study was to determine the long-term outcome among 390 patients with ulcerative colitis who underwent ileal J pouch-anal anastomosis and whether patient or operative factors influenced results. The combined operative morbidity rate for the pouch-anal anastomosis and the subsequent closure of the temporary ileostomy was 29% (bowel obstruction, 22%; pelvic sepsis, 5%), with one death due to pulmonary embolus. The probability of a successful outcome at 5 years was 94%. Of the 24 patients who failed (6% of total), 18 did so within 1 year (4%), three during year 2 (1%), three during year 3 (1%), and none thereafter. Stool frequency (7 stools/24 h), the occurrence of pouchitis (14%), and satisfactory daytime continence (94% of patients) remained stable over 4 years after operation, whereas nocturnal fecal spotting decreased (51% of patients to 20%). Women had more spotting than men, whereas patients over 50 years old had more stools per day than those 50 years or younger. In conclusion, ileal pouch-anal anastomosis achieved a reasonable stool frequency and satisfactory continence in patients with ulcerative colitis over the long-term. These results support the ileal pouch-anal anastomosis as a safe, satisfactory alternative to permanent ileostomy.     

Enteric bacteriology, absorption, morphology and emptying after ileal pouch-anal anastomosis

The aim was to determine whether changes in enteric bacteriology, absorption, morphology, and emptying occur after ileal pouch-anal anastomosis for ulcerative colitis, and to relate any changes to the clinical result. Twenty patients were studied 26 +/- 2 months (mean +/- s.e.m.) after operation. Eight patients had a good result, six a poor result, and six a history of recurrent pouch ileitis. Anaerobic and aerobic overgrowth occurred in the jejunum of patients with a poor result, but not in those with a good result or with pouch ileitis. In contrast, ileal pouch bacterial overgrowth occurred in all patients regardless of the clinical result. Patients with jejunal overgrowth had increased 24 h stool volume and stool nitrogen, but other patients did not. The larger the stool volume, the greater the anaerobic overgrowth. Pouch biopsies showed chronic inflammation in all patients, while 45 per cent had colonic metaplasia. Neither the inflammation nor the metaplasia correlated with the clinical result, nor did the clinical result correlate with the efficiency of pouch emptying. In conclusion, jejunal bacterial overgrowth after ileal pouch-anal anastomosis was associated with an increased stool output, azotorrhoea, and a poor clinical result. A distinguishing bacterial, absorptive, morphological, or emptying abnormality was not found in patients with a history of recurrent pouch ileitis.     

Anoneorectal evaluation after colectomy and endorectal ileoanal anastomosis in children and young adults

Recent improvements in the technique of colectomy, rectal mucosectomy, and endorectal ileoanal anastomosis allow a satisfactory result in most patients. However, the clinical outcome is not entirely satisfactory in about 5% to 10% of patients because of excessive stool frequency or episodic fecal incontinence or both. We evaluated anoneorectal function postoperatively to help explain the mechanisms of the difficulties. Six patients with imperfect functional results (group 1) and 6 with good functional results (group 2) after ileoanal anastomosis and closure of the loop ileostomy were compared with 12 healthy volunteers who had not had operation, through a series of tests designed to evaluate anal sphincter and neorectal function. All patients were instructed in balloon dilation of the neorectum to develop a reservoir while awaiting closure of the ileostomy. Anal sphincter manometric measurements of resting and squeeze pressures were obtained with a 4-channel probe attached to a noncompliant pneumohydraulic perfusion system. Incremental inflation of an intraluminal bag while pressures were simultaneously recorded allowed determinations of neorectal capacity and distensibility. The efficiency of neorectal evacuation was assessed by instilling a labeled synthetic viscous load into the distal bowel. Patients in group 1 had lower resting anal pressures (P less than 0.05), lower squeeze pressures (P less than 0.05), smaller neorectal capacities (P = 0.13), and less neorectal distensibility (P = 0.27) than patients in group 2. Furthermore, the values for patients in group 2 closely approximated those found in healthy volunteers.(ABSTRACT TRUNCATED AT 250 WORDS)     

Can a meta-analysis answer the question: is mucosectomy and handsewn or double-stapled anastomosis better in ileal pouch-anal anastomosis?

Although ileal pouch-anal anastomosis (IPAA) is the procedure of choice for polyposis and ulcerative colitis with medically refractory disease or dysplasia, controversy exists concerning whether mucosal preservation with double-stapled (DS) IPAA is superior to mucosectomy and handsewn (HS) IPAA anastomosis for postoperative function. Prospective studies have shown no statistically significant differences. The use of meta-analysis can strengthen statistical power by combining the data from related studies. A meta-analysis was performed to determine whether there was a significant difference in functional and manometric outcome between HS-IPAA and DS-IPAA. Prospective, randomized studies were identified using a literature search. Functional outcome variables included number of normal continence, minor incontinence, nocturnal evacuation, the ability to discriminate flatus from stool, and antidiarrheal medication. Manometric outcomes included postoperative resting and squeeze anal pressures. Four prospective, randomized trials were identified. Of the 184 total patients, the HS-IPAA group included 86 patients (48 men and 38 women) and the DS-IPAA group included 98 patients (49 men and 49 women). There were no significant differences in functional outcome between HS-IPAA and DS-IPAA. In addition, there was no significant difference in sphincter resting and squeeze pressures between the two patient groups. This meta-analysis demonstrates that DS-IPAA offers no advantage in functional or manometric outcome when compared with HS-IPAA.     

回肠储袋与直肠肌管吻合术治疗家族性腺瘤性息肉病15例分析

目的探讨回肠储袋与直肠肌管吻合术在治疗家族性腺瘤性息肉病中的价值。方法回顾性分析15例FAP患者行全大肠切除回肠储袋与肛管或直肠肌管吻合术的手术方式、并发症以及结肠镜、肛肠测压等随访资料。结果回肠储袋与直肠肌管吻合术安全可靠,无严重并发症,较回肠储袋肛管吻合术术后排便频率明显降低,肛管静息压力和最大收缩压力明显增高,肛管长度明显延长。结论与传统的回肠储袋肛管吻合术相比,回肠储袋与直肠肌管吻合术简化了手术,减少了盆底肌肉和肛门括约肌损伤,保留了更多控便功能。     

腹腔镜辅助下回肠储袋与直肠肌管吻合术治疗家族性腺瘤性息肉病的临床体会

目的:探讨腹腔镜辅助下回肠储袋与直肠肌管吻合术治疗家族性腺瘤性息肉病(familial adenomatous polyposis,FAP)的临床价值。方法:回顾分析2006～2011年为13例FAP患者分别行腹腔镜辅助回肠储袋与直肠肌管吻合术及回肠储袋与肛管吻合术的临床资料,并进行对比分析。结果:两组患者手术时间、术中出血量、术后切口长度、进食时间、住院时间、住院费用差异均无统计学意义。术后6个月随访,腹腔镜辅助下回肠储袋与直肠肌管吻合术较回肠储袋肛管吻合术后患者排便次数明显减少,肛管静息压及最大收缩压明显增高。结论:与传统回肠储袋肛管吻合术相比,回肠储袋直肠肌管吻合手术保留了部分直肠肌管,不仅有效减少了盆底肌肉损伤的可能性,而且很好地保护了肛门括约肌,因而可更好地保留患者的控排便功能。     

Preservation of continence after ileoanal anastomosis by the coordination of ileal pouch and anal canal motor activity.

Nocturnal incontinence may occur after ileoanal anastomosis and may be related to loss of an effective anal canal pressure barrier during sleep; how pressure and contractions in the proximal bowel influence this barrier is unknown. Our aim was to evaluate the relationship between anal canal pressure and contractions and contractile activity of the pouch in continent subjects after ileal pouch-anal anastomosis (IPAA) and of the rectum in normal controls. A fully ambulatory system for 24-hour pressure recording was used. A flexible transducer catheter was introduced endoscopically so that sensors were at 2, 3, 8, 12, 16, and 24 cm from the anal orifice in 12 healthy controls (7 men, 5 women, mean age: 35 years) and 7 fully continent IPAA patients (4 men, 3 women, mean age: 34 years) more than 12 months postoperatively. Twenty-four hour spontaneous motor activity was stored in a 2.5 megabyte (MB) digital portable recorder. Mean anal canal pressure was calculated, and rectal motor complexes and ileal pouch large pressure waves were characterized. During sleep, resting anal canal pressures were similar in the two groups (72 +/- 12 mm Hg in controls versus 66 +/- 9 mm Hg in IPAA patients [mean +/- standard deviation (SD)], p = NS), but anal canal pressure showed cyclic relaxations (periodicity: 95 +/- 11 min in controls, 54 +/- 18 min in IPAA patients, p less than 0.05), during which the mean pressure trough was 15 +/- 4 mm Hg in controls and 14 +/- 5 mm Hg in IPAA patients (p = NS). In the control patients, during sleep, a mean of six rectal motor complexes were identified (range: 3 to 9). In patients with IPAA, during sleep, a mean of eight large pressure waves per hour were identified (range: 2 to 20). Importantly, in both controls and patients, rectal motor complexes or large pressure waves were always accompanied by rapid return of anal canal pressure from trough to basal values and increased contractile activity. We concluded that, in healthy patients and in continent patients after IPAA, motor activity of the rectum and of the ileal pouch was associated with changes in pressure and contractile activity of the anal canal so that rectal- and neorectal-anal canal pressure gradient, and, in turn, fecal continence were preserved.