Ileal pouch-anal anastomosis after failure of straight ileoanal anastomosis. Case report

The technique for creating an ileoanal anastomosis and an ileal reservoir with stapling technique is described. It was used in two patients in whom severe complications after colectomy and straight ileoanal anastomosis had necessitated ileostomy. The functional result was satisfactory.     

Proctocolectomy and ileoanal anastomosis

An account is given of the evolution of proctocolectomy with construction of a pelvic ileal pouch and an ileoanal anastomosis, which has probably become the most popular elective operation at the present time for ulcerative colitis. The technique favored by the author for this procedure is described and the results obtained in 422 cases at the Mayo Clinic are analyzed, with 188 of them analyzed in detail. Outstanding issues regarding technical methods and outcome are discussed.

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Resumen Se hace un informe sobre la evolución histórica de la proctocolectomía con construcción de una boisa pélvica ileal y anastomosis ileoanal, procedimiento que ha venido a convertirse en la operación electiva probablemente más popular de la actualidad para colitis ulcerosa. Se describe la técnica predilecta del autor para la realización de este tipo de procedimiento y se presentan los resultados en 422 casos de la Clínica Mayo, 188 de ellos en forma detallada. Se discuten aspectos de importancia relativos a los métodos técnicos y al resultado final.

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Résumé Un récit de l'évolution de la proctocolectomie avec constitution d'un réservoir pelvien et d'une anastomose iléo-anale est donné, cette intervention devenant l'opération élective la plus répandue pour traiter de nos jours la colite ucléreuse. La technique employée par l'auteur est décrite et les résultats obtenus dans 442 cas traités à la Mayo Clinic sont donnés et spécialement en détail pour 188 d'entre eux. Les résultats marquants en fonction des techniques employées et de leur évolution sont discutés.

     

Proctocolectomy with ileoanal anastomosis

Conclusion Ileoanal anastomosis has evolved through many phases before arriving at the highly successful procedure currently used at major centers. Interesting, in reviewing the world’s literature, those series that report patient outcomes stratified by year show significant improvements in function and quality of life in patients who have received the operation more recently when compared with patients receiving the operation in the earlier years. Continued technical advances and greater surgeon experience can only further improve function, outcome, and patient satisfaction. Despite some opposition,³¹ under elective conditions, IPAA remains an excellent option for patients with CUC and FAP once the decision for surgery has been mutually reached by the patient and surgeon.³² With technical modifications and with experience, mucosal proctectomy and IPAA can now be performed with a low rate of complications, with good functional results and quality of life and excellent long-term outcome. As these patients, especially those with CUC, experience more frequent inflammatory episodes or become refractory to medical management, their medical and surgical management will require a closely coordinated effort by their gastroenterologists and their surgeons. Unless the colectomy is urgent, these patients typically tend to get referred earlier and therefore have more favorable outcomes. Optimal results are obtained by careful patient selection, appropriate preoperative management, meticulous standardized surgical technique, appropriate postoperative education, and rigorous follow-up.     

Portal vein thrombus after pediatric proctocolectomy with ileoanal anastomosis

In adults, mesenteric venous thrombosis with extension into the portal system is a known complication of total proctocolectomy with pouch ileoanal anastomosis. Although frequently reported in adults, this complication is rare in pediatric patients undergoing this operation. We report 2 cases of adolescent patients with ulcerative colitis who experienced portal vein thrombosis after this procedure. Both were treated with systemic anticoagulation therapy with complete resolution of their clots. We recommend that mesenteric/portal venous thrombosis be considered in the differential diagnosis in any child presenting with fever, abdominal pain, and leukocytosis after restorative proctocolectomy with ileal pouch anastomosis and that imaging obtained to evaluate abdominal complaints in this population be directed toward ruling out this complication.     

J pouch with ileoanal anastomosis

The physical inconvenience and adverse psychological impact of ileostomy on patients led surgeons to seek a more normal and acceptable alternative. This is a report of the Mayo Clinic experience with, and modifications of, the ileoanal reservoir procedure. The hospital charts of 188 patients who had a J-pouch construction were reviewed. The operative technique is described. There were no hospital deaths. In 10 patients the operation was a failure. Complications included pelvis sepsis (21 patients), anastomotic sinus (15), anastomotic stricture (22), small-bowel obstruction (43), peritonitis after ileostomy closure (10) and pouchitis (15). Careful patient selection for the procedure is important. Crohn's disease is a contraindication. Of the patients studied, 95% found life more acceptable with an ileoanal anastomosis than with a loop ileostomy.     

Usefulness of valproate sodium for treatment of incontinence after ileoanal anastomosis

We report on the excitatory effect of gamma-aminobutyric acid, which increased after the oral administration of valproate sodium, on anal canal resting pressure in human beings, gamma-aminobutyric acid receptors. We used this drug in order to improve continence after ileoanal anastomosis. Seventeen patients (eight with ulcerative colitis and nine with adenomatosis coli) were tested after receiving ileoanal anastomosis. The placebo showed no effect, but valproate sodium could ameliorate frequent defecation and soiling and the resulting perianal skin complications. Increasing anal resting pressure was also observed during valproate sodium administration without the amplitude, frequency of peristaltic wave, or voluntary squeeze pressure being affected. These results suggest that the subchronic administration of valproate sodium may be useful in the treatment of minor incontinence after ileoanal anastomosis.     

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.     

Restorative proctocolectomy with J-pouch ileoanal anastomosis

Restorative proctocolectomy with ileoanal anastomosis, complemented by a pouch formed with the last foot of terminal ileum, is the procedure of choice for patients in need of surgical treatment for ulcerative colitis and familial polyposis. The procedure has undergone many technical modifications that have ensured a very high degree of continence and an acceptable number of daily bowel movements. Herein we describe the operative technique we use in the majority of our patients, a restorative proctocolectomy with hand-sewn J-pouch ileoanal anastomosis with protecting ileostomy. We also comment on the immediate postoperative care and on the long-term functional results.     

Adenocarcinoma below stapled ileoanal anastomosis after restorative proctocolectomy for ulcerative colitis

A case of adenocarcinoma arising in a 39-year-old patient after restorative proctocolectomy is reported. The patient underwent an ileal pouch-anal anastomosis with double-stapled technique for severe ulcerative colitis 18 years earlier, without evidence of associated neoplasm or dysplasia in operative specimen. After endoscopic diagnosis of adenocarcinoma, the patient was submitted to excision of the pouch and permanent ileostomy, followed by combined radiotherapy and chemotherapy. Pathology showed an AJCC stage III moderately differentiated mucinous adenocarcinoma. The patient died 24 months after the operation, due to cancer progression. There are 50 reported cases in the indexed medical literature of carcinoma arisen after ileal pouch-anal anastomosis for ulcerative colitis. Twenty-five out of these arose after mucosectomy and hand-sewn anastomosis, and 25 after stapling technique. Furthermore, in 48% of the patients, dysplasia or cancer was already present at the time of the colectomy. The increase of reported cases suggests a routine long-term endoscopic surveillance in patients with long-standing ileal pouches, especially in presence of dysplasia or cancer in the proctocolectomy specimen.     

Surgery of ulcerative colitis using ileoanal anastomosis

The ideal surgical treatment for ulcerative colitis is the ileoanal anastomosis (IAA), which, however, is not yet generally accepted as a practical procedure because of a suboptimal fecal function, frequent postoperative complications and technical difficulties. Based on one (U.) of the authors experiences on 36(34) polyposis and 19(12) colitis (paracentesis indicate the number of cases in (U.)'s previous appointment, Tokyo Medical and Dental University, 1977-1983). The practical procedure of IAA can be achieved by combining the following basic principles; a direct anastomosis of J-shape ileal pouch to the anal sphincteric mechanism, temporarily exclusion of the anastomosis by a loop-ileostomy, mucosectomy confined to the lower rectum leaving the short muscular cuff, and meticulous dissection of inflamed mucosa of the anal canal minimizing the damage to the internal sphincter which is achieved by the prone ano-abdominal approach. At elective operation, the procedure can be performed either as primary surgery or as the secondary following rectum preserving operation, in which, coeco-rectal anastomosis is advisable for preserving the ileocolic vessels that is helpful for J-pouch construction. In emergency surgical program, IAA is still be preserved as a final restructive surgery following colectomy with an open rectal exclusion or Turnbull' s total colonic exclusion. In this occasion, an ascendicostomy is advisable for preserving the ileocolic vessels.     

Anal sphincter electromyography after colectomy, mucosal rectectomy, and ileoanal anastomosis

Electromyography (EMG) was used to evaluate the external anal sphincter in 27 patients following colectomy, distal mucosal rectectomy, and ileoanal anastomosis. The studies were conducted four months to 58 months (mean, 20 months) following the restoration of intestinal continuity. Nine patients underwent endoanal rectal mucosal stripping, while in 18 patients the rectum was everted to facilitate the stripping. Postoperative continence varied widely, from perfect to frequent and severe mucous of fecal leak. Abnormal motor-unit potentials were identified by EMG in nine patients and this finding was usually associated with poor continence. The sex of the patient, technique of mucosal stripping, and type of anastomosis did not influence the EMG result, but patients at least 40 years old all had abnormal EMGs. We conclude that poor continence after ileoanal anastomosis correlates with an abnormal EMG of the external anal sphincter. The cause of the EMG abnormality is unclear.     

Video-assisted total proctocolectomy with ileoanal anastomosis]

The indication for laparoscopy in digestive surgery has evolved with the development of the laparoscopic material as well its increasingly frequent practice in the medical community. Those complex operations such as restorative proctocolectomy require a high level of technical skill as well as a specifically designed operative approach. The study aim was to report our experience of the video-assisted approach to restorative proctocolectomy.     

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)     

Endorectal ileoanal anastomosis with isoperistaltic ileal reservoir after colectomy and mucosal proctectomy.

Forty-nine patients with chronic ulcerative colitis refractory to medical therapy and four with multiple polyposis have undergone total colectomy, mucosal protectomy, and endorectal ileal pull-through with ileoanal anastomosis at the UCLA Medical Center during the past 12 years (mean age, 19.4 years). Thirty-eight patients underwent second-stage closure of the ileostomy with construction of a side-to-side isoperistaltic ileal reservoir (mean, 6 months) after the ileal pullthrough operation. The anastomosis extended over a 20-30 cm distance and the lower end was placed within 6-8 cm of the ileonanal anastomosis. Transient reservoir inflammation, which occurred in half of the patients, was reduced by the use of oral metranidazole and was rarely found 6 months after operation. No patients died during the early or late post-operative periods. Cuff abscess in two patients and obstruction of the ileal reservoir outlet have required takedown of the reservoir (two patients) or temporary ileostomy (three patients). Of the 38 patients who have undergone lateral ileal reservoir construction, 33 have achieved a good to excellent result with complete continence and an average of five stools per 24 hours after 6 months. At least 12 patients now participate in competitive athletics; normal sexual activity has been achieved in all but one patient. Seven patients await construction of the reservoir. Although a technically difficult operation, the long-term results (mean, 19.4 months) indicate that the pullthrough operation is a good alternative to standard proctocolectomy.