Stricture at the pouch-anal anastomosis after restorative proctocolectomy

PURPOSE: The aim of this study was to determine what factors may be responsible for the development of a stricture at the pouch-anal anastomosis after restorative proctocolectomy. METHODS: A consecutive series of 115 patients was studied retrospectively a median of 34 months (range, 4–100 months) after operation or ileostomy closure. The procedure failed in 11 patients (9.6 percent) who subsequently had to have a permanent ileostomy. Another two patients were excluded from the analysis, one of whom was awaiting ileostomy closure, whereas the other had a stricture due to a desmoid tumor. Of the remaining 102 patients, 39 (38 percent) developed an ileoanal anastomotic stricture, which was severe and persistent in 16 percent. RESULTS: The results were analyzed with the aid of multivariate logistic regression analysis. Factors which predisposed significantly to the development of an ileoanal anastomotic stricture were 1) use of the 25-mm (small) diameter stapling gun (P<0.05), 2) use of a quadruplicated reservoir (P=0.05), 3) use of a defunctioning ileostomy (P=0.03), and 4) anastomotic dehiscence and pelvic sepsis (P=0.03). The single patient whose operation failed because of a stricture had also developed pelvic sepsis associated with an anastomotic dehiscence. CONCLUSIONS: The eventual clinical, functional outcome after dilation of a stricture in the 39 patients who developed a stricture was as good as the outcome in the 63 patients who did not a develop stricture.     

One-stage restorative proctocolectomy without temporary ileostomy for ulcerative colitis

PURPOSE: This study was designed to determine the safety of omitting a temporary defunctioning ileostomy in restorative proctocolectomy for ulcerative colitis. METHOD: One hundred consecutive patients with ulcerative colitis were treated electively by restorative proctocolectomy and pouch-anal anastomosis, without mucosal stripping; 50 had a defunctioning ileostomy added, and 50 underwent a one-stage procedure without ileostomy. RESULTS: There was no operative mortality. The incidence of postoperative complications was similar in the two groups of patients. Lifethreatening complications, however, were more common among patients who did not have a defunctioning ileostomy, of whom 11 developed pelvic sepsis and 7 required reoperation. Among patients with an ileostomy, seven developed pelvic sepsis but none required reoperation (P <0.02). Emergency reoperations were required in 11 patients without an ileostomy but in only 1 patient with an ileostomy (P <0.01). CONCLUSION: One-stage restorative proctocolectomy without a defunctioning ileostomy is associated with increased risk to life. Its routine use cannot be recommended.Read at the meeting of The American Society of Colon and Rectal Surgeons, Orlando, Florida, May 8 to 13, 1994.     

Videoproctographic assessment after restorative proctocolectomy

Videoproctography was performed in 40 patients after restorative proctocolectomy to evaluate pouch emptying, anopouch angle, and pelvic floor movement in relationship to functional outcome. Results were compared between the two different pouch designs tested and a control group of 26 patients who had an intact rectum. There was no difference in emptying between the two pouch designs or compared with the control subjects. Emptying did not influence either the frequency of defecation or patient soiling rate. The presence of an anal stricture was associated with poor emptying in each case in the pouch group. Anorectal angle was no different between the different pouch designs or compared with the control group at rest, during pelvic floor contraction, or attempted defecation. A similar finding was obtained with anorectal angle position and movement during pelvic floor contraction and attempted defecation in both pouch design groups and when compared with normal rectum. This study shows that the only factor that is consistently associated with poor pouch emptying is the presence of an anal stricture.Read at the meeting of The American Society of Colon and Rectal Surgeons, Toronto, Canada, June 11 to 16, 1989.     

One-stage restorative proctocolectomy without temporary defunctioning ileostomy

A temporary ileostomy has been employed routinely by most medical centers to defunction the ileal reservoir after restorative proctocolectomy. The aim of this study was to compare the clinical outcome in patients who underwent restorative proctocolectomy with and without the use of a temporary, defunctioning ileostomy. A consecutive series of 58 patients was studied. Each patient underwent restorative proctocolectomy with quadruplicated ileal reservoir and stapled pouch-anal anastomosis, without mucosectomy; 28 had a temporary, defunctioning ileostomy and 30 did not. The decision for or against an ileostomy was taken at the end of the operation. The two groups of patients were similar in age and sex distribution. There was no postoperative mortality. There were no significant differences in the incidence of pelvic sepsis, anastomotic stricture, and intestinal obstruction in patients without an ileostomy compared with patients with an ileostomy. The total length of stay in hospital after the operation was significantly reduced in the group of patients without an ileostomy (P <0.01). The avoidance of a temporary ileostomy did not lead to an increase in postoperative complications and was associated with a shorter length of stay in hospital after restorative proctocolectomy.Read at the meeting of The American Society of Colon and Rectal Surgeons, Boston, Massachusetts, May 12 to 17, 1991.     

Functional results after restorative proctocolectomy complicated by pouchitis

This study aimed to examine the incidence and cumulative risk of pouchitis after restorative proctocolectomy for ulcerative colitis and to evaluate the clinical and functional results in patients with pouchitis. METHODS: A total of 291 patients had proctocolectomy with ileal pouch-anal anastomosis for ulcerative colitis between January 1985 and January 1996. During follow-up, 65 patients had one or more episodes of pouchitis based on clinical, histologic, and endoscopic criteria. Functional results and patient satisfaction in these patients were compared with those of 65 matched control patients who had experienced no episodes of pouchitis. RESULTS: Pouchitis developed in 65 patients (22 percent), giving rise to a cumulative frequency of 28 percent at 11 years after the operation. Only 13 patients (4.5 percent) had chronic pouchitis that required long-lasting treatment. A permanent ileostomy had to be constructed in one patient (0.3 percent) because of pouchitis. During the last year (1995), 60 percent of patients with pouchitis had medication, most often metronidazole and/or corticosteroids. Defecation frequency per 24 hours was 6.7 for all patients with pouchitis, 8.2 for those with chronic pouchitis (P<0.05), and 6.3 for patients without pouchitis. Nighttime defecation occurred in 44 (80 percent) patients with pouchitis, compared with 37 (67 percent) of those without pouchitis (P>0.05). Frequencies of soiling or flatus incontinence did not differ between the two groups. During the last year, 43 (80 percent) of the pouchitis patients, who answered the questionnaire, were working all the year or were on sick-leave less than one month. CONCLUSIONS: Episodic pouchitis is easily treated and causes minimum functional consequences, whereas chronic pouchitis increases defecation frequency and needs prolonged medication. Pouchitis seems not to be a major threat to preventing the use of restorative proctocolectomy in ulcerative colitis, but still the small group of chronic pouchitis patients remains a problem.Supported by grants from the Foundation of Gastroenterological Diseases, Helsinki, Finland.     

Randomized trial to determine the optimum level of pouch-anal anastomosis in stapled restorative proctocolectomy

PURPOSE: This study was undertaken to identify the optimum level of stapled ileal pouch-anal anastomosis. METHOD: A prospective, randomized trial was completed to compare double-stapled ileoanal anastomosis placed at the top of anal columns (high, n=26) with anastomosis at the dentate line (low, n=21). RESULTS: There was no significant difference in the overall complication rate between operations (high, n=7,vs. low, n=8; P<0.21). Pouchanal functional score (scale 0–12; 0=excellent, 12=poor) was significantly better in the high anastomosis group (median (range): 2 (1–9) vs. 5.5 (1–12); P<0.05). Incontinence occurred in only two patients randomized to high anastomosis compared with six in the low anastomosis group. Nocturnal soiling was reported in three patients after high anastomosis and in six patients after dentate line anastomosis. Both operations caused a significant but comparable reduction of maximum anal resting pressure (31 percent after high anastomosis (P<0.05); 23 percent after low anastomosis (P<0.05)). However, a significant fall in functional length of the anal canal was only seen after a low pouch-anal anastomosis (P<0.05). CONCLUSION: Stapled pouch-anal anastomosis at the top of anal columns gives better functional results compared with a stapled anastomosis at the dentate line.K. I. Deen was supported by the Medical Research Council of Great Britain.     

Anal manometry with microtransducer technique before and after restorative proctocolectomy

Anal manometry, with microtransducer technique, was performed in 55 patients after restorative proctocolectomy. Forty-two patients were followed regularly from before surgery until 12 months after surgery, and 23 patients until 24 months of function. Postoperatively, sphincter function was severely impaired. At 12 months, the mean height was less than 60 percent, mean area less than 50 percent, and mean length less than 90 percent of the preoperative values of the high pressure zone. There was no improvement between 12 and 24 months. Mean maximal squeeze pressure was restored at 12 months. Rectoanal inhibitory reflex was constantly present preoperatively, but in only 4 of 30 patients, postoperatively. Those patients with preoperative resting pressure 100 cm H ₂ O or greater had significantly higher resting tones at 12 months than those with less than 100 cm H ₂ O. Patients with 5 or fewer bowel movements every 24 hours had significantly higher resting tones than those with more than 6 movements every 24 hours (66 vs. 45 cm H ₂ O). Patients with deferral 60 minutes or greater had significantly higher resting pressures than those with deferral less than 30 minutes (65 vs. 44 cm H ₂ O). No correlation was found between resting pressure and state of continence.Supported in part by The Swedish Cancer Society (Project numbers 2240-B86-01X and 2240-B87-02X).     

Effect of rectosigmoid stump length on restorative proctocolectomy after subtotal colectomy

BACKGROUND: The length of the rectosigmoid stump left after subtotal colectomy and ileostomy is believed to affect postoperative complications, including sepsis, success of future restorative proctocolectomy, and long-term functional outcome. METHODS: We reviewed the charts of 60 patients with toxic ulcerative colitis who were treated with subtotal colectomy leaving either a short (25) or long (35) rectosigmoid stump and who eventually underwent restorative proctocolectomy between 1983 and 1992 at a large tertiary care center. Data were collected on preoperative disease duration and steroid use, operative time, blood loss, transfusion requirements, length of stay, stool frequency, fecal incontinence, and sexual dysfunction. RESULTS: There were no statistically or clinically significant differences between groups. CONCLUSIONS: Rectosigmoid stump length does not appear to affect complications or long-term outcome in patients with toxic ulcerative colitis treated with subtotal colectomy and restorative proctocolectomy.Poster presentation at the meeting of The American Society of Colon and Rectal Surgeons, Orlando, Florida, May 8 to 13, 1994.     

Comparison of the functional results of restorative proctocolectomy for ulcerative colitis between the J and W configuration ileal pouches with sutured ileoanal anastomosis

PURPOSE: This study was designed to compare function of patients who had undergone reconstruction following proctocolectomy for ulcerative colitis using the J or W configuration ileoanal pouch. METHODS: Of 126 patients who underwent restorative proctocolectomy between January 1981 and March 1993, 101 had surgery for ulcerative colitis. Eighty-seven of these patients were available for review by personal or postal interview. All operative procedures were performed by one surgeon. The group comprised 35 W-pouches and 52 J-pouches. RESULTS: More patients with a J-pouch had a stool frequency of greater than 8 per 24 hours (P =0.044), and they were also more likely to use a perineal pad (P =0.019). No difference in the rates of nocturnal stool frequency, fecal incontinence, or use of constipating agents between the two pouch designs was found. Significantly more patients with a J-pouch have had episodes of pouchitis (P =0.001). Of the total patient group 91.9 percent felt that restorative proctocolectomy had improved their quality of life. CONCLUSION: Minor differences in the function of the W configuration ileoanal pouch and the J configuration ileoanal pouch are demonstrated in this study.Read in part as the Bacon Oration at The meeting of the American Society of Colon and Rectal Surgeons, Chicago, Illinois, May 2 to 7, 1993.     

Obstructing inflammatory fibroid polyp in pelvic ileal reservoir after restorative proctocolectomy in ulcerative colitis

PURPOSE: This study was designed to describe clinical, endoscopic, and histopathologic features of an inflammatory fibroid polyp occurring in the pelvic ileal reservoir after restorative proctocolectomy in ulcerative colitis. METHOD: A case report describing the clinical course of such a patient is presented. RESULTS: Three years postoperatively, the patient developed diarrhea, anemia, weight loss of 10 kg, and symptoms of obstructed defecation. Ileoscopy showed pouchitis and a polypoid tumor filling the pouch. Biopsies revealed chronic inflammation without signs of malignancy. At laparotomy, a 5 cm×3.5 cm×3.5 cm submucosal, solid, circumscribed tumor was found within the pouch, and histopathologic examination yielded the diagnosis. The pelvic pouch was resected and replaced by a Brooke ileostomy. During 18 months of follow-up, the course has been uneventful. CONCLUSION: Inflammatory fibroid polyp is a rare, reactive, non-neoplastic lesion, which, for the first time, is reported in a pelvic ileal reservoir. It may cause pouch dysfunction. It is always benign but may masquerade as a malignant tumor.     

Internal anal sphincter activity after restorative proctocolectomy for ulcerative colitis: A study using continuous ambulatory manometry

PURPOSE: The aim of this study was to further investigate continuous ambulatory anal manometry which has recently been introduced as a method for studying anorectal activity in ambulant patients, thereby avoiding many of the potential drawbacks of static techniques. METHOD: In this study continuous ambulatory manometry was used to assess the activity of the internal anal sphincter in patients who had undergone restorative proctocolectomy, and, in particular, to compare patients who had undergone conventional mucosal proctectomy with sutured endoanal, ileoanal anastomosis with patients who had undergone restorative proctocolectomy with preservation of the entire anal canal by means of stapled, end-to-end, ileoanal anastomosis without mucosectomy. RESULTS: Evidence of basal internal sphincter activity was found in only 38 percent of patients after mucosal proctectomy with sutured endoanal anastomosis, whereas all patients after restorative proctocolectomy with stapled end-to-end anastomosis and all control individuals showed such activity of the internal sphincter. Similarly, the number of sampling episodes seen in patients after mucosal proctectomy with endoanal anastomosis was significantly less (median, 0.0/hours (0–30/hours)) than the number of sampling episodes observed in patients after end-to-end anastomosis (median, 4.5/hours (1–48/hours)) or in control individuals (median, 5.6/hours (0–31/hours)) ( P <0.001). CONCLUSIONS: These results suggest that the internal anal sphincter is damaged in the course of mucosal proctectomy and endoanal anastomosis. In contrast, after restorative proctocolectomy with stapled, end-to-end anastomosis normal function of the internal sphincter is preserved.Read at the meeting of The American Society of Colon and Rectal Surgeons, San Francisco, California, June 7 to 12, 1992.     

Results of the pelvic-pouch procedure in patients with Crohn's disease

The pelvic-pouch procedure has become a standard operation for selected patients with ulcerative colitis, but is contraindicated in patients with Crohn's disease at our institution. However, the distinction between ulcerative colitis and Crohn's colitis can sometimes be difficult, if not impossible. Between January 1982, and March 1989, 272 patients with ulcerative colitis underwent pelvic-pouch procedures at our institution. Nine (35 percent) of these patients eventually were found to have Crohn's disease. The records of these patients were examined to assess their clinical outcome and complication rate. There were five females and four males with a mean age of 28.8 years. In five patients (Group I) the diagnosis of Crohn's disease was made postoperatively on histologic examination of the rectum. The ileostomy was closed in all patients. Two developed complications necessitating excision of the pouch. Three patients are well. In the other four cases (Group II) the mean time to diagnosis was 2.5 years after the pouch procedure. Three patients developed pouch-vaginal fistula, and one multiple anal fissures and stenosis. Two required excision of the pouch whereas two have a functioning pouch but with a persistent pouch-vaginal fistula (n=1) or anal fissures (n=1). Overall, four patients have had their pouches removed, and five patients have functioning pouches: three with no complications and two with persistent perianal disease. Thus, we would conclude that the pelvic-pouch procedure should not knowingly be performed in patients with Crohn's disease because of the high associated complication rate.Read at the meeting of The American Society of Colon and Rectal Surgeons, St. Louis, Missouri, April 29 to May 4, 1990.     

Safety of urgent restorative proctocolectomy with ileal pouch-anal anastomosis for fulminant colitis

PURPOSE: Subtotal colectomy with ileostomy is the operation of choice for patients with fulminant colitis. Restorative proctocolectomy (RPC) with ileal pouch-anal anastomosis (IPAA) is preferred for patients who undergo elective surgery for ulcerative colitis. We retrospectively evaluated the safety of RPC with IPAA in patients with a moderate form of fulminant colitis. METHODS: A chart review of 737 patients who underwent RPC with IPAA for ulcerative and indeterminate colitis from 1983 through 1992 was performed. Moderate fulminant colitis was defined as acute disease requiring hospitalization and parenteral steroid therapy, but without hypotension (systolic blood pressure, <100 mmHg), tachycardia (>120 beats/min), or megacolon. RESULTS: Twelve patients with moderate fulminant colitis underwent urgent surgery (1.6 percent). They had been treated preoperatively for 5.1±2.3 days with intravenous high-dose steroids, total parenteral nutrition, and antibiotics. These patients had a shorter length of disease ( P =0.01), lower hemoglobin, hematocrit, and albumin (P=0.001), and higher temperature (P=0.002) and leukocyte count (P=0.007) than patients undergoing elective surgery. No early septic complications occurred, although perianal abscess occurred in one patient and pouch-anal fistula in another patient, 13 and 14 months after surgery, respectively. CONCLUSION: In carefully selected, hemodynamically stable patients with fulminant colitis and without megacolon, RPC with IPAA can be safely performed.Poster presentation at the meeting of The American Society of Colon and Rectal Surgeons, Orlando, Florida, May 8 to 13, 1994.     

Recovery of anal sphincter function after the ileoanal reservoir procedure in patients over the age of fifty

PURPOSE: This study was undertaken to postoperatively assess the progression of anal sphincter function and clinical outcome in patients 50 years old (Group I) compared with those <50 years old (Group II). METHODS: Clinical data were assessed after ileostomy closure by a questionnaire. These data were compiled to obtain an incontinence score, which ranged from 0 (perfect continence) to 20 (total incontinence). Anorectal manometry was performed preoperatively (MN1) and postoperatively, before (MN2) and after (MN3) ileostomy closure. Wilcoxon and paired t-test were used to compare the clinical and functional results, respectively. RESULTS: Group I consisted of 22 patients (mean age, 56 years) and Group II, 50 patients (mean age, 32 years). No differences were found relative to either preoperative pressures or clinical outcome. However, both the mean and high resting pressures were significantly lower in Group I at the MN2 examination. CONCLUSION: The effect on anal sphincters of ileoanal reservoir in patients over the age of 50 years is similar to that noted in younger patients. Transient impairment of internal anal sphincter function observed after ileoanal reservoir is more severe in older patients (P=0.01). However, as in younger patients, it does completely recover after ileostomy closure.Poster presention at the meeting of The American Society of Colon and Rectal Surgeons, Chicago, Illinois, May 2 to 7, 1993.     

Quality of life after restorative proctocolectomy with a pelvic ileal reservoir compares favorably with that of patients with medically treated colitis

There remains some reluctance among physicians to refer patients for restorative proctocolectomy (RP). They argue that their patients would be worse off with a pouch because of the attendant problems of urgency and frequent bowel actions. The aim of this study was to compare quality of life in patients who had undergone RP with that of patients with ulcerative colitis on long-term medical treatment. A detailed questionnaire and the Hospital Anxiety and Depression (HAD) test were completed by 103 patients who had undergone RP and by 95 patients with ulcerative colitis on medical treatment and in remission attending a gastroenterology clinic. Patients with a pouch had a greater frequency of bowel action [five times per 24 hours (range, 4–7) vs.two times per 24 hours (range, 1–3);P <0.001] but less urgency of defecation [12/103 (11.7 percent) vs.69/95 (72.6 percent);P <0.001] than patients with medically treated colitis. Efficiency of evacuation, discrimination between flatus and feces, use of perianal pads, and perianal soreness were similar. Use of antidiarrheal medication was more common in the pouch group [53 of 103 patients (51.5 percent) vs.3 of 95 patients (3.2 percent);P < 0.05], whereas use of topical steroids was more common in medically treated patients [40 of 95 patients (47.1 percent) vs.9 of 103 patients (8.7 percent);P <0.05]. Limitation of social activity and HAD scores were significantly higher in medically treated patients. Quality of life for patients with a pouch appears to be as good as that for patients with medically treated colitis.Read at the meeting of The American Society of Colon and Rectal Surgeons, San Francisco, California, June 7 to 12, 1992.     

Does eversion of the anorectum during restorative proctocolectomy influence functional outcome?

PURPOSE: The aim of this study was to determine the effect of eversion of the anorectum during restorative proctocolectomy (RP) for ulcerative colitis on functional outcome. METHODS: One hundred seventeen patients underwent RP with stapled end-to-end ileal pouch-anal anastomosis (EEA), without resection of the anal mucosa. Sixty-four underwent EEA with eversion of the anorectum, and 53 underwent EEA without eversion. Each patient underwent paired studies of anorectal function before and a median of 12 months after RP. RESULTS: One year after RP, median (interquartile range) maximum resting pressure was 69 (range, 51–88) cmH ₂ O in those patients who underwent eversion vs. 80 (range, 64–90) cmH ₂ O in patients without eversion (P{bd>0.04). Threshold sensation in the upper, middle, and lower thirds of the anal canal were 9.1, 7.4, and 6.8 mA after eversionvs. 6.9, 4.9, and 3.8 mA without eversion (P =0.003,P<0.001,P<0.001, respectively). Before operation, all patients had a rectoanal inhibitory reflex; however, after RP, 54 of 64 patients in the eversion group and 50 of 53 patients with a stapled EEA without eversion had an inhibitory reflex (P =not significant). Leakage of mucus was experienced by 11 patients who underwent eversion, compared with 9 patients without eversion. Fifty-six of 64 patients with eversion could defer defecation for more than 30 min compared with 43 of 53 patients without eversion. Twenty-two of 64 patients in the eversion group retained perfect discrimination between flatus and feces compared with 38 of 54 without eversion (P<0.001). Level of the anastomosis was 1 (range, 0.5–3) cm above dentate line after eversion compared with 1.5 (range, 0–6) cm without eversion. CONCLUSION: Clinical outcome after RP with eversion was not as good as outcome after stapled EEA without eversion. Such a conclusion requires confirmation in a prospective control trial.Read at the meeting of The American Society of Colon and Rectal Surgeons, Montreal, Quebec, Canada, May 7 to 12, 1995.     

Surgical treatment of enterovesical fistulas in Crohn's disease

A review of the surgical treatment of enterovesical fistula in Crohn's disease was undertaken to evaluate its effectiveness and long-term results. Sixty-three patients, 39 men and 24 women, with a mean age of 34.4 years were identified with enterovesical fistula. They had documented Crohn's disease for a mean period of 7.0 years. Distribution of anatomic pattern was 34.9 percent ileal, 7.9 percent colonic, and 57.2 percent ileocolic. Nineteen (30.1 percent) had previous abdominal surgery for Crohn's disease. Presenting symptoms included frequency and dysuria in 93.6 percent, pneumaturia in 79.3 percent, and fecaluria in 63.4 percent; 60.3 percent of patients had all three features. Enterovesical fistula was confirmed preoperatively in 43 patients, suspected clinically in 15 patients, and diagnosed intraoperatively in 5 patients. Sixty-one of 63 patients underwent surgery with resection of the phlegmon or abscess with the diseased bowel and curettage or resection of the fistula. After curettage of the bladder defect, pelvic and bladder drainage was instituted. Coexistent fistulas, most commonly ileosigmoid, occurred in 31 patients. Intra-abdominal abscesses were found in 21 patients, of whom 15 required two-stage procedures. One patient died (mortality 1.6 percent), urine leak occurred in 3.2 percent, and wound infection occurred in 1.6 percent. Follow-up (mean, 106 months) has identified one recurrence of enterovesical fistula due to Crohn's disease, and a further recurrence from concomitant sigmoid diverticulitis. Enterocutaneous fistulas developed in 6.4 percent and 11 patients (17.4 percent) have required further resections for Crohn's disease. Surgical treatment of enterovesical fistula in Crohn's disease is a safe and effective treatment.Study performed at The Cleveland Clinic Foundation.Read at the meeting of The American Society of Colon and Rectal Surgeons, Toronto, Canada, June 11 to 16, 1989.     

Outcome of ileorectal anastomosis for Crohn's colitis

One hundred thirty-one patients underwent ileorectal anastomosis (IRA) for Crohn's colitis. Preoperatively, 84 patients (63 percent) were found to have mild or moderate proctitis and 47 (37 percent) had rectal sparing. Sixty-eight (52 percent) had associated small bowel disease, and 20 (15 percent) had perianal disease. Sixty-five IRAs were performed at the time of subtotal colectomy, while 56 were done after previous surgery. Anastomotic leaks occurred in four patients. There were no operative deaths. Thirteen patients (10 percent) with protecting stomas never underwent closure. Among the remaining 118 patients with functioning IRAs, 30 (23 percent) required later proctectomy and 16 (13 percent) required proximal diversion, with the mean period with a functioning IRA in these 46 patients being 4.1 years (range, 6.2 months–12.7 years). An additional 13 patients required preanastomotic resection and neo-IRA, and 11 required proximal small bowel resection. The mean duration of function of all 118 IRAs was 9.2 years. At the time of review, after a mean follow-up of 9.5 years, 72 patients (61 percent) retained a functioning IRA, with 44 being free of disease, while 28 were being treated with steroids or antidiarrheal medication. The mean stool frequency was 4.7 per day. In patients with Crohn's colitis, IRA should be considered as an alternative to proctocolectomy if the rectum is not severely diseased and sphincter function is not compromised.Read at the meeting of The American Society of Colon and Rectal Surgeons, Boston, Massachusetts, May 12 to 17, 1991.     

Selective omission of loop ileostomy in restorative proctocolectomy

Omission of a temporary ileostomy in patients undergoing restorative proctocolectomy is controversial. Although fewer operations may be required and some complications avoided, the risks of anastomotic dehiscence and pelvic sepsis may be greater. Patients undergoing restorative proctocolectomy with no ileostomy (Group NI, n=72) were compared retrospectively with patients given a conventional loop ileostomy (Group I, n=30). Criteria for avoiding faecal diversion included: absence of severe acute colitis, good nutritional status and favourable surgery with creation of a sound, tension-free anastomosis. Steroid intake was not a contraindication to single-stage surgery. Delayed stomas were necessary in 8% of Group NI. For Groups NI and I, the rates of anastomotic leak (3% vs 3%), pelvic sepsis without demonstrable leak (3% vs 0%), pouch fistula (3% vs 10%) and intestinal obstruction (8% vs 3%) were similar. Closure of the temporary ileostomy in Group I was associated with a 10% complication rate. Cumulative post-operative hospital stay was significantly less in Group NI (median 11 vs 16 days). Functional results at 1 year were similar. A temporary loop ileostomy can be safely avoided in carefully selected patients undergoing restorative proctocolectomy. Accepted: 10 February 1998     

The value of the rectus abdominis myocutaneous flap in the treatment of complex perineal fistula

Complex perineal fistula and persistent perineal sinus are difficult to treat. We describe our experience with wide excision of the diseased perineum using a combined abdominoperineal approach. Ten patients were reconstructed by a rectus abdominis myocutaneous flap (n=7), rectus abdominis muscle flap (n=2), and omental graft (n=1). Primary healing was achieved in all cases. A median follow-up of 18 months (range 6–54 months) has shown no recurrence of perineal disease or associated abdominal incisional hernia. There were no perioperative deaths. We propose that the rectus abdominis myocutaneous flap is indicated if large amounts of perineal skin has to be sacrificed. When less skin is removed a repair with greater omentum or rectus muscle alone is adequate. The abdominoperineal approach together with filling the residual pelvic cavity with well-vascularized tissue allows definitive treatment to be carried out in one stage.Based on an oral presentation at the Tripartite Meeting, Birmingham, United Kingdom, June 19–22, 1989.