Reconstruction of proctocolectomy: which is the best surgical procedure?

Total proctocolectomy is commonly performed in patients with ulcerative colitis or familial adenomatosis coli. The standard surgical procedure for reconstruction is the ileal pouch anal anastomosis with rectal mucosal stripping (IPAA), which is radical treatment for the disease, or stapled ileal pouch anal anastomosis with preserved anal canal (stapled IPAA), which results in a lower incidence of soiling with a high possibility of one-stage surgery. Postoperative cancer surveillance colonoscopy is recommended in patients with stapled IPAA, and patients with IPAA have also at risk for cancer in the anastomotic site, although at very low incidence. Quality of life (QOL) studies (SF36, etc.) found good QOL after surgery in patients who underwent both procedures. Patients with permanent ileostomy for preoperative anal dysfunction also had good QOL. The surgical procedure for reconstruction should be determined based on surgical indications, preoperative anal function, and patient's request. For improved QOL in the future, pouch surgery should have a lower incidence of diverting ileostomy and result in fewer bowel movements and a lower incidence of soiling, with optimal management of pouchitis.     

Functional outcomes after ileal pouch-anal anastomosis for chronic ulcerative colitis

OBJECTIVE: To assess long-term outcomes after ileal pouch-anal anastomosis (IPAA) for chronic ulcerative colitis (CUC) with specific emphasis on patient sex, childbirth, and age. SUMMARY BACKGROUND DATA: Childbirth and the process of aging affect pelvic floor and anal sphincter function independently. Early function after IPAA is good for most patients. Nonetheless, there are concerns about the impact of the aging process as well as pregnancy on long-term functional outcomes after IPAA. METHODS: Functional outcomes using a standardized questionnaire were prospectively assessed for each patient on an annual basis. RESULTS: Of the 1,454 patients who underwent IPAA for CUC between 1981 and 1994, 1,386 were part of this study. Median age was 32 years. Median length of follow-up was 8 years. Pelvic sepsis was the primary cause of pouch failure irrespective of sex or age. Functional outcomes were comparable between men and women. Eighty-five women who became pregnant after IPAA had pouch function, which was comparable with women who did not have a child. Daytime and nocturnal incontinence affected older patients more frequently than younger ones. Incontinence became more common the longer the follow-up in older patients, but this was not found in younger patients. Poor anal function led to pouch excision in only 3 of 204 older patients. CONCLUSIONS: Incontinence rates were significantly higher in older patients after IPAA for CUC compared with younger patients. However, this did not contribute to a greater risk of pouch failure in these older patients. Patient sex and uncomplicated childbirth did not affect long-term functional outcomes.     

Pouch reconstruction in the pelvis

ILEAL POUCH RECONSTRUCTION: Proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the procedure of choice in mucosal ulcerative colitis (MUC) and familial adenomatous polyposis (FAP). Because the disease is cured by surgical resection, functional results, pouch survival prognosis, and disease or dysplasia control are the major determinants of success. There is controversy as to whether the IPAA should be handsewn with mucosectomy or stapled, preserving the mucosa of the anal transitional zone. Crohn's disease is a contraindication for IPAA, but long-term outcome after IPAA is similar to that for MUC in patients with indeterminate colitis who do not develop Crohn's disease. As development of dysplasia and cancer in the ileal pouch have been reported, a standardized surveillance program is mandatory in cases of MUC, FAP, and chronic pouchitis. COLONIC POUCH RECONSTRUCTION: Construction of a colonic pouch is a widely accepted technique to improve functional outcome after low or intersphincteric resection for rectal cancer. Several randomized studies comparing colo-pouch-anal anastomosis (CPA) with straight coloanal anastomosis (CAA) have found the pouch functionally superior. Most controlled studies cover only 1-year follow-up, but randomized studies with 2-year follow-up show similar functional results of CPA and CAA. Evacuation difficulty as initially observed was related to pouch size, and the results with smaller pouches (5-6 cm) are more favorable, showing adequate reservoir function without compromising neorectal evacuation. The transverse coloplasty pouch may offer several advantages to J-pouch reconstruction. Current series question whether the neorectal reservoir is the physiological key of the pouch, but rather the decreased motility. The major advantage reported with colonic pouch reconstruction is the lower incidence of anastomotic complications.     

Laparoscopic rectopexy for recurrent volvulus of J pouch after total proctocolectomy and ileal pouch anal anastomosis

Ileal‐pouch anal anastomosis (IPAA) is most commonly performed after total proctocolectomy for ulcerative colitis and familial adenomatous polyposis. Small‐bowel obstruction is one of the complications that can occur years after the operation, but intestinal obstruction due to volvulus of the J pouch is a rare condition. We report a case of recurrent volvulus in a patient who had undergone IPAA after total proctocolectomy for cancer of the rectum and multiple colonic polyps. The patient underwent laparoscopic rectopexy and had no recurrence of volvulus.     

Clinical Outcomes After Restorative Proctocolectomy With Ileal Pouch Anal Anastomosis Using Ultrasonically Activated Scalpel for Ulcerative Colitis

We compared 3 different initial operative procedures performed in patients with ulcerative colitis who underwent an ileal pouch anal anastomosis (IPAA) procedure with a Harmonic Scalpel (HS). We selected 775 patients who underwent a restorative proctocolectomy with a mucosectomy using an HS and hand-sewn IPAA. Ninety-six patients underwent a total colectomy (3-stage procedure) as the initial operation, whereas 258 underwent IPAA without ileostomy (1-stage procedure) and 421 underwent IPAA with ileostomy (2-stage procedure). There were no significant differences regarding early pouch functional rate among the 3 groups. After 5 years with a functioning ileal pouch, the survival rates for the total colectomy, IPAA with ileostomy, and IPAA without ileostomy groups were 100%, 99.3%, and 99.0%, respectively. There was low operative mortality, and acceptable rates of early and late complications in patients with ulcerative colitis who underwent a restorative proctocolectomy and IPAA using an HS.     

Volvulus of ileal S-pouch: A rare complication of ileal pouch anal anastomoses

INTRODUCTION

Ileal pouch anal anastomosis (IPAA) after total proctocolectomy is a frequently performed surgery for medically refractory ulcerative colitis (UC). Volvulus of the ileal pouch as a complication of IPAA is extremely rare. We present a case of volvulus of S-type ileal pouch.

PRESENTATION OF CASE

A 28 year old male, with history of total proctocolectomy with IPAA for severe UC in 2009 presented with signs of bowel obstruction. Emergency laparotomy was done and a volvulus of the S-type ileal pouch was derotated and pouchpexy done.

DISCUSSION

The IPAA has a wide spectrum of complications, with obstruction of proximal small bowel occurring frequently. Volvulus of the ileal pouch is extremely rare with only 3 reported cases. Early diagnosis and intervention is important to salvage the pouch. Computed tomography (CT) may aid the diagnosis in stable patients.

CONCLUSION

The diagnosis of ileal pouch volvulus although rare, should be kept in mind when dealing with patients complaining of recurrent obstruction following IPAA.     

Results and complications after ileal pouch anal anastomosis: a meta-analysis of 43 observational studies comprising 9,317 patients

OBJECTIVE: To analyze the literature of ileal pouch anal anastomosis (IPAA) regarding complications and functional outcome, to provide audit data for individual surgeons and units to assess their own performance against and also to serve as reference standard for the assessment of novel alternatives. BACKGROUND: IPAA is the standard restorative procedure for ulcerative colitis (UC) and familial adenomatous polyposis (FAP). This operation is, however, associated with distinct rates of failure, complications and fecal incontinence. METHODS: A meta-analysis on pooled incidences of complications of IPAA was conducted. Medline search and cross-reference search identified studies on IPAA (n > or = 50). Two authors independently performed the data extraction on study characteristics, diagnosis, type of operation, pouch-related complications, pouch failure and functional results. In case of disagreement consensus was reached by joint review of the study. Estimates of pouch-related complications, pouch failure and functional results are described as pooled percentages with 95% confidence interval. RESULTS: The initial search based on 1,206 abstracts yielded 43 studies eligible for further analysis. Indications for IPAA were UC in 87.5%, FAP in 8.9% and other diagnoses in 3.6%. The median follow-up was 36.7 months. Pouch failure was 6.8%, increasing to 8.5% in case of follow-up of more than 60 months. Pelvic sepsis occurred in 9.5%. Severe, mild and urge fecal incontinence were reported in 3.7, 17, and 7.3%, respectively. No effect of experience, duration of follow-up and type of surgical technique on the incidence of pouch failure and pelvic sepsis was demonstrable. CONCLUSIONS: Current techniques for restorative surgery after proctocolectomy are associated with non-negligible complication rates and leave room for improvement and continuation of development of alternative procedures.     

An early experience in robotic ileoanal pouch surgery with robotic intracorporeal single-stapled anastomosis (RiSSA) at a tertiary referral centre

Aim

A robotic approach to ileal pouch–anal anastomosis (IPAA) surgery offers advantages over other approaches in terms of precision, improved access to the pelvis and less muscular fatigue for the surgeon. The integrity of the anastomosis is also fundamental to successful IPAA surgery. The robotic platform can permit intracorporeal suturing deep within the pelvis to create a single-stapled, double purse-string anastomosis, which may reduce the risk of anastomotic complications. This study describes the safety and early outcomes of robotic intracorporeal single-stapled anastomosis (RiSSA) amongst patients operated consecutively at a tertiary centre immediately before and following the pandemic.

Method

A retrospective study of prospectively collected data analysing the outcome of patients undergoing robotic IPAA between 2019 and 2022 was conducted. All procedures were performed with the da Vinci Xi Surgical System (with a hand-assisted suprapubic incision to fashion the pouch). All pouch–anal anastomoses were performed using a double purse-string, single-stapled (RiSSA) method. Demographic, clinical and outcome data were collected.

Results

Twenty consecutive patients (nine with ulcerative colitis and 11 with familial adenomatous polyposis) were included with a median age of 25 years (range 16–52); 18 had American Society of Anesthesiologists classification II, and mean body mass index was 24 kg/m² (range 18.1–34.3). Nine patients (eight ulcerative colitis and one familial adenomatous polyposis) had undergone prior subtotal colectomy and therefore underwent restorative proctectomy with IPAA. Eleven patients underwent restorative proctocolectomy. All procedures were completed robotically. The median length of stay was 9 days (5–49). There were no unplanned admissions to intensive care and no deaths. Three patients were readmitted following hospital discharge for (i) an ileus managed conservatively, (ii) small bowel obstruction managed conservatively and (iii) small bowel obstruction due to constriction at the stoma site necessitating surgery. There were two additional reoperations both for drain complications, one for drain removal and one for drain erosion. On mobilization of the pouch in the latter case, an anastomotic defect was observed. In total, 19/20 patients underwent RiSSA without postoperative anastomotic problems.

Discussion

RiSSA offers a safe and feasible alternative technique to other minimally invasive approaches with low rates of anastomosis-related complications.     

Prevalence and risk factors for adenomas in the ileal pouch and the afferent loop after restorative proctocolectomy for patients with familial adenomatous polyposis

Background

Restorative proctocolectomy with ileal pouch–anal anastomosis (IPAA) has become the treatment of choice in familial adenomatous polyposis (FAP) to prevent the risk of colorectal cancer. However, it currently is recognized that adenomas may develop in the ileal pouch. The risk of adenoma occurring in the afferent ileal loop above the pouch is less clearly identified. This study aimed to evaluate the difference in prevalence of adenomas between the ileal pouch and the afferent ileum after IPAA in FAP.

Methods

The study analyzed 442 endoscopies performed between 2003 and 2008 for 139 FAP patients. The patients had undergone an IPAA in 118 cases, an ileorectal anastomosis in 13 cases, or an ileostomy in 8 cases.

Results

Among the 118 IPAA patients, 57 (48.3 %) had pouch adenomas a median of 15 years after surgery. The risk factors for pouch adenomas were delay since pouch construction [odds ratio (OR), 1.11; p = 0.016] and presence of advanced duodenal adenomas (OR, 4.35; p = 0.011). Seven patients had pouch adenomas with high-grade dysplasia. Only nine patients had afferent ileal loop adenomas (6.5 %). The only significant risk factor for ileal adenomas was the presence of pouch adenomas (OR, 2.16; p = 0.007).

Conclusion

After restorative proctocolectomy in FAP, adenoma recurrence is frequent in the pouch, with a higher risk for patients with advanced duodenal adenomas and an increasing risk over time, whereas adenomas are rarely found in the afferent ileal loop. This finding may help to propose redo ileal pouch anal anastomosis if required.     

Adenocarcinoma Arising Below an Ileoanal Anastomosis After Restorative Proctocolectomy for Ulcerative Colitis: Report of a Case

We report a case of adenocarcinoma developing in remnant rectal mucosa below a hand-sewn ileal pouch–anal anastomosis (IPAA) after restorative proctocolectomy for ulcerative colitis (UC). To our knowledge, this is the first such case to be reported from Japan. A 60-year-old man with a 13-year history of UC underwent proctocolectomy with a hand-sewn IPAA and mucosectomy for anal stenosis and serious tenesmic symptoms. About 7 years later, a follow-up endoscopy showed a flat elevated malignant lesion, 2 cm in diameter, below the ileoanal anastomosis. He was treated by abdominoperineal resection of the pouch and anus with total mesorectal excision. Histopathological examination of the resected specimen confirmed the presence of a well-differentiated adenocarcinoma but there were no metastatic lymph nodes. He recovered uneventfully and remains well without evidence of recurrent disease 2 years and 3 months after his last operation.     

Surgical management of pouch-vaginal fistula after restorative proctocolectomy

BACKGROUND: Pouch-vaginal fistula (PVF) is a devastating complication after restorative proctocolectomy with ileal pouch anal anastomosis (IPAA). The aim of this study was to evaluate the surgical management of PVF. METHODS: After Institutional Review Board approval, all patients treated for PVF between 1988 and 2003 were retrospectively reviewed. Success of treatment was defined as the complete absence of symptoms or no radiologic evidence of fistula. RESULTS: The study included 23 female patients; indications for IPAA were mucosal ulcerative colitis in 20 (87%), indeterminate colitis in 1 (4.3%), and familial adenomatous polyposis in 2 (8.7%) patients. Seven patients with mucosal ulcerative colitis were postoperatively diagnosed with Crohn's disease. Mean time interval from initial IPAA to development of symptomatic fistula was 17.2 months. Mean number of surgical treatments was 2.2. Overall, success was achieved in 17 (73.9%) patients at a mean followup of 52.3 months. Fistulas in patients with Crohn's disease occurred relatively late after IPAA (p = 0.015) and required a median of three (p = 0.001) surgical procedures, compared with patients without Crohn's disease. Pelvic sepsis after original IPAA occurred in eight (35.8%) patients, four (50%) of whom ultimately required pouch excision. CONCLUSIONS: Fecal diversion and local procedures are effective in the majority of patients with PVF after IPAA. Patients with Crohn's disease tend to have a delayed onset of fistula occurrence and require more extensive surgical management. Pelvic sepsis can be a predictive factor of poor outcomes.     

Long‐term functional outcome and quality of life after restorative proctocolectomy with ileo‐anal anastomosis for colitis

Aim The study aimed to evaluate long‐term health‐related quality of life (HRQOL) and functional outcome in patients who had undergone restorative proctocolectomy with ileo‐anal anastomosis (IPAA) for ulcerative colitis and familial adenomatous polyposis. Method A total of 156 patients who underwent IPAA during the period 1984–2003 and who still had an intact pouch were included. The HRQOL score was compared with 4152 individuals from the general Norwegian population using the SF‐36 questionnaire, and function was evaluated using the Wexner Continence Grading Scale. Results One hundred and ten (71%) patients answered the questionnaires, 60 (55%) of whom were men. All except five patients had ulcerative colitis. Median (range) age at interview was 47 (19–66) years, and time after surgery was 12 (2–22) years. The IPAA patients scored slightly, but significantly, lower in four of six SF‐36 health domains than the control subjects, adjusted for age and gender. Multiple regression analysis showed frequency of nocturnal defaecation, faecal incontinence and urgency to be independent negative prognostic factors of quality of life. Frequency of defaecation was a median of 7 (3–12) bowel movements during the day and 2 (0–6) at night. The majority had some degree of faecal incontinence, median (range) Wexner score of 8 (0–17), and 40% reported urgency of defaecation necessitating alterations in lifestyle. Conclusion Patients with IPAA reported slightly lower HRQOL rates than the general population and had an inferior functional outcome.     

Quantification of risk for pouch failure after ileal pouch anal anastomosis surgery

OBJECTIVE: To identify risk factors associated with ileal pouch failure and to develop a multifactorial model for quantifying the risk of failure in individual patients.SUMMARY BACKGROUND DATA Ileal pouch anal anastomosis (IPAA) has become the treatment choice for most patients with ulcerative colitis and familial adenomatous polyposis who require surgery. At present, there are no published studies that investigate collectively the interrelation of factors related to ileal pouch failure, nor are there any predictive indices for risk stratification of patients undergoing IPAA surgery. METHODS: Data from 23 preoperative, 7 intraoperative, and 10 postoperative risk factors were recorded from 1,965 patients undergoing restorative proctocolectomy in a single center between 1983 and 2001. Primary end point was ileal pouch failure during the follow-up period of up to 19 years. The "CCF ileal pouch failure" model was developed using a parametric survival analysis and a 70%:30% split-sample validation technique for model training and testing. RESULTS: The median patient follow-up was 4.1 year (range, 0-19 years). Five-year ileal pouch survival was 95.6% (95% CI, 94.4-96.7). The following risk factors were found to be independent predictors of pouch survival and were used in the final multivariate model: patient diagnosis, prior anal pathology, abnormal anal manometry, patient comorbidity, pouch-perineal or pouch-vaginal fistulae, pelvic sepsis, anastomotic stricture and separation. The model accurately predicted the risk of ileal pouch failure with adequate calibration statistics (Hosmer Lemeshow chi2 = 3.001; P = 0.557) and an area under the receiver operating characteristics curve of 82.0%. CONCLUSIONS: The CCF ileal pouch failure model is a simple and accurate way of predicting the risk of ileal pouch failure in clinical practice on a longitudinal basis. It may play an important role in providing risk estimates for patients wishing to make informed choices on the type of treatment offered to them.     

家族性腺瘤性息肉病两种术式的对比研究

目的探讨家族性腺瘤性息肉病采用回肠贮袋肛管吻合术与回肠直肠吻合术两种术式的手术效果。方法回顾性分析两组在手术结果、术后排便功能和生活质量的差异。结果30例患者中行回肠直肠吻合术12例,贮袋吻合术18例,术后无死亡,无吻合口瘘等严重并发症,均无膀胱和性功能障碍。平均住院时间、手术时间和失血量直接吻合组优于贮袋组(P<0 01),在并发症发生率、术后排气排便时间和肠蠕动次数两组相似(P>0 05)。随访时间最短6个月,最长16年。3例(25% )直接吻合者术后直肠息肉癌变需切除直肠。两种术式的术后排便功能相似,仅在白天排便次数和肛周刺激方面IRA组优于IPAA组(P<0 05)。结论两组患者术后排便功能和术后生活质量相似,但回肠贮袋肛管吻合术可减少术后残留的直肠黏膜癌变机会,因而是较理想的手术方式。     

Anal Function During Pregnancy and Postpartum After Ileal Pouch Anal Anastomosis for Ulcerative Colitis

Purpose Total proctocolectomy and ileal pouch anal anastomosis (IPAA) is now a common procedure for ulcerative colitis (UC). Moreover, it has been reported that fertility is preserved in women who undergo this procedure, many of whom can experience normal delivery.Methods We assessed the perinatal outcomes and changes in anal function in four women, aged from 27 to 35 years, who gave birth after undergoing IPAA for UC. Pregnancies were confirmed 15–111 months after IPAA, three women had full-term pregnancies, and one gave birth after 31 weeks gestation.Results Cephalic delivery with a vacuum extractor was used for one patient, and another underwent cesarean section. The other two patients experienced normal delivery. None of the patients needed artificial insemination and none had any symptoms of intestinal obstruction during their pregnancy. After delivery, two patients suffered a transient increase in bowel frequency and soiling, which gradually resolved.Conclusions Although transient anal dysfunction occurred in the puerperal period, there were no changes in anal function during pregnancy. Therefore, there are no factors directly prohibiting pregnancy and vaginal delivery in women who undergo IPAA for UC.     

Repeat ileal pouch-anal anastomosis to salvage septic complications of pelvic pouches: clinical outcome and quality of life assessment.

OBJECTIVE: To evaluate the outcome of repeat ileal pouch-anal anastomosis (IPAA) for septic complications of pelvic pouch surgery; to assess the relationship between diagnosis and outcome; to assess quality of life after surgery. SUMMARY BACKGROUND DATA: Pelvic and perineal sepsis due to ileal pouch-anal anastomotic leaks frequently results in pouch loss. Many surgeons believe that pelvic sepsis and/or dense pelvic fibrosis makes salvage surgery unsafe or that pouches salvaged under these circumstances may not function well. As a result, there are few studies of pouch salvage procedures for septic indications. METHODS: The authors reviewed records of Cleveland Clinic Foundation patients who had undergone repeat IPAA surgery after septic complications from previous pelvic pouch surgery and who had completed at least 6 months of follow-up. Final diagnoses included ulcerative colitis (n = 22), Crohn's disease (n = 10), indeterminate colitis (n = 1), and familial polyposis (n = 2). Patients with functioning pouches were interviewed about functional problems and quality of life using an in-house questionnaire and the validated SF-36 Health Survey. RESULTS: Of 35 patients, 30 (86%) had a functioning pouch 6 months after repeat IPAA. In 4 patients, complications led to pouch removal or fecal diversion. One patient declined stoma closure. Of the patients with mucosal ulcerative colitis (MUC), 95% (21/22) had a functioning pouch 6 months after surgery. For patients with Crohn's disease (CD) 60% (6/10) have maintained a functioning pouch. Of the 30 patients with functioning pouches, 17 (57%) rated their quality of life as either "good" or "excellent," the remaining 13 (43%) selected "fair" or "poor." All said they would choose repeat IPAA surgery again. An SF-36 Health Survey completed by all patients with a functioning pouch at follow-up showed a mean physical component scale of 46.4 and a mean mental component scale of 47.6, scores well within the normal limit. CONCLUSIONS: Repeat IPAA can often salvage pelvic pouches in patients with MUC who suffer major chronic perianastomotic and pelvic sepsis. Patients who had successful repeat IPAA surgery often report functional problems but would still choose to have the surgery again. For patients with CD, ultimate pouch excision or fecal diversion have been required in 40% indicating a guarded prognosis for these patients. Data on the success of the procedure for patients with indeterminate colitis and familial adenomatous polyposis were inconclusive because of small sample sizes.     

Diffuse colorectal angiodysplasia misdiagnosed preoperatively as ulcerative colitis in a child: Report of a case

Angiodysplasia is primarily a disease of the elderly, and it is rarely encountered in the pediatric population. We report a case of diffuse colorectal angiodysplasia, diagnosed postoperatively in a 13-year-old boy who underwent hand-assisted laparoscopic total proctocolectomy and ileal pouch anal anastomosis (IPAA) for assumed corticosteroid-resistant ulcerative colitis. The fi ndings of preoperative repeated colonoscopies and biopsies had been consistent with active colitis. Distinguishing ulcerative colitis from angiodysplasia is not usually difficult in patients with rectal bleeding. To our knowledge, this is the fi rst case report of such a challenging diagnostic problem.     

RESTORATIVE PROCTOCOLECTOMY WITH ILEAL POUCH–ANAL ANASTOMOSIS IN 203 PATIENTS: THE AUCKLAND EXPERIENCE

Background : Restorative proctocolectomy with ileal pouch–anal anastomosis (IPAA) has become an established operation for patients with ulcerative colitis and familial adenomatous polyposis (FAP). The results of a 15-year experience with IPAA are reported. Methods : Between September 1982 and June 1997, 203 patients had IPAA surgery. From a review of the charts, data were collected on the surgical procedure, the diagnosis and early and late complications. Pouch function was assessed by means of a postal questionnaire. Results : Of the 201 patients (median age of 32 years; 89 women) with complete records, 122 had J pouches, 65 had W pouches and 14 S pouches were constructed. The pre-operative diagnosis in 88% was ulcerative colitis and in 10% it was FAP. During a median follow-up time of 6.1 years the diagnoses were changed for 8% of the patients; in 4% the diagnosis was changed to Crohn’s disease. The overall mortality was 1.5% (early = 2, late = 1) The overall morbidity was 62% (early = 17%, late = 52%). The pouch was removed or was non-functional in 9%. All patients with a final diagnosis of Crohn’s disease have had their pouch excised. The median stool frequency was 4.0 (range 1.3–8.7) during the day, and 0.7 (range 0–2.1) during the night. The fewer night-time stools (J = 1.0 ± 0.6; W = 0.4 ± 0.5 P < 0.0001) and the reduced requirement of the W-pouch patients for anti-diarrhoeals (P = 0.004) were offset by the need for two W-pouch patients to pass a catheter to empty their pouches. Conclusions : The type of patients who present for IPAA surgery and the outcomes observed in this series of Auckland patients are similar to those reported from major centres elsewhere.     

全大肠切除回肠贮袋肛管吻合术的远期疗效评价

目的　探讨全大肠切除回肠贮袋肛管吻合术治疗溃疡性结肠炎 (UC)和家族性腺瘤性息肉病 (FAP)的远期疗效。方法　 1985～ 2 0 0 2年间共对 6 1例患者行全结肠直肠切除回肠贮袋肛管吻合术 ,其中UC 2 5例、FAP 34例、其他 2例 ,应用S袋 2 5例、S J袋 13例、J袋 17例以及W袋 6例 ,术后随诊 1～ 18年、平均 8年 ,比较分析术后控便功能及并发症。结果　全部患者存活。并发症发生率为 16 % ( 10 / 6 1) ,其中UC患者 ( 2 4 % ,6 / 2 5 )高于FAP患者 ( 12 % ,4 / 34) ,W袋高于其他各袋 ,手法吻合 ( 2 0 % ,8/ 4 1)高于吻合器吻合 ( 10 % ,2 / 2 0 ) ,但差异均无显著性 (P >0 0 5 )。术后 2 4h大便次数平均为 4 2次。日间 84 % ( 4 3/ 5 1)、夜间 75 % ( 38/ 5 1)的患者排便能自控 ,6 % ( 3/ 5 1)的患者有明显的大便失禁。大部分患者对目前的生活质量表示满意。结论　全大肠切除回肠贮袋肛管吻合术治疗可维持UC与FAP患者肛管自控功能和可接受的大便次数 ,术后并发症较少 ,是较为理想的手术方式     

Successful endoscopic needle knife therapy combined with topical doxycycline injection of chronic sinus at ileal pouch–anal anastomosis

Aim Chronic presacral sinus at the anastomosis after restorative proctocolectomy and ileal pouch–anal anastomosis (IPAA) has been difficult to manage and results in a high rate of pouch failure. The aim was to present a novel technique with a combining endoscopic doxycycline injection and needle knife therapy for a sinus at the ileoanal anastomosis. Methods We applied repeat Doppler ultrasound‐guided endoscopic needle knife therapy to open the orifice of the anastomotic sinus followed by topical injection of doxycycline. Results After six sessions of the endoscopic therapy, the refractory sinus was completely healed. Conclusion The Doppler ultrasound guided endoscopy therapy may provide an alternative treatment option for the patients with anastomotic sinus.