Gastrointestinal transit after proctocolectomy with ileal pouch-anal anastomosis or ileostomy

Proctocolectomy with ileal pouch-anal anastomosis increases the frequency of stooling, perhaps due in part to the loss of an ileocecal or colonic braking effect on gastrointestinal transit. To assess whether colectomy with ileal pouch-anal anastomosis (IPAA) or with ileostomy accelerates gastrointestinal transit, we studied 16 IPAA patients (mean +/- SEM stool frequency, 8 +/- 1 stools/day), 5 patients after colectomy and Brooke ileostomy, and 8 healthy, unoperated controls (1 +/- 1 stools/day). Gastric emptying of liquids and small bowel transit of chyme were measured concurrently with a dual isotope technique. Gastric emptying was similar among all groups. In contrast, postprandial small bowel transit of the head of a duodenal marker was slowed, not accelerated, in IPAA patients (178 +/- 26 min) compared to Brooke subjects (80 +/- 32 min, P less than 0.05) and controls (75 +/- 15 min, P less than 0.01). Maximal filling of both the ileal pouch (341 +/- 19 min) and the ileostomy bag (348 +/- 12 min) occurred later than filling of the colon in controls (243 +/- 32 min, P less than 0.01). Overall stool frequency did not correlate with small bowel transit in the ileoanal patients, but the two ileoanal subjects with greatest stool frequency (11 and 18 stools/day) had the earliest arrival of marker at the pouch. In conclusion, removal of the colon markedly slowed small bowel transit in most patients, although it did not alter gastric emptying of liquids. Creation of an ileal pouch and ileoanal anastomosis further slowed transit of the head of the meal.(ABSTRACT TRUNCATED AT 250 WORDS)     

Small intestinal obstruction complicating ileal pouch-anal anastomosis.

Small bowel obstruction remains the most common complication after proctocolectomy with ileal pouch-anal anastomosis. Of 626 patients who underwent this operation between January 1981 and October 1986 for ulcerative colitis (544 patients), familial adenomatous polyposis (72 patients), or indeterminate colitis (ten patients), 17% developed small bowel obstruction, 7.5% of whom required surgical intervention. The obstruction occurred either before or after closure of the temporary ileostomy. Patients who had a temporary Brooke ileostomy were more likely to develop obstruction (four of 32 patients, 12.5%) than those who had a loop ileostomy (25 of 564 patients, 4.6%) (p = 0.07). Also, patients who had had previous operations were at greater risk of obstruction (8.5%) than those who had not (2.2%) (p less than 0.04).     

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.     

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.     

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.     

Ileal pouch-anal anastomosis. The Emory University experience.

The ileal pouch-anal anastomosis has become a practical alternative to proctocolectomy for the treatment of ulcerative colitis and polyposis coli. To evaluate its success, the Emory University Affiliated Hospital experience from February 1984 to March 1989 was retrospectively reviewed. There were a total of 50 patients identified; 84 per cent had ulcerative colitis, and 16 per cent had polyposis coli (familial polyposis and Gardner's syndrome). The majority of these patients underwent a two-stage operation, but one-third required a three-stage procedure due to difficulty in mucosal proctectomy or toxic megacolon. J-pouch construction was performed in 72 per cent of patients, S-pouch construction in 14 per cent, straight ileo-anal anastomosis in 8 per cent, and lateral isoperistaltic ileo-anal anastomosis in 6 per cent. Of the 50 patients, 36 (72%) have had closure of the temporary ileostomy. Fourteen patients have not had ileostomy closure due to change in diagnosis to Crohn's disease, operative complications, or ileostomy closure pending. The combined operative morbidity per patient for the ileal pouch-anal anastomosis and the closure of the ileostomy was 32 per cent. This included bowel obstruction, 16 per cent; pelvic abscess, 6 per cent; and ileo-anal separation, 4 per cent. Follow-up on patients with ileostomy closure ranged from 6 months to 4 years (mean, 1.3 years). Stool frequency was 5.9 stools per 24 hours at 6 months and improved with time. During the follow-up period, all patients were eventually completely continent of stool during the day, and most became completely continent of stool at night.(ABSTRACT TRUNCATED AT 250 WORDS)     

Complications and risk factors after ileal pouch-anal anastomosis for ulcerative colitis associated with primary sclerosing cholangitis.

OBJECTIVE: This study determined predictive factors for postoperative complications and outcome after ileal pouch-anal anastomosis in patients with ulcerative colitis and primary sclerosing cholangitis. SUMMARY BACKGROUND DATA: Patients with ulcerative colitis and primary sclerosing cholangitis treated by colectomy and ileostomy are at high risk of troublesome bleeding from peristomal varices. METHODS: Postoperative complications and outcome were assessed in 40 patients with ulcerative colitis and sclerosing cholangitis who received an ileal pouch-anal anastomosis between January 1981 and February 1990. RESULTS: Immediate postoperative and remote ileoanal anastomosis-related complications were high but related directly to the severity of liver disease. No patient had perianastomotic anal bleeding. CONCLUSIONS: In patients with both ulcerative colitis and primary sclerosing cholangitis, ileal pouch-anal anastomosis is safe and is not associated with perianastomotic bleeding.     

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.     

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.     

Ileal pouch-anal anastomosis. A single surgeon's experience with 100 consecutive cases.

Between August 1982 and November 1985, 100 patients underwent ileal "J" pouch-anal anastomosis (IPAA) at the University of Utah. All operations were performed in a standard fashion by a single surgeon. Seventy-eight patients were operated on for chronic ulcerative colitis and 22 for familial polyposis coli. Sixty of the patients were male and 40 were female with a mean age of 33.2 years and a range of 11-63 years. Mean +/- SEM operating time was 5.9 +/- 0.4 hours, blood loss was 666 +/- 49 ml, and total hospitalization was 10.1 +/- 0.3 days. No operative deaths occurred. The overall operative morbidity was 13% after IPAA. Clinical "pouchitis" was observed in 18 patients, all of whom were operated on for chronic ulcerative colitis. No patients had frank incontinence. Twenty per cent of patients experienced frequent nocturnal leakage in the early postoperative period with a significant improvement over the ensuing 6 months. Stool frequency at 1, 3, 6, 12, and 24 months was 7.5 +/- 0.2, 6.5 +/- 0.1, 6.2 +/- 0.3, 5.4 +/- 0.1, and 5.4 +/- 0.2, respectively. Stool frequency at 12 months correlated inversely with ileal pouch capacity and the diagnosis of familial polyposis. It is concluded that ileal pouch-anal anastomosis is a safe and effective operation for patients with chronic ulcerative colitis and familial polyposis coli.     

Emergency total proctocolectomy in an uninsured patient with Familial Adenomatous Polyposis Syndrome and acute lower gastrointestinal hemorrhage in a community hospital: A case report

IntroductionRectal bleeding is the most common symptom of Familial Adenomatous Polyposis (FAP). This case investigates the efficacy of emergency surgery for FAP with total proctocolectomy end ileostomy for recurrent lower gastrointestinal (GI) hemorrhage in an uninsured patient in a 266-bed community hospital. The optimal treatment for FAP with acute lower GI hemorrhage and hemodynamic compromise unresponsive to conservative management is unclear.Presentation of caseA 41-year-old uninsured African American man with no past medical or family history presented to the emergency department with hematochezia lasting three days. A clinical diagnosis of FAP made on colonoscopy with biopsies revealed villous and tubulovillous adenomas without dysplasia. After blood products resuscitation, an emergency total proctocolectomy with end ileostomy was performed. A staged ileal J pouch to anal anastomosis and creation of protective loop ileostomy was performed months later after securing state funding. A final loop ileostomy reversal occurred six weeks later. His self reported quality of life is improved.DiscussionLower GI hemorrhage from FAP unresponsive to blood products may require emergency total proctocolectomy and end ileostomy with a staged ileal J pouch to anal anastomosis, which can be done in a community acute care hospital for an uninsured patient.ConclusionA total proctocolectomy is feasible in the emergency setting in an uninsured patient with lower GI bleeding and FAP. A staged ileal J pouch-anal anastomosis is easier to justify to the hospital compared to a staged completion colectomy with proctectomy. It is essential to monitor the ileo-anal anastomosis with anoscopy.     

Evolution of the pelvic pouch procedure at one institution: the first 100 cases.

BACKGROUND: Total extirpation of the colon with pelvic pouch formation, and the avoidance of a permanent stoma, continues to pose a challenge for better results, both technically and functionally. The aims of this study were to investigate the first 100 pelvic ileal-pouch procedures, assessing changes in surgical technique, their relationship to morbidity and long-term outcome, and compare this to the few large international series. METHODS: Between 1984 and 1997, 100 patients had a pelvic J-shaped ileal-pouch formed, 58 two-stage and 42 three-stage procedures. Fifty had a hand-sewn pouch-anal anastomosis and 50 a double-stapled anastomosis. Seventy-three were for ulcerative colitis, five for indeterminate colitis, 20 for familial adenomatous polyposis (FAP), one for multiple primary colorectal cancers, and one for constipation. RESULTS: After a median follow-up of 68 months, 97% of patients still have a functioning pouch. There were two postoperative deaths (one after-pouch formation and one after-stoma closure). Morbidity occurred in 52 patients, including three patients with pouch leaks and three pouch-anal anastomosis leaks (6% leak rate), 27% with a small bowel obstruction (2% early, 20% late, 5% both), a 19% anal stricture rate, and a 9% pouchitis rate. Three pouches have been removed (all for Crohn's disease). Median number of bowel movements per day was six, with 85% of patients reporting a good quality of life. Patients following a double-stapled procedure have less anal seepage and improved continence over those with a hand-sewn ileal pouch-anal anastomosis. CONCLUSIONS: Despite high morbidity rates, pelvic pouch formation provides satisfactory long-term results for patients requiring total proctocolectomy, with functional results and morbidity rates comparable to larger overseas series.     

Filling Sensations after Restorative Proctocolectomy

Objective : in order to improve insights in rectal filling sensation, we studied pouch filling sensations after ileal J pouch-anal anastomosis (IPAA) before and after re-establishment of bowel continuity.

Methods : anal manometry and a pouch filling sensation test were performed before as well as 1 and 6 weeks after closure of the loop ileostomy in 17 patients who had undergone restorative proctocolectomy with stapled (8 patients) or manual pouch-anal anastomosis (9 patients). The results were compared with those of 12 control subjects. Results : before ileostomy closure, pouch pressure necessary for inducing the respective sensation thresholds was higher than in controls; the difference was significant for constant and urge sensation. The volumes for urge and maximum tolerable sensation level were significantly lower, with reduced pouch compliance. After stoma closure, pressure and volume thresholds at all sensation levels became completely comparable with control data. No relevant differences were observed between stapled and manual ileal pouch-anal anastomoses.

Conclusions : all levels of filling sensation levels are preserved after restorative proctocolectomy and their parameters are comparable with those of normal rectal filling sensation. Diversion of an ileal J pouch results in resetting of filling sensation thresholds towards lower volume and higher pressure values, but all sensation thresholds normalize within 6 weeks after stoma closure. These data document that neither the rectum, nor the mucosa of the anorectal junction and upper part of the anal canal are involved in filling and urge sensation.     

Conversion of malfunctioning J pouch to Kock's pouch. Case report

A patient with ulcerative colitis previously treated with restorative proctocolectomy and ileal J-pouch anal anastomosis had recurrent pelvic abscess and poor functional results for 3 years postoperatively. To improve the quality of life, the J pouch was converted to a Kock's pouch. The successful result implies that Kock's continent ileostomy is a good replacement for failed pelvic pouch.     

Ileal "J" pouch-anal anastomosis. Clinical outcome.

One hundred eighty-eight patients undergoing abdominal colectomy with distal mucosal proctectomy and endorectal ileal pouch-anal anastomosis were reviewed to assess long-term functional results and to identify factors that might influence them. There was no postoperative mortality, but 10 patients (5.3%) required permanent ileostomy because of postoperative complications or the development of unsuspected Crohn's disease. Immediate postoperative complications, including pelvic sepsis, small bowel obstruction requiring surgery, anastomotic stricture, and ileostomy dysfunction, were observed in 11%, 9%, 14% and 9% of patients, respectively. No males were impotent but nine (9%) developed retrograde ejaculation. Pouchitis occurred in 8% of patients. Among 157 patients assessed at least 60 days after ileostomy closure (mean +/- SD, 375 +/- 216 days), all evacuated their neorectum spontaneously, and stool frequency was 6.0 +/- 2.6 daily and 1.2 +/- 1.3 nightly. While continence was generally good, 2.5% of patients during waking hours and 4.5% during sleep had occasional frank soilage. Moreover, seepage was noted in 25 and 47% of patients during daytime and nighttime, respectively. Both stool frequency and degree of continence improved with time. Patients less than 50 years of age and those with polyposis coli had fewer stools and better continence than those older than 50 or those with ulcerative colitis. It is concluded that ileal "J" pouch-anal anastomosis can be performed safely and will provide acceptable anorectal function without late deterioration.     

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.     

Endoscopy-assisted transanal division of an apical pouch bridge after restorative proctocolectomy with a J-shaped ileal pouch

Restorative proctocolectomy and J-shaped ileal pouch-anal anastomosis have been performed as a standard operation for ulcerative colitis. However, functional problems are sometimes troublesome in the postoperative period. The J pouch was constructed from 2 ileal limbs using the gastrointestinal anastomosis (GIA) stapler. A residual mucosal bridge remained because the stapler had a safety margin at the top of the cartridge. Apical pouch bridge is a residual septum above the ileoanal anastomosis. There are several reports of so-called apical pouch bridge syndrome due to outlet obstruction of the J-shaped ileal pouch by an apical bridge. Division of this septum can resolve the outlet obstruction. We describe a successful endoscopic procedure for division of an apical pouch bridge. An Endo-GIA stapler was introduced into the ileal pouch alongside the endoscope, and division of the apical bridge required a few firings of the Endo-GIA stapler under transanal endoscopic guidance. The symptoms related to the apical pouch bridge were resolved completely without creation of an ileostomy.     

Anastomosis ileoanal con reservorio en pacientes con enfermedad de Crohn. Estado actual

Ileal pouch-anal anastomosis has become the standard surgical procedure for the treatment of ulcerative colitis and familial polyposis of the colon. Nevertheless, its use in Crohn's disease patients remains controversial. A review was carried out in order to determine the present scientific evidence on the usefulness of ileal pouch-anal anastomosis in Crohn's disease patients. There are no clinical trials analysing this issue. Scientific evidence is based on case series and retrospective studies. Most authors agree that Crohn's disease remains a contraindication for ileal pouch-anal anastomosis, due to the high rate of complications and pouch failure. Nevertheless, a small group of authors consider ileal pouch-anal anastomosis as a good alternative for selected Crohn's disease patients. Both groups agree that if the pouch can be preserved, functional results are good.According to our review, current scientific evidence does not recommend ileal pouch-anal anastomosis for Crohn's disease patients.     

Laparoscopic proctocolectomy with ileal pouch-anal anastomosis

In recent years laparoscopic proctocolectomy with ileal pouch-anal anastomosis has been used as an alternative to conventional open techniques. However, many published series on proctectomy and ileal pouch-anal anastomosis are based on open experience. This paper presents our experience of laparoscopic proctocolectomy with ileal pouch-anal anastomosis to 23 patients with ulcerative colitis and familial adenomatous polyposis. In operations only sample exteriorization and pouch formation were performed using a small left flank incision of about 4 cm, all other steps were performed entirely laparoscopically. None of the laparoscopic procedures required conversion to an open operation, and there were no intraoperative complications. The median operative time was 315 minutes (240 to 460 min), the average blood loss was 130 mL (70 to 270 mL). Postoperative pain was minimal and no patients required analgesic drugs. Bowel function returned in a median of 2 days (1 to 3 d). Postoperative complications were encountered in 5 patients 22%). No patient required surgical reintervention. The median hospital stay was 9 days (7 to 16 d). In conclusion, laparoscopic proctocolectomy with ileal pouch-anal anastomosis is technically feasible and safe. The technique described in this study provides some potential advantages such as improved cosmetic result and less blood loss. It can be used in patients with familial adenomatous polyposis and ulcerative colitis.     

Does an ileoanal pouch offer a better quality of life than a permanent ileostomy for patients with ulcerative colitis?

Although an ileoanal pouch is frequently offered to patients with ulcerative colitis, it is still not clear to what extent this operation offers advantages over a permanent ileostomy. The aim of this study was to determine whether patients with a pouch have less morbidity and a better quality of life than a matched group of patients with a Brooke ileostomy. Nineteen patients (12 males and 7 females, median age 41 years) who had undergone total colectomy and ileoanal pouch formation for ulcerative colitis were individually matched with patients who had had a panproctocolectomy and ileostomy; patients were matched for disease process, sex, age, socioeconomic status, and time since surgery. Quality of life was assessed using the Short-Form 36 version 2 questionnaire, the inflammatory bowel disease questionnaire, and a few additional questions on perception of body image. The scores were compared using the nonparametric Wilcoxon signed-rank test for paired samples. The number and type of postoperative complications, as well as the number of operative stages, were recorded prospectively. Restorative proctocolectomy was associated with a significantly better perception of body image than a permanent stoma, although quality of life in general was similar in both groups. Patients with a pouch had more long-term complications than patients with an ileostomy within the same period of time (52.6% vs. 26.3%). The median number of stages for pouch construction was two, compared to a median of one stage for an ileostomy (P < 0.0001). Because of the high long-term complication rate and the relatively small quality-of-life advantage associated with restorative proctocolectomy, patients need to be counseled thoroughly before agreeing to this operation. Presented at the Millenium Joint Scientific Meetings of the Association of Surgeons of Great Britain and Ireland and the Surgical Research Society, Cardiff, Wales, May 23–26, 2000; and published as an abstract in British Journal of Surgery 2000;87(Suppl 1):47. Supported by an educational grant from ConvaTec Ltd.