Retained mucosa after double-stapled ileal reservoir and ileoanal anastomosis

A study was undertaken to assess the incidence of inflammation and dysplasia in retained mucosa after double-stapled ileoanal reservoir (IAR) for mucosal ulcerative colitis (MUC). Between September 1988 and February 1992, 56 patients with MUC underwent an IAR. Forty-five patients had a double-stapled IAR (DS-IAR), seven patients had a transanal pursestring stapled IAR (PS-IAR), and four patients had a PS-IAR with mucosectomy. Distal donuts obtained from the stapled IAR were submitted for pathologic review in 55 patients. Nine patients had only small bowel, connective tissue, and/or muscle noted on review. Mucosa was qualified as squamous epithelium (SE), transitional epithelium (TE), or columnar epithelium (CE). All samples were examined for evidence of inflammation and dysplasia. Four patients had SE only, one patient had TE, and 18 had CE. In addition, three patients had SE and CE, seven patients had SE and TE, two patients had CE and TE, and nine patients had all three types. The distance from the dentate line to the anastomosis ranged from 0 to 2.5 cm (mean, 1 cm). In 19 patients (35 percent), the distal donut revealed MUC. Of these 19 patients, six had persistent MUC (43 percent) at the time of subsequent biopsy. An additional four patients had MUC evident on follow-up biopsy but not on distal donuts; two of these four patients had no mucosa in their distal donuts. Only one of the patients with evidence of MUC on donuts and/or biopsy experienced any symptoms referable to active MUC (1.8 percent). None of the specimens examined had any evidence of dysplasia. In 31 patients, no MUC was present in the initial donuts or follow-up biopsies. Although the double-stapled technique appears safe, periodic monitoring is suggested.Read at the meeting of The American Society of Colon and Rectal Surgeons, San Francisco, California, June 7 to 12, 1992.     

Straight ileoanal anastomosis after longitudinal strip myectomy in the swine model

In an attempt to improve the function of the straight ileoanal anastomosis, an experimental study was performed using the swine model. The terminal ileum was altered by completely removing two longitudinal strips of muscle prior to performing a straight ileoanal anastomosis. The intent of the study was to determine whether muscle stripping was technically possible and whether bowel thus treated would remain viable to passively form a pelvic reservoir. The length of time required for formation of the reservoir was noted. All animals survived the procedure to allow evaluation. The muscle stripping was not difficult to perform. Viability was not a problem since the myectomy animals thrived well and demonstrated continence, weight gain, and reservoir formation. The results are encouraging. It appears that strips of muscularis propria can be removed from the terminal ileum without jeopardizing its viability. This seems to disrupt sufficiently the tonus of the bowel to allow better function of the straight ileoanal anastomosis through formation of a passive pelvic reservoir within a month's time in the swine model, and it may have application in the human.Read at the meeting of The American Society of Colon and Rectal Surgeons, Toronto, Canada, June 11 to 16, 1989.Winner of 1989 Piedmont Society Colon & Rectal Surgeons Award.The opinions expressed are solely those of the authors and do not necessarily represent those of the United States Army or the Department of Defense.     

Return to normal body composition after ileoanal J-pouch anastomosis for ulcerative colitis

In 16 patients with ulcerative colitis, total body fat, total body protein, and total body water were measured before and two weeks, three months, and twelve months after the establishment of an ileoanal J-pouch anastomosis. The 16 patients underwent elective surgery for their inflammatory bowel disease but were significantly protein depleted before surgery when their body composition was first measured. Twelve months later, all patients were in good health, back to work, and had normally functioning pouches (average stool frequency 4.3 ±1.4 per day). As a group, their stores of body protein and hydration state had returned to normal limits although their body fat stores were increased. Over the postoperative period there were significant losses of weight, protein, fat, fat-free mass, and total body water. These levels had returned to preoperative values (but not to normal) three months later. It is concluded that protein depleted patients with ulcerative colitis presenting for major surgery continue to have distorted body composition for several months after surgery but after approximately 12 months, when they have returned to work and feel well, body composition has returned to normal.This study was supported by the Medical Research Council of New Zealand.     

Ileoanal anastomosis without covering ileostomy

Ileoanal anastomosis is usually performed with covering ileostomy. This is primarily done because of fear of pelvic sepsis. Temporary ileostomy may, however, be a source of significant complications. The first 21 patients in the authors clinic were operated upon using covering loop ileostomy in ileoanal operations. These patients had no anastomotic or pouch complications, but there were complications, especially with the closure of the ileostomy. Therefore, a trial of one-stage operations in ileoanal anastomosis was started. Ileoanal anastomosis without ileostomy was performed on 25 consecutive patients. All the patients were operated upon for ulcerative colitis. There was one patient with pelvic abscess who needed diverting ileostomy. Thus, the early failure rate in patients operated upon without ileostomy was 4 percent. There were many other complications among these patients, but no other relaparotomy was needed. The complication rate was not different in patients operated upon without ileostomy compared with the authors first 21 patients operated upon with ileostomy (60 and 52 percent, respectively). Patients with one-stage operation needed a significantly shorter mean hospital stay than patients with two-stage operation (13.6 days and 25.3 days, respectively;P <0.001).The use of corticosteroids appears not to be a contraindication for one-stage operation, because there were significantly more patients using corticosteroids in the one-stage group compared with the two-stage group (92 and 62 percent, respectively;P <0.05).     

The double-stapled ileal reservoir and ileoanal anastomosis

Fifteen consecutive patients (nine males and six females) who underwent construction of a double-stapled ileoanal reservoir (DS-IAR) were prospectively evaluated. Mean and maximal resting pressures preoperatively, before ileostomy closure, and at 12 months, were 53 and 84 mm Hg, 39 and 62 mm Hg, and 62 and 81 mm Hg. Mean and maximal squeeze pressures at those same time periods were 96 and 153 mm Hg, 111 and 173 mm Hg, and 95 and 168 mm Hg. There were no significant decreases in either resting or squeeze pressure between preoperative values and those obtained 12 months after surgery. However, the length of the high pressure zone decreased from 3–8 cm preoperatively to 2.3 cm at 12 months. This reflects the sacrifice of the cephalad 1.5 cm of the internal anal sphincter necessary to effect this anastomosis at a mean of 1.4 cm from the dentate line. However, this maneuver did not result in poor continence. Eleven patients whose ileostomies were closed for a mean of 9 months, ranging from 3 to 15 months, were evaluated regarding functional outcome. Only one patient had any incontinence and this patient had incomplete circularstapled tissue rings, which necessitated transanal suture repair of the anastomotic defect. Similarly, three of the four patients who sometimes or rarely use a pad at night had transanal-suture reinforcement. Ten of the 11 patients never wear a pad during the day. No pelvic or perianal sepsis occurred. Stratified squamous epithelium was found in 6 of the 13 distal stapler donuts that were examined. In addition, 10 patients underwent biopsy of the tissue immediately caudad to the circular staple line at the time of ileostomy closure; in five, only stratified squamous epithelium was noted. The DS-IAR is associated with excellent objective physiologic and subjective functional results.Read at the XIIIth Biennial Congress of the International Society of University Colon and Rectal Surgeons, Graz, Austria, June 24 to 28, 1990.     

Improvement of anal sensation with preservation of the anal transition zone after ileoanal anastomosis for ulcerative colitis

One of the most important considerations in restorative proctocolectomy for ulcerative colitis is postoperative continence. Preservation of the anal transition zone has been associated with improved results after this procedure in the pediatric age group. This study was carried out to determine the effect of preservation of the amal transition zone in adult patients undergoing restorative proctocolectomy, comparing a group of patients with the anal transition zone preserved with a group of patients with the anal transition zone removed. Physiologic testing demonstrated improved sensation in those patients with a preserved anal transition zone. Functional results were not significantly improved, although there was a trend toward improved continence and discrimination in those with the anal transition zone preserved. Although the results are early and are not conclusive from the clinical standpoint, they are certainly encouraging and may justify continued use of this technique.Read at the XIIth Biennial Congress of the International Society of University Colon and Rectal Surgeons, Glasgow, Scotland, July 10 to 14, 1988.Mr. Richard Miller is supported by a grant from the medical research council.     

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.     

State of the defunctionalized sphincter in patients undergoing ileoanal pouch anastomosis

PURPOSE: Our aim was to determine manometric status and functional outcome of the ileoanal pouch procedure in a subset of patients with defunctionalized anal sphincters as a result of long-term fecal diversion. METHODS: The anal manometric profiles of 12 patients defunctionalized for one year or more were compared with 26 patients with nondefunctionalized anal sphincters. Functional data were obtained from the Lahey Clinic Ileoanal Pouch Registry. RESULTS: Preoperative manometric data revealed a mean resting pressure of 91.5 mmHg in the nondefunctionalized group vs.68.7 mmHg in the defunctionalized group; mean squeezing pressure was 171.7 mmHg (nondefunctionalized group) vs.102.3 mmHg (defunctionalized group); and squeezing pressure volume was 1,283,000 mmHg ³ (nondefunctionalized group)vs.585,000 mmHg ³ (defunctionalized group). Functionally both groups had a mean of 6.1 bowel movements in a 24-hour period and could defer defecation for a mean of 2 hours. Leakage occurred in 22 percent of the defunctionalized group and 17 percent of the nondefunctionalized group (P=0.35). CONCLUSION: Despite physiologic perturbations, the long-term, defunctionalized anal sphincter can adequately support a restorative procedure without regard to timing of pouch creation.Poster presentation at the meeting of The American Society of Colon and Rectal Surgeons, Chicago, Illinois, May 2 to 7, 1993.     

Lymphoma of the pouch after ileal pouch-anal anastomosis

The most common cause of pouch dysfunction after ileal pouch-anal anastomosis is pouchitis. Although low-grade dysplasia in the mucosa of the pouch has been recently described in the presence of pouchitis, there has been no report of carcinoma arising in the pouch itself. We describe a patient who developed a large-cell lymphoma of the ileal pouch after ileal pouch-anal anastomosis.     

Comparing functional results one year and ten years after ileal pouch-anal anastomosis for chronic ulcerative colitis

Proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the treatment of choice for most patients with chronic ulcerative colitis. Long-term results, however remain undefined; the major concern is that function may deteriorate. PURPOSE: The aim of this study was to assess functional outcome in a subgroup of patients who have an IPAA for chronic ulcerative colitis for >10 years. METHODS: Among 1400 IPAA patients, 75 consecutive subjects (31 females and 44 males; median age 31 at operation) were identified who had the procedure prior to 1982. All patients had functional results recorded 1 year and 10 years following ileostomy closure. RESULTS: There were four deaths during the follow-up period; none were pouch related. Two patients refused ileostomy closure. Of the remaining 69 patients, there were 8 (11 percent) failures, leaving 61 subjects available for study. Stool frequency (7±3, mean±SD) remained unchanged. Of the 50 subjects with initially excellent daytime continence, 39 (78 percent) remained the same, 10 (20 percent) developed minor incontinence, and 1 developed poor control after 10 years. Four of 10 subjects (40 percent) with initial minor daytime incontinence remained unchanged, 4 (40 percent) improved, and 2 (20 percent) worsened. The one subject with poor control at one year was unchanged. Nocturnal fecal spotting increased over the 10-year period but not significantly (38 percent vs.52 percent;P=0.08). CONCLUSIONS: After IPAA, functional results in terms of stool frequency and rate of fecal incontinence did not deteriorate with time.Read at the meeting of The American Society of Colon and Rectal Surgeons, Chicago, Illinois, May 2 to 7, 1993.     

Anal sphincter function after intersphincteric resection and stapled ileal pouch-anal anastomosis

This study was done to determine the effect of the direct ileal pouch-anal anastomosis upon pressure and sensory components of the anal canal and ileal pouch. These findings were related to postoperative continence. Thirty-three patients with ileal pouch-anal anastomosis (25 continent, eight with episodic minor incontinence) were studied 3±0.3 and 25±5 months after ileostomy takedown. The maximum resting pressure in the anal canal was significantly lower in patients with an imperfect result (35±5 mm Hg) than in continent patients (44±5 mm Hg) (P<0.05). Postoperatively the maximum squeeze anal pressure was slightly greater in continent than in incontinent patients (99±8 mm Hg vs.87±7 mm Hg) (P>0.05). The postoperative recto-(ileo-)anal inhibitory reflex was present in 27 percent. The linear correlation between strength of rectal (ileal) distension and depth resp. duration of internal sphincter relaxation as preoperatively observed disappeared postoperatively in every group of patients. Simultaneous measurements of pouch and anal pressure in patients with imperfect results revealed a reduced positive pouch anal pressure gradient compared to the continent group. This low pouch-anal pressure gradient is thought to be responsible for the increased incidence of soiling in some of our patients.     

Assessment of peripouch inflammation after ileoanal anastomosis using endoluminal ultrasonography

PURPOSE: This study was designed to assess the impact of endoluminal transpouch ultrasonography in the investigation and management of inflammatory complications of pelvic pouches and to compare endoluminal transpouch ultrasonography to pouchography and computerized axial tomograph scanning. METHODS: A prospective evaluation was made of the presentation, investigation, treatment, and clinical outcome of 16 patients referred for endoluminal transpouch ultrasonography with dysfunctional pelvic pouches and no evidence of pouchitis on endoscopy. RESULTS: There were 5 normal and 11 abnormal examinations. Six patients had peripouch inflammatory phlegmons, four patients had peripouch abscesses, and one patient had a rectovaginal fistula. A total of nine patients had anastomotic leaks detected. Two patients had abscesses drained under ultrasound guidance and a pigtail catheter left in situ.Pouchography detected only 3 of 8 (38 percent) anastomotic leaks detected by endoluminal transpouch ultrasonography. Computerized axial tomograph scan detected 2 of 5 (40 percent) peripouch abscesses or phlegmon detected by endoluminal transpouch ultrasonography. Patients with peripouch sepsis had significantly thicker anal wall thickness (23.8 vs. 16.8 mm; P<0.02) and external sphincter thickness (9.1 vs. 7.3 mm;P<0.05) than pouches with no sepsis. CONCLUSIONS: Endoluminal transpouch ultrasonography appears to detect anastomotic leaks and peripouch sepsis and may guide the initial management of patients with dysfunctional pelvic pouches and an inconclusive clinical and endoscopic examination.M. J. Solomon was supported in part by The Wigston Foundation, Toronto, Canada, Ethicon Canada Ltd., Samuel Lunenfeld Research Institute, Mount Sinai Hospital, Toronto, Canada, and the Jenour Foundation, Australia.Presented at the Royal College of Physicians and Surgeons meeting, Vancouver, Canada, September 1993.     

Inverted U-pouch construction for restoration of function in patients with failed straight ileoanal pull-throughs

Patients who have undergone straight ileoanal pull-through operations without a reservoir in adult life frequently have unsatisfactory results. Operative correction of this problem has been difficult. We propose a new operation that preserves the ileoanal anastomosis, constructs a reservoir, and has resulted in good restoration of bowel function in three patients. The operative procedure consists of division of the ileum 30 cm above the dentate line. The distal ileum is then folded over itself so that the point of division reaches into the pelvis, between the rectal muscular cuff and pulled-through ileum, to a point just proximal to the dentate line. The two limbs of ileum are connected using a stapler, completing the reservoir construction. The proximal divided ileum is anastomosed, end-to-side, to the pouch. A protective ileostomy that can be closed in three months is constructed.Poster presentation at the meeting of The American Society of Colon and Rectal Surgeons, Toronto, Canada, June 11 to 16, 1989.     

Ileal pouch-anal anastomosis function following childbirth

PURPOSE: Women undergoing Ileal pouch-anal anastomosis (IPAA) are frequently within reproductive years and eager to bear children. Management issues have been raised regarding the effects of pregnancy and delivery on the pouch, particularly with respect to obstetric care. Our experience is updated to search for delayed sequelae of pregnancy and delivery and to establish whether other factors have an adverse effect on pouch function. These results are also compared with the outcome of pregnancy and delivery in patients with ileostomy or Kock pouch. METHODS: Records of 43 women who had a successful pregnancy and delivery following IPAA were reviewed, including 8 women who had more than 1 pregnancy. RESULTS: Pregnancy was generally well tolerated, with complications being managed nonoperatively. Stool frequency (P<0.01), incontinence (P<0.01), and pad usage (P<0.05; sign rank test) were significantly increased during pregnancy, but prepregnancy function was restored following delivery. Vaginal delivery, multiple births, length of labor, and birth weight had no adverse permanent effect on subsequent pouch function. Longer follow-up after vaginal delivery (mean, 2.4 years) demonstrated no compromise of pouch function. CONCLUSIONS: Incidence of pouch-related complications in patients with IPAA compares favorably with incidence in patients with ileostomy or Kock pouch. Operative rate for complications was 0 percent in IPAA patients compared with 9 percent in patients with ileostomy and 19 percent in patients with Kock pouch. The cesarean section rate was higher in patients with IPAA than in those with ileostomy or Kock pouch, and this may be caused by uncertainty about how to manage delivery in patients with IPAA. Pregnancy and childbirth are well tolerated in women with IPAA, with a lower complication rate and a higher cesarean section rate than women with ileostomy or Kock pouch. Type of delivery should be influenced by obstetric considerations, with vaginal delivery avoided in patients with a noncompliant, rigid perineum.Read at the meeting of The American Society of Colon and Rectal Surgeons, San Francisco, California, June 7 to 12, 1992.     

Evolutionary changes in the pathologic diagnosis after the ileoanal pouch procedure

PURPOSE: Inadequate initial differentiation between ulcerative colitis and Crohn's disease may lead to a diagnosis of indeterminate colitis. Construction of an ileoanal pouch in these patients may result in significant morbidity and pouch failure when the ultimate diagnosis is Crohn's disease. METHOD: We prospectively studied 543 patients with idiopathic inflammatory bowel disease to determine whether a patient's pathologic diagnosis changed with time and how it affected outcome. RESULTS: Preoperative diagnosis was ulcerative colitis in 499 patients, indeterminate colitis in 42 patients, and Crohn's disease in 2 patients. Prior colectomy was performed in 58 percent of patients with ulcerative colitis and in all patients with indeterminate colitis and Crohn's disease. Postoperatively, the diagnosis changed in 20 patients with ulcerative colitis (13 to indeterminate colitis, 7 to Crohn's disease). Another two patients with indeterminate colitis showed evidence of Crohn's disease in the resected rectal specimen. As patients were followed up, an additional 13 patients were found to have Crohn's disease (5 indeterminate colitis, 8 ulcerative colitis). With the current diagnosis, perineal complications and pouch failure occurred, respectively, in 23 and in 2 percent of patients with ulcerative colitis, in 44 and in 12 percent of patients with indeterminate colitis, and in 63 and in 37 percent of patients with Crohn's disease. Pathologic diagnosis was altered in 35 patients (6 percent) overall, with a 12-fold increase in the diagnosis of Crohn's disease. Only 3 percent of patients with ulcerative colitis compared with 13 percent of patients with indeterminate colitis had a change in diagnosis to Crohn's disease (P =0.006; Fisher's exact test). CONCLUSION: Pouch-related complications, eventual pouch failure, and discovery of underlying Crohn's disease occurred in a significant number of patients with a diagnosis of indeterminate colitis. Until more accurate diagnostic differentiation is available, caution is advised in recommending the ileoanal pouch procedure to patients with indeterminate colitis.Read at the meeting of The American Society of Colon and Rectal Surgeons, Seattle, Washington, June 9 to 14, 1996.     

Rediversion after ileal pouch-anal anastomosis

PURPOSE: The aim of this study was to understand better the cause and predictability of pouch failure requiring rediversion after ileal pouch-anal anastomosis and to assess the ultimate outcome of patients in a large ileal pouch series who required rediversion. METHODS: Data from 460 patients completing ileal pouch-anal anastomosis at one institution were recorded from both a prospectively accumulated ileal pouch registry and patient medical records. RESULTS: Of 460 patients, 21 (4.6 percent) who underwent ileal pouch-anal anastomosis required rediversion. Five of these patients subsequently had successful restoration of pouch continuity, leaving a permanent failure rate of 16 of 460 patients (3.5 percent). The most common reasons for rediversion were pouch fistula formation (12) and poor functional results (5). Preoperative factors, including age, previous colectomy, and indication for colectomy, did not predict eventual need for rediversion. Patients requiring rediversion had significantly higher rates of postoperative complications (95 vs.43 percent;P <0.001). Specifically, this group had a higher rate of postoperative pouch fistula (57 vs.3.4 percent;P <0.001). Additionally, a final diagnosis of Crohn's disease significantly predicted the need for rediversion. Permanent pouch failure occurred in 36.8 percent of patients with a final diagnosis of Crohn's disease compared with 1.4 percent of patients with a final diagnosis of ulcerative colitis ( P <0.001). All five salvaged patients had fistula formation in the absence of Crohn's disease. CONCLUSIONS: The overall rate of permanent pouch failure is low. The majority of failures were related to fistula formation associated with Crohn's disease or poor functional results. Pouches complicated by fistulas not associated with Crohn's disease can be salvaged with temporary rediversion.Read in part at the meeting of The American Society of Colon and Rectal Surgeons, Chicago, Illinois, May 2 to 7, 1993.     

Extent of smooth muscle resection during mucosectomy and ileal pouchanal anastomosis affects anorectal physiology and functional outcome

PURPOSE: In patients undergoing colectomy with ileal pouch-anal anastomosis, controversy exists regarding the necessity for and appropriate extent of rectal mucosal resection. Our aim was to assess histologically the extent of anorectal smooth muscle resected at the time of mucosal proctectomy and to correlate this with postoperative bowel and anal sphincter function. METHODS: Surgical specimens of 79 patients undergoing colectomy, mucosal proctectomy, and ileal pouch-anal anastomosis were examined histologically in a blinded fashion, and the content of smooth muscle in the mucosal proctectomy specimens was scored. Degree of smooth muscle resection was correlated with postoperative anorectal manometry and with functional outcomes, including stool frequency and nocturnal leakage of stool after 3 and 12 months of follow-up. RESULTS: Degree of smooth muscle loss correlated with decreased resting pressure of the internal anal sphincter as early as three months after surgery (r=−0.26;P=0.03), and the correlation was even stronger after 12 months (r=−0.37;P=0.005). Decreases in resting pressure were related, in turn, to increased stool frequency at 12 months (r=0.32;P=0.02), but stool frequency was also inversely related to volume of the ileal pouch (r=−0.27;P=0.05). Multivariate analysis confirmed that resting pressure and pouch volume were both significant determinants of stool frequency. The likelihood of nocturnal stool leakage at 12 months was primarily a function of stool frequency (P<0.01) but also increased with patient age (P<0.02). CONCLUSIONS: These findings indicate that loss of resting pressure of the internal anal sphincter can be correlated with the extent of smooth muscle resection during rectal mucosectomy and that these factors, in turn, correlate with increased stool frequency and a greater likelihood of nocturnal stool leakage. Consequently, an optimum functional result requires care in identifying and preserving maximum anorectal smooth muscle during mucosectomy. Supported by the Crohn's and Colitis Foundation of America. Read at the meeting of The American Society of Colon and Rectal Surgeons, Seattle, Washington, June 9 to 14, 1996.     

Double-stapledvs. handsewn ileal pouch-anal anastomosis in patients with chronic ulcerative colitis

Proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the treatment of choice for most patients with chronic ulcerative colitis. Whether or not a double-stapled technique, which should preserve the anal transition zone and avoid prolonged anal dilation, facilitates superior fecal continence compared with conventional mucosal resection and handsewn anastomosis is unknown. PURPOSE: The aim of this study was to compare functional results after double-stapled and handsewn IPAA. METHODS: Twenty-seven consecutive patients (13 females, 14 males; mean age, 37 years) who had proctocolectomy and double-stapled IPAA (J) for chronic ulcerative colitis were identified. Each was matched by sex, age, and surgeon to a control who had undergone a conventional handsewn anastomosis. Functional results at six months after ileostomy closure were compared. RESULTS: Median stool frequency in each group was seven. The prevalence of pouchitis was 22 percent in both groups. One pouch failure occurred in each group. The percentage of patients from the double-stapled group with daytime spotting was similar to that of the handsewn group (18 percent vs. 26 percent,P>0.5). Nighttime soiling rates were similar as well (41 percent vs.48 percent,P>0.5). CONCLUSIONS: Double-stapled IPAA appears to convey no early functional advantage over handsewn IPAA for chronic ulcerative colitis.Presented at the Tripartite Meeting, Sydney, Australia, October 1993.     

Optimization of sphincter function after the ileoanal reservoir procedure

PURPOSE: Impairment of sphincter function in patients who undergo ileoanal reservoir is usually most severe immediately after ileostomy closure. Therefore, a prospective, randomized trial was undertaken to assess the potential value of preileostomy closure sphincter-strengthening exercises to improve early functional outcome. METHODS: Patients were randomized either to a control group (Group 1) or to undergo a five-week pelvic floor exercise program (Group 2). An incontinence score from 0 to 20 was used to clinically assess the functional results. Anorectal manometric assessment included: highpressure zone length, mean resting pressure, highest resting pressure, mean squeezing pressure, and highest squeezing pressure. The paired t-test was used to compare the functional results preoperatively and at the time of ileostomy closure. This time corresponded to the conclusion of the exercise program or the equivalent time period for the control group. RESULTS: Twenty-six patients who underwent double-stapled ileoanal reservoir between July 1991 and June 1992 were studied. They included 16 males and 10 females with a mean age of 38 (range, 17–69) years. When both evaluations were compared, the mean incontinence score decreased from 0.2 to 2.8 (=2.6) in Group 1 and from 0.2 to 2.0 ( = 1.8) in Group 2 (P=0.07). None of the changes between the preoperative and postoperative clinical and physiologic evaluations were statistically significant (P>0.05). CONCLUSION: Sphincter-strengthening exercises before ileostomy closure did not minimize the transient impairment of functional results.Poster presentation at the meeting of The American Society of Colon and Rectal Surgeons, Chicago, Illinois, May 2 to 7, 1993.     

Alteration in intestinal permeability after ileal pouch-anal anastomosis

PPURPOSE: The physiologic changes that occur when the small bowel is used as a reservoir, as in the ileal pouchanal anastomosis, are poorly understood. Alterations in bowel permeability, which may lead to bacterial translocation that could result in illness or dysfunction of the pouch, may be one such consequence of the pouch procedure. METHODS: Whole-bowel permeability was evaluated in patients with and without the pouch through the use of an orally consumed nonmetabolizable sugar clearance technique. Patients in whom the ileal pouchanal anastomosis was performed for ulcerative colitis (17 patients) and patients with familial polyposis (7 patients) were compared with normal healthy volunteers (10 patients) and patients with ulcerative colitis with and without curative colectomy and ileostomy (6 and 5 patients, respectively). RESULTS: Measured by this technique, no differences were noted in bowel permeability between the volunteers and patients with ulcerative colitis, even after colectomy and ileostomy (1.7±0.4 in normal healthy volunteers, 1.8±0.5 in patients with ulcerative colitis without stoma, and 1.4±0.2 in patients with ulcerative colitis with ileostomy). The group of patients with an ileal reservoir, however, had a significantly increased index of measured bowel permeability (3.5±0.5 in patients with ulcerative colitis and 5.1±0.7 in patients with familial polyposis; P<0.05 by analysis of variance compared with normal healthy volunteers and patients with ulcerative colitis with or without ileostomy). CONCLUSION: The exact site, cause, and consequence of this possible alteration of bowel permeability are unclear but appear to be related to the presence of the pouch and are not caused by the underlying pathologic diagnosis.Poster presentation at the meeting of The American Society of Colon and Rectal Surgeons, Boston, Massachusetts, May 12 to 17, 1991. Winner of the New Jersey Society of Colon and Rectal Surgeons Award, 1991.