Enhancing release of peptide yy after near-total proctocolectomy: jejunal pouch vs. ileal pouch-distal rectal anastomosis

Reconstructing the enteric tract after near-total proctocolectomy by interposing a jejunal pouch between the distal ileum and the distal rectum slows small intestinal transit and decreases the number of stools per day compared to a conventional ileal pouch-distal rectal reconstruction. Our hypothesis was that the jejunal pouch operation brings about these results by protecting the ability of the ileal mucosa to secrete peptide YY, thus augmenting the hormonal ileal brake on small intestinal transit and decreasing the stool frequency. In five jejunal pouch dogs and five ileal pouch dogs, more than 6 months after the operation, serum peptide YY concentrations were determined before and at 30-minute intervals for 180 minutes after a standard meal. Fasting serum concentrations of peptide YY, measured by radioimmunoassay, were greater in jejunal pouch dogs (mean ± SEM, 1340 ±143 pg/ml) than in ileal pouch dogs (804 ±52 pg/ml; P <0.01). Postprandial peptide YY concentrations in jejunal pouch dogs were also greater at 30 minutes (jejunal pouch = 1524 ±131 pg/ml, ileal pouch = 913 ±67 pg/ml; P = 0.01) and 60 minutes after the meal (jejunal pouch = 1723 ±250 pg/ml, ileal pouch = 1001 ±70 pg/ml; P = 0.05) and peaked sooner (jejunal pouch = 81 ±17 minutes, ileal pouch = 147 ±12 minutes; P = 0.01). We concluded that the jejunal pouch operation results in greater ileal fasting and postprandial secretion of peptide YY than the ileal pouch operation. The greater release may account, in part, for the slower small bowel transit and decreased number of stools after the jejunal pouch operation. Supported by the Ministry of Education and Sport (CAPES), Brasilia, Brazil, and the Mayo Foundation, Rochester, Minn. Presented at the Forty-First Annual Meeting of The Society for Surgery of the Alimentary Tract, San Diego, Calif., May 21–24, 2000, and published as an abstract in Gastroenterology 118:A1047, 2000.     

Proctocolectomy and ileoanal anastomosis with J-shaped or S-shaped ileal pouch

This article reports an experience of 150 ileoanal anastomoses with pelvic ileal pouches performed between January, 1982 and March, 1986. The pouches were J-shaped in 70 patients, and S-shaped in 80 (with an exit conduit not longer than 2.5 cm). In most of the former group, a long cuff of rectal muscle coat (10 cm from the pectinate line) was preserved, while only a short cuff (2 cm from the pectinate line) was retained in some of the former group and all of the latter group, a modification which had considerable technical advantages and seemed to carry no detriment to subsequent function. An attempt was made to assess the influence of these variations in operative technique on the quality of the functional result by a special study of 82 patients: 39 with a J pouch and long rectal cuff, 2 with an S pouch and long rectal cuff, 28 with a J pouch and short cuff, and 13 with an S pouch and short cuff. At an initial survey, the patients with J pouches reported more urgency and frequency of defecation and more frequent disturbances at night than did those with S pouches. Almost all these differences disappeared 8 months later. At this stage, 94% of the patients were very pleased with the outcome of their surgery and glad to have avoided an ileostomy, but, even so, most of them continued to have some bowel complaints.

---

Resumen El artículo registra la experiencia con 150 anastomosis ileoanales con bolsas ileales pélvicas, realizadas entre enero de 1982 y marzo de 1986. Las bolsas fueron del tipo en J en los primeras 70 pacientes, y del tipo en S (con un conducto de egreso no mayor de 2.5 cm) en los Últimos 80. En la mayoría de los casos del primer grupo, se preservó un mango largo de capa muscular (10 cm a partir de la línea pectínea), mientras que en algunos del primer grupo y en todos los del segundo sólo se preservó un mango corto (2 cm a partir de la línea pectínea), una modificación técnica que exhibe considerables ventajas técnicas y que parece no acarrear problemas en cuanto al resultado funcional.Se realizó la evaluación de la influencia de estas variaciones en la técnica operatoria sobre la calidad del resultado funcional mediante el estudio de 82 pacientes: 39 con bolsa de tipo J y un mango rectal largo, 2 con bolsa de tipo S y un mango largo, 28 con bolsa de tipo J y un mango corto, y 13 con bolsa de tipo en S y un mango corto. En una revisión inicial los pacientes con bolsas en J informaron mayor urgencia y frecuencia en las defecaciones y mayores dificultades durante la noche que los pacientes con bolsas en S. Sin embargo, a los 8 meses casi todas estas diferencias habían desaparecido. En la actualidad, 94% de los pacientes se halla muy satisfecho con el resultado de la operación y complacido con haberse evitado una ileostomá, pero aÚn así la mayoría de ellos continuó con algunos problemas intestinales.

---

Résumé Cet article concerne une expérience de 150 anastomoses iléorectales avec un réservoir iléal pelvien réalisées de janvier 1982 à mars 1986. Les 70 premiers réservoirs avaient une forme en J, les 80 dernières une forme en S (avec un conduit d'évacuation long de 2.5 cm au plus). Dans la majorité des cas du premier groupe, un long manchon de la paroi musculaire rectale (10 cm depuis la ligne pectinée) fut conservé cependant que dans quelques cas du premier groupe et la totalité des cas du second groupe un court manchon (2 cm depuis la ligne pectinée) fut préservé, modification qui eut des avantages techniques considérables et ne parut avoir aucun effet nocif fonctionnel.Une étude a été faite pour apprécier l'effet de ces variations techniques sur les résultats fonctionnels chez 82 opérés: 39 porteurs d'un réservoir en J avec un long manchon rectal, 2 avec un réservoir en S et un long manchon, 28 avec un réservoir en J et un court manchon, et 13 avec un reservoir en S et un court manchon. Au moment de l'étude initiale, les opérés porteurs d'un réservoir en J ont fait état d'une défécation plus fréquente et plus pressante, de troubles nocturnes plus nombreux que les opérés porteurs d'un réservoir en S. Huit mois plus tard presque toute différence avait disparu et 94% des opérés étaient satisfaits et heureux d'avoir évité une iléostomie encore que la plupart d'entre eux se plaignaient de quelques troubles intestinaux.

     

Bile acid absorption after near-total proctocolectomy in dogs: Ileal pouch vs. jejunal pouch-distal rectal anastomosis

Bile acid malabsorption is often present in patients after near-total proctocolectomy and ileal pouchanal canal anastomosis, suggesting ileal dysfunction. Experiments were performed in dogs to compare bile acid absorption after a modified procedure, in which a jejunal pouch was interposed between the terminal ileum and the distal rectum, with that after a conventional ileal pouch operation. Fecal bile acid output (equivalent to hepatic bile acid biosynthesis) and composition were determined by gas chromatography/mass spectrometry in five jejunal pouch dogs and in five ileal pouch dogs more than 6 months after operation. Fecal bile acid output in the jejunal pouch dogs (mean +standard deviation) was 215 ±59 mg/day(10.1 ±2.7 mg/kg-day), a value similar to that obtained in the ileal pouch dogs (261 ±46mg/day [12.8 ±3.1 mg/kg-day]; P >0.05). These values were also similar to those reported by others for healthy unoperated dogs, indicating that increased bile acid biosynthesis occurring in response to bile acid malabsorption was not present. Fecal bile acids in pouch dogs were completely deconjugated and extensively 7-dehydroxylated (jejunal pouch = 90.4% ±3.9% dehydroxylated; ileal pouch = 88.6% ±6.6% dehydroxylated) and consisted predominantly of deoxycholic acid derivatives. We conclude that when either a jejunal pouch or an ileal pouch is used as a rectal substitute in dogs, an anaerobic pouch flora develops that efficiently deconjugates and dehydroxylates bile acids, rendering them membrane permeable. The resultant passive absorption of unconjugated bile acids appears to compensate for any loss of active ileal absorption of conjugated bile acids, and bile acid malabsorption does not occur. Supported by the Mayo Foundation and the Ministry of Education and Sport, Brasilia, Brazil; National Institutes of Health grant DK 37172; a grant-in-aid from the Falk Foundation e.V., Freiburg, Germany; and the Zoological Society of San Diego. Presented in part at the Annual Meeting of the American Gastroenterological Association, May 22, 2000, San Diego, Calif., and published as an abstract in Gastroenterology 118:A316, 2000.     

Proctocolectomy with ileal reservoir and anal anastomosis

A technique of proctocolectomy avoiding an ileostomy has been developed for patients with ulcerative colitis or polyposis coli. After excision of all diseased tissue a reservoir of terminal ileum is constructed which is brought through the rectal stump denuded of mucosa; an ileo-anal anastomosis is then carried out. Twenty-one patients (17 ulcerative colitis, 4 polyposis) have been treated and 20 followed for from 2 to 34 months (mean 13·5 months). There was no mortality but early complications occurred in 9 patients. All are currently well, with no disturbance of urinary or sexual function. Continence of faeces is complete in all during the day, but 1 patient evacuates unconsciously at night. The average frequency of evacuation is 3·8 times in 24 h. Ten patients void spontaneously. All patients tolerate a full diet and only 2 use medicaments to reduce frequency. This operation appears to be a satisfactory alternative to proctocolectomy with a permanent ileostomy.     

Proctocolectomy and ileoanal pouch anastomosis without conservation of a rectal muscular cuff

The technique of proctocolectomy and formation of an ileal reservoir with ileoanal anastomosis is well described. It is believed that the conservation of a rectal muscular cuff is necessary for continence but no data are available to support this contention. The aims of this study were to describe the clinical and physiological aspects of continence after proctocolectomy and ileal J pouch anastomosis without conservation of a rectal muscular cuff. Eighteen consecutive patients (mean age 37.3 years, 16 ulcerative colitis, two familial polyposis) who underwent proctocolectomy and ileoanal anastomosis on the dentate line were studied 6 months after closure of the loop ileostomy. The 18 patients and eight controls underwent: (a) anal manometry; (b) determination of maximum tolerable volume (MTV); (c) liquid continence test (infusion of NaCl at 60 ml/min for 25 min) with simultaneous measurement of ileal reservoir pressure. The volume evacuated during 5 min after the continence test was also measured. The frequency of bowel actions was (mean +/- s.e.m.) 5.3 +/- 0.4 per 24 h (nocturnal 1.14 +/- 0.26). Seventeen of 18 patients (94 per cent) had normal continence and defaecation; one patient was incontinent. A decrease in resting anal canal pressure (102.5 +/- 4 versus 47.5 +/- 6 cmH2O) was observed after ileoanal anastomosis. A rectoanal inhibitory reflex was elicited in one of the 18 patients (6 per cent). Patients were able to retain 1023 +/- 68 ml saline during the liquid continence test. The percentage evacuation of the ileal reservoir was 61 +/- 4.5 per cent. Correlations were found (P = 0.05) between daily stool frequency and the volume of saline retained during the liquid continence test. It is concluded that conservation of a rectal muscular cuff is not necessary for the achievement of good clinical results.     

Proctocolectomy without ileostomy: ileo-anal anastomosis with an ileal reservoir

Six patients with polyposis coli and five with chronic ulcerative colitis underwent total colectomy and mucosal proctectomy with preservation of the anal sphincter and levator ani muscle. An ileal reservoir, constructed from the terminal ileum, is brought out through the anal sphincter for anastomosis to to the anus at the dentate line. Two patients in the series had a three-limb reservoir with anastomosis of a short efferent ileal limb to the anus (Parks technique). Nine patients had a two-limb J-shaped reservoir with the apex of the reservoir anastomosed to the anus (Utsunomiya technique). All patients had a temporary defunctioning ileostomy. There were no deaths. Two patients suffered from severe infection within the rectal muscle cuff. One resolved completely with spontaneous drainage into the reservoir; the other had continuing sepsis and eventually required excision of the anus and conversion to a continent ileostomy. All patients remain in good general condition with no disturbance of urinary or sexual function. Continence is satisfactory in all patients but two wear a pad at night. All evacuate their reservoirs spontaneously: none requires the use of a catheter. For most patients stool frequency varies from four to eight times daily but two patients have more frequent bowel motions. Colitis patients have more frequent bowel activity than those with polyposis. Three patients take Imodium tablets to lessen bowel frequency. The operation should be reserved for specialized centres and is still under trial; however, it appears likely to become the operation of choice for all patients with polyposis coli and for many patients with chronic ulcerative colitis.     

Proctocolectomy and ileoanal anastomosis with an S pouch: functional results

Patients with total colonic ulcerative colitis or familial polyposis traditionally require a proctocolectomy. In an effort to preserve the normal pathway for defecation and avoid the nuisance of an abdominal stoma, a continence-preserving procedure involving a pelvic reservoir has been performed at the University of Minnesota Hospitals on 120 patients. The majority were operated on for colonic ulcerative colitis. There were no deaths. The mean hospital stay after restorative proctocolectomy was 10 days and after ileostomy takedown the mean stay was 7 days. Functional results were assessed in 52 patients. Daytime bowel movements averaged 6.4 and night-time movements 1.4. Major daytime incontinence occurred in 6% of the patients, 21% had moderate soiling at night and 70% wore a perineal pad in the evening. Ninety-two percent of the patients expressed satisfaction with the procedure. The most serious complication was pelvic sepsis. It occurred in nine patients, six of whom required subsequent surgery. The Parks S pouch provides a means of maintaining anal continence. This series and others have shown that young, healthy, well-motivated persons will benefit most from a restorative proctocolectomy.     

全结肠或全结直肠切除、回肠J-袋直肠或肛管吻合术

目的　评估全结肠或结直肠切除 (TC或PC)后 ,回肠J -袋直肠或肛管吻合术的效果。方法　回顾性总结分析 12例全结肠或结直肠切除后J -袋直肠或肛管吻合术的临床资料。结果　男性 5例 ,女性 7例手术经过顺利 ,除一例于术后第一天有肛门出血外 ,其余均顺利恢复 ,无手术死亡。肛门排便功能随时间推移 ,经三个月逐步改善 ,六个月后随访 ,大便多已成形 ,每天平均 3 -5次。有 2例加作短段回肠倒置术 ,术后第一个月不需口服肠蠕动抑制药 ,每天排便亦仅 4-6次。结论　该手术能保持良好的排便功能 ,病人生活质量感到满意 ,是全结肠或结直肠切除后的一种有效而理想的肠道重建方式 ,若再加作回肠倒置术效果更好     

Ileal pouch anal anastomosis without ileal diversion

OBJECTIVE: To evaluate continued experience with a one-stage stapled ileoanal pouch procedure without temporary ileostomy diversion. SUMMARY BACKGROUND DATA: Most centers perform colectomy, proctectomy, and ileal pouch anal anastomoses (IPAA) with a protective ileostomy. Following a previous report, the authors performed 126 additional stapled IPAA procedures for ulcerative colitis and familial adenomatous polyposis, of which all but 2 were without an ileostomy. Outcomes in these patients question the need for temporary ileal diversion, with its complications and need for subsequent surgical closure. METHODS: Two hundred one patients underwent a stapled IPAA since May 1989, 192 as a one-stage procedure without ileostomy, and 1 with a concurrent Whipple procedure for duodenal adenocarcinoma. Patient charts were reviewed or patients were contacted by phone to evaluate their clinical status at least 1 year after their surgery. RESULTS: Among the patients who underwent the one-stage procedure, 178 had ulcerative colitis (38 fulminant), 5 had Crohn's disease (diagnosed after IPAA), 1 had indeterminate colitis, and 8 had familial adenomatous polyposis. The mean age was 38 +/- 7 (range 7--70) years; there were 98 male patients and 94 female patients. The average amount of diseased tissue between the dentate line and the anastomosis was 0.9 +/- 0.1 cm, with 35% of the anastomoses at the dentate line. With 89% follow-up at 1 year or more (mean 5.1 +/- 2.4 years) after surgery, the average 24-hour stool frequency was 7.1 +/- 3.3, of which 0.9 +/- 1.4 were at night. Daytime stool control was 95% and night-time control was 90%. Only 2.3% needed to wear a perineal pad. Average length of hospital stay was 10 +/- 0.3 days, with 1.5 +/- 0.5 days readmission for complications. Abscesses or enteric leaks occurred in 23 patients; IPAA function was excellent in 19 of these patients (2 have permanent ileostomies). In patients taking steroids, there was no significant difference in leak rate with duration of use (29 +/- 8 with vs. 22 +/- 2 months without leak) or dose (32 +/- 13 mg with vs. 35 +/- 3 mg without leak). Two (1%) patients died (myocardial infarction, mesenteric infarction). CONCLUSIONS: The triple-stapled IPAA without temporary ileal diversion has a relatively low complication rate and a low rate of small bowel obstruction, provides excellent fecal control, permits an early return to a functional life, and can be performed in morbidly obese and older patients.     

Proctocolectomy with ileoanal anastomosis

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

Ileal pouch salvage following failed ileal pouch-anal anastomosis

Attempts have been made to salvage failed ileal pouch-anal anastomoses (IPAA) performed for ulcerative colitis or familial polyposis coli. These can be categorized as total reconstruction of the IPAA, partial transabdominal approach, and partial transperineal approach. The aims of our study were to determine the overall success of pouch salvage; to examine the demographics, indications, and outcomes for each approach; and to assess anorectal physiology and patient satisfaction in those with successful salvage operations. We reviewed data, including results of anorectal manometry, from 29 patients undergoing salvage procedures for failed IPAA. Seventeen salvage attempts were successful, 11 attempts failed, and one patient was lost to follow-up. Success rates were 100% in the total reconstruction group, 25% in the partial transabdominal group, and 55% in the transperineal group. In those undergoing total reconstruction of the IPAA (n = 9), functional outcome, as measured by incontinence, improved with 50% reporting incontinence preoperatively compared to 0% postoperatively (P = 0.055). Mean 24-hour stool frequency and nighttime stool frequency declined. All patients reported satisfaction with their outcomes. Sixty percent of patients who underwent ileal pouch salvage following IPAA have been successful in avoiding permanent ileostomy. These results suggest that a continued effort to salvage failed IPAA, including the use of total reconstruction, is a viable alternative to permanent ileostomy. Presented at the Thirty-Ninth Annual Meeting of The Society for Surgery of the Alimentary Tract, New Orleans, La., May 17–20, 1998.     

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.     

Male sexual function improves after ileal pouch anal anastomosis

PURPOSE: Restorative Proctocolectomy and Ileal Pouch Anal Anastomosis has become the gold standard surgical therapy for the majority of patients with mucosal ulcerative colitis. However sexual functional disturbances after this procedure can be a concern for patients. Therefore the aim of this study was to determine the outcome of sexual-function related quality of life in male patients undergoing restorative proctocolectomy. METHODS: One hundred and twenty-two male patients who underwent restorative proctocolectomy with ileal pouch anal anastomosis between 1995 and 2000 were evaluated by the validated International Index of Erectile Function (IIEF) scoring instrument. This index scale examines sexual function in five categories. These are erectile function, orgasmic function, sexual desire, intercourse satisfaction and overall satisfaction. The IIEF instrument was administered after surgery and then scores before and after RP/IPAA were evaluated and compared. The significance of age at the time of the surgery, type of surgery, type of anastomotic technique (mucosectomy vs stapled) and septic complications on sexual functional outcome were also investigated. RESULTS: Mean age at the time of the surgery was 39.9 +/- 11.5 years. The mean follow-up period (time between pouch surgery and IIEF completed) was 3.6 +/- 1.8 years. There was statistically significant improvement in 4 of 5 categories of sexual function (erectile function, sexual desire, intercourse satisfaction, and overall satisfaction) where patients had improved scores after surgery compared to prior to surgery. The mean erectile function score increased pre to post surgery by 2.12 points (P = 0.02), which indicates better sexual results. Anastomotic technique and septic complication did not influence the results, however, older age had a negative impact on results. CONCLUSIONS: Despite some adverse sexual functions, male patients who undergo RP/IPAA for the surgical management of their colitis may preserve or improve their overall sexual functional outcome.     

Fate of the pouch in 151 pediatric patients after ileal pouch anal anastomosis

Background/Purpose: Ileal pouch anal anastomosis (IPAA) offers many pediatric patients a surgical cure for mucosal ulcerative colitis (MUC) with preservation of anal continence. However, some patients incur serious problems after surgery including chronic pouchitis and pouch failure. The goal of this study is to identify clinical and pathologic factors that are associated with an adverse outcome of IPAA. Methods: A retrospective analysis of outcome was performed in 151 consecutive patients [le ] 21 years of age who underwent IPAA with a mean follow-up of 7.24 years (range, 2 to 15 years). Patients were categorized into 4 outcome groups: A, no pouchitis; B, mild, acute pouchitis; C, chronic refractory pouchitis; and D, pouch failure. Pairwise comparisons were used to test the association between the groups and clinical and pathologic variables including age, sex, duration of symptoms, perianal disease, colonoscopic histology, terminal ileitis, operation type, staged versus unstaged IPAA, colonic specimen histology, early postoperative complications defined as less than 31 days postsurgery, late postoperative complications defined as 31 or more days postsurgery, and pouch fistulae. Crohn's disease as a definitive diagnosis and indeterminant colitis, a histologic diagnosis, also were tested for association with the above variables and outcome groups. Results: One hundred and fifty-one pediatric patients underwent IPAA utilizing mucosectomy and hand-sewn S or J (n = 44) and stapled J or S-W anastomosis (n = 107) with 0% mortality rate and outcome as follows: group A, n = 54; group B, n = 73; group C, n = 11; group D, n = 13. Variables strongly associated with poor outcome, groups C and D, were duration of symptoms (P = .03), perianal disease (P = .03), late complications (P [lt ] .001), pouch fistulae (P [lt ] .001), and Crohn's disease (P [lt ] .0001). Furthermore, Crohn's disease was associated strongly with female gender (P = .01), perianal disease (P = .004), early (P = .006) and late (P [lt ] .001) complications, and pouch fistula (P [lt ] .001). The findings of indeterminant colitis, terminal ileitis, and early postoperative complications did not show significant differences between the 4 outcome groups. Conclusions: Crohn's disease appears to be an important determinant of postoperative complications, chronic pouchitis, and pouch failure and occurred in 15% of the authors' patients after IPAA. Indeterminant colitis and the intraoperative findings of terminal ileitis are not associated with Crohn's disease or adverse outcome after IPAA in pediatric patients. Operation type and stage do not alter the clinical course after IPAA in pediatric patients. J Pediatr Surg 38:78-82.     

The jejunal pouch as a rectal substitute after proctocolectomy

Our hypothesis was that a jejunal pouch used as a rectal substitute after proctocolectomy would slow enteric transit, delay defecation, and decrease stool frequency compared to an ileal pouch so used. Twelve dogs underwent proctocolectomy; six had a jejunal pouch-distal rectal anastomosis and six had an ileal pouch-distal rectal anastomosis. After recovery, postprandial mouth-to-anus transit was slower in jejunal pouch dogs (253 ±18 minutes [mean ± SEM]) than in ileal pouch dogs (112 ±7.9 minutes; P <0.05). Moreover, jejunal pouch dogs passed only 4.1 ± 0.3 stools during the 12 hours after eating, whereas ileal pouch dogs passed 6.3 ± 0.9 stools (P <0.05). The mean frequency of proximal ileal pacesetter potentials after feeding was less in jejunal pouch dogs (12 ± 0.4 cycles/min) than in ileal pouch dogs (16 ± 0.3 counts/min; P = 0.01), and jejunal pouches had more action potentials (jejunal = 82% ±4.3% of pacesetter potentials had action potentials, ileal = 61% ±3.0%; P <0.05). In contrast, gastric emptying and pouch motility, emptying, mucosal integrity, and bacteriologie and histologic properties were similar in the two groups of dogs. We concluded that the jejunal pouch operation slowed enteric transit, delayed defecation, and decreased postprandial stooling compared to the ileal pouch operation. Supported by the Ministry of Education and Sport (CAPES), Brasilia, Brazil. Presented at the Fortieth Annual Meeting of The Society for Surgery of the Ahmenrary Tract, May 16–10, 1999, Orlando, Fla., and published as an abstract in Gastmntemlogy 116-S1032, 1999.     

腹腔镜辅助下全大肠切除、回肠储袋与直肠肌管吻合术治疗家族性腺瘤性息肉病

目的 探讨腹腔镜辅助下全大肠切除、回肠储袋与直肠肌管吻合术在治疗家族性腺瘤性息肉病(familial adenomatous polyposis,FAP)中的价值.方法 回顾性统计分析7例FAP患者行腹腔镜辅助下全大肠切除、回肠储袋与直肠肌管吻合术的手术、术后恢复情况及随访资料,并与同期开腹手术患者相比较.结果 腹腔镜手术患者手术切口平均长度为4.32 cm,明显短于开腹手术,差异有统计学意义;术后排气时间平均为1.45 d,短于开腹患者,两组间差异无统计学意义;住院时间平均为11.95d,明显短于开腹手术患者,差异有统计学意义.术后6个月随访资料显示回肠储袋与直肠肌管吻合术安全可靠,较回肠储袋肛管吻合术后患者排便次数明显减少,肛管静息压和最大收缩压明显增高.结论 与原有回肠储袋肛管吻合术相比,腹腔镜辅助全大肠切除、回肠储袋直肠肌管吻合术不仅手术创伤小,手术方式简单,手术难度低,而且减少了可能发生的盆底肌肉和肛门括约肌损伤,更好地保留患者控排便功能.     

Bowel obstruction in a pregnant patient with ileal pouch–anal anastomosis

Bowel obstruction is a rare but serious complication of pregnancy for both the mother and the developing fetus. This report describes the case of 17-year-old girl with ileal pouch–anal anastomosis (IPAA). She presented at 36 weeks’ gestation with a complete small-bowel obstruction. Because conservative management was unsuccessful, labour was induced to relieve the obstruction or simplify surgery. Soon after spontaneous vaginal delivery she began to pass copious amounts of flatus and stool. The bowel obstruction resolved within hours. This report illustrates how IPAA alters the anatomy of the gastrointestinal tract, placing the ileal pouch at risk from compressive obstruction by the gravid uterus. Induction of labour in a near-term fetus is a reasonable initial method of management in such women.     

Improved quality of life with jejunal pouch reconstruction after total gastrectomy

BACKGROUND: There is increasing evidence that the effect of jejunal pouch reconstruction is satisfactory for reservoir function in several randomized control studies. However, these studies were performed in patients with advanced gastric cancer, where significant numbers of the patients died of disease recurrence. In order to exclude the influence of disease recurrence, we performed jejunal pouch reconstruction after total gastrectomy in patients with early gastric cancer in a randomized controlled study and investigated whether or not an improved quality of life (QOL) was observed with jejunal pouch reconstruction. METHODS: Fifty consecutive patients receiving total gastrectomy for early gastric cancer were prospectively divided into the Roux-en-Y reconstruction group without pouch (RY group) or the jejunal pouch reconstruction group (pouch group). Body weight, eating capacity, QOL assessment by gastrointestinal symptom rating scale (GSRS), nutritional parameters, endoscopical examination, 24-hour pH monitoring and Bilitec monitoring were evaluated at 3, 12, and 48 months after surgery. RESULTS: Jejunal pouch reconstruction provided the better QOL than Roux-en-Y reconstruction without pouch both at short-term and long-term periods in a randomized control study. Moreover, as a new finding, pouch reconstruction provided less bile reflux into the esophagus compared with Roux-en-Y reconstruction. CONCLUSIONS: Jejunal pouch reconstruction provided improvement of QOL in patients receiving total gastrectomy.