Gastric emptying function after ileal J pouch-anal anastomosis for ulcerative colitis

BACKGROUND: Little is known of the effects on gastric function after ileal J pouch-anal anastomosis (IPAA) for ulcerative colitis. This study aimed to determine whether patients with postoperative high stool frequency after IPAA exhibit impaired gastric function. METHODS: Gastric emptying time (GET) for a solid diet (rice gruel) with the use of a radioisotope method and for a liquid diet (orange juice) with the use of an acetaminophen method were assessed in 36 patients with ulcerative colitis more than 30 months after closure of protective ileostomy. Patients were divided into 2 groups: 18 patients with stool frequency less than 6 per day (group A) and 18 patients with stool frequency more than 7 per day (group B). GET for solid and liquid diets in groups A and B were compared with those in 18 healthy volunteers (group C). We correlated the time of peak blood concentration of acetaminophen (TPBCA) and both individual stool frequency per day and the length of distal ileum removed. RESULTS: GET for the solid diet in groups A and B was not altered by IPAA compared with group C. GET for the liquid diet in groups A and B was slower than in group C (P<.0001). GETs for the liquid diet at 60 minutes or more in group A were slower than in group B (P<.0001); TPBCA was longer in group A than in groups B or C (P<.01). There were inverse correlations between TPBCA and individual stool frequency per day and between TPBCA and length of distal ileum removed (P<.001). CONCLUSIONS: Rapid transit from the stomach of the liquid diet in group B compared with group A may influence high stool frequency after IPAA. Our results suggested that, to obtain an adequate stool frequency after IPAA, the length of distal ileum removal should be less than 15 cm.     

Dietary habits after ileal pouch-anal anastomosis

Dietary habits of patients who had undergone ileal pouch-anal anastomosis were assessed and correlated with bowel function. Twenty-four well-adapted patients (11 women, 13 men; mean age 32 years) voluntarily entered the study 30 +/- 4 months after closure of the diverting ileostomy. A standardized questionnaire on 108 food items and a 3-day food journal were used in the assessment. Twenty-one patients had no difficulty in selecting an appropriate diet. Caloric intake was adequate. Specific symptoms associated with several foods were as follows: increased stool frequency (beer, spirits, chinese food), decreased stool consistency (beer, wine, fried fish), perianal irritation (spicy foods), undigested particles (grapefruit, lettuce), odours (eggs). Pasta and bananas were associated with increased stool consistency. The authors believe that these observations may help in dietary counselling after ileal pouch-anal anastomosis.     

Stricture and pouchitis after ileal pouch-anal anastomosis

Ileal pouch-anal anastomosis is a surgical procedure used for the treatment of people with chronic ulcerative colitis and familial adenomatous polyposis. The surgery is intended to preserve anal sphincter function, but it carries a risk for certain complications, including pouchitis and anastomotic stricture. The purpose of this article is to review the clinical manifestations, causes, and treatment of anastomotic stricture and pouchitis after ileal pouch-anal anastomosis.     

Laparoscopic ileal pouch-anal anastomosis

Total coloproctectomy with ileal pouch-anal anastomosis is the operation of choice for both ulcerative colitis and familial adenomatous polyposis. In experienced teams, it is now possible to do this operation through a laparoscopic approach. Laparoscopy allows to perform the same operation than during open surgery, but with reduction of the surgical trauma, especially for the abdominal wound.     

Determinants of stool frequency after ileal pouch-anal anastomosis

The aim of our study was to determine whether ileal pouch motility and evacuability and the 24 hour fecal output influence stool frequency after ileal pouch-anal anastomosis. In 23 patients, at a mean of 24 months postoperatively (range 22 to 26 months), ileal pouch motility was measured using an intraluminal bag and pressure-sensitive catheters. The pattern and efficiency of ileal pouch emptying was determined scintigraphically. A 24 hour stool collection was made and the stool output and stool frequency recorded. The volume of ileal pouch distention at which large amplitude propulsive waves appeared (the threshold volume) correlated closely with stool frequency. The larger the threshold volume, the fewer the stools per 24 hours (correlation coefficient -0.70; p less than 0.01). Also, the greater the 24 hour stool output, the greater the stool frequency (correlation coefficient 0.79, p less than 0.001). In contrast, the efficiency of ileal pouch evacuation was less strongly related to stool frequency (correlation coefficient -0.41, p = 0.05). We conclude that ileal pouch motility and stool output are major determinants of stool frequency after ileal pouch-anal anastomosis. Inefficient pouch emptying is less commonly associated with frequent bowel movements.     

Salvage reoperation for complications after ileal pouch-anal anastomosis

BACKGROUND: Surgical revision may be possible in patients with a poor outcome following ileal pouch-anal anastomosis (IPAA), using either a transanal approach or a combined abdominoperineal approach with pouch revision and reanastomosis. METHODS: Sixty-four patients underwent revisional surgery. The indication for salvage was sepsis in 47 patients, mechanical dysfunction in ten, isolated complications of the residual glandular epithelial cuff in three and previous intraoperative difficulties in four patients. RESULTS: A transanal approach was used in 19 patients and a combined abdominoperineal procedure in 45. Six of the latter had pouch enlargement and 25 received a new pouch. During a mean(s.d.) follow-up of 30(25) months, three patients required pouch excision because of Crohn's disease. Two patients had poor continence after abdominoperineal surgery. At last follow-up 60 (94 per cent) of 64 patients had a functional pouch. Half of the patients experienced some degree of daytime and night-time incontinence, but it was frequent in only 15 per cent. Of 58 patients analysed, 27 of 40 who had an abdominoperineal procedure and 13 of 18 who had transanal surgery rated their satisfaction with the outcome as good to excellent. CONCLUSION: Surgical revision after failure of IPAA was possible in most patients, yielding an acceptable level of bowel function in two-thirds of patients.     

Factors influencing bowel function after ileal pouch-anal anastomosis

Seventeen patients were studied 3-31 months (median 6.4 months) after mucosal proctectomy and ileal pouch-anal anastomosis for ulcerative colitis (n = 15) or adenomatous polyposis (n = 2). Seven had a triplicated pouch, and ten a duplicated pouch. Clinical bowel function was determined by detailed questionnaire, and correlations sought between clinical end-points such as frequency of defaecation, urgency of defaecation and continence, and the results of laboratory investigations, comprising anal manometry, capacity and compliance of the pouch, completeness of emptying, faecal bacteriology and mucosal inflammation. Frequency of defaecation was found to be inversely correlated with both the capacity (rs = -0.66, P less than 0.01) and the compliance (rs = -0.53, P less than 0.05) of the pouch. Patients who could postpone defaecation for greater than 30 min had higher anal squeeze pressures (P less than 0.05) than patients who had greater urgency of defaecation. Patients with perfect anal continence had higher resting anal pressure (P less than 0.05) and emptied the pouch more completely (P less than 0.01) than patients who experienced minor leakage. The faecal flora of the pouches showed a greater predominance of anaerobes (P less than 0.01) and increased numbers of bacteroides (P less than 0.01) compared with the faecal flora of ileostomies, but the changes in the flora did not correlate with any aspect of bowel function. The best clinical results (i.e. perfect continence, low frequency of defaecation and little urgency) were associated with high anal pressure and with large volume, high compliance and complete emptying of the pouch. The completeness of emptying was similar for both designs of pouch, but the capacity and compliance of triplicated pouches were greater than the capacity and compliance of duplicated J pouches (P less than 0.05), and this was associated with a better clinical result in the triplicated pouches.     

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.     

The S ileal pouch-anal anastomosis

In order to determine the results with the S ileal pouch-anal anastomosis, 116 consecutive patients who had undergone total abdominal colectomy with rectal mucosectomy and endorectal ileal pouch-anal anastomosis were assessed following ileostomy closure. In 11 patients (9.5%) pouch removal and/or conversion to permanent ileostomy was necessary because of Crohn's disease (3), pelvic sepsis (3), pouchitis (2), incontinence (2), or perineal fistula (1). Although no postoperative mortality was experienced, one or more complications was experienced in 87 patients. These consisted mainly of small bowel obstruction in 35%, pouchitis in 22%, anastomotic stricture in 14%, pelvic sepsis in 9.5%, and perianal abscess or fistula in 5%. Laparotomy was required in 29% of patients mostly for resolution of small bowel obstruction. Follow-up in the remaining 105 patients ranged from 5 to 67 months with a mean of 28 months following ileostomy closure. Stool frequency was 6.6 bowel movements per day and 1.4 bowel movements per night. Eighty-nine percent evacuated their pouches spontaneously, and 61% did not require the use of medication for bowel movement regulation. Major daytime incontinence occurred in 4%, while 15% reported nocturnal incontinence. Minor incontinence was experienced by 30% and 48% during daytime and nighttime, respectively. Despite a myriad of complications, 96% of patients unhesitatingly stated that they would undergo the procedure again so that they could avoid a permanent stoma. We conclude that restorative proctocolectomy utilizing the ileal S pouch-anal anastomosis is an acceptable procedure that should be considered as a viable choice in the treatment of chronic ulcerative colitis and familial polyposis requiring surgical intervention.

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Resumen Con el propósito de determinar los resultados con la anastomosis entre la bolsa ileal en S y el ano, se estudiaron 116 pacientes consecutivos sometidos a colectomía abdominal total con mucosectomía rectal y anastomosis endorrectal bolsa ileal-ano, una vez efectuado el cierre de la ileostomía. Once pacientes (9.5%) requirieron resección de la bolsa y/o conversión a ileostomía permanente debido a enfermedad de Crohn (3), sepsis pélvica (3), bolsitis (2), incontinencia (2), y fístula perineal (1). Aunque no se registró mortalidad postoperatoria, se presentaron una o más complicaciones en 87 pacientes. Estas representaron principalmente obstrucción intestinal en 35%, bolsitis en 22%, estenosis de la anastomosis en 14%, sepsis pélvica en 9.5%, y absceso perianal o fístula en 5%. La laparotomía fue necesaria en 29% de pacientes, principalmente para solucionar obstrucción intestinal. El seguimiento de los restantes 105 pacientes osciló entre 5 y 67 meses con un promedio de 28 meses después del cierre de la ileostomía. La frecuenica de la defecación fue de 6.6 movimientos intestinales diurnos y 1.4 nocturnos. Ochenta y nueve por ciento evacuaron sus bolsas en forma espontánea, y 61% no requirieron medicamentos para la regulación de sus movimientos intestinales. Incontinencia fecal diurna mayor se presentó en 4% de los pacientes, en tanto que 15% informaron incontinencia nocturna. Incontinencia menor diurna fue informada por 30% y nocturna por 48%. A pesar de una miriada de complicaciones, 96% de pacientes informaron en forma indudable que volverían a someterse al procedimiento con el fín de evitar un estoma permanente. Nuestra conclusión es que la proctocolectomía restauradora utilizando la anastomosis entre una bolsa ileal en S y el ano es un procedimiento aceptable que debe ser considerado como una escogencia viable en el tratamiento de la colitis ulcerosa crónica y de la poliposis familiar que requieren intervención quirúrgica.

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Résumé Dans le but de déterminer les résultats obtenus par l'anastomose entre une poche iléale en S et l'anus, une série de 116 patients qui ont subi une colectomie totale avec exérèse de la muqueuse endo-rectale et constitution d'une anastomose entre la poche iléale et l'anus ont été étudiés après fermeture de l'iléostomie provisoire. Chez 11 (9.5%) d'entre eux l'ablation du réservoir et/ou la conversion en iléostomie permanente a été nécessaire en raison des faits suivants: maladie de Crohn (3), infection pelvienne (3), inflammation de la poche (2), incontinence (2), fistule périnéale (1). Si aucun cas de mortalité opératoire n'a été à déplorer, des complications se sont manifestées chez 87 opérés. Elles ont consisté principalement en occlusion iléale (35%), inflammation de la poche (22%), sténose au niveau de l'anastomose (14%), infection pelvienne (9.5%), abcès périnéal ou fistule périnéale (5%). Une laparotomie fut nécessaire dans 29% des cas principalement pour traiter l'obstruction du grêle. Le contrôle post-opératoire de 105 opérés après fermeture de l'iléostomie provisoire s'étend de 5 à 67 mois avec une moyenne de 28 mois. La fréquence des selles diurnes fut de 6.6, celle des selles nocturnes de 1.4. L'évacuation spontanée fut observée dans 89% des cas et il ne fut pas nécessaire d'employer de régulateur de la mobilité intestinale dans 61% des cas. Une incontinence diurne moyenne fut observée dans 4% des cas et une incontinence nocturne dans 15% des cas. Une incontinence mineure fut enregistrée dans 30% et 48% des cas au cours respectivement du jour et de la nuit. Malgré de nombreuses complications 96% des opérés ont manifesté sans réserve le désir de se prêter à la même intervention pour éviter une iléostomie permanente. On peut conclure de ces faits que la protocolectomie utilisant la poche en S anastomosée à l'anus est une méthode acceptable qui doit être prise en considération pour traiter la colite ulcéreuse chronique et la polypose familiale relevant de l'intervention chirurgicale.

     

Gangrenous pyoderma and enterocutaneous fistulas after ileal pouch-anal anastomosis

We describe the medical-surgical management of a patient with a complex inflammatory bowel disease who developed 2 acute episodes of pyoderma gangrenosum and enterocutaneous fistulas after ileal pouch-anal anastomosis for ulcerative colitis. The rarity of this postsurgical complication is emphasized. A good response to topical tacrolimus was achieved in cutaneous wounds. A less favorable response to infliximab was achieved in the abdominal fistulas, requiring surgical excision of the pouch.     

The J ileal pouch-anal anastomosis

The experience at the Mayo Clinic, Rochester, Minnesota, U.S.A., with abdominal colectomy, mucosal proctectomy, and ileo-anal anastomosis is now approaching 600 patients. The procedure is safe and, with careful timing and selection of patients, can be performed with minimal mortality. Postoperative morbidity, however, is still considerable, even in the most experienced hands. Increasing experience with the procedure has been shown to be associated with a continuing decline in the incidence of postoperative complications, and a defunctioning ileostomy is still a necessity in the majority of patients.Long-term functional results of the procedure are satisfactory and have been shown to improve both with the experience of the operator and with the passage of time after surgery. Patient acceptance remains the ultimate sanction, and it appears that the majority of patients are satisfied with their outcome after ileo-anal anastomosis, with only very few being prepared to consider an alternative. The operation appears to provide a superior quality of life relative to that expected after proctocolectomy and Brooke ileostomy.Not all patients with chronic ulcerative colitis or adenomatosis coli are potential candidates for this procedure, however. The problems of age, obesity, indeterminate colitis and Crohn's disease, co-existing colorectal neoplasia, technical difficulties at the time of the operation, and the wishes of the patient all must be taken into consideration when assessing the optimal operation in a particular situation. Proctocolectomy with Brooke ileostomy or continent ileostomy and total abdominal colectomy with ileo-rectal anastomosis both still have roles in the management of diseases such as chronic ulcerative colitis and adenomatosis coli. For a patient who is young, relatively fit, and well motivated and in whom there is little or no doubt about the diagnosis, ileo-anal anastomosis must be considered as the possible treatment of choice. Increasing experience with the procedure and improvements in functional results seem to be confirming this position.

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Resumen La experiencia de la Clínica Mayo, Rochester, Minnesota, U.S.A., con colectomía abdominal, mucosectomía rectal, y anastomosis ileoanal se acerca a los 600 pacientes. El procedimiento es seguro y, con una cuidadosa selección y programación de los pacientes, puede ser realizado con mínima mortalidad. Sin embargo, la morbilidad postoperatoria es todavía considerable, aún en las manos más experimentadas. La creciente experiencia con este procedimiento ha demostrado una disminución continuada en la incidencia de complicaciones postoperatorias; una ileostomía desfuncionalizante es todavía necesaria en la mayoría de los pacientes.Los resultados del procedimiento a largo plazo son satisfactorios y han demonstrado mejoría en relación con la experiencia del cirujano y con el transcurso del tiempo después de la operación. La aceptación por parte del paciente representa la verdadera sanción, y tal parece que la mayoría de los pacientes se encuentran satisfechos con el resultado de la anastomosis ileoanal, puesto que sólo unos poco están preparados para contemplar una alternativa. La operación parece proveer una calidad de la vida superior a la que se espera después de una proctocolectomía con ileostomía de Brooke.Sin embargo, no todos los pacientes con colitis ulcerosa crónica o poliposis intestinal son candidatos potenciales para este procedimiento. Factores tales como edad, obesidad, colitis indeterminada y enfermedad de Crohn, neoplasias colorrectales coexistentes, dificultades técnicas en el momento de la operación, y los deseos del paciente deben ser tenidos en cuenta para determinar cual es la operación ideal en cada situación particular. Tanto la proctocolectomía con ileostomía de Brooke o con ileostomía continente y la colectomía abdominal total con anastomosis ileorrectal todavía tienen indicación en el manejo de entidades tales como la colitis ulcerosa crónica y la poliposis intestinal. En un paciente joven, en relativo buen estado físico, y bien motivado, y en quien no exista duda sobre el diagnóstico, se debe considerar la anastomosis ileoanal como el posible tratamiento de escogencia. La creciente experiencia con el procedimiento y la mejoría en los resultados funcionales parecen confirmar esta posición.

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Résumé L'expérience de la Mayo Clinic, Rochester, Minnesota, U.S.A., concernant la colectomie avec résection de la muqueuse rectale et anastomose iléo-anale est proche de 600 cas. La méthode est sûre et grâce au choix opportun du moment de l'intervention et des malades qui peuvent en bénéficier, la mortalité est réduite. En revanche, la morbidité post-opératoire est encore considérable même entre des mains expérimentées. L'expérience croissante va de pair avec une diminution des complications post-opératoires et une iléostomie défonctionnalisée est encore une nécessité dans la majorité des cas.Les résultats fonctionnels à long terme sont satisfaisants et se sont améliorés avec l'expérience acquise par le chirurgien et aussi avec la durée. L'appréciation des résultats de la méthode par l'opéré constitue le meilleur critère de la valeur de l'intervention. Il apparait que la majorité des opérés sont satisfaits et seuls quelques-uns réclament une autre intervention. La méthode apporte une qualité de vie supérieure à celle qui peut être fournie par l'iléostomie de Brooke.Il est à noter que tous les malades atteints de colite ulcéreuse ou de polypose colique ne sont pas des candidats à ce type d'opération. Il est nécessaire de prendre en considération, avant de la choisir, les problémes posés par l'âge, l'obésité, le diagnostic entre la maladie de Crohn, la colite d'origine indéterminée, la coexistence d'une affection néoplasique colorectale, les difficultés techniques au moment de l'intervention, les désirs exprimés par le malade, et ceci pour chaque cas particulier. La proctocolectomie avec iléostomie de Brooke, l'iléostomie continente, et la colectomie totale avec anastomose iléo-rectale ont toujours leur place pour traiter la colite ulcéreuse chronique et la polyadenomatose colique. Cependant chez le malade jeune, en bon état, bien motivé, et chez qui le diagnostic ne prête pas au doute l'anastomose iléo-anale peut être considérée comme l'opération de choix. L'experience croissante acquise pour la réaliser et l'amélioration des résultats fonctionnels ne peuvent que confirmer cette prise de position.

     

Physiologic determinants of nocturnal incontinence after ileal pouch-anal anastomosis

The goals of the ileal pouch-anal anastomosis (IPAA) operation are the construction of a fecal reservoir and the preservation of anal function, without compromising continence. Some of the patients are incontinent at night. The aim of our study was to identify the mechanisms responsible for nocturnal incontinence. We analyzed patients undergoing IPAA for ulcerative colitis, who underwent anorectal tests between 1993 and 1995. All patients were subjected to pull-through manometry and pelvic floor function studies, and 33 patients underwent overnight ambulatory manometry. Among 44 patients (27 men and 17 women), 22 had complete continence, whereas 22 had nocturnal incontinence. Mean age was 40±1 years. There were no differences with regard to sex, age, stool consistency, and ability to differentiate gas from stool between groups; only stool frequency was lower in the continent group (median [range] 6 [3 to 10] vs. 8 [5 to 25] stools/24 hours;P=0.011). Resting and squeezing anal canal pressure did not differ (P=0.42 andP=0.73, respectively). Resting, squeezing, and defecating anorectal angle, percentage of pouch evacuation, and perineal descent, all measured scintigraphically, did not differ between groups (allP>0.05). Ambulatory manometry showed that the mean anal canal pressure was higher in continent patients compared to incontinent patients, both during awake (88±11 vs. 62±8;P=0.032) and sleep (81±14 vs. 49±9;P=0.029) periods. The motility index was similar (awake,P=0.88; sleep,P=0.95), as was the number of episodes where the pouch pressure was greater than the anal canal pressure (P=0.28). In otherwise continent patients after IPAA, the combination of high stool frequency and low basal anal canal pressure may be related to nocturanal incontinence. Moreover, standard anorectal physiology tests cannot identify these subtle differences. Supported in part by the Crohn's and Colitis Foundation of America, Inc. Presented at the Thirty-Seventh Annual Meeting of The Society for Surgery of the Alimentary Tract, San Francisco, Calif., May 19–22, 1996.     

Working capacity and resting energy expenditure after ileal pouch-anal anastomosis

BACKGROUND: The aim was to evaluate the working capacity and resting energy expenditure in patients who had undergone restorative proctocolectomy. METHODS: Of 72 patients operated on between April 1990 to September 1998, 51 were eligible and 38 participated in the study. Resting energy was assessed by indirect calorimetry, and working capacity by ergospirometry on an exercise bicycle. RESULTS: The median functional score was 2 (range 0-7). Oxygen uptake during rest was reduced for men compared with predicted values. The corresponding values for women were in keeping with predicted values. The median working capacity was 96 (range 59-102) per cent for women and 91 (range 51-113) per cent for men, compared with reference values of maximum workload based on age, height and sex. There was no correlation between functional score and any other variable measured. CONCLUSION: Patients who have undergone restorative proctocolectomy for ulcerative colitis have normal resting energy expenditure and working capacity.     

Late functional adaptation after colectomy, mucosal proctectomy, and ileal pouch-anal anastomosis

Ileal pouch-anal anastomosis (IPAA) is currently an alternative to proctocolectomy and ileostomy for patients with ulcerative colitis or familial polyposis. Some studies have suggested significant anal sphincter damage after mucosal proctectomy. Our aim was to assess prospectively late sphincter function after IPAA. In 250 patients, anorectal pressures were assessed with a pneumohydraulic perfused catheter manometry system. Each patient underwent colectomy, mucosal proctectomy, ileoanal anastomosis of a 15 cm ileal J-pouch, and loop ileostomy. Eight weeks after IPAA, anal manometry was repeated, and the ileostomy was closed. Manometry was repeated at yearly intervals. A decline in resting tone of the anal sphincter occurred early after IPAA with a gradual recovery toward control. External sphincter squeeze after pressures were not affected by IPAA and steadily increased to 8 years after operation. During this time, a progressive increase in J-pouch capacity was noted, and 24-hour stool frequency declined from 7.9 +/- 0.3 stools to 6.5 +/- 0.3 stools (p less than 0.05). We conclude that mucosal proctectomy results in internal anal sphincter trauma but is associated with long-term sphincter recovery, coupled with a significant improvement in external sphincter capacity, ileal pouch volume, and stool frequency.     

Functional outcome of stapled ileal pouch-anal canal anastomosis versus handsewn pouch-anal anastomosis

This study was conducted to determine whether stapled ileal pouch-anal canal anastomosis (IACA) preserving the anal transitional zone (ATZ) or hand-sewn ileal pouch-anal anastomosis with mucosectomy (IPAA) is more beneficial in achieving disease eradication and better postoperative function. IACA was performed in 10 patients with ulcerative colitis (UC) and 10 patients with familial adenomatous polyposis (FAP), 15 of whom were examined proctoscopically. IPAA was performed in 4 patients with UC and 8 patients with FAP. The mean maximum resting pressure (MRP) was 55 mmHg in the IACA group and 34 mmHg in the IPAA group (P < 0.01). The anorectal inhibitory reflex was positive in 18 patients (90%) from the IACA group and 5 (42%) from the IPAA group (P < 0.05). The pre- and postoperative MRPs were 61 mmHg and 55 mmHg, respectively, in the IACA group vs 63 mmHg and 34 mmHg, respectively, in the IPAA group (P < 0.01). Whereas 16 (80%) of the 20 IACA patients could discriminate feces from gas, only 4 (33%) of the 12 IPAA patients could (P < 0.05). The mean observation period was 2.3 years, the mean length of the columnar cuff was 2.8 cm, and no case of dysplasia or adenoma was seen. Postoperative function is more favorable following IACA than following IPAA, both physiologically and symptomatically. However, long-term surveillance of the residual mucosa is necessary before making a final recommendation. Received: April 20, 1999 / Accepted: January 7, 2000     

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.     

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

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