Influence of ileal pouch capacity and anal sphincteric function on the clinical outcome after ileal pouch-anal anastomosis

This study was designed to determine the influence of ileal pouch capacity and anal sphincteric function on the clinical outcome after ileal pouch-anal anastomosis. A total of 24 patients who had undergone ileal pouch-anal anastomosis (J pouch) for ulcerative colitis were studied. The 24-hour stool frequency was found to be inversely correlated with the sensitivity threshold volume (STV), maximal tolerance volume (MTV), and distensibility, but was independent of the maximal resting pressure and maximal squeeze pressure. Patients experiencing nocturnal fecal incontinence had maximal resting pressures that were significantly lower than those of nocturnally continent patients. Among the patients with fecal incontinence, those with frequent soiling had lower resting pressures, STV, and distensibility than the patients with intermittent spotting. In addition, the STV in patients needing nocturnal evacuation were lower than those of patients who did not evacuate after falling asleep. The conclusions are as follows. Both stool frequency and the need for nocturnal pouch evacuation correlated directly with pouch volume. Anal incontinence was more common in patients with low internal sphincteric function. In addition, frequent and gross nocturnal incontinent patients demonstrate a worse function in both the anal sphincter and reservoir than those with intermittent spotting.     

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.     

回肠储袋与直肠肌管吻合术治疗家族性腺瘤性息肉病15例分析

目的探讨回肠储袋与直肠肌管吻合术在治疗家族性腺瘤性息肉病中的价值。方法回顾性分析15例FAP患者行全大肠切除回肠储袋与肛管或直肠肌管吻合术的手术方式、并发症以及结肠镜、肛肠测压等随访资料。结果回肠储袋与直肠肌管吻合术安全可靠,无严重并发症,较回肠储袋肛管吻合术术后排便频率明显降低,肛管静息压力和最大收缩压力明显增高,肛管长度明显延长。结论与传统的回肠储袋肛管吻合术相比,回肠储袋与直肠肌管吻合术简化了手术,减少了盆底肌肉和肛门括约肌损伤,保留了更多控便功能。     

Filling Sensations after Restorative Proctocolectomy

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

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

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

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.     

Possible role of the autonomic nervous system in sphincter impairment after restorative proctocolectomy

Peroperative manometry was performed in 12 patients operated on with endoanal proctectomy and a hand-sewn pouch-anal anastomosis and in 12 in whom proctectomy was performed entirely from above, with the ileal pouch stapled to the top of the anal canal. Results from both groups showed that division of the superior rectal artery reduced the median (95 per cent confidence interval (c.i.)) resting anal pressure from 77.5 (69.9-83.3) mmHg to 64.5 (55.2-70.0) mmHg (P < 0.01). Complete rectal mobilization to the pelvic floor decreased resting pressure by an additional 22 per cent, to a median of 50.0 (95 per cent c.i. 40.1-53.5) mmHg (P < 0.01). After completion of anastomosis, irrespective of the operative technique used, a further decline in median pressure to 35.0 (95 per cent c.i. 26.0-47.7) mmHg could be demonstrated (P < 0.05). This study indicates that anal sphincter pressure is reduced to a similar extent after hand-sewn and stapled anastomoses. Injury to the autonomic nervous supply to the anal sphincter mechanism might be the major cause for this reduction.     

Recovery of the internal anal sphincter and continence after restorative proctocolectomy

The internal anal sphincter (IAS) was assessed prospectively using electromyography and manometry in 66 patients (48 men) undergoing restorative proctocolectomy to determine its role in the gradual return of continence. Twenty-nine patients received a J pouch and 37 a W reservoir. Some 38 pouches (J, ten; W, 28) were hand-sewn (mucosal proctectomy with endoanal anastomosis) and 28 (J, 19; W, nine) stapled (end-to-end pouch-anal anastomosis 1 cm above the dentate line). Twelve patients underwent a one-stage procedure (all J pouches), while the remainder had a covering loop ileostomy. Each patient was reassessed immediately after restorative proctocolectomy and again at 7 days, 1 month, 4 months, 9 months and 18 months after pouch formation. Internal sphincter electromyographic activity was greatly reduced after pouch-anal anastomosis (median preoperative frequency 0·51 Hz versus immediate postoperative frequency 0·21 Hz, P < 0·003) and gradually recovered from 4 months after surgery. At 18 months, measurements of IAS function had not fully recovered to preoperative values (median frequency 0·31 Hz; P < 0·03). Resting anal pressures (median preoperative value 99 cmH₂O) decreased by over 50 per cent after surgery (median immediate postoperative resting pressure 44 cmH₂O) and recovered gradually but incompletely (median pressure at 18 months 63 cmH₂O). Eleven patients reported leakage in the follow-up period. The median (range) resting pressure in these patients (54 (40–71) cmH₂O) was not significantly different at 9 months from that of those who were continent either before or after operation (59 (46–68) cmH₂O). Prolonged recordings in patients with faecal leakage revealed evidence of high-pressure pouch waves that overwhelmed anal sphincter pressures and coincided with leakage. These episodes were most common during sleep, when anal sphincter activity was reduced.     

Adenocarcinoma of the anal transitional zone after double stapled ileal pouch-anal anastomosis for ulcerative colitis

The development of adenocarcinoma in the anal transitional zone, after restorative proctocolectomy for ulcerative colitis, is rare. We report the first Asian and sixth known case. A 41-year-old Indian lady had a long standing history of ulcerative colitis. Restorative proctocolectomy and stapled ileal pouch-anal anastomosis without mucosectomy was performed. She remained asymptomatic until 3 years later when she complained of discomfort on defecation. A poorly differentiated adenocarcinoma in the anal transition zone was diagnosed and she subsequently underwent an abdomino-perineal resection. The previously reported cases in the literature are reviewed. We also discuss the suggested surveillance for high-risk patients who have undergone an ileal-anal pouch anastomosis.     

A clinico-physiological comparison of ileal pouch-anal and straight ileoanal anastomoses

The ileal pouch-anal anastomosis improves clinical results after colectomy and mucosal proctectomy compared to the straight ileoanal anastomosis. The question was what physiologic changes brought about by the pouch led to the improvement. Among 124 patients who had had ileoanal anastomosis, 25 volunteered for a detailed clinicophysiologic evaluation. Fourteen had had the ileal pouch-anal operation a mean of 8 months previously, and 11 had the straight ileoanal operation a mean of 25 months previously. Both groups of patients had satisfactory anal sphincter resting pressures (mean +/- SEM, pouch = 68 +/- 8 cm H2O, straight = 65 +/- 9 cm H2O, p greater than 0.05) and neorectal capacities (pouch = 278 +/- 26 ml, straight = 233 +/- 36 ml, p less than 0.05), and all could evacuate spontaneously. However, the pouch patients had a more distensible neorectum (delta V/delta P pouch = 9.5 +/- 1.3 ml/cm H2O, straight = 4.9 +/- 0.9 ml/cm H2O, p less than 0.05) and smaller amplitude neorectal contractions (pouch = 36 +/- 5 cm H2O, straight = 90 +/- 13 cm H2O; p less than 0.05). We concluded that the pouch-anal anastomosis increased the distensibility of the neorectum and decreased its propulsive drive, and so improved clinical results.     

Reconstruction of proctocolectomy: which is the best surgical procedure?

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

应用吻合器手术治疗家族性腺瘤样息肉病21例分析

目的探讨3种吻合器在治疗家族性腺瘤样息肉病的临床应用价值。方法回顾性分析华中科技大学同济医学院附属同济医院2000年1月至2005年12月间采用吻合器手术治疗家族性腺瘤样息肉病21例的临床资料。结果21例病人均采用3种吻合器手术,行全结肠切除、直肠超低位前切除、回肠J形贮袋肛管吻合术,并预防性回肠造口。全组无手术死亡病人、无吻合口瘘、盆腔脓肿、吻合口狭窄等严重并发症发生。1例病人发生贮袋粘连,在直肠镜下分离治愈;2例吻合口附近发现息肉经内镜电灼切除。全组病人排便功能满意,排便次数控制在每天2～5次。结论采用3种吻合器进行结肠切除、直肠超低位前切除、回肠贮袋与肛管吻合术,并预防性回肠造口,手术安全、简捷省时、术后并发症较少,应作为首选手术方式,手术后应进行长期随访,及时发现和处理复发息肉。     

全大肠切除回肠贮袋肛管吻合术的远期疗效评价

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

Pouch reconstruction in the pelvis

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

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.     

Restorative proctocolectomy with ileal pouch-anal anastomosis for ulcerative colitis:A narrative review

Restorative proctocolectomy with ileal pouch-anal anastomosis(RP-IPAA) is the gold standard surgical treatment for ulcerative colitis.However,despite the widespread use of RP-IPAA,many aspects of this treatment still remain controversial,such as the approach(open or laparoscopic),number of stages in the surgery,type of pouch,and construction type(hand-sewn or stapled ileal pouch-anal anastomosis).The present narrative review aims to discuss current evidence on the short-,mid-,and long-term results of each of these technical alternatives as well as their benefits and disadvantages.A review of the MEDLINE,EMBASE,and Ovid databases was performed to identify studies published through March 2016.Few large,randomized,controlled studies have been conducted,which limits the conclusions that can be drawn regarding controversial issues.The available data from retrospective studies suggest that laparoscopic surgery has no clear advantages compared with open surgery and that one-stage RP-IPAA may be indicated in selected cases.Regarding 2- and 3-stage RP-IPAA,patients who underwent these surgeries differed significantly with respect to clinical and laboratory variables,making any comparisons extremely difficult.The long-term results regarding the pouch type show that the W- and J-reservoirs do not differ significantly,although the J pouch is generally preferred by surgeons.Hand-sewn and stapled ileal pouch-anal anastomoses have their own advantages,and there is no clear benefit of one technique over the other.     

腹腔镜辅助下回肠储袋与直肠肌管吻合术治疗家族性腺瘤性息肉病的临床体会

目的:探讨腹腔镜辅助下回肠储袋与直肠肌管吻合术治疗家族性腺瘤性息肉病(familial adenomatous polyposis,FAP)的临床价值。方法:回顾分析2006～2011年为13例FAP患者分别行腹腔镜辅助回肠储袋与直肠肌管吻合术及回肠储袋与肛管吻合术的临床资料,并进行对比分析。结果:两组患者手术时间、术中出血量、术后切口长度、进食时间、住院时间、住院费用差异均无统计学意义。术后6个月随访,腹腔镜辅助下回肠储袋与直肠肌管吻合术较回肠储袋肛管吻合术后患者排便次数明显减少,肛管静息压及最大收缩压明显增高。结论:与传统回肠储袋肛管吻合术相比,回肠储袋直肠肌管吻合手术保留了部分直肠肌管,不仅有效减少了盆底肌肉损伤的可能性,而且很好地保护了肛门括约肌,因而可更好地保留患者的控排便功能。     

Quality of life after Brooke ileostomy and ileal pouch-anal anastomosis. Comparison of performance status.

Although the clinical results of Brooke ileostomy are good, patients are permanently incontinent of stool and gas. Alternative operations designed to restore enteric continence, such as ileal pouch-anal anastomosis, must not only be as safe and effective as Brooke ileostomy, but should provide an improved quality of life in order to establish long-term acceptability. Ileal pouch-anal anastomosis has been performed safely and good functional results have been reported. The quality of life after ileal pouch-anal anastomosis, however, has not been documented. Two hundred ninety-eight ileal pouch patients and 406 Brooke ileostomy patients who had the operations performed for chronic ulcerative colitis or familial adenomatous polyposis formed the basis of the study. After adjusting for age, diagnosis, and reoperation rate, logistic regression analysis of performance scores in seven different categories was used to discriminate between operations. Median follow-up was longer in Brooke ileostomy patients than in ileal pouch patients (104 months vs. 47 months, respectively), and Brooke ileostomy patients were slightly older (38 years vs. 32 years). A great majority of patients in each group were satisfied (93% Brooke ileostomy; 95% ileal pouch-anal anastomosis). Thirty-nine per cent of Brooke ileostomy patients, however, desired a change in the type of ileostomy they had. At 47 months, ileal pouch patients had a median of 5 stools per day and 1 at night, 77% did not experience any daytime incontinence, while 22% reported occasional spotting. In each performance category, the performance score discriminated between operations, with the probability of having had an ileal pouch-anal anastomosis operation increasing with improvement in performance scores (p less than 0.05). We concluded that after ileal pouch-anal anastomosis, patients experienced significant advantages in performing daily activities compared to patients with Brooke ileostomy and thus may experience a better quality of life. These results help further to establish ileal pouch-anal anastomosis as a safe, attractive, and valid alternative to Brooke ileostomy.     

Functional results after “high” coloanal anastomosis and “low” coloanal anastomosis with a colonic J-pouch for rectal carcinoma

The aim of this study was to determine the postoperative function of neorectoanal components using two different types of very low coloanal reconstruction. The two groups of patients assessed were 22 who underwent abdominal rectal resection and stapled “high” coloanal anastomosis without a pouch, being the HCAA-P group; and 34 who underwent anoabdominal rectal resection and “low” coloanal anastomosis with a colonic J-pouch, being the LCAA+P group. Manometric metric examination was performed 1, 3, 6, and 12 months postoperatively, and the patients were also assessed by a questionnaire. The LCAA+P group had remarkably less daily stool frequency and urgency, but there were no significant differences in the other functional parameters. Maximum resting pressure (MRP) was significantly less, while threshold volume (TV) and maximum tolerable volume (MTV) were greater in the LCAA+P group than in the HCAA-P group. The colonic J-pouch compensated for decreased MRP. Thus, when HCAA-P is performed, 3.0 cm of residual rectum with internal anal sphincter may be required, and construction of the pelvic pouch is desirable in low coloanal anastomosis.     

Immediate and long-term results in ileoanastomosis with reservoir in 335 consecutive cases

Restorative proctocolectomy with ileal pouch anal anastomosis is the first choice procedure for the treatment of ulcerative colitis and familial adenomatous polyposis. The introduction of the stapled technique has shortened the duration of the procedure and reduced the complication rates. Data on 335 consecutive patients undergoing ileal pouch anal anastomosis for ulcerative colitis (277 pts), Indeterminate colitis (20 pts) and familial adenomatous polyposis (38 pts) between 1984 and 1998 were prospectively collected. Parameters evaluated included diagnosis, surgical technique, functional outcome, early and late complications and their management and results. Twenty-nine patients (8.6%) presented with pelvic sepsis. Twelve patients (3.5%) experienced late perianal fistulas. The pouch failure rate was 3.4%. Six patients required a re-do pouch procedure, with 75.9% preservation of sphincter function. No correlation was found between complication rates and diagnosis. The mean number of stools was 5.2/24 h. The study confirmed the safety and effectiveness of the procedure. In particular, morbidity rates are comparable to those of major abdominal procedures and the long-term functional results are satisfactory. However, a number of technical aspects, such as the anastomosis technique, the need for temporary ileostomy and the treatment of indeterminate colitis, still remain controversial.     

Clinical and Functional Comparison Between Stapled Colonic J-Pouch Low Rectal Anastomosis and Hand-Sewn Colonic J-Pouch Anal Anastomosis for Very Low Rectal Cancer

Purpose. We investigated intersphincteric resection with hand-sewn coloanal anastomosis, which may be an alternative to standard low anterior resection for very low rectal cancer when stapled anastomosis is technically impossible. Methods. The present study compared the clinical and functional results of 16 patients who underwent stapled colonic J-pouch low rectal anastomosis (CJLRA) with those of 15 patients who underwent intersphincteric excision and hand-sewn colonic J-pouch anal anastomosis (CJAA). Results. After a median follow-up period of 59 months, local recurrence was found in four patients from the CJAA group, three of whom subsequently underwent curative abdominoperineal resection. Defecatory function 6 and 12 months after surgery did not differ between the groups, although pads were used significantly more frequently in the CJAA group. Anorectal physiologic study before and 12 months after surgery revealed that the internal anal sphincter function was impaired to a larger extent after CJAA than after CJLRA, probably due to the partial or subtotal resection of the internal sphincter, and the anal dilatation during resection and anastomosis. Conclusion. Although the prevention of intraoperative tumor implantation and the early detection of local recurrence is of utmost importance, CJAA may be an acceptable sphincter-preserving procedure for selected patients in whom stapled anastomosis is impossible. Received: February 26, 2001 / Accepted: September 11, 2001