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.     

Previous subtotal colectomy with ileostomy and sigmoidostomy improves the morbidity and early functional results after ileal pouch-anal anastomosis in ulcerative colitis

The aim of this work was to study the effects of previous subtotal colectomy (STC) with ileostomy and sigmoidostomy on the outcome of ileal J-pouch-anal anastomosis (IPAA) in patients with acute ulcerative colitis. Between 1983 and 1991, we conducted a prospective, nonrandomized study of 156 patients who underwent IPAA in our center. Fifty-five patients (34.3 percent) had undergone STC with ileostomy and sigmoidostomy for either severe acute colitis (36.5 percent of cases) or nonresolving acute colitis (63.5 percent) up to six months before IPAA with covering ileostomy. There were no perioperative deaths; six patients (11 percent) developed complications requiring reoperation (three cases of pelvic sepsis, two occlusions, and one stenosis of the ileostomy). IPAA was successfully carried out at a later stage in all cases. The results of IPAA in these patients were compared with those in 78 patients who underwent the classical two-stage IPAA procedure. The rates of pelvic sepsis and postoperative occlusion were lower in the subgroup of patients who underwent the three-step procedure. Three months after closure of the ileostomy, the mean number of daily stools was significantly lower in the patients who had undergone prior STC (5.09 vs.5.9), but there was no significant difference between the two groups with regard to diurnal and nocturnal continence, the need to wear a pad, discrimination between gas and stools, or the use of antidiarrheal medication. In addition, there was no significant difference at one year in terms of functional parameters. We conclude that STC is a simple and safe procedure for the treatment of a severe attack of colitis and that it does not compromise the results of later IPAA. Because it does not increase the morbidity of subsequent IPAA and is associated with more rapid functional recovery, STC appears to be suitable for the treatment of patients with nonresolving acute colitis before the onset of malnutrition or steroid dependency.     

Delayed ileal pouch-anal anastomosis

In patients with chronic ulcerative colitis (CUC), ileal pouch-anal anastomosis (IPAA) can be performed either at the time of colectomy or as a delayed procedure after total abdominal colectomy and ileostomy. There has been debate as to whether delayed IPAA results in superior functional results, since patients are frequently steroid-free and have little evidence of active disease. To assess this, we analyzed 95 patients who had undergone total abdominal colectomy, either with ileostomy and Hartmann's procedure or with ileorectostomy, 2–183 months prior to IPAA. Postoperative complications and functional results were compared with those of 776 CUC patients who underwent IPAA at the time of abdominal colectomy. Indications for prior colectomy included toxic megacolon (40 percent), failed medical therapy (36 percent), other reasons (e.g.,iatrogenic perforation, cancer) (6 percent), and reasons unclear (18 percent). Nineteen percent of delayed-IPAA patients were taking steroids at the time of pouch construction. Follow-ups were similar in the two groups. The incidence of septic and obstructive complications after delayed IPAA vs. IPAA at the time of colectomy were 10.5 percent vs.5.4 percent and 6.5 percent vs.14.5 percent, respectively. There were no significant differences in postoperative functional results between the two groups. Delayed IPAA confers no advantage over IPAA performed at the time of colectomy in terms of functional outcome. Delayed IPAA was associated with a significantly higher rate of septic complications but a lower incidence of postoperative obstruction.Read at the meeting of The American Society of Colon and Rectal Surgeons, St. Louis, Missouri, April 29 to May 4, 1990.     

Safety of urgent restorative proctocolectomy with ileal pouch-anal anastomosis for fulminant colitis

PURPOSE: Subtotal colectomy with ileostomy is the operation of choice for patients with fulminant colitis. Restorative proctocolectomy (RPC) with ileal pouch-anal anastomosis (IPAA) is preferred for patients who undergo elective surgery for ulcerative colitis. We retrospectively evaluated the safety of RPC with IPAA in patients with a moderate form of fulminant colitis. METHODS: A chart review of 737 patients who underwent RPC with IPAA for ulcerative and indeterminate colitis from 1983 through 1992 was performed. Moderate fulminant colitis was defined as acute disease requiring hospitalization and parenteral steroid therapy, but without hypotension (systolic blood pressure, <100 mmHg), tachycardia (>120 beats/min), or megacolon. RESULTS: Twelve patients with moderate fulminant colitis underwent urgent surgery (1.6 percent). They had been treated preoperatively for 5.1±2.3 days with intravenous high-dose steroids, total parenteral nutrition, and antibiotics. These patients had a shorter length of disease ( P =0.01), lower hemoglobin, hematocrit, and albumin (P=0.001), and higher temperature (P=0.002) and leukocyte count (P=0.007) than patients undergoing elective surgery. No early septic complications occurred, although perianal abscess occurred in one patient and pouch-anal fistula in another patient, 13 and 14 months after surgery, respectively. CONCLUSION: In carefully selected, hemodynamically stable patients with fulminant colitis and without megacolon, RPC with IPAA can be safely performed.Poster presentation at the meeting of The American Society of Colon and Rectal Surgeons, Orlando, Florida, May 8 to 13, 1994.     

Restorative proctocolectomy without diverting ileostomy

PURPOSE: Restorative proctocolectomy (RPC) by abdominal colectomy and ileal pouch-anal anastomosis (IPAA) in the setting of chronic ulcerative colitis (CUC) and familial adenomatous polyposis (FAP) has gained widespread popularity among surgeons and patients. Traditionally, temporary loop ileostomy has been established proximal to the ileal pouch in an effort to mitigate the effects of any suture line complications that may occur. This study compares functional results and complications encountered after RPC with mucosectomy with and without temporary ileostomy. METHODS: One hundred forty-three consecutive patients with either CUC or FAP underwent RPC including mucosectomy and ileal J reservoir. Proximal loop ileostomy was performed in 69 patients, and ileostomy was omitted in 74. Ileostomy was omitted if the patient was taking no immunosuppressives and less than 20 mg of prednisone daily in the month preceding surgery, the anastomosis was absolutely tension-free, and blood supply to the pouch was excellent. RESULTS: There were no perioperative deaths. There were two instances of pelvic abscess, one in the diverted group and one in the nondiverted group. Occurrence of IPAA suture line dehiscence was not significantly different between the two groups (ileostomy, 4/69 (6 percent),vs. no ileostomy, 6/74 (8 percent);P>0.05). Comparison of 129 patients with colitis with and without diversion also failed to demonstrate a significant difference with regard to IPAA suture line dehiscence (ileostomy, 4/69 (6 percent) vs. 4/60 (7 percent);P>0.05). Frequency of bowel movements and continence were the same in both groups and were comparable with results obtained without mucosectomy. Mean hospital stay at the time of RPC for the nondiverted group was significantly longer (12 days vs. 10 days; P=0.0004). Significantly fewer patients without an ileostomy were hospitalized for partial intestinal obstruction (ileostomy, 13/69 (19 percent),vs. no ileostomy, 3/74 (4 percent);P=0.02), and significantly fewer required enterolysis (ileostomy, 7/69 (10 percent),vs. no ileostomy, 1/74 (1 percent);P=0.04). On average, patients without an ileostomy spent significantly fewer total days in the hospital (17 vs. 24;P=0.002). CONCLUSION: Restorative proctocolectomy with mucosectomy and without ileostomy is the procedure of choice for selected patients with FAP and CUC. Septic complications and functional results are similar to those seen in patients managed with a stoma. Anastomotic leakage, when it occurs, can be safely managed in most cases without surgery. RPC without ileostomy results in significantly fewer episodes of intestinal obstruction, fewer instances of re-exploration, and fewer total days in the hospital.Presented in part as a poster presentation at the meeting of The American Society of Colon and Rectal Surgeons, Orlando, Florida, May 8 to 13, 1994.     

Familial adenomatous polyposis: Results following ileal pouch-anal anastomosis and ileorectostomy

To compare the clinical and functional results of ileorectostomy (IR) and ileal pouch-anal anastomosis (IPAA) in patients with familial adenomatous polyposis (FAP), we reviewed the results of 94 IPAA patients and 21 IR patients who were operated upon between 1978 and 1988. The groups were similar with respect to age and sex. None of the patients died postoperatiyely. Postoperative complications occurred in 28 percent of the IPAA group and in 17 percent of the IR group (P >0.1). Seven percent of IPAA patients described symptoms compatible with pouchitis. Sixty-one percent of IR patients required subsequent fulguration of rectal polyps at least once. IR patients had a mean (±SD) of 4 (±2) stools per day, while IPAA patients had 5 (±2) stools per day (P >0.05). No significant difference in daytime soiling was present between IR (6 percent) and IPAA (4 percent). Nighttime spotting was also similar between the two groups. Nighttime soiling, however, was reported by 4 percent of IPAA patients but not by IR patients (P <0.05). One IPAA patient (1 percent) required pouch excision for a desmoid tumor, while two IR patients (11 percent) required proctectomy and ileostomy for recurrent dysplastic polyps (P <0.05). Adhesions and a shortened ileal mesentery prevented the construction of an ileoapal procedure in these latter patients. In conclusion, the postoperative complication rate and functional results are similar after IR and IPAA in patients with FAP; however, IR does not eradicate rectal polyps and may indeed preclude IPAA for those requiring subsequent proctectomy.Read in part at the meeting of The American Society of Colon and Rectal Surgeons, St. Louis, Missouri, April 29 to May 4, 1990.     

Management of fulminant ulcerative colitis by primary restorative proctocolectomy

Severe acute ulcerative colitis unresponsive to medical management is characterized by multiple associated risk factors including anemia, hypoproteinemia, and high steroid requirements when urgent surgery is required. Current surgical options include use of primary ileal pouch-anal anastomosis (IPAA) vs. historic trends favoring colectomy with ileostomy. PURPOSE: To evaluate the efficacy of primary IPAA in patients with severe colitis, we reviewed our own experience in 20 patients with this condition. METHODS: Patients undergoing primary restorative proctocolectomy included 13 males and 7 females (mean age, 30.5±2.4 years). Exclusion criteria for primary reconstruction included septic patients and patients with associated medical conditions such as pulmonary or cardiovascular disease. History of ulcerative colitis averaged 3.1±1.1 years (range, 1 month to 19 years). Preoperative mean total serum protein concentration was 5.0±0.2 g/dl, and mean albumin concentration was 2.1±0.2 g/dl, reflecting disease severity. The average daily steroid requirement at the time of urgent colectomy was 58.0±4.4 mg of prednisone (or intravenous equivalent). Primary IPAA included 18 W reservoirs, 1 S reservoir, and 1 J reservoir. RESULTS: Major surgical complications included mild pancreatitis (10 percent), anastomotic leak (5 percent), adrenal insufficiency (15 percent), an upper gastrointestinal bleed (5 percent), and small bowel obstruction (15 percent). There were no deaths, and no patients developed pelvic sepsis or required IPAA removal. At three and twelve months, 24-hr stool frequency averaged 7.3±0.4 and 4.9±0.3, respectively. Overall day and night continence was excellent and not different from patients who underwent elective IPAA procedures for ulcerative colitis. CONCLUSIONS: Improved options such as primary IPAA may be safely used in selected patients requiring urgent surgery for severe or fulminant ulcerative colitis. Medical management should be abbreviated when disease control cannot be promptly achieved.     

Long-term results of ileal pouch-anal anastomosis in patients with Crohn's disease

PURPOSE: Ileal pouch-anal anastomosis (IPAA) is the surgical treatment of choice for most patients with chronic ulcerative colitis. Crohn's disease is, however, a contraindication. Because distinction between UC and Crohn's disease can be difficult, some patients with Crohn's disease inadvertently undergo IPAA. The aim of this study was to determine the long-term outcome of patients with Crohn's disease who have undergone IPAA. METHODS: A total of 37 patients (20 men) were studied. Each had undergone mucosectomy with handsewn IPAA (J-pouch, n=35; S-pouch, n=1; W-pouch, n=1). Histologic examination of the resected specimen at time of IPAA showed features of ulcerative colitis (n=22), indeterminate colitis (n=9), or Crohn's disease (n=6). The stoma was closed in all patients. RESULTS: A total of 11 of 37 patients developed complex fistulas (pouch-cutaneous (n=6), pouch-vaginal (n=4), or pouch-vesical (n=1). Crohn's disease has recurred in the pouch (n=20), anal canal (n=4), pouch and anal canal (n=10), and elsewhere (n=3). After ten years (range, 3–14), the pouch remains in situ in 20 patients in whom frequency of bowel movement is seven times (3–10)/24 hours,in situ but defunctioned in seven patients, and excised in ten patients (failure rate, 45 percent). CONCLUSIONS: Inadvertent IPAA for Crohn's disease is associated with a high rate of failure (45 percent) but an acceptable long-term functional result if the pouch can be kept in situ.Read at the meeting of the Association of Surgeons of Great Britain and Ireland, Glasgow, United Kingdom, May 22 to 24, 1996.     

Ileal pouch-anal anastomosis without ileostomy

Thirty-seven patients underwent construction of a J-ileal pouch-anal anastomosis (IPAA) without temporary diverting ileostomy for chronic ulcerative colitis (CUC) (20 patients), familial adenomatous polyposis (FAP) (15 patients), indeterminate colitis (1 patient) and nonhereditary polyposis coli (1 patient) between 1981 and 1990. Seven of 20 CUC patients (35 percent) were on steroids at the time of hospital admission. The postoperative course of these patients was compared with that of a group of patients undergoing IPAA with ileostomy during that same time period and matched for age, sex, diagnosis, date of surgery, and steroid use. Eight patients (22 percent) in the group without ileostomy and four patients (11 percent) with ileostomy experienced one or more postoperative pouch-related complications. Complications requiring reoperation in patients without ileostomy occurred more frequently in patients either taking steroids or having previous pelvic radiation therapy. Functional results in patients undergoing one-stage procedures after a mean of 28 postoperative months were comparable to those in patients having staged procedures. Surgeons' criteria for a one-stage procedure in these patients should include absolute lack of tension on the anastomosis, good blood supply to the terminal ileum, good general health, and absence of recent intake of steroids at the time of surgery. We conclude that J-pouch construction with IPAA can be safely performed without diverting ileostomy, provided that these selection factors are taken into account.Read at the meeting of The American Society of Colon ar Rectal Surgeons, St. Louis, Missouri, April 29 to May 4, 1990.     

Social and sexual function following ileal pouch-anal anastomosis

PURPOSE: Patiens who undergo surgery for ulcerative colitis are usually young and active. When surgery becomes necessary, their future social and sexual function is of major concern. This study was performed to be able to give more detailed information of what is to be expected. METHODS: Forty-nine consecutive patients (26 men and 23 women) who underwent ileal J-pouch-anal anastomosis for ulcerative colitis between November 1983 and September 1986 in the authors' institution were personally interviewed regarding details of their preoperative and postoperative social and sexual functions. RESULTS: Eighty-eight percent had reduced capacity to work preoperatively compared with 6 percent postoperatively. Thirty-one percent resumed work in the period with diverting ileostomy. Leisure time activities were reduced in 47 percent preoperatively, whereas 6 percent had limitations postoperatively. In 35 percent of women, frequency of intercourse was increased postoperatively, and none reported a decreased frequency. None of the women who were able to achieve orgasm preoperatively reported a postoperative disturbance of this ability, and 16 percent experienced an increased quality of orgasm. Postoperatively none reported dyspareunia, vaginal discharge, or changes in their menstrual cycle. Frequency of intercourse and ability to achieve orgasm remained unchanged for the majority of men; however, one developed erectile dysfunction, and one complained of retrograde ejaculation. Sexual activity in men was less affected by the presence of an ileostomy, and 69 percent had intercourse in the period with ileostomy compared with 30 percent of women. None of the patients complained of anal pain, soiling, or fecal leakage during intercourse, but one woman reported some discomfort from the pouch during intercourse. None of the patients wanted to return to a life with an ileostomy. CONCLUSION: The social and sexual function, quality of life, after ileal J-pouch anastomosis is improved when compared with the period with ulcerative colitis and the time with diverting ileostomy. In men, however, a frequency of sexual dysfunction similar to what is seen after proctectomy for benign diseases should be underlined.     

Functional results after restorative proctocolectomy complicated by pouchitis

This study aimed to examine the incidence and cumulative risk of pouchitis after restorative proctocolectomy for ulcerative colitis and to evaluate the clinical and functional results in patients with pouchitis. METHODS: A total of 291 patients had proctocolectomy with ileal pouch-anal anastomosis for ulcerative colitis between January 1985 and January 1996. During follow-up, 65 patients had one or more episodes of pouchitis based on clinical, histologic, and endoscopic criteria. Functional results and patient satisfaction in these patients were compared with those of 65 matched control patients who had experienced no episodes of pouchitis. RESULTS: Pouchitis developed in 65 patients (22 percent), giving rise to a cumulative frequency of 28 percent at 11 years after the operation. Only 13 patients (4.5 percent) had chronic pouchitis that required long-lasting treatment. A permanent ileostomy had to be constructed in one patient (0.3 percent) because of pouchitis. During the last year (1995), 60 percent of patients with pouchitis had medication, most often metronidazole and/or corticosteroids. Defecation frequency per 24 hours was 6.7 for all patients with pouchitis, 8.2 for those with chronic pouchitis (P<0.05), and 6.3 for patients without pouchitis. Nighttime defecation occurred in 44 (80 percent) patients with pouchitis, compared with 37 (67 percent) of those without pouchitis (P>0.05). Frequencies of soiling or flatus incontinence did not differ between the two groups. During the last year, 43 (80 percent) of the pouchitis patients, who answered the questionnaire, were working all the year or were on sick-leave less than one month. CONCLUSIONS: Episodic pouchitis is easily treated and causes minimum functional consequences, whereas chronic pouchitis increases defecation frequency and needs prolonged medication. Pouchitis seems not to be a major threat to preventing the use of restorative proctocolectomy in ulcerative colitis, but still the small group of chronic pouchitis patients remains a problem.Supported by grants from the Foundation of Gastroenterological Diseases, Helsinki, Finland.     

Incidence,risk factors,and treatment of dysplasia in the anal transitional zone after ileal pouch-anal anastomosis

Preservation of the anal transitional zone (ATZ) after restorative proctocolectomy and stapled ileal pouch-anal anastomosis (IPAA) for ulcerative colitis is controversial. PURPOSE: To evaluate the incidence, risk factors, and treatment options for dysplasia and/or cancer after restorative proctocolectomy and stapled IPAA. METHODS: We reviewed the records of all 254 patients operated on for ulcerative colitis who had a restorative proctocolectomy, stapled IPAA, and annual postoperative biopsies of ATZ. Follow-up studies included an annual questionnaire and physical examination. RESULTS: During a follow-up of 2.3±1.4 (mean ± standard deviation) years, low-grade dysplasia was found in eight patients (3.1 percent), 16 (median: range, 6–56) months after surgery. Repeated biopsies revealed dysplasia in only two of eight patients, and completion mucosectomy was performed. Dysplasia in ATZ was associated with a preoperative (P=0.02) or postoperative (P=0.04) pathologic diagnosis of ulcerative colitis with concurrent dysplasia or cancer. No association (P>0.05) was found between dysplasia and the following: age, sex, preoperative length of disease, use of a double-stapledversus single-stapled technique, or anastomotic distance from the dentate line. CONCLUSIONS: Incidence of low-grade dysplasia in ATZ was low. Restorative proctocolectomy with total mucosectomy of the anal canal and handsewn IPAA is recommended for patients with preoperative diagnosis of ulcerative colitis and concurrent cancer or dysplasia. Frequent follow-up with biopsies is recommended for patients with incidental finding of cancer or high-grade dysplasia after restorative proctocolectomy and stapled IPAA with preservation of ATZ. For persistent or recurrent low-grade dysplasia, we recommend a completion mucosectomyRead at the meeting of The American Society of Colon and Rectal Surgeons, Orlando, Florida, May 8 to 13, 1994.     

Indeterminate colitis predisposes to perineal complications after ileal pouch-anal anastomosis

This study retrospectively evaluated 288 patients who had undergone ileal pouch-anal anastomosis to determine the incidence of perineal complications and to relate these findings to the pathologic diagnosis, with the goal of specifically clarifying the appropriate surgical management of patients with indeterminate colitis. Of these 288 patients, 235 patients (82 percent) had a diagnosis of chronic ulcerative colitis, 18 patients (6 percent) had indeterminate colitis, 6 patients (2 percent) had Crohn's disease, and 29 patients (10 percent) had familial polyposis. All complications occurred at least 6 months after closure of the stoma and required operative therapy. Of 18 patients with indeterminate colitis, 9 patients experienced complications (50 percent) vs. 8 of 235 patients with chronic ulcerative colitis (3 percent), a highly significant difference (P <0.001). Furthermore, the risk of eventual ileostomy because of perineal complications was 0.4 percent in patients with chronic ulcerative colitis vs. 28 percent in patients with indeterminate colitis (P< 0.001). We conclude that a diagnosis of indeterminate colitis predisposes the patient undergoing ileal pouchanal anastomosis to perineal complications, with a resultant high chance of reservoir loss. Ileal pouch-anal anastomosis should be considered with caution in the patient with a diagnosis of indeterminate colitis.Read at the meeting of The American Society of Colon and Rectal Surgeons, St. Louis, Missouri, April 29 to May 4, 1990.     

Water and electrolyte balance after ileoanal anastomosis

Water and electrolyte balance was studied in 30 patients with ileoanal anastomosis and J pouch, 10 patients with conventional ileostomy, and nine nonoperated patients with quiescent ulcerative colitis. Serum electrolyte concentrations, daily urinary volume, and daily losses of sodium, potassium, and chloride were measured in all patients. Daily fecal weight and daily losses of sodium and potassium were analyzed in patients with ileoanal anastomosis or conventional ileostomy. Serum chloride in patients with ileoanal anastomosis was significantly lower (P<0.05) than in those with conventional ileostomy or in nonoperated patients. Daily urinary loss of sodium in nonoperated patients was significantly higher than in patients with ileoanal anastomosis(P<0.01) or conventional ileostomy (P<0.05). Daily urinary loss of chloride in patients with ileoanal anastomosis was significantly lower (P<0.05) than in nonoperated patients. Daily fecal loss of potassium in patients with ileoanal anastomosis was significantly higher (P<0.05) than in those with conventional ileostomy. Daily urinary volume and fecal weight did not differ significantly in patients with ileoanal anastomosis or conventional ileostomy. The present study indicates that changes in water and sodium balance after ileoanal anastomosis are similar to those after conventional ileostomy but chloride balance is more altered after ileoanal anastomosis.     

Omission of temporary diversion in restorative proctocolectomy — Is it safe?

PURPOSE: The aim of our study was to evaluate the safety and functional outcome of restorative proctocolectomy (RP) without diversion. METHODS: Fifty patients underwent RP without diversion for ulcerative colitis (82 percent), familial adenomatous polyposis (12 percent), and indeterminate colitis (6 percent). The perioperative course and functional outcome of these patients were compared with another group of 50 patients undergoing RP with diverting ileostomy during the same time period (1989–1991) and closely matched for age, gender, surgeon, diagnosis, extent and duration (median, 10 years) of colitis, prior colectomy (22 percent), steroid use (40 percent), type of pouch, distance of ileal pouch-anal anastomosis from the dentate line (median, 1.5 cm), and the duration of follow-up (median, 12 months). All patients had a stapled ileal pouch-anal anastomosis without mucosectomy and a smooth conduct of the operation. RESULTS: There was no operative mortality. Anastomotic leaks and pelvic abscess were more common in patients without ileostomy (7/50 or 14 percent vs. 2/50 or 4 percent); 8 of these 9 patients were taking 20 mg of prednisone/day. Septic complications requiring relaparotomy (6 percent vs. 0 percent), prolonged ileus, and fever of unknown origin (10 percent vs. 4 percent) were also more common in patients without ileostomy. Despite similar functional results at 6 weeks and at 12 months after initial pouch function, patients without ileostomy had a poorer quality of life index (5 vs. 8; 10 being best) in the early period (0–6 weeks) of pouch function. CONCLUSION: In equally favorable cases, RP without diversion is not as safe as RP with diversion, especially in patients taking 20 mg of prednisone/day.Read at the meeting of The American Society of Colon and Rectal Surgeons, Chicago, Illinois, May 2 to 7, 1993.     

Ileostomy output of gas and feces before and after conversion from conventional to reservoir ileostomy

In 28 patients who had previously had a proctocolectomy for ulcerative colitis, the ileostomy output of feces was determined before and after conversion to continent reservoir ileostomy, as was the output of gas in 20 of the patients. The median output of feces/24 hours collected in the hospital was 576 g before and 692 g after conversion (P < 0.05); when collected at home the corresponding figures were 734 g and 740 g, respectively. In the majority of patients, the change in fecal ileostomy output after the conversion was not considerable, while in a few patients there was a marked increase. The fecal output was 24 percent (P < 0.01) and 11 percent (P < 0.01) larger at home than in hospital before and after conversion, respectively. The proportion dry weight of ileostomy discharge decreased after conversion (P < 0.01). The median gas volume in the ileostomy output/24 hours was 1,664 ml before and 1,450 ml after conversion. The gas constituted 58 percent of the output and is significant with respect to the required reservoir capacity. Recording the emptying volumes and frequency in patients with reservoir ileostomy showed that, in general, patients with large output expand their reservoir capacity instead of increasing their emptying frequency.Sources of financial support: The Swedish Medical Research Council (Project No 577 and 9905), The Göteborg Medical Society, and The Foundation of the Faculty of Medicine.     

Selective preservation of the anal transition zone in ileoanal pouch procedures

PURPOSE: A prospective trial was conducted to evaluate use of certain preoperative criteria in the choice of operative technique for ileal pouch-anal anastomosis (IPAA). Handsewn vs. stapled anastomotic techniques were compared as was preservation vs. excision of the anal transition zone (ATZ). METHODS: Over an 18-month period, 40 consecutive patients underwent restorative proctocolectomy with IPAA for ulcerative colitis (31 cases) or familial adenomatous polyposis (9 cases). In 28 patients, ATZ was completely excised, by either a transanal mucosectomy with handsewn anastomosis (Group I, 13 cases) or by double-stapled technique (Group II, 15 cases). The ATZ was preserved and the anastomosis was double-stapled in colitis patients with suboptimum sphincter function and/or greater than 50 years of age in the absence of dysplasia or severe distal proctitis (Group III, 12 cases). RESULTS: Groups I and II patients were homogeneous in their preoperative variables and had equivalent functional outcome. Group III patients were older ( P=0.0001), with weaker preoperative anal sphincter resting tone ( P=0.024). Compared with Groups I and II, patients in Group III had significantly greater 24-hour stool frequency ( P=0.0056), daytime stool frequency ( P=0.0125), and incidence of daytime fecal seepage ( P=0.007). There was no significant difference in other outcome variables in Group III patients. There was no difference in morbidity in the three groups. CONCLUSIONS: Transanal mucosectomy with handsewn anastomosis provided early functional results equivalent to low anal transection with double-stapled IPAA in younger patients with excellent preoperative sphincter function. A double-stapled technique with preservation of the ATZ may be reserved for older patients, with poorer anal sphincter function, at minimum dysplasia/cancer risk, to optimize continence figures.Read at the meeting of New England Surgical Society, Montreal, Quebec, Canada, September 29 to October 1, 1995.No reprints are available.     

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.     

Predicting the functional result of anastomoses to the anus: The paradox of preoperative anal resting pressure

This article examines the effect of ileal pouch-anal (n=134) and coloanal (n=16) anastomoses on resting anal canal pressures in 150 patients. METHODS: Patients underwent anal manometry before ileal pouch-anal anastomosis (IPAA) and coloanal anastomosis (CAA) and again six weeks after ileostomy closure following these procedures. A water-perfused catheter system with four radial ports was used for manometry, pressures being recorded during both station and continuous pull through. RESULTS: Patients with IPAA were younger than those with CAA (34 years vs. 50 years) and had a different ratio of hand-to-stapled anastomosis (12.6 vs. 1.31). All CAA patients had had rectal cancer while IPAA patients suffered mainly from ulcerative colitis (n=114) or familial polyposis (n=10). The mean preoperative resting pressure for all patients was 79 mmHg (75–87, 95 percent confidence limit) and the mean fall in this pressure after surgery was 25 mmHg (–21 to –29, 95 percent confidence limit). There was no difference in preoperative pressure or fall between handsewn and stapled anastomoses, or between IPAA and CAA. CONCLUSION: There was a significant relationship between preoperative pressure and change in pressure that held true for all subgroups (change=–0.7 × preoperative pressure + 31,r=0.69). Analysis of the functional results confirmed that patients with high preoperative pressure are at risk for severe falls after surgery and are not guaranteed a good result. Conversely, patients with low preoperative pressures may actually have an increase with surgery and are not always incontinent. Patients with low preoperative anal resting pressures should not be denied anastomosis to the anus if they are continent.     

Colectomy-proctomucosectomy with S-pouch: Operative procedures,complications, and functional outcome in 69 consecutive patients

Sixty-nine patients were operated upon in a three-stage procedure. Early complications occurred in 29 percent after colectomy-ileostomy, in 25 percent after proctomucosectomy with ileoanal anastomosis and loop ileostomy, and in 9 percent after closure of loop ileostomy. Only three of these were considered serious. Seventy-one percent of the patients were readmitted into the hospital between the three operations or after the last one. Total hospital stay was 49 days (median); the range was 20 to 345 days. Reconstruction of the reservoir was performed in four patients owing to defecation problems, with satisfying functional results in two patients, while two emptied by catheter. There was no postoperative mortality or pelvic sepsis, and no pouches were excised. Ileostomy was re-established in two patients. At histopathologic reevaluation of colectomy specimens, the diagnosis was changed from ulcerative colitis to Crohn's disease in three patients and to indeterminate colitis in five. Median follow-up was 4.3 years. Continent anal defecation without ileostomy was achieved in 67 patients (97 percent), with 4.1 bowel movements per day and 0.6 per night. Perfect continence was achieved in 55 percent in the daytime and in 43 percent at night. The low rate of reservoirthreatening complications is attributed to the three-stage procedure and the technical details in the surgical procedures.This work was supported by grants from The Medical Research Council of the Swedish Life Insurance Companies and grants from the Karolinska Institutet.