Defecation mechanisms after anterior resection with J-pouch-anal and side-to-end anastomosis in dogs

Background Colonic J-pouch-anal anastomosis or colonic side-to-end anastomosis is the reconstruction of choice after low anterior resection. However, the mechanisms of defecation after both reconstruction forms are still speculative. Methods Low anterior rectal resections were performed in 12 dogs with six colonic J-pouch-anal (pouch) and six coloanal side-to-end (SE) reconstructions. Four months postoperative stool frequency, intestinal transit time, and neorectal compliance were determined by radiography and barostat. Defecation mechanisms were evaluated radiographically during expulsion of artificial stool. Results One dog with pouch reconstruction could not be evaluated due to an anastomotic leak, while the others had uncomplicated course. Spontaneous stool frequency was significantly increased with both reconstruction methods (control 2.0±0.9, pouch 2.7±1.2, SE 3.3±0.9 day; p<0.05). Intestinal transit time was significantly higher with pouch reconstruction due to storage of stool in the pouch and the descending colon compared to SE (control 760±82, pouch 592±97, SE 550±87 min; p<0.05). Compliance and functional capacity were higher in pouch than in side-to-end reconstructions (pouch 5.0±0.7 ml/mmHg, 124±23 ml; SE 2.7±0.3 ml/mmHg, 92±24 ml; p<0.05). During defecation, there were no contractions of the pouch detectable. Conclusions The colonic J-pouch reconstruction results in better functional outcome than side-to-end coloanal anastomosis. Our results show that pouch evacuation is passive and independent from pouch motility. The functional principle of the colonic J-pouch is not its reservoir function but a delay of colonic motility.     

Recovery of the Rectoanal Inhibitory Reflex After Restorative Proctocolectomy

PURPOSE: The rectoanal inhibitory reflex has an important role in fecal sampling and discrimination of rectal contents. The aim of this study was to determine the significance of rectoanal inhibitory reflex after restorative proctocolectomy with ileal pouch-anal anastomosis for mucosal ulcerative colitis. METHODS: The medical records of 345 patients who underwent ileal pouch-anal anastomosis from September 1988 to May 1999 were retrospectively reviewed. One hundred patients who underwent double-stapled ileal pouch-anal anastomosis and had anorectal physiology testing within 3 months before surgery as well as after ileostomy closure (mean, 23.1; range, 3–77 months) were analyzed. Anorectal physiology testing included detecting the presence of the rectoanal inhibitory reflex, sensory threshold volume, and rectal or pouch capacity and compliance. Parameters to determine incontinence included daytime and nocturnal bowel movement frequency, nocturnal spotting, status of continence for solid or liquid stool, gas, use of pads, and lifestyle alteration were surveyed in 62 of the 100 patients at a mean of 3.9 (range, 1–9.1) years to determine the incontinence score. RESULTS: Whereas the rectoanal inhibitory reflex was noted in 96 (96 percent) patients before surgery, it was found in only 53 (53 percent) after ileostomy closure (P < 0.0001). Incontinence status data was available in only 62 of the 100 patients (32 RAIR-positive; 30 RAIR-negative). There were no significant differences between the rectoanal inhibitory reflex-positive and the rectoanal inhibitory reflex-negative groups relative to the interval between surgery and manometry (22 vs. 25 months), postoperative threshold sensation volume (32 vs. 31 ml), postoperative compliance (19 vs. 12 cm H2O/ml), postoperative capacity (85 vs. 66 ml), daytime/nighttime stool frequency (6.2/2 vs. 5.5/1.5), or postoperative incontinence score (3.9 vs. 1.8). However, there were significant differences relative to the incidence of nocturnal soiling (12/30 (40 percent) vs. 23/32 (72 percent), P = 0.0012) favoring the presence of the rectoanal inhibitory reflex. CONCLUSION: Preservation of the rectoanal inhibitory reflex correlated with a decrease in the incidence of nocturnal soiling after double-stapled ileoanal reservoir construction.     

Comparison of functional results of ileorectal and ileo-anal anastomoses in familial adenomatous polyposis. Conversions of ileorectal anastomoses into ileo-anal anastomoses]

The aim of this study was to compare the functional results of ileo-rectal anastomosis and ileal pouch-anal anastomosis in a group of patients with familial adenomatous polyposis who had conversion of a ileorectostomy into a ileal pouch-anal anastomosis. In 2 cases (8.3 percent), the conversion was impossible because of abdominal desmoid tumors. For the remaining 21 patients, with more than 1 year follow-up, the number of bowel movements per 24 hours was 3.8 +/- 0.2 before and 4.6 +/- 0.3 after conversion. Daytime and nighttime continence and sensation of the need to defecate were unchanged. The number of patients having nocturnal bowel movements were higher after the pouch procedure (40 vs 10.5 percent). After ileorectostomy and after conversion, 89.5 and 80 percent of the patients had good functional results respectively. Ninety percent of the patients said that results were unchanged or improved after the conversion. In familial adenomatous polyposis the functional results of ileal pouch-anal anastomosis are similar to those of ileorectostomy but the first procedure eradicates the risk of rectal cancer. A conversion to ileal pouch-anal anastomosis should to be proposed to patients with ileorectostomy and at high risk for rectal cancer.     

Straight ileoanal anastomosis with multiple ileal myotomies as an alternative to pelvic pouch

. An alternative technique of restorative proctocolectomy, by means of straight ileoanal anastomosis with multiple myotomies (SIAM) of the terminal ileum in 15 patients, nine with familial adenomatous polyposis (FAP) and six with ulcerative colitis (UC) is reported. Surgical technique: eight to ten longditudinal myotomies (3 – 4 cm long, on three different circumferential sites) were performed on the terminal ileum for a total length of 12 – 14 cm. Clinical results: at a mean follow up of 44 months (range 3 – 84 months) from the closure of the ileostomy, daytime continence was achieved in all the patients; stool frequency per 24 hours (±SD) was 4.1±1.8 for FAP patients and 5.8±1.7 for UC patients; nocturnal defecation was 1.0±0.5 and 1.2±0.8 for FAP and UC patients respectively; frequent nocturnal soiling was present in 2/5 of UC patients, and in 3/9 of FAP patients. SIAM failed in one UC patient that was converted to an ileoanal reservoir because of poor functional result. Signs of ileal mucosal inflammation were never observed at endoscopic examination. Histopathological assessment showed no evidence of acute terminal ileitis. Manometric findings: a significant postoperative reduction in anal resting pressure was observed after SIAM. Neither the absence of anal inhibitory reflex nor the presence of high pressure waves generated in the terminal ileum during air insufflation were related to the presence of soiling. The closure of the loop ileostomy was followed by an increased capacity and distensibility of the terminal ileum. Values of neorectal compliance were similar in FAP and UC patients although FAP patients were able to reach higher values of maximum tolerated volume and pressure. Conclusions: 1) SIAM can be an alternative to pelvic pouch in patients who have undergone restorative proctocolectomy when the construction of the pouch is not feasible. 2) The functional result observed after SIAM has been shown to be similar to that observed after pouch construction.     

Transverse Coloplasty Pouch After Total Mesorectal Excision: Functional Assessment of Evacuation

PURPOSE Colon pouch reconstruction after total mesorectal excision is functionally superior to straight colorectal/anal anastomosis. In the long-term, stool evacuation difficulties could jeopardize the functional benefit. The transverse coloplasty pouch presents an alternative to the standard J-pouch. This study was designed to analyze functional outcome and defecography findings after total mesorectal excision and transverse coloplasty pouch reconstruction.METHODS Thirty consecutive patients with cancer of the middle and lower third of the rectum underwent a total mesorectal excision and were examined in a prospective study. In all patients, reconstruction was performed with a transverse coloplasty pouch. Pouch and anastomosis were checked by Gastrografin^® enema postoperatively. Patients were examined within eight months by means of defecography, manometry, pouch volumetry, and a standardized continence questionnaire.RESULTS Total mesorectal excision with transverse coloplasty pouch anastomosis was performed successfully in all patients. Symptomatic anastomotic leakage was observed in 2 of 30 patients and the radiologic leak rate was 4 of 30. All patients evacuated the pouch completely; none needed enemas or suppositories to facilitate defecation. Twenty-five of 27 patients had a maximum of three bowel movements per day, and all patients were continent for solid stools. Patients with abnormal findings on defecography proved more likely to have anal dysfunction.CONCLUSIONS Transverse coloplasty pouch reconstruction after total mesorectal excision leads to good functional results and is not associated with stool evacuation problems. Urgency and incontinence correlate rather with impaired pelvic floor movement than with pouch size or anal sphincter tonus.Presented at the Congress: Rectal Cancer Treatment, Heidelberg, Germany, October 9 to 11, 2003.Reprints are not available.     

Ileo-anal pouch anastomosis: results in ulcero-hemorrhagic rectocolitis and in familial adenomatous polyposis

Two hundred twenty-four ileal pouch-anal anastomoses have been made, 122 for ulcerative colitis and 102 for familial adenomatous polyposis. All the patients had a J pouch and a diverting temporary ileostomy. Mortality was 0.5%. Twenty-eight % of the patients with ulcerative colitis and 24% of the patients with familial adenomatous polyposis had various postoperative complications. Seventy-two patients with ulcerative colitis had a follow-up of more than one year. They had a mean of 4.6 stools per 24 hours; 84% had a normal day-time continence and 70% a normal nocturnal continence. Sixty-nine patients with familial adenomatous polyposis had a follow-up of more than one year. They had a mean of 4.1 stools per 24 hours; 93% had a normal daytime continence and 91% a normal nocturnal continence. In conclusion, ileal pouch-anal anastomosis can be made safely, with good functional results.     

The effect of pregnancy and delivery on the ileal pouch-anal anastomosis functions

Since 1981, a total of 729 ileal pouch-anal anastomoses have been performed at the Mayo Clinic-affiliated hospitals. Three hundred fifty-four were in women. Twenty of these patients subsequently had at least one successful pregnancy and delivery. Eleven deliveries were vaginal with episiotomy, and nine were cesarean sections. No maternal deaths occurred. One child died of hyaline membrane disease. The frequency of nocturnal stooling increased in the ileal pouch-anal anastomosis patients during pregnancy (P<.01) and the increase persisted for three months after delivery (P<.05). In contrast, the frequency of daytime stools, the incidence of incontinence, the consistency of the stool, and the development of perineal seepage or skin irritation were not greatly altered by pregnancy or delivery. Moreover, postpartum pouch function was not influenced by the type of delivery (vaginalvs. cesarean section). In conclusion, pregnancy and delivery are safe in patients with the ileal pouch-anal anastomosis, but they lead to more frequent nocturnal stools. The type of delivery (vaginalvs. cesarean section) does not influence pouch functional outcome. Read in part at the meeting of the American Society of Colon and Rectal Surgeons, Anaheim, California, June 12 to 17, 1988.     

The endorectal ileal pouch-anal anastomosis

One hundred thirteen patients with either chronic ulcerative colitis (108 patients) or familial polyposis coli (five patients) received an ileal J pouch-anal anastomosis after sphincter-saving proctocolectomy. There were no postoperative deaths. Leaks (radiologic and/or clinical) from the pouch or ileoanal anastomosis occurred in 14 per cent of patients. Small-bowel obstruction, requiring operative correction, occurred in 7 per cent and 3 per cent, respectively, of patients after either proctocolectomy or closure of the loop ileostomy. All 66 patients whose diverting ileostomy had been closed for at least three months could defectate spontaneously and their mean (±SE) stool frequency per 24 hours was 9.0±1 at one month and 5.9±at 12 months. Major fecal incontinence was observed in 3 per cent of patients, and two patients eventually required a permanent ileostomy. The ileal J pouch-anal anastomosis has become our procedure of choice in selected patients who require proctocolectomy Presented in part at the annual meeting of the American Society of Colon and Rectal Surgeons, Boston, Massachusetts, June 5 to 9, 1983. Supported in part by the Medical Research Council of Canada, NIH Grants AM18278 and RR00585 and the Mayo Foundation.     

Different role of the colonic pouch for low anterior resection and coloanal anastomosis

Abstract Background Functional outcome after sphincter-saving operations can be improved by colonic pouch compared to the straight procedure. However, it is not clear whether the colonic pouch has a different behavior in patients treated by low anterior resection with colorectal (LAR) or coloanal anastomosis (CAA). Methods We evaluated the 1-year results of 75 patients who underwent a sphincter-saving operation for rectal carcinoma or villous tumor of the middle or lower third of the rectum: 18 patients underwent coloanal anastomosis (CAA), in 13 patients we performed a coloanal anastomosis with a colonic pouch (PCAA), 20 patients had low anterior resection (LAR) and 24 had LAR with pouch construction (PLAR). The two groups of patients were similar in terms of age and gender. Anorectal function was assessed 12 months after the initial operation by an interview and anorectal manometry. Results One year after surgery, the daily mean number of defecations was significantly higher in the LAR group than in the other groups (2.0±1.5 in CAA group, 2.2±1.0 in PCAA, 2.3±1.8 in PLAR, 4.1±0.7 in LAR; p<0.05). Frequent soiling was observed in all the groups except PLAR. A lower degree of incontinence and a lower frequency of urgency were found in PCAA than in CAA. There were no differences in anal resting pressure and squeeze pressure among the various groups. Greater distensibility and compliance of the neorectum were observed in CAA, PCAA and PLAR compared to LAR, respectively 8.5±7.0 ml air/mmHg for CAA, 8.7±5.0 ml air/mmHg for PCAA, 6.3±4.0 ml air/mmHg for PLAR and 3.1±2.7 ml air/mmHg for LAR. A significant inverse linear correlation was present between the mean daily number of defecations and compliance. No difference in sense of incomplete evacuation was observed among the groups of patients. Conclusions Colonic J-pouch provides an advantage over straight anastomosis in sphincter-saving operations by reducing the daily number of defecations, and the frequencies of fecal soiling and urgency. The role of the pouch seems to be different in LAR compared to CAA. In fact, in LAR the pouch increases compliance and consequently decreases the daily number of defecations. In CAA, the pouch does not reduce the number of defecations or the compliance, but reduces the frequency of fecal soiling and urgency.     

Heal pouch pressures after defecation in continent and incontinent patients

After ileal pouch-anal anastomosis, a pouch/anal canal pressure gradient is present such that mean pressures in the anal canal exceed pressures in the pouch facilitating fecal continence. Such a relationship was not present in incontinent patients. PURPOSE: Our aim was to evaluate characteristics of pouch pressures dynamically in continent and incontinent patients following ileal pouch-anal anastomosis (IPAA). METHODS: A multichannel microtransducer catheter was positioned in eight continent patients and nine incontinent patients after IPAA. Twenty-four-hour recordings of pouch pressures and large pressure wave contractions were recorded when patients were awake, asleep, and after evacuation. RESULTS: When patients were awake, pouch pressures were similar. However, nocturnal pouch pressures were higher in the incontinent group (P <0.05). Large pressure wave amplitude was higher in incontinent patients when awake and asleep (P <0.05). Moreover, pouch pressures failed to decline in the incontinent group after evacuation, unlike continent patients. CONCLUSION: Compared with continent patients, incontinent patients after IPAA had persistently high phasic and basal pouch pressures at night and following pouch evacuation.     

Laparoscopic-Assisted vs. Open Ileal Pouch-Anal Anastomosis: Functional Outcome in a Case-Matched Series

PURPOSE Functional outcomes in laparoscopic-assisted ileal pouch-anal anastomosis have been incompletely studied. More than one-year follow-up has rarely been reported in these patients. This study was designed to assess operative, functional, and quality of life outcomes in patients with ulcerative colitis or familial adenomatous polyposis a minimum of one year after. METHODS Thirty-three laparoscopic-assisted ileal pouch-anal anastomosis and 33 open ileal pouch-anal anastomosis patients, with a median of 13 months and minimum of 12 months follow-up, were identified from a prospective, laparoscopic database. Functional outcome was prospectively assessed by using a standardized survey. These cohorts were matched by individual patient for year of surgery, age, gender, body mass index, and indication. RESULTS Median age was 27 years (open) and 28 years (laparoscopic). There were 27 females and 6 males in each group. All operations occurred between 1999 and 2001. Median body mass index was 22.3 (open) and 21.7 (laparoscopic) groups. There were no significant differences in diagnosis, use of diversion, and anastomotic technique. Postoperative morbidity occurred in 6 percent of the laparoscopic cases and 12 percent of the open cases. Functional outcome after a minimum of one year revealed equivalent median day and median nocturnal number of stools of six to seven and one to two respectively. Consistency of stool, medication usage, and continence were no different between groups. Daytime and nocturnal incontinence was similar. Quality of life in regard to social, home life, family, travel, sports, recreation, and sex life were equivalent. CONCLUSIONS The function and quality of life outcomes for patients undergoing laparoscopic-assisted ileal pouch-anal anastomosis seem to be equivalent to our open experience. Laparoscopic-assisted ileal pouch-anal anastomosis offers selected patients a safe, feasible, and durable alternative. Poster presentation at the meeting of The American Society of Colon and Rectal Surgeons, Dallas, Texas, May 8 to 13, 2004.     

Indeterminate colitis

Uncertainty persists concerning the long-term results of ileal pouch-anal anastomosis performed for indeterminate colitis. PURPOSE: This study was designed to compare functional outcomes of ileal pouch-anal anastomosis in patients with typical chronic ulcerative colitis and indeterminate colitis. METHOD: Seventy-one ileoanal pouch patients were identified with a diagnosis of indeterminate colitis. Mean follow-up was 56 months. Outcomes were compared with 1,232 chronic ulcerative colitis patients after ileal pouchanal anastomosis. Mean follow-up was 60 months. RESULTS: (mean±SD) There was no difference in the frequency of daily bowel movements (indeterminate colitis, 7±3,vs.chronic ulcerative colitis, 7±2). Daytime and nighttime incontinence rates were likewise similar. Prevalence of pouchitis was identical (33 percent). However, failure rate was higher in the indeterminate colitis group (indeterminate colitis, 19 percent,vs. chronic ulcerative colitis, 8 percent; (P =0.03)). CONCLUSIONS: At a mean of nearly five years after surgery, failure appears to occur more frequently in patients with indeterminate colitis than in patients with chronic ulcerative colitis. However, the great majority of indeterminate colitis patients (>80 percent) have long-term functional results identical to those of patients with chronic ulcerative colitis.     

Functional outcome of conversion of ileorectal anastomosis to ileal pouch-anal anastomosis in patients with familial adenomatous polyposis and ulcerative colitis

PURPOSE: The aim of this study was to review the functional outcome in 20 patients with familial adenomatous polyposis and ulcerative colitis who were converted from ileorectal anastomosis to ileal pouch-anal anastomosis. METHODS: From 1985 to 1997, 12 patients with familial adenomatous polyposis (5 males; mean age, 39.1 years) and 8 patients with ulcerative colitis (5 males; mean age, 36.7 years) underwent conversion from ileorectal anastomosis to ileal pouch-anal anastomosis. Clinical and operative data were analyzed retrospectively. Functional results were obtained by telephone interview in 16 patients (94 percent) after pouch construction. Four patients were not interviewed (2 were deceased, 1 was lost to follow-up, and 1 was not reachable). RESULTS: Indications for conversion were uncontrollable rectal polyps (10 patients) and colonic cancer found in the pathology specimen after ileorectal anastomosis in patients with familial adenomatous polyposis (2 patients), intractable proctitis (5 patients), colonic cancer found in the pathology specimen of patients with ulcerative colitis after ileorectal anastomosis (2 patients), and rectal dysplasia (1 patients). Mean follow-up time was 5 (range, 1–11) years. Ileal pouch-anal anastomosis was handsewn in 14 patients, and the remaining cases were double-stapled in 4 patients with ulcerative colitis. No intraoperative difficulties were reported in 13 cases; technical problems were related to adhesions (3 cases), difficult rectal dissection (2 cases), and stapler-related difficulties (2 cases). Postoperative complications after ileal pouch-anal anastomosis included small-bowel obstruction (4 patients) and ileal pouch-anal anastomosis leak (1 patient). Patients with ileorectal anastomosisvs. those with ileal pouch-anal anastomosis had a better functional outcome with regard to nighttime continence (14 (88 percent)vs. 6 (38 percent) patients) and average bowel movements (<6/day; 12 (75 percent)vs. 4 (25 percent) patients). Complete daytime continence, 15 (94 percent)vs. 10 (62 percent) patients, was similar in the two groups. Physical and emotional well-being were similarly rated as very good to excellent. CONCLUSIONS: In patients with familial adenomatous polyposis and ulcerative colitis with ileorectal anastomosis, conversion to ileal pouch-anal anastomosis may be required. In view of the risk of rectal cancer or intractable proctitis, patients seem to accept the conversion in spite of poorer bowel function.Read at the meeting of The American Society of Colon and Rectal Surgeons, San Antonio, Texas, May 2 to 7, 1998.     

Parking the Pouch: Pouch Salvage After Anastomotic Leak Following Restorative Proctocolectomy. Report of a Case

Anastomotic leak is a feared complication after restorative proctocolectomy with formation of an ileal pouch. We describe the use of a technique that is appropriate for profound anastomotic failure in the immediate postoperative period, which will aid in controlling sepsis and may allow salvage of the pouch. A 59-year-old man who failed medical treatment underwent restorative proctocolectomy and ileal pouch-anal anastomosis as a single-stage procedure. The patient developed an anastomotic leak that was not controlled by defunctioning stoma formation. Further surgery was undertaken and the pouch was exteriorized as a mucous fistula. A redo pouch-anal anastomosis was performed 12 months after the original procedure. The patient has good functional outcome with complete continence. Anastomotic leak after restorative proctocolectomy and ileal pouch-anal anastomosis often can be managed by conservative or local procedures. Laparotomy may be required rarely, but this subgroup is associated with pouch failure in up to half of the patients. Awareness that the ileal pouch-anal anastomosis can be taken down and the pouch temporarily parked in the abdominal cavity may persuade surgeons to retain a pouch with the knowledge that the acute pelvic sepsis after an anastomotic leak can be safely treated.     

Incidence and subsequent impact of pelvic abscess after ileal pouch-anal anastomosis for chronic ulcerative colitis

PURPOSE: This study was designed to measure the impact of pelvic abscess on eventual pouch failure and functional outcome after ileal pouch-anal anastomosis in patients with chronic ulcerative colitis. PATIENTS AND METHODS: The outcome of 1,508 patients who underwent ileal pouch-anal anastomosis for chronic ulcerative colitis at the Mayo Clinic was determined from a central patient registry; data were collected prospectively. RESULTS: Seventy-three patients developed a pelvic abscess as a complication of ileal pouch-anal anastomosis. Pouch failure occurred in 19 (26 percent). Forty-eight patients (55 percent) required transabdominal salvage surgery, 6 (8 percent) underwent local surgery, and the remaining 27 (37 percent) were treated nonsurgically. Wound infection was more common in patients who experienced pelvic abscess. The majority of pouch failures secondary to pelvic abscess formation occurred within two years of ileal pouch-anal anastomosis. Daytime incontinence, the use of a protective pad, and the need for constipating or bulking medication were significantly more common among patients who had an abscess but kept their reservoir. Ability to perform work and domestic activities and to undertake recreational activities were significantly more restricted among these patients. CONCLUSIONS: Pouch failure occurs in one-fourth of patients who retain their pouch despite pelvic abscess after ileal pouch-anal anastomosis. Among patients who retain their pouch despite postoperative pelvic abscess, functional outcome and quality of life are significantly poorer than in patients in whom no sepsis occurred.     

Coloplasty in low colorectal anastomosis

PURPOSE: After resection of the distal rectum with a straight reanastomosis, poor bowel function can occur. This is felt to be because of the loss of the rectal reservoir. To overcome this, a neoreservoir using a colonic J-pouch has been advocated in low colorectal and coloanal anastomosis. However, difficulties in reach, inability to fit the pouch into a narrow pelvis, and postoperative evacuation problems can make the colonic J-pouch problematic. Coloplasty is a new technique that may overcome the poor bowel function seen in the straight anastomosis and the problems of the colonic J-pouch. The purpose of this study was to compare the functional results after a low colorectal anastomosis among patients receiving a coloplasty, colonic J-pouch, or straight anastomosis. METHODS: Twenty patients underwent construction of a coloplasty with a low colorectal anastomosis. Postoperative manometry and functional outcome of these patients was compared with a matched group of 16 patients who had a colonic J-pouch and low colorectal anastomosis and 17 patients who had a straight low colorectal anastomosis. RESULTS: Maximum tolerated volume was significantly favorable in the coloplasty (mean, 116.9 ml) and colonic J-pouch group (mean, 150 ml) vs. the straight anastomosis group (mean, 83.3; P < 0.05) The compliance was also significantly favorable for the coloplasty (mean, 4.9 ml/mmHg) and the colonic J-pouch group (mean, 6.1 ml/mmHg) vs. the straight anastomosis group (mean, 3.2 ml/mmHg; P < 0.05) The coloplasty (mean, 2.6; range, 1-5) and colonic J-pouch (mean, 3.1; range, 2-6) had significantly fewer bowel movements per day than the straight anastomosis group (mean, 4.5; range, 1-8; P < 0.05). Similar complication rates were noted in the three groups. CONCLUSIONS: Patients with a coloplasty and low colorectal anastomosis seem to have similar functional outcome along with similar pouch compliance compared with patients with colonic J-pouch and low colorectal anastomosis. However, the coloplasty may provide an alternative method to the colonic J-pouch for a neorectal reservoir construction when reach or a narrow pelvis prohibits its formation. Technically it also may be easier to construct.     

Long-term functional evaluation of straight coloanal anastomosis and colonic J-pouch

AIM: This study was designed to analyze the functional and clinical outcomes of straight coloanal anastomosis compared with colonic J-pouch performed after low anterior resection. MATERIALS AND METHODS: Between September 1989 and June 1996, all patients who underwent low anterior resection with anastomosis less than 4 cm from the dentate line were classified into two groups based on the restoration of intestinal continuity: “straight” coloanal anastomosis (n=39) or colonic J-pouch (n=44). Both groups were assessed according to the level of anastomosis, anastomotic complications (stricture, leak, pelvic abscess), age, and gender. For comparison of functional outcome, daily bowel movements, tenesmus, urgency, incontinence score (range, 0–20), and anorectal manometric findings were evaluated preoperatively and at six months, and one and two years after surgery. RESULTS: There were no significant differences between the groups relative to age: (coloanal anastomosis, 66.3±10.1 (range, 46–86),vs. colonic J-pouch, 64.9±13.2 (range, 39–88) years); gender (females): (coloanal anastomosis, 46.2 percentvs. colonic J-pouch; 38.6 percent); diagnosis: (rectal carcinoma: coloanal anastomosis, 84.6 percent,vs. colonic J-pouch, 77.3 percent); preoperative incontinence score (coloanal anastomosis, 1.5±4.6,vs. colonic J-pouch, 1.1±4); bowel movements: (coloanal anastomosis, 2.1±2.3,vs. colonic J-pouch, 2.1±1.9/day); level of anastomosis: (coloanal anastomosis, 1.8±1.3,vs. colonic J-pouch, 1.5±1.3 cm from the dentate line); history of perioperative radiation therapy: (coloanal anastomosis, 15.4 percent,vs. colonic J-pouch, 20.5 percent); or manometric findings. There was also no significant difference in postoperative mortality: (coloanal anastomosis, 5.1 percent,vs. colonic J-pouch, 2.3 percent); or anastomotic complications: (coloanal anastomosis, 7/39 (17.9 percent),vs. colonic J-pouch, 2/44 (4.5 percent)P=0.08); strictures: (10.3vs. 0 percent); leaks: (5.1vs. 2.3 percent); bleeding: (2.6vs. 0 percent); rectovaginal fistula: (0vs. 2.3 percent). Also, in the colonic J-pouch group, two patients developed pouchitis, and one patient experienced difficult evacuation one year after surgery. There was a statistically significant better function judged by less frequent bowel movements (4±2vs. 2.4±1.3/day;P<0.005) and urgency (36.7vs. 7.7 percent;P<0.05), incontinence score (2.2±3.7vs. 0.8±1.6;P<0.05) up to one year after surgery. At two years, the coloanal anastomosis group did not show statistical improvement in functional results compared with one year postoperatively. Rectal compliance in manometric findings was significantly increased in the coloanal anastomosis group at one year after surgery (12.4±12.6vs. 4.2±1.5 ml/mmHg;P<0.05). However, these differences were less profound after two years. CONCLUSION: The functional superiority of the colonic J-pouch was greatest at one year after surgery. By two years, adaptation of the “straight” coloanal anastomosis yielded similar functional results. However, the almost fourfold reduction in anastomotic complications in the colonic J-pouch group reveals a second potential advantage of this technique.     

Quality of life after proctocolectomy and ileal pouch-anal anastomosis in patients with ulcerative colitis

Purpose

While ileal pouch-anal anastomosis is performed in many patients with ulcerative colitis, conflicting data exist about its effects on quality of life. We aimed to determine quality of life and to identify risk factors for impaired quality of life in these patients.

Methods

Forty-eight of 82 patients (59 %; median follow-up 57 months [range 21–93 months]) after ileal pouch-anal anastomosis for ulcerative colitis were compared to 48 matched healthy controls. Generic, health-, and disease-related, as well as symptom-specific quality of life was analyzed using five well-established quality of life instruments.

Results

Although generic quality of life was comparable between groups, health-related quality of life was impaired after ileal pouch-anal anastomosis. While high stool frequency was associated with impaired health-related and disease-specific quality of life, fecal incontinence and history of pouchitis also caused a deterioration of generic and symptom-related quality of life. Seventy-seven percent of patients reported their quality of life to be better compared to the situation before surgery and 88 % would undergo ileal pouch-anal anastomosis again.

Conclusions

Overall quality of life after ileal pouch-anal anastomosis is good. However, high stool frequency, fecal incontinence, and pouchitis are associated with impaired quality of life and should be prevented or treated to the best possible extent.     

Functioning neorectum

Seventeen patients (15 males, 2 females) underwent restorative proctocolectomy during the 4 year period 1983-87. Twelve patients had familial adenomatous polyposis. Two of these had superimposed malignancy--one each in the cecum and transverse colon. Five patients had ulcerative colitis. Ten pouch procedures were of the J type, six of the S type and one of W configuration. There was one death (mortality 6%). Mean stool frequency was 4.2 per day at one year after surgery and all patients were totally continent at this time. The ileal pouch-anal anastomosis provided a functioning neorectum with low stool frequency and complete continence. The J pouch was found to be functionally superior though the numbers were too small to allow statistical comparison.     

Consequences of delayed ileostomy closure after ileal pouch-anal anastomosis

Temporary diverting loop ileostomy is a generally accepted component of the ileal pouch-anal anastomosis (IPAA) procedure. Ileostomy closure is usually performed within two to three months but may be delayed because of disruption of the ileoanal anastomosis, suspected leak from the ileal reservoir, concomitant medical problems, or patient convenience. Of 362 patients undergoing IPAA at The Cleveland Clinic Foundation for inflammatory bowel disease, 10 have had their ileostomy closures delayed for more than six months. Clinical and manometric parameters are examined in these patients and compared with those who had earlier closure. There appears to be no significant difference in the functional outcome of IPAA in these patients in terms of number of bowel movements and degree of continence. Reservoir compliance and maximum tolerated volumes are similar. We conclude that delaying ileostomy closure for more than six months after IPAA has no deleterious effect on pouch function.