Laparoscopic total abdominal colectomy with ileorectal anastomosis for familial adenomatous polyposis

PURPOSE: This study was undertaken to describe our results in a series of patients undergoing total abdominal colectomy with ileorectal anastomosis (TAC/IRA) using laparoscopic techniques in patients with familial adenomatous polyposis (FAP) and rectal-sparing. Young patients with FAP requiring TAC/IRA may be ideal candidates for minimally invasive surgery, because they are generally thin and have benign disease. They might benefit maximally from the theoretic advantages of these techniques. METHODS: We have performed laparoscopic TAC/IRA in 16 FAP patients (10 females; mean age, 18 years). Procedures were entirely intracorporeal, with a 3-cm to 6-cm specimen extraction incision. RESULTS: Median operative time was 232 (range, 156–285) minutes, and blood loss 175 (range, 50–675) ml. The only intraoperative complication, a twisted ileorectal anastomosis, was noted intraoperatively and revised. There were no conversions to conventional laparotomy. Median postoperative interval to passage of flatus was three days,^1–4 and for bowel movements it was three days.^1–4 Median hospital stay was five days.^3–11 One case of early postoperative small-bowel obstruction was treated nonoperatively, and one case of brachial plexus neuropraxia resolved spontaneously. CONCLUSIONS: Based on this preliminary experience, we believe laparoscopic TAC/ IRA can be a safe and effective treatment for selected patients with FAP. As techniques and instrumentation for laparoscopic colon surgery are perfected, this procedure will likely become an appealing option in the management of patients with FAP. Poster presentation at the meeting of The American Society of Colon and Rectal Surgeons, Seattle, Washington, June 9 to 14, 1996. No reprints are available     

Fate of the rectal stump after colectomy and ileorectal anastomosis for familial adenomatous polyposis

The justification of colectomy and ileorectal anastomosis as the primary treatment for familial adenomatous polyposis (FAP) remains questionable because of the rectal cancer risk. We estimated both the cancer risk and the need of rectal excision for benign polyposis in 100 FAP patients. We also evaluated the effects of sulindac therapy and the complications of polyp fulgurations during the follow-up time of the median of 10.6 years (2 to 29 years) after ileorectal anastomosis. There were 46 women and 54 men with a mean age of 32 years (17–67 years) at the operation. Forty-two patients were propositi and 15 had colon cancer primarily. Cumulative risk of rectal cancer and combined risk of cancer and rectal excision for other causes were estimated (Kaplan-Meier analysis) both from the date of surgery and from birth. Nine patients developed rectal cancer, while 12 others has the rectum excised for benign conditions. The cumulative rectal cancer risk was 4%, 5.6%, 7.9% and 25% at 5, 10, 15 and 20 years after the operation, respectively. Rectal excision rates were 7.3%, 13.7%, 23.6%, and 36.6%, correspondingly and finally 73.8%. Age-dependent rectal cancer risks were 3.9%, 12.8% and 25.7% at 40, 50 and 60 years, and the rectal excision rates 9.5%, 26.3% and 44%, respectively. Sulindac caused at least partial regression of rectal adenomas in 71% of patients without major adverse effects, but the long term effects of sulindac and impact on malignant transformation of rectal adenomas are not known. Our results favour proctocolectomy and ileonal anastomosis as the primary operation for FAP instead of colectomy and ileorectal anastomosis.

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Résumé. La justification d'une colectomie avec anastomose iléo-rectale comme constituant le traitement primaire d'une polypose adénomateuse familiale reste très controversée en raison du seul risque de cancer rectal. Nous avons tenté de définir à la fois le risque de cancer et la nécessité d'une excision rectale pour des polypes bénins chez 100 patients porteurs de FAP. Nous avons également évalué l'effet d'un traitement au sulindac et les complications de l'électrocoagulation de polypes durant la période suivie qui est en moyenne de 10,6 ans (2 à 29 ans) après une anastomose iléo-rectale. Quarante-six hommes et 54 femmes avec un age moyen de 32 ans (17–67 ans) ont été opérés. Quarante-deux patients étaient porteurs d'une pré-cancérose et 15 avaient un cancer colique certain. Le risque comulé de cancer du rectum et le risque combiné d'un cancer et d'une excision rectale pour d'autres causes ont été estimés (analyse selon Kaplan-Meier) à la fois à partir de la date d'intervention chirurgicale et à partir de la naissance. Neuf patients ont développé un cancer du rectum alors que 12 ont eu leur rectum excisé pour les lésions bénignes. Le risque cumulatif des cancers du rectum est de 4%, 5,6%, 7,9% et 25% à 5, 10, 15 et 20 ans de l'opération respectivement. Les taux d'excision rectale sont de 7,3%, 13,7%, 23,6% et 36,6%. Le risque d'un cancer du rectum on fonction de l'age est de 3,9%, 12,8%, 25,7% à 40, 50 et 60 ans et le taux d'excision du rectum respectivement de 9,5%, 26,3% et 44%. Le sulindac entra?ne au moins une régression partielle des adénomes du rectum dans 71% des cas, sans effet secondaire majeur mais les résultats à long terme du sulindac et les répercussions sur l'éventuelle transformation maligne des adénomes du rectum ne sont pas connues. Nos résultats sont en faveur d'une proctocolectomie et d'une anastomose iléo-anale comme traitement de choix de première intention en cas de FAP à la place de la colectomie avec anastomose iléo-rectale.

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Accepted: 17 December 1996     

Risk factors for rectal cancer morbidity and mortality in patients with familial adenomatous polyposis after colectomy and ileorectal anastomosis

PURPOSE: The aims of the study were to investigate the effects of ileorectal anastomosis and the follow-up program on rectal cancer morbidity and mortality and to identify risk factors that predict the fate of the rectal stump. METHODS: One hundred ninety-five patients with familial adenomatous polyposis on whom an ileorectal anastomosis was performed between 1957 and the end of 1995 were included. Median follow-up time was 14 (range, 1-39) years. The cumulative risks of rectal cancer and rectal excision were estimated using survival analysis. RESULTS: Eighteen patients (9.2 percent) developed cancer, 17 in the retained colorectal segment and one on the ileal side of the anastomosis, and nine died of their cancer during the study period. The cumulative rectal cancer morbidity and mortality 20 years after ileorectal anastomosis was 12.1 percent (95 percent confidence interval = 5.7-18.5) and 7 percent (95 percent confidence interval = 2-12), respectively. The cumulative age-dependent risk of rectal cancer was 22.9 percent (95 percent confidence interval = 11.4-34.5) and 25.7 percent (95 percent confidence interval = 13.2-38.2) at the ages of 60 and 70 years, respectively. The corresponding cumulative mortality was 11.1 percent (95 percent confidence interval = 2.9-19.3) at the age of 70 years. Patients with dense polyposis at colectomy had an increased risk for cancer in the retained colorectal segment compared with patients with intermediate or sparse polyposis (P = 0.04). Sixty-six patients (34 percent) had their rectum removed, and the cumulative rectal excision rate 35 years after ileorectal anastomosis was 65.5 percent (95 percent confidence interval = 53-78). CONCLUSION: Patients on whom ileorectal anastomosis was performed had, despite the high rectal excision rate, a substantial risk of developing cancer in the retained colorectal segment, with an ensuing high mortality. Our results indicate that patients with dense polyposis should undergo restorative proctocolectomy as primary operation for familial adenomatous polyposis. In younger patients with intermediate or sparse polyposis and good expected follow-up compliance, ileorectal anastomosis still is an alternative.     

Quality of life after prophylactic colectomy and ileorectal anastomosis in patients with familial adenomatous polyposis

BACKGROUND: Prophylactic colectomy or proctocolectomy is standard treatment for colorectal manifestation of familial adenomatous polyposis (TAP), a dominantly inherited disorder for which the risk of developing colorectal cancer in an untreated patient is close to 100 percent. Hereditary nonpolyposis colorectal cancer (HNPCC) is also dominantly inherited but has a lower risk of colorectal cancer than FAP and does not have a clinically obvious phenotype. The role of prophylactic colectomy in patients with HNPCC is controversial. PURPOSE: This study was performed to examine the outcome of colectomy and ileorectal anastomosis (TRA) so its use as a prophylactic procedure can be better evaluated. METHODS: Records of all patients undergoing IRA for FAP between 1985 and 1993 were reviewed. Demographic data and data about the operation were collected. Surgical outcome data included length of hospital stay, complications, bowel function, quality of life, and patient satisfaction. RESULTS: There were 51 patients with a median age of 28 years; 24 were male. All but eight patients were asymptomatic, and all had less than 1,000 polyps in the resected specimen. Mean surgery time was 3.5 hours, mean blood loss was 406 ml, and median length of hospital stay was seven days. There were no deaths, and eight patients (16 percent) had complications. Mean number of stools per day after median follow-up of 4.2 years was 3.6. Only 11 patients had nighttime stooling. Four patients reported seepage, 9 had some incontinence, and 16 had urgency. Quality of life, rated on a scale of 0 to 10, was 7 or above in 44 of 48 assessed patients. Quality of health was rated 7 or higher in all 48 patients, energy level was 7 or higher in 39 patients, and overall happiness with surgery was 7 or higher in 47 patients. CONCLUSION: Colectomy and IRA is a relatively safe operation that results in minimum disturbance of bowel function. Patient satisfaction is usually high. Prophylactic colectomy can be offered to HNPCC gene carriers with a greater understanding of the likely outcome of surgery.     

Life expectancy after colectomy and ileorectal anastomosis for familial adenomatous polyposis

PURPOSE: Despite the introduction of screening, surveillance, and prophylactic colectomy surgery, patients with familial adenomatous polyposis (FAP) are at risk of dying from other malignancies. METHODS: In order to quantify this risk and identify the causes of mortality, a retrospective life table analysis was performed on 222 patients with familial adenomatous polyposis who had undergone a total colectomy and ileorectal anastomosis between 1948 and 1990. These FAP patients were compared with an age- and sex- matched group of the general population and a relative risk of dying was calculated. RESULTS: Of 222 patients, 53 have died. In a matched group of the general population the expected number of deaths would be 15.8. The relative risk of dying is therefore 3.35. There has been no significant improvement with time and the relative risk is greatest for female patients. CONCLUSION: The three main causes of mortality are upper gastrointestinal malignancy, desmoid disease, and perioperative complications. Further research should therefore be aimed at prevention and improved treatment of these in order to improve survival.This work was performed at St. Mark's Hospital. Ms. K. P. Nugent was funded by the St. Mark's Research Foundation.     

The risk of developing rectal cancer after colectomy and ileorectal anastomosis in Danish patients with polyposis coli

Fifty-eight Danish polyposis patients had been treated with colectomy and ileorectal anastomosis by the end of 1982. Three of these patients developed rectal cancer despite regular proctoscopic control, but one was probably an overlooked synchronous cancer. The cumulative risk at five and ten years after operation (actuarial method) was 3.5 and 13.3 per cent (95 per cent confidence limits 0–10.3 and 0–70.3 per cent, respectively), which seem to be acceptably low figures. This study supports the assumption that colectomy and ileorectal anastomosis is still the operation of choice in polyposis patients without rectal cancer.     

Colectomy with ileorectal anastomosis lowers rectal mucosal cell proliferation in familial adenomatous polyposis

Rectal polyp regression has been observed in familial adenomatous polyposis (FAP) after colectomy and ileorectal anastomosis (IRA). In view of the association between risk of neoplasia and epithelial cell turnover rates, a study was conducted to determine the effect of colectomy and IRA on rectal mucosal proliferation in FAP. Endoscopic biopsies of flat rectal mucosa were taken from 12 FAP patients with an established IRA and 10 FAP patients prior to colectomy. Mucosal proliferation was assessed by flash-labeling S-phase cells with bromodeoxyuridine. Labeled cells were visualized on paraffin sections with an immunohistochemical stain using a monoclonal antibody to bromodeoxyuridine. Twenty crypt columns were analyzed. The mean labeling index (percent labeled cells/crypt) of the FAP patients with established IRAs (7.0±1.4 percent) was significantly less than that of the precolectomy patients (12.8±3.0 percent) (Mann-Whitney U test,P =0.0004). Comparison of labeled distribution curves shows a contraction of the crypt proliferative zone in the IRA group. Colectomy with IRA in FAP is associated with a significant reduction in rectal mucosal cell proliferation. These findings support the claim of reduced risk of rectal cancer following this procedure in FAP and are of relevance to the study of environmental vs.genetic control of cell proliferation.Presented at the meeting of the British Society of Gastroenterology, London, September 1991.Dr. Farmer was supported by the St. Mark's Research Foundation.     

Comparison of ileal pouch-anal anastomosis and ileorectal anastomosis in patients with familial adenomatous polyposis

PURPOSE: The aim of this study was to evaluate the surgical complications and long-term outcome and assess the functional results and quality of life after ileorectal anastomosis and ileal pouch-anal anastomosis in patients with familial adenomatous polyposis. METHODS: From 1980 to 1997, 131 patients with familial adenomatous polyposis were operated on or were followed up or both at the Familial Gastrointestinal Cancer Registry at Mount Sinai Hospital. Demographic and operative data were prospectively collected in the ileal pouch-anal anastomosis group, and retrospectively in the ileorectal anastomosis group. A questionnaire or telephone interview or both were undertaken to evaluate functional outcome and quality of life. RESULTS: The ileorectal anastomosis group consisted of 60 patients (mean age, 31 years; mean follow-up, 7.7 years). In the ileal pouch-anal anastomosis group there were 50 patients (mean age, 35 years; mean follow-up, 6 years). There were no statistically significant differences with respect to anastomotic leak rate in ileal pouch-anal anastomosisvs. ileorectal anastomosis (12vs. 3 percent;P=0.21), risk of small-bowel obstruction (24vs. 15 percent;P=0.58), and risk of intra-abdominal sepsis (3vs. 2 percent;P=0.86). Reoperation rate was similar in the two groups (14vs. 16 percent;P=0.94). Twenty-one patients (37 percent) with ileorectal anastomosis were converted to ileal pouch-anal anastomosis (12 patients) or proctocolectomy (9 patients), because of rectal cancer (5 patients), dysplasia (1 patient), or uncontrollable rectal polyps (15 patients). Two pelvic pouches were excised, and another one was defunctioned. Information regarding functional results and quality of life was obtained in 40 patients (66.6 percent) in the ileorectal anastomosis group and in 43 patients (86 percent) in the ileal pouch-anal anastomosis group. Patients with ileorectal anastomosis had a significantly better functional outcome with regard to nighttime continence and perineal skin irritation. But otherwise, functional results and quality of life were similar. CONCLUSIONS: Although ileorectal anastomosis has a better functional outcome, ileal pouch-anal anastomosis may be preferable because of the lower long-term failure rate. Ileorectal anastomosis is still an option in patients with familial adenomatous polyposis with rectal polyp sparing and good compliance for follow-up.Read at the meeting of The American Society of Colon and Rectal Surgeons, San Antonio, Texas, May 2 to 7, 1998.     

Risk of cancer and secondary proctectomy after colectomy and ileorectal anastomosis in familial adenomatous polyposis

Purpose

The aim of our retrospective study was to review the outcome of patients undergoing colectomy with ileorectal anastomosis (IRA) due to familial adenomatous polyposis (FAP) in Finland during the last 50 years.

Methods

The cumulative risk of rectal cancer and the rate of anus preservation were analyzed. A total of 140 FAP patients with previous colectomy combined with ileorectal anastomosis were included. Kaplan–Meier analysis was performed to evaluate cumulative risks.

Results

Secondary proctectomy was performed for 39 (28 %) of 140 patients. The cumulative risk of secondary proctectomy was 53 % at 30 years after colectomy with IRA. A total of 17 (44 %) secondary proctectomies were performed due to cancer or suspicion of cancer, and another 17 (44 %) secondary proctectomies were performed due to uncontrollable rectal polyposis. During our study, the anus preservation rate in secondary proctectomies was 49 %. The cumulative risk of rectal cancer was 24 % at 30 years after colectomy with IRA. Therefore, the cumulative rectal cancer mortality 30 years after colectomy with IRA was 9 %.

Conclusions

Proctocolectomy and ileal pouch-anal anastomosis (IPAA) should be favored as a primary operation for patients not having technical or medical contraindications for it because colectomy with IRA carried a rectal cancer risk of 13 % with a mortality of 7 % during our study, and because IPAA is likely to succeed better at earlier phase of the disease. Patients with attenuated FAP had no rectal cancer in our study, and they may form a group where IRA should still be the first choice as an exception.     

Outcome of primary and secondary ileal pouch-anal anastomosis and ileorectal anastomosis in patients with familial adenomatous polyposis

PURPOSE: The aim of this study was to present Swedish experiences of the ileal pouch-anal anastomosis in patients with familial adenomatous polyposis from the introduction in 1984. The study also compared the surgical and functional outcome of different anal continence preserving procedures: ileal pouch-anal anastomosis as primary surgery, ileal pouch-anal anastomosis as secondary surgery after colectomy and ileorectal anastomosis, and ileorectal anastomosis alone. METHODS: The material comprises all 120 patients with familial adenomatous polyposis reported to the Swedish Polyposis Registry who had undergone prophylactic colorectal surgery, including those operated on because of colorectal cancer from 1984 until the end of 1996. Anal continence preserving surgery was performed on 102 patients: 20 had ileal pouch-anal anastomosis as primary surgery at a median age of 24.5 years, 39 had ileal pouch-anal anastomosis as secondary surgery at a median age of 34 years, and 43 had ileorectal anastomosis alone, at a median age of 26 years, because 6 of the initially ileorectal anastomosis-operated patients were converted to ileal pouch-anal anastomosis as secondary surgery. Surgical outcome was assessed on the basis of hospital records. A questionnaire was used to evaluate the functional outcome. Fisher's exact probability test was used for statistical analysis. RESULTS: Complications occurred in 51 percent of the patients after ileal pouch-anal anastomosis: 40 percent after ileal pouch-anal anastomosis as primary surgery and 56 percent after ileal pouch-anal anastomosis as secondary surgery. When the previous ileorectal anastomosis was taken into account 67 percent of the patients suffered complications which was significantly more compared with ileal pouch-anal anastomosis as primary surgery. After ileorectal anastomosis, 26 percent had complications which was significantly less compared with all other procedures but ileal pouch-anal anastomosis as primary surgery. No cancer occurred after ileal pouch-anal anastomosis, either in the ileal pouch or in retained rectal mucosa, but two of the patients who had an ileorectal anastomosis developed rectal cancer. One pouch excision was performed compared with ten rectal excisions. Functional outcome did not differ between ileal pouch-anal anastomosis as primary surgery and ileal pouch-anal anastomosis as secondary surgery. However, ileorectal anastomosis-operated patients had significantly better bowel function with regard to nighttime stool frequency, continence and perianal soreness. CONCLUSION: These findings indicate that major advantages of ileal pouch-anal anastomosis are the low excision rate and, so far, no cancer in the ileal pouch. Moreover, the surgical outcome of ileal pouch-anal anastomosis as primary surgery is not significantly different from that of ileorectal anastomosis. However, the good surgical and functional outcome of ileorectal anastomosis, despite the long-range prognosis including rectal cancer and excision risks, has to be taken into consideration when selecting patients with familial adenomatous polyposis for primary surgery.Parts of the functional outcome part of the study were presented at the Leeds Castle Polyposis Group meeting in Noordwijk, the Netherlands, June 4 to 7, 1997.Supported by the Cancer Society in Stockholm and the Karolinska Institute.     

Development of invasive adenocarcinoma following colectomy with ileoanal anastomosis for familial polyposis coli

PURPOSE: Proctocolectomy with ileoanal anastomosis has gained increasing acceptance for the prophylactic treatment of patients with familial polyposis coli. Longterm surveillance of the ileal pouch and the pouch-anal anastomosis has not been emphasized despite concern regarding retained rectal mucosa following the procedure. METHODS: A 34-year-old patient with a strong family history of familial polyposis coli was treated at 14 years of age by single-stage proctocolectomy with straight ileoanal anastomosis. Follow-up proctoscopic examinations revealed development of adenomatous changes at the ileoanal anastomosis. RESULTS: This report presents a patient with familial polyposis coli who developed invasive adenocarcinoma at the ileoanal anastomosis 20 years after proctocolectomy with ileoanal anastomosis. CONCLUSIONS: We stress the need for lifelong proctoscopic surveillance in patients with familial polyposis coli treated by proctocolectomy with ileoanal anastomosis.     

Total abdominal colectomy and ileorectal anastomosis for inflammatory bowel disease

PURPOSE: This retrospective study assesses the results of total colectomy and ileorectostomy for inflammatory bowel disease. METHODS: Between January 1974 and December 1990, 90 patients underwent total colectomy and ileorectal anastomosis for chronic ulcerative colitis (n=48) or Crohn's colitis (n=42) at the Mayo Clinic. Patients' records were reviewed retrospectively. Long-term results were assessed by chart reviews and postal questionnaires. Conversion to a permanent ileostomy, with or without proctectomy, was considered a failure of the procedure. The Kaplan-Meier method was used to estimate survivorship free of failure. The log-rank test was used to compare survivorship curves. Ninety-five percent confidence intervals were calculated at selected time points.P values<0.05 were considered to be statistically significant. RESULTS: The main indication for surgery was refractory chronic disease. There were no immediate postoperative deaths. The anastomotic leakage rate was 4.4 percent, and small-bowel obstruction occurred in 15.6 percent. At the time of follow-up (mean, 6.5±4.8 years), 46 patients (58.9 percent) had recurrence or exacerbation of the disease. This was the most common indication for subsequent proctectomy/permanent ileostomy in the follow-up period. There were 8 failures in 48 patients with ulcerative colitis (16.7 percent) and 11 failures in 42 patients with Crohn's disease (26.2 percent), although this difference was not statistically significant. Cumulative probability of having a functioning ileorectal anastomosis at five years was 84.2 percent (95 percent confidence interval, 71–95.9 percent) for ulcerative colitis and 73.8 percent (95 percent confidence interval, 58.6–88.6 percent) for Crohn's disease. In the latter group, females showed a significantly lower cumulative probability of having a functioning ileorectal anastomosis (females, 634 percent; males, 92.3 percent;P =0.04). Crohn's patients 36 years of age or younger also showed a lower probability of success (patients 36 years, 57 percent; patients >36 years, 93.8 percent;P =0.03). In the group with chronic ulcerative colitis, younger patients also seemed to require additional surgery more frequently; however, this difference was not statistically significant. Previous duration of symptoms, with mild or moderate disease in a distensible rectum, had no effect on results in either disease group. Functional results were acceptable in 63.6 and 87.5 percent of patients with Crohn's and ulcerative colitis, respectively. Eighty-four percent of ulcerative colitis patients and 91 percent of Crohn's disease patients reported an improvement in their quality of life, and overall, more than 90 percent considered their health status to be better than before surgery. One patient with ulcerative colitis developed carcinoma of the rectal stump 11.5 years after the colectomy and ileorectal anastomosis (cumulative probability of remaining free of cancer, 85.7 percent at 12 years; 95 percent confidence interval, 57.7–100 percent). CONCLUSIONS: These results demonstrate that, in selected patients with a relatively spared rectum and without severe perineal disease, total colectomy and ileorectal anastomosis still remains a viable option to total proctocolectomy with extensive Crohn's colitis. In addition, ileorectal anastomosis, as a sphincter-saving procedure, continues to have a place in the surgical treatment of chronic ulcerative colitis for high-risk or older patients who are not good candidates for ileal pouch-anal anastomosis, when the latter procedure cannot be done because of technical reasons and in the presence of advanced carcinoma concomitant with colitis, when life expectancy is limited.     

Clinical outcome and bowel function following total abdominal colectomy and ileorectal anastomosis in the oriental population

Total abdominal colectomy with ileorectal anastomosis is a commonly performed surgical procedure. The postoperative outcome of these patients, however, has not been studied in detail in the Asian population. AIM: The purpose of this study was to analyze the functional outcome of patients following total abdominal colectomy and ileorectal anastomosis. METHOD: All patients subjected to a total abdominal colectomy with ileorectal anastomosis during a six-year period from February 1989 to October 1995 were reviewed. RESULTS: Sixty-six patients (male:female, 40:26) with a mean age of 55.2 (range, 20–88) years underwent total abdominal colectomy with ileorectal anastomosis. Median follow-up after surgery was 26 (range, 4–78) months. Indications for surgery were synchronous or metachronous tumors (18), complicated pancolonic diverticular disease (15), obstructed tumors with impending perforation (13), familial adenomatous polyposis (7), slow-transit constipation (6), and others (7). Mean operative time was 137±48 minutes. Mean postoperative hospitalization was 13.3±11.9 days. Time to first bowel movement and commencement of solid diet were 4.7±1.8 and 7.2±2.4 days, respectively. Four patients had prolonged postoperative ileus. Average stool frequencies per day were 5.5 at one week, 4.3 at one month, 3.9 at six months, 3.2 at one year, and 2.9 at two years postoperatively. Thirty-three patients (50 percent) required antidiarrheal treatment for a transient period, but none required long-term therapy. Ninety-seven percent of all patients rated the functional outcome as good to excellent, and 3 percent said it was fair. There was two perioperative mortalities. Five cases required re-laparotomy, three for anastomotic complications and two for hemoperitoneum. Five patients had recurrent admissions for adhesion colic, which resolved with nonsurgical therapy. Ten patients succumbed on follow-up, six to tumor recurrence, two to unrelated cancers (stomach and bladder), and three to medical conditions. CONCLUSION: The functional outcome of ileorectal anastomosis is generally rated as good to excellent by patients. Acceptable bowel function and control is regained within six months of the operation and levels off at one year after surgery, and no patient requires long-term antidiarrheal medication.     

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.     

Measurement of rectal capacity in the assessment of patients for colectomy and ileorectal anastomosis in Crohn's colitis

A group of 38 patients with Crohn's colitis underwent measurement of rectal capacity prior to colectomy and ileorectal anastomosis. Median values for constant and maximum tolerated volumes were significantly higher in patients who still possessed a satisfactorily functioning ileorectal anastomosis at a mean follow-up of 6.8 years, and measurement of these sensory parameters of rectal capacity was of prognostic value in predicting the likely outcome of ileorectal anastomosis.     

Single incision laparoscopic total abdominal colectomy with ileorectal anastomosis for synchronous colon cancer

Single incision laparoscopy is currently performed mostly for basic laparoscopic procedures involving single abdominal quadrants. The aim of this case report is to show that single incision laparoscopic techniques can be utilized for complex abdominal laparoscopic procedures with a large target organ and a working space involving all quadrants of the abdominal cavity. A single incision laparoscopic total abdominal colectomy with an ileorectal anastomosis and intraoperative CO₂ colonoscopy was performed for a patient with synchronous adenocarcinoma of the cecum and the sigmoid colon. The patient was discharged home on postoperative day 4 and had no immediate postoperative complications. Single incision laparoscopy is feasible for complex colorectal procedures. Some of the techniques used may be adapted further to achieve colonic resection via a natural orifice in the future.     

Treatment of familial rectocolonic polyposis with total colectomy using ileorectal anastomosis in 6 members of a family: the value of early diagnosis

We report on the observation of six cases in a family of eight, all under 30, in whom the diagnosis was obtained at first hand by rectosigmoidoscopy. This procedure appears sufficient as the number of polyps tends to decrease with increasing distance from the anal margin. The recent finding of abnormalities of chromosome 5 (long arm) permits the identification of carriers of this genotype by simple blood examination (DNA probe), thus greatly enhancing the possibilities of screening for the disease. Each of our cases was managed with subtotal colectomy and ileorectal anastomosis. Preservation of the rectum was preferred to other techniques as all subjects were young, mildly affected and with good motivation for twice-yearly endoscopic follow-up. The surgical technique appears simple and quite safe with satisfactory functional results and easy feasibility of endoscopic surveillance.