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

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

Ileal pouch-anal anastomosis for chronic ulcerative colitis. Long-term results.

The aim of this study was to determine the long-term outcome among 390 patients with ulcerative colitis who underwent ileal J pouch-anal anastomosis and whether patient or operative factors influenced results. The combined operative morbidity rate for the pouch-anal anastomosis and the subsequent closure of the temporary ileostomy was 29% (bowel obstruction, 22%; pelvic sepsis, 5%), with one death due to pulmonary embolus. The probability of a successful outcome at 5 years was 94%. Of the 24 patients who failed (6% of total), 18 did so within 1 year (4%), three during year 2 (1%), three during year 3 (1%), and none thereafter. Stool frequency (7 stools/24 h), the occurrence of pouchitis (14%), and satisfactory daytime continence (94% of patients) remained stable over 4 years after operation, whereas nocturnal fecal spotting decreased (51% of patients to 20%). Women had more spotting than men, whereas patients over 50 years old had more stools per day than those 50 years or younger. In conclusion, ileal pouch-anal anastomosis achieved a reasonable stool frequency and satisfactory continence in patients with ulcerative colitis over the long-term. These results support the ileal pouch-anal anastomosis as a safe, satisfactory alternative to permanent ileostomy.     

Surgical treatment of hemorrhagic proctocolitis]

Surgical treatment of chronic ulcerative colitis requires restorative proctocolectomy with ilial pouch-anal anastomosis to remove all the disease bowel and provide cure. A one-stage or two-stage procedure can be performed after subtotal colectomy with ileostomy and colostomy. Restorative proctocolectomy is not advised for very old patients or patients with anal sphincter insufficiency. In such cases, total colectomy with ileo-rectal anastomosis is proposed. The rectal stump must be examined regularly by rectoscopy because of the risk of cancer. A proctocolectomy with definitive ileostomy is proposed after pouch-anal excision for pelvic septic complications (5% of ileal pouch-anal anastomoses). Surgical treatment of chronic ulcerative colitis is indicated when medical treatment fails, at onset of fulminant acute colitis, or because of colorectal dysplasia.     

溃疡性结直肠炎的外科治疗

目的介绍一种全大肠切除回肠与肛管一期吻合治疗溃疡性结直肠炎的方法。方法本术要求在直肠游离达肛提肌水平后继续推进于直肠内外括约肌之间,使直肠从肛管内翻拖出后,皮肤、齿状线及直肠粘膜成同一平面,其间无间沟及反折。在齿缘水平回肠与肛管于肛外行一期吻合。结果本组16例。主要表现为严重便血、腹泻贫血及营养不良。均经过长期的内科治疗。癌变的两例病史分别为7年、17年。术后一个月内每周排便6～12次,3个月后正常。16例中随访6个月～5年,均获治愈。结论因其结直肠切除彻底故而无复发,回肠肛管血运极其丰富,吻合易于成功。     

Proctocolectomy with jejunal pouch-distal rectal anastomosis: An alternative to ileal pouch reconstruction

The aim of this study was to determine whether a jejunal pouch would have a lower resting pressure, be more distensible, and have more interdigestive migrating myoelectric complexes and less fecal bacterial overgrowth than would an ileal pouch after proctocolectomy and pouch-distal rectal anastomosis. In six conscious dogs with a jejunal pouch-distal rectal anastomosis and six with an ileal pouch-distal rectal anastomosis (controls), pouch distensibility and motility were measured using a barostat and perfused pressure-sensitive catheters passed per anum, pouch electrical activity was recorded using chronically implanted electrodes, and the number of bacteria per gram of stool was assessed by culture. Dogs with a jejunal pouch had lower resting pouch pressures, more distensible pouches, faster frequencies of pacesetter potentials in the pouch, more phase 3 intervals of the interdigesive migrating myoelectric complex reaching the pouch, but similar numbers and types of bacteria in their stools compared to the dogs with an ileal pouch. We concluded that jejunal pouches have a lower resting pressure, are more distensible, have more cleansing contractions, but a similar fecal flora compared to ileal pouches. A jejunal pouch has features that make it an attractive alternative to an ileal pouch for pouch-distal rectal or pouch-anal canal anastomosis after proctocolectomy. Supported by the Mayo Foundation, Tohoku University, and the Nigro grant. Presented at the Thirty-Eighth Annual Meeting of The Society for Surgery of the Alimentary Tract, Washington, D.C., May 11–14, 1997. An abstract of this work was published in Gastroenterology 112:A1478, 1997.     

Ileal pouch-anal anastomosis: comparison of results in familial adenomatous polyposis and chronic ulcerative colitis.

The aim of this study was to compare the immediate postoperative results and the long-term outcome of ileal pouch-anal anastomosis in 94 patients with familial adenomatous polyposis to those in 758 patients with ulcerative colitis. Two colitis patients died after operation (0.3%), but no polyposis patients died. Overall operative complications appeared in 26% and 29% of polyposis and colitis patients, respectively (NS). Reoperation for intestinal obstruction did not differ between the two groups, but sepsis requiring reoperation was more common in colitis patients (6%) than in polyposis patients (0%, p less than 0.04). At follow-up (mean, 3 years), polyposis patients had fewer daytime stools (4.5 stools per day), less nighttime fecal spotting (26%), and less pouchitis (7%) than colitis patients (5.8 stools per day; spotting, 40%; pouchitis, 22%; p less than 0.002). The conclusion was that polyposis patients tolerated the operation better and had less long-term disability than did colitis patients. The data suggest that postoperative sepsis, daytime stooling frequency, nocturnal incontinence, and pouchitis may be, at least in part, disease related and not surgeon or operation related.     

An alternative conversion technique for salvaging a failed ileal J-pouch-anal anastomosis to a modified H-pouch

Ileal J-pouch-anal anastomosis is a commonly accepted surgical treatment for patients with ulcerative colitis. However, making a J-pouch anal anastomosis can be difficult due to anatomical variations of patients. We experienced an informative case of ulcerative colitis in which the ileal pouch was damaged when it was pulled down into the anal canal because of a fatty short mesentery. To preserve intestinal consistency and functioning fecal continence, a modified H-pouch was converted from a damaged J-pouch and anastomosed to the dentate line. This operation achieved a satisfactory functional result and, we believe, presents an option for reconstructing ileal J-pouch-anal anastomosis.     

Complications and risk factors after ileal pouch-anal anastomosis for ulcerative colitis associated with primary sclerosing cholangitis.

OBJECTIVE: This study determined predictive factors for postoperative complications and outcome after ileal pouch-anal anastomosis in patients with ulcerative colitis and primary sclerosing cholangitis. SUMMARY BACKGROUND DATA: Patients with ulcerative colitis and primary sclerosing cholangitis treated by colectomy and ileostomy are at high risk of troublesome bleeding from peristomal varices. METHODS: Postoperative complications and outcome were assessed in 40 patients with ulcerative colitis and sclerosing cholangitis who received an ileal pouch-anal anastomosis between January 1981 and February 1990. RESULTS: Immediate postoperative and remote ileoanal anastomosis-related complications were high but related directly to the severity of liver disease. No patient had perianastomotic anal bleeding. CONCLUSIONS: In patients with both ulcerative colitis and primary sclerosing cholangitis, ileal pouch-anal anastomosis is safe and is not associated with perianastomotic bleeding.     

回肠储袋与直肠肌管吻合术治疗家族性腺瘤性息肉病15例分析

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

The J-pouch Swenson procedure for ulcerative colitis and familial polyposis.

Total colectomy with mucosal proctectomy and ileal pouch-anal anastomosis has proven to be a favorable option in the treatment of ulcerative colitis and familial polyposis coli. The main advantages of this procedure are that it obviates the need for a permanent stoma, it preserves anal continence, and it removes all disease-prone mucosa. As an alternative to this procedure, the authors have found success with the Swenson pull-through following proctocolectomy in children. This technique involves resection of the rectum at the dentate line, thus, eliminating the need for mucosal proctectomy. This may be particularly advantageous in patients with severely diseased rectal mucosa. Ileoanal anastomosis is performed after creation of an ileal J-pouch using the terminal ileum. The procedure has been used in two children with familial polyposis coli and in three with ulcerative colitis. Median follow-up after closure of the diverting ileostomy is 13 months (5-33 months). Continence has been preserved in all five patients. There have been no complications involving bladder or sexual dysfunction. This technique provides a reliable alternative for the definitive treatment of ulcerative colitis and familial polyposis coli.     

Stricture and pouchitis after ileal pouch-anal anastomosis

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

Ileal pouch-anal anastomosis. A single surgeon's experience with 100 consecutive cases.

Between August 1982 and November 1985, 100 patients underwent ileal "J" pouch-anal anastomosis (IPAA) at the University of Utah. All operations were performed in a standard fashion by a single surgeon. Seventy-eight patients were operated on for chronic ulcerative colitis and 22 for familial polyposis coli. Sixty of the patients were male and 40 were female with a mean age of 33.2 years and a range of 11-63 years. Mean +/- SEM operating time was 5.9 +/- 0.4 hours, blood loss was 666 +/- 49 ml, and total hospitalization was 10.1 +/- 0.3 days. No operative deaths occurred. The overall operative morbidity was 13% after IPAA. Clinical "pouchitis" was observed in 18 patients, all of whom were operated on for chronic ulcerative colitis. No patients had frank incontinence. Twenty per cent of patients experienced frequent nocturnal leakage in the early postoperative period with a significant improvement over the ensuing 6 months. Stool frequency at 1, 3, 6, 12, and 24 months was 7.5 +/- 0.2, 6.5 +/- 0.1, 6.2 +/- 0.3, 5.4 +/- 0.1, and 5.4 +/- 0.2, respectively. Stool frequency at 12 months correlated inversely with ileal pouch capacity and the diagnosis of familial polyposis. It is concluded that ileal pouch-anal anastomosis is a safe and effective operation for patients with chronic ulcerative colitis and familial polyposis coli.     

Surgery of ulcerative colitis using ileoanal anastomosis

The ideal surgical treatment for ulcerative colitis is the ileoanal anastomosis (IAA), which, however, is not yet generally accepted as a practical procedure because of a suboptimal fecal function, frequent postoperative complications and technical difficulties. Based on one (U.) of the authors experiences on 36(34) polyposis and 19(12) colitis (paracentesis indicate the number of cases in (U.)'s previous appointment, Tokyo Medical and Dental University, 1977-1983). The practical procedure of IAA can be achieved by combining the following basic principles; a direct anastomosis of J-shape ileal pouch to the anal sphincteric mechanism, temporarily exclusion of the anastomosis by a loop-ileostomy, mucosectomy confined to the lower rectum leaving the short muscular cuff, and meticulous dissection of inflamed mucosa of the anal canal minimizing the damage to the internal sphincter which is achieved by the prone ano-abdominal approach. At elective operation, the procedure can be performed either as primary surgery or as the secondary following rectum preserving operation, in which, coeco-rectal anastomosis is advisable for preserving the ileocolic vessels that is helpful for J-pouch construction. In emergency surgical program, IAA is still be preserved as a final restructive surgery following colectomy with an open rectal exclusion or Turnbull' s total colonic exclusion. In this occasion, an ascendicostomy is advisable for preserving the ileocolic vessels.     

Preservation of continence after ileoanal anastomosis by the coordination of ileal pouch and anal canal motor activity.

Nocturnal incontinence may occur after ileoanal anastomosis and may be related to loss of an effective anal canal pressure barrier during sleep; how pressure and contractions in the proximal bowel influence this barrier is unknown. Our aim was to evaluate the relationship between anal canal pressure and contractions and contractile activity of the pouch in continent subjects after ileal pouch-anal anastomosis (IPAA) and of the rectum in normal controls. A fully ambulatory system for 24-hour pressure recording was used. A flexible transducer catheter was introduced endoscopically so that sensors were at 2, 3, 8, 12, 16, and 24 cm from the anal orifice in 12 healthy controls (7 men, 5 women, mean age: 35 years) and 7 fully continent IPAA patients (4 men, 3 women, mean age: 34 years) more than 12 months postoperatively. Twenty-four hour spontaneous motor activity was stored in a 2.5 megabyte (MB) digital portable recorder. Mean anal canal pressure was calculated, and rectal motor complexes and ileal pouch large pressure waves were characterized. During sleep, resting anal canal pressures were similar in the two groups (72 +/- 12 mm Hg in controls versus 66 +/- 9 mm Hg in IPAA patients [mean +/- standard deviation (SD)], p = NS), but anal canal pressure showed cyclic relaxations (periodicity: 95 +/- 11 min in controls, 54 +/- 18 min in IPAA patients, p less than 0.05), during which the mean pressure trough was 15 +/- 4 mm Hg in controls and 14 +/- 5 mm Hg in IPAA patients (p = NS). In the control patients, during sleep, a mean of six rectal motor complexes were identified (range: 3 to 9). In patients with IPAA, during sleep, a mean of eight large pressure waves per hour were identified (range: 2 to 20). Importantly, in both controls and patients, rectal motor complexes or large pressure waves were always accompanied by rapid return of anal canal pressure from trough to basal values and increased contractile activity. We concluded that, in healthy patients and in continent patients after IPAA, motor activity of the rectum and of the ileal pouch was associated with changes in pressure and contractile activity of the anal canal so that rectal- and neorectal-anal canal pressure gradient, and, in turn, fecal continence were preserved.     

Adenocarcinoma following restorative proctocolectomy for ulcerative colitis: a case report and review of the literature

Restorative proctocolectomy with ileal pouch-anal anastomosis has been accepted as the surgical treatment of choice for most patients with ulcerative colitis. The occurrence of adenocarcinoma arising near or into the ileal pouch is rare. Only 19 such cases have been reported so far. The authors report a case of a 67-year old male who developed an adenocarcinoma in the small rectal stump 12 years after a restorative proctocolectomy with double stapled ileal pouch-low rectal anastomosis for ulcerative colitis unresponsive to medical treatment. They, after a literature review, examine same steps of the procedure and emphasize the importance of regular and prolonged follow-up for all patients having restorative proctocolectomy for ulcerative colitis.     

V4Total laparoscopic restorative proctocolectomy for ulcerative colitis

Introduction:  Laparoscopic ileal pouch-anal anastomosis (IPAA) has been shown to be a safe and feasible technique for patients with ulcerative colitis refractory to medical management and familial polyposis. We aim to demonstrate our technique of total laparoscopic proctocolectomy with intracorporeal pouch-anal anastomosis with specific reference to intaroperative tricks of the trade.
Patient and Methods:  The patient is a 16-year-old male with ulcerative colitis. The video demonstrates a total laparoscopic proctocolectomy and formation of a (J) ileal pouch anal anastomosis. A standard colonic mobilisation of the colon was performed with the use of the Goldfinger retractor to aid vessel division and the use of the harmonic scalpel for mesenteric division apart from the transverse mesocolon where the ligasure was employed. The right colon was only mobilised after complete mesenteric division of the left & transverse colon to prevent looping. The rectum, once mobilised to the pelvic floor, was divided in the AP direction with the endoGIA. Techniques to prevent twisting of the pouch and inadvertent twisting of the proximal small bowel are demonstrated. The video also highlights the importance of positioning the patient and use of 0 and 30 degree scopes. A technique to tackle a defect in the anal stump is also described.
Conclusion:  The technique of laparoscopic IPAA adheres to the principles of open pouch surgery but we await the development of more suitable laparoscopic staplers to aid the clinician in division of the anorectal junction.     

Function after ileal pouch and stapled pouch-anal anastomosis for ulcerative colitis

Fourteen patients with ulcerative colitis underwent formation of an S ileal pouch and construction of a stapled pouch-anal anastomosis by a modified technique, which eliminated the use of purse-string sutures. Eleven have had their covering ileostomies closed. Anal manometry performed before and a median of 9 months after ileostomy closure showed significant impairment of internal anal sphincter function. Night evacuation was significantly reduced in the stapled group compared with a similar group of patients who had undergone S ileal pouch formation, mucosal proctectomy and manual transanal anastomosis, but this was the only parameter of function to show a difference. A stapled pouch-anal anastomosis may be superior to the conventional procedure but it still may lead to internal anal sphincter damage which cannot be due to mucosectomy or prolonged anal retraction.     

Subtotal colectomy in ulcerative colitis—long term considerations for the rectal stump

BACKGROUNDThe initial operation of choice in many patients presenting as an emergency with ulcerative colitis is a subtotal colectomy with end ileostomy. A percentage of patients do not proceed to completion proctectomy with ileal pouch anal anastomosis.AIMTo review the existing literature in relation to the significant long-term complic-ations associated with the rectal stump, to provide an overview of options for the surgical management of remnant rectum and anal canal and to form a consolidated guideline on endoscopic screening recommendations in this cohort.METHODSA systematic review was carried out in accordance with PRISMA guidelines for papers containing recommendations for endoscopy surveillance in rectal remnants in ulcerative colitis. A secondary narrative review was carried out exploring the medical and surgical management options for the retained rectum.RESULTSFor rectal stump surveillance guidelines, 20% recommended an interval of 6 mo to a year, 50% recommended yearly surveillance 10% recommended 2 yearly surveillance and the remaining 30% recommended risk stratification of patients and different screening intervals based on this. All studies agreed surveillance should be carried out via endoscopy and biopsy. Increased vigilance is needed in endoscopy in these patients. Literature review revealed a number of options for surgical management of the remnant rectum.CONCLUSIONThe retained rectal stump needs to be surveyed endoscopically according to risk stratification. Great care must be taken to avoid rectal perforation and pelvic sepsis at time of endoscopy. If completion proctectomy is indicated the authors favour removal of the anal canal using an intersphincteric dissection technique.     

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

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

Laparoscopic ileal pouch-anal anastomosis

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