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.     

Influence of sleep on anal sphincteric pressure in health and after ileal pouch-anal anastomosis

Fecal incontinence at night may be a disturbing consequence of ileal pouch-anal anastomosis (IPAA). The hypothesis was that decreases in anal canal resting pressure occur as sleep deepens and that the decreases are more profound in pouch patients with incontinence than in controls. Using a sleeve catheter assembly for recording intraluminal anal canal pressure and polysomnographic recordings of sleep stages, progressive decreases in anal canal resting pressure with deepening sleep occurred in 11 healthy controls (mean±SEM: 57±3 mm Hg to 43 ±3 mm Hg: P <0.05) and in 11 patients after IPAA (55 ±3 mm Hg to 42±4 mm Hg;P <0.05). Minute-to-minute variations in mean pressure were also found in both controls and IPAA patients, and they were greater at night in patients ( P <0.05), except during rapid eye movement (REM) sleep. In three patients, resting pressure during REM sleep decreased markedly to 31±8 mm Hg. This decrease plus the variations in pressure during REM sleep led to incontinence. In conclusion, decreases in anal resting pressure coupled with marked minute-to-minute variations in pressure during sleep occurred in controls and in patients after IPAA and, when profound, led to nocturnal fecal incontinence in some patients.Read in part at the meeting of The American Society of Colon and Rectal Surgeons, Toronto, Ontario, Canada, June 11 to 16, 1989.An abstract of this work has been published in Gastroenterology 1989;96:A378.Supported by U.S.P.H.S. NIH Grants RR585, DK18278, and DK34988 and by the Mayo Foundation.     

Transducer manometry and the effect of body position on anal canal pressures

Anal canal manometry is performed conventionally with balloons, sleeves, perfused or nonperfused open-tipped catheters, or with multiport probes. The authors constructed a new manometer with four transducers embedded in a probe (15 mm outside diameter) and oriented radially, 90 apart. The transducer probe was validated in 27 healthy volunteers by comparing its performance to that of a standard four-port perfused manometer and then used to measure anal canal and rectal pressures in body positions more physiologic (standing, sitting) than that usually employed (left lateral) for such measurements. Both devices measured similar anal canal resting pressure in the left lateral position (mid canal, 58±3 mm Hg perfused vs. 62±4 mm Hg transducer;P>0.05).The transducer probe, however, recorded higher squeeze pressures (mid canal, 100±6 mm Hg perfused vs. 143±14 mm Hg transducer;P<0.05).The transducer probe detected higher intrarectal and resting anal canal pressures when subjects were standing or sitting, compared with the left lateral position (rectum, 3±1 mm Hg left lateral; 17±2 mm Hg standing; 20±1 mm Hg sitting; P<0.05; mid anal canal, 57±3 mm Hg left lateral; 86±4 mm Hg standing; 81±5 mm Hg sitting, P<0.05). The rise in resting anal canal pressure was uniform circumferentially. Neither anal canal length nor squeeze pressure changed with change in position. The authors concluded that 1) transducer manometry recorded similar resting but higher squeeze pressures compared with perfused manometry; 2) transducer manometry recorded the same radial variation in anal canal resting and squeeze pressures as that recorded by the perfused manometer; and 3) standing and sitting caused a four-fold rise in intrarectal pressure, which was associated with a concomitant rise in resting anal canal pressure.Supported in part by USPHS Grants DK 37990 and DK34988 from the National Institutes of Health and the Mayo Foundation, Rochester, Minnesota.     

Risk of residual rectal mucosa after proctocolectomy and ileal pouch-anal reconstruction with the double-stapling technique

PURPOSE: This study was designed to assess the risk of retained rectal mucosa after proctocolectomy and ileal pouch-anal anastomosis with the double-stapling technique. METHODS: A total of 113 patients underwent proctocolectomy with an ileal pouch-anal reconstruction. In 57 patients the anastomosis between pouch and proximal anal canal was performed using the double-stapling technique. In 26 patients the procedure was carried out without a protecting ileostomy. Of the remaining 31 patients with a proximal ileostomy, 15 underwent endoscopy six weeks postoperatively. Circular biopsies were taken just distal from the pouch-anal anastomosis. RESULTS: Histologic examination revealed rectal mucosa in at least one biopsy in 7 of 15 patients. At follow-up (mean 18 months) no (distal) pouchitis was clinically noticed. In one patient with familial polyposis, a few polyps, distal of the anastomosis, had to be endoscopically removed. CONCLUSIONS: Double-stapled ileal pouch-anal anastomosis has a considerable risk of residual rectal mucosa, because of combined linear transection and circular stapling with bilateral dog-ear formation of rectal mucosa. Residual rectal mucosa did not seem to influence clinical results at follow-up.     

Anal canal inflammation after ileal pouch-anal anastomosis

One technique used during restorative proctocolectomy to prevent loss of continence involves preservation of the anal canal. This technique retains a small amount of colonic mucosa and transitional mucosa that may become inflamed or develop dysplastic or neoplastic changes. PURPOSE: This study was designed to determine the presence and severity of anal canal inflammation and the need for treatment. METHOD: Records of 217 patients with mucosal ulcerative colitis who underwent restorative proctocolectomy with a stapled ileal pouch-anal anastomosis without anal mucosectomy from 1987 through 1990 were retrospectively reviewed. RESULTS: Anal canal inflammation was evident on both endoscopy and biopsy in 48 patients (22.11 percent); 18 patients (8.29 percent) had a normal ileal pouch (9 had symptoms; 5 required topical treatment), and 30 patients (13.82 percent) had associated ileal pouch inflammation (23 with symptoms requiring systemic treatment because of pouchitis; 10 patients had concomitant topical treatment). CONCLUSION: Symptomatic inflammation of the retained mucosa occurred in 32 (14.7 percent) patients. Nine (4.1 percent) patients had inflammation of the anal canal alone, and 23 (10.6 percent) had pouchitis in addition. The need for treatment occurred in 28 (12.9 percent) of the total ((2.3 percent) patients with anal canal inflammation and 23 (10.6 percent) with anal canal inflammation plus pouchitis).Read at the meeting of The American Society of Colon and Rectal Surgeons, Orlando, Florida, May 8 to 13, 1994.     

Randomized trial to determine the optimum level of pouch-anal anastomosis in stapled restorative proctocolectomy

PURPOSE: This study was undertaken to identify the optimum level of stapled ileal pouch-anal anastomosis. METHOD: A prospective, randomized trial was completed to compare double-stapled ileoanal anastomosis placed at the top of anal columns (high, n=26) with anastomosis at the dentate line (low, n=21). RESULTS: There was no significant difference in the overall complication rate between operations (high, n=7,vs. low, n=8; P<0.21). Pouchanal functional score (scale 0–12; 0=excellent, 12=poor) was significantly better in the high anastomosis group (median (range): 2 (1–9) vs. 5.5 (1–12); P<0.05). Incontinence occurred in only two patients randomized to high anastomosis compared with six in the low anastomosis group. Nocturnal soiling was reported in three patients after high anastomosis and in six patients after dentate line anastomosis. Both operations caused a significant but comparable reduction of maximum anal resting pressure (31 percent after high anastomosis (P<0.05); 23 percent after low anastomosis (P<0.05)). However, a significant fall in functional length of the anal canal was only seen after a low pouch-anal anastomosis (P<0.05). CONCLUSION: Stapled pouch-anal anastomosis at the top of anal columns gives better functional results compared with a stapled anastomosis at the dentate line.K. I. Deen was supported by the Medical Research Council of Great Britain.     

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

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

Functional assessment of coloanal anastomosis with reservoir and excision of the anal transition zone

Conservation of the anal transition zone (ATZ) has been deemed necessary for continence after coloanal anastomosis (CAA) with reservoir. Therefore, we have studied functional and manometric results after CAA with reservoir and excision of the ATZ in 18 consecutive patients (mean age, 65.2 years; ten males and eight females), 17.4 months after closure of a temporary loop colostomy (Study 1). Twelve of the 18 initial patients were studied again 30.2 months after closure (Study 2). In Study 1, all patients underwent 1) a standardized interview, 2) a manometric study with measurement of anal pressure at rest (PR), voluntary contraction (VC), inhibitor anal reflex (IAR), conscious sensation (CS), and maximum tolerable volume (MTV), and 3) a liquid continence test (LCT) with measurement of colonic reservoir pressure during infusion. In Study 2, patients underwent all the same tests except the LCT. Results were compared with those of six controls (mean age, 65.8 years; two females and four males). In Study 1, 14/18 patients were continent; PR, VC, and CS did not differ among continent patients, incontinent patients, and controls. MTV was significantly lower in incontinent patients (mean ± SD, 165±46.5 ml) than in continent patients and controls (mean±SD, 261±50.8 mlvs. 250.7±83 ml). IAR was not observed in continent or incontinent patients but was observed in controls. Contraction waves in the colonic reservoir during LCT were more frequent in incontinent patients (4/4) than in continent patients (4/14), and their amplitudes were higher (119vs. 32 mm Hg). In Study 2, 12/12 patients were continent; PR and MTV remained unchanged except in the two initially incontinent patients, in whom MTV was increased. VC was slightly increased (94.7vs. 116 mm Hg). IAR remained absent in all patients. We conclude that 1) excision of the ATZ did not increase the risk of incontinence, and 2) poor functional results were mainly due to small MTV and contraction waves in the colonic reservoir.Partial results of this work were read at the meeting of the British Society of Gastroenterology, Sheffield, United Kingdom, September 14 to 16, 1988.     

Rediversion after ileal pouch-anal anastomosis

PURPOSE: The aim of this study was to understand better the cause and predictability of pouch failure requiring rediversion after ileal pouch-anal anastomosis and to assess the ultimate outcome of patients in a large ileal pouch series who required rediversion. METHODS: Data from 460 patients completing ileal pouch-anal anastomosis at one institution were recorded from both a prospectively accumulated ileal pouch registry and patient medical records. RESULTS: Of 460 patients, 21 (4.6 percent) who underwent ileal pouch-anal anastomosis required rediversion. Five of these patients subsequently had successful restoration of pouch continuity, leaving a permanent failure rate of 16 of 460 patients (3.5 percent). The most common reasons for rediversion were pouch fistula formation (12) and poor functional results (5). Preoperative factors, including age, previous colectomy, and indication for colectomy, did not predict eventual need for rediversion. Patients requiring rediversion had significantly higher rates of postoperative complications (95 vs.43 percent;P <0.001). Specifically, this group had a higher rate of postoperative pouch fistula (57 vs.3.4 percent;P <0.001). Additionally, a final diagnosis of Crohn's disease significantly predicted the need for rediversion. Permanent pouch failure occurred in 36.8 percent of patients with a final diagnosis of Crohn's disease compared with 1.4 percent of patients with a final diagnosis of ulcerative colitis ( P <0.001). All five salvaged patients had fistula formation in the absence of Crohn's disease. CONCLUSIONS: The overall rate of permanent pouch failure is low. The majority of failures were related to fistula formation associated with Crohn's disease or poor functional results. Pouches complicated by fistulas not associated with Crohn's disease can be salvaged with temporary rediversion.Read in part at the meeting of The American Society of Colon and Rectal Surgeons, Chicago, Illinois, May 2 to 7, 1993.     

Fecal short-chain fatty acid concentrations and effect on ileal pouch function

Random stool samples were obtained from 14 ileal pouch-anal anastomosis (IPAA) patients 43 ± 5 (mean ± SEM) months after surgery, and the concentrations of individual short-chain fatty acids (SCFAs) were determined by gas liquid chromatography. Stool frequency was determined from a diary recorded for 15 days prior to stool sampling. The frequency, amplitude, and duration of phasic contractions (PCs) within the pouch following infusion of a physiologic concentration of SCFAs and normal saline randomly into the pouch of six IPAA patients were determined manometrically. The mean total SCFA concentration after IPAA did not differ significantly from normal stools (83 ± 20 mM after IPAA vs. 97 ± 10 mM for controls; P > 0.05). In the IPAA patients, regression analysis demonstrated an inverse relationship between stools per day and total SCFA concentration (r = 0.73; P < 0.001). Moreover, no change in frequency (3.0 ± 0.9 vs. 3.2 ± 0.8 PCs/30 minutes), amplitude (26 ± 5 vs. 25 ± 4 mmHg), or duration (23 ± 3 vs. 26 ± 2 seconds) of PCs was found after SCFA infusion compared with saline control (P >0.1). These findings demonstrate that SCFAs are present in ileal pouch effluent and that stool frequency may be related to fecal SCFA concentration. Also, the normal contractile response of the terminal ileum to SCFAs does not occur in the ileal pouch.Supported in part by Research Grants DK 37990, RR 585, and DK 34988 from the National Institutes of Health and the Mayo Foundation, Rochester, Minnesota.     

Sphincter Defects Are Not Associated With Long-Term Incontinence Following Ileal Pouch-Anal Anastomosis

INTRODUCTION Frequent loose stools test the integrity of sphincter function in patients undergoing ileal pouch-anal anastomosis. The authors hypothesized that women with anal sphincter defects were more likely to experience incontinence episodes than women with intact sphincter muscles following ileal pouch-anal anastomosis.METHODS From 1996 to 1998, 42 women with a mean age of 42 (range, 22–63) years were prospectively evaluated by anorectal manometry and endoanal ultrasound before pouch surgery. Forty women underwent a stapled ileal pouch-anal anastomosis and two underwent a handsewn anastomosis. All patients considered themselves continent of stool before the procedure. A postoperative survey including the Cleveland Clinic Florida scale, Fecal Incontinence Severity Index, and Fecal Incontinence Quality of Life scale was sent to study participants.RESULTS Nineteen women with an obstetrical history had significant sphincter defects associated with significant lower mean resting pressure, mean squeeze pressure, and shorter anal canal length (3 vs. 3.7 cm, P = 0.0007). Thirty-five women (83 percent) responded resulting in a mean follow-up of 62 (range, 49-72) months. Fourteen responders (mean age, 46 years) had sphincter defects but no significant difference was found in Cleveland Clinic Florida scale, Fecal Incontinence Severity Index, or Fecal Incontinence Quality of Life scale scores when compared with those without defects.CONCLUSION Although almost all women reported episodes of seepage, marked sphincter defects associated with low anal pressures and shorter anal canal length did not affect anal function following pouch surgery. This study supports the findings that continent women with significant sphincter defects on ultrasound evaluation may be considered for restorative proctocolectomy.Poster presentation at the meeting of The American Society of Colon and Rectal Surgeons, New Orleans, Louisiana, June 22 to 26, 2003.     

Redo pouches: Salvaging of failed ileal pouch-anal anastomoses

From October 1, 1984 to December 31, 1991 at the Clinica Chirurgica II of the University of Bologna, 140 patients submitted to ileal pouch-anal anastomosis for ulcerative colitis (UC) and familial adenomatous polyposis (FAP). Nineteen patients (13.5 percent) developed septic complications. Of these, 11 patients (7.8 percent) had pelvic sepsis. Eight patients required further surgical intervention. Five patients underwent the redo pouch procedure. Another redo pouch was performed in a patient who had previously, in another hospital, had an ileal pouch-anal anastomosis placed and then removed because of ischemic necrosis of the reservoir. No deaths are reported in the reoperated patients. Currently, five of the six patients who underwent the redo pouch procedure have a well-functioning ileoanal anastomosis. The redo pouch procedure should always be attempted prior to the establishment of pelvic fibrosis.     

Mechanism of sphincter impairment following low anterior resection

It has been postulated that reduction in anal resting pressure following low anterior resection is due to intraoperative injury to the internal anal sphincter during transanal passage of the stapling device or damage to its nerve supply in the course of rectal mobilization. The aim of this study was to assess the relative importance of either mechanism. Fourteen dogs had a standard segment of colon and distal rectum excised. Colorectal reconstruction was performed using either a low stapled EEA^® (U.S. Surgical Corporation, Norwalk, CT) colorectal anastomosis (n=7) or a handsewn anastomosis (n=7). Anorectal manometry was performed preoperatively and again on the 10th postoperative day. Resting anal pressure was significantly reduced after EEA^® anastomosis (mean±SEM: before, 49±3 mm Hg; after, 20±4 mm Hg; P <0.001) and handsewn anastomosis (mean±SEM: before, 46±4 mm Hg; after, 35±4 mm Hg; P<0.01). Postoperative resting pressures were also significantly reduced (P<0.05) following EEA^® anastomosis when compared with the handsewn group. This study suggests that damage to the innervation of the internal anal sphincter during rectal mobilization and further direct injury to the sphincter during transanal instrumentation both contribute to the fall in anal resting pressure observed following low anterior resection.Read at the meeting of The Surgical Research Society (England), July 16, 1990. Proceedings published in Br J Surg 1990;77: 1421.This study was carried out entirely in the University Department of Surgery, Regional Hospital, Wilton, Cork, Ireland.     

Obstruction after ileal pouch-anal anastomosis: A preventable complication?

Small bowel obstruction is a common complication after ileal pouch-anal anastomosis. This review of 460 patients examines the frequency of small bowel obstruction and determines potential risk factors. The leading indication for ileal pouch-anal anastomosis was ulcerative colitis (83 percent). In 142 patients (31 percent), loop ileostomy was rotated 180° to facilitate emptying of the ileostomy. Ninety-four patients (20 percent) had 109 episodes of obstruction. Obstruction occurred after creation of the pouch (40 episodes), closure of the ileostomy (29 episodes), or developed during the subsequent followup period (40 episodes). Operative intervention was required in 39 percent of the episodes (7 percent of all patients). At operation, the most common point of obstruction was at closure of the ileostomy (n=22/42, 52 percent). In 16 of these patients, the ileostomy had been rotated. Multiple risk factors, including age, sex, primary diagnosis, surgeon incidence, pouch type, prior colectomy, steroid usage, stomal rotation, technique of closure of the ileostomy, and prior obstruction, were examined by univariate and multivariate analysis. Of all factors, only stomal rotation was statistically significant (P = 0.0005, chi-squared analysis). Rotation of the loop ileostomy during ileal pouch-anal anastomosis, although an apparent technical refinement, is unnecessary and predisposes to obstruction.Dr. Marcello was supported by a grant from the Eleanor Naylor Dana Charitable Trust, New York, New York.Read at the meeting of The American Society of Colon and Rectal Surgeons, San Francisco, California, June 7 to 12, 1992.     

Extent of smooth muscle resection during mucosectomy and ileal pouchanal anastomosis affects anorectal physiology and functional outcome

PURPOSE: In patients undergoing colectomy with ileal pouch-anal anastomosis, controversy exists regarding the necessity for and appropriate extent of rectal mucosal resection. Our aim was to assess histologically the extent of anorectal smooth muscle resected at the time of mucosal proctectomy and to correlate this with postoperative bowel and anal sphincter function. METHODS: Surgical specimens of 79 patients undergoing colectomy, mucosal proctectomy, and ileal pouch-anal anastomosis were examined histologically in a blinded fashion, and the content of smooth muscle in the mucosal proctectomy specimens was scored. Degree of smooth muscle resection was correlated with postoperative anorectal manometry and with functional outcomes, including stool frequency and nocturnal leakage of stool after 3 and 12 months of follow-up. RESULTS: Degree of smooth muscle loss correlated with decreased resting pressure of the internal anal sphincter as early as three months after surgery (r=−0.26;P=0.03), and the correlation was even stronger after 12 months (r=−0.37;P=0.005). Decreases in resting pressure were related, in turn, to increased stool frequency at 12 months (r=0.32;P=0.02), but stool frequency was also inversely related to volume of the ileal pouch (r=−0.27;P=0.05). Multivariate analysis confirmed that resting pressure and pouch volume were both significant determinants of stool frequency. The likelihood of nocturnal stool leakage at 12 months was primarily a function of stool frequency (P<0.01) but also increased with patient age (P<0.02). CONCLUSIONS: These findings indicate that loss of resting pressure of the internal anal sphincter can be correlated with the extent of smooth muscle resection during rectal mucosectomy and that these factors, in turn, correlate with increased stool frequency and a greater likelihood of nocturnal stool leakage. Consequently, an optimum functional result requires care in identifying and preserving maximum anorectal smooth muscle during mucosectomy. Supported by the Crohn's and Colitis Foundation of America. Read at the meeting of The American Society of Colon and Rectal Surgeons, Seattle, Washington, June 9 to 14, 1996.     

Reduction in tissue blood flow in J-shaped pelvic ileal reservoirs

PURPOSE: This study sought to evaluate tissue blood flow during J-shaped ileal reservoir construction. METHODS: Using laser Doppler flowmetry, tissue blood flow was measured at various locations in J-shaped ileal reservoirs constructed in 10 dogs before pouch-anal anastomosis. For 12 weeks postoperatively, animals were assessed for clinical complications. In another five dogs, tissue blood flow was measured at various stages of J-pouch construction. RESULTS: Tissue blood flow in the reservoir was reduced and was lowest at the apex of the J. the site of clinical stricture in one animal. During reservoir construction, longitudinal enterotomy was associated with the greatest reduction in tissue blood flow. Lowest blood flow in the reservoir was at the site of the intended pouch-anal anastomosis (11.5±1.6 ml/100 g/min vs.43.4±3.4 ml/100 g/min (controls);P <0.05). CONCLUSIONS: Operative maneuvers of J-shaped ileal reservoir construction, particularly longitudinal enterotomy, significantly reduce tissue perfusion in the involved bowel segment. Tissue blood flow in the pouch is lowest at the site of intended pouch-anal anastomosis, and this may contribute to development of complications seen clinically.Supported in part by grants from the Department of Veterans Affairs and the National Foundation for Ileitis and Colitis.     

Physiologic characteristics of straight and colonic J-pouch anastomoses after rectal excision for cancer

PURPOSE: The colonic J-pouch anastomosis has been advocated to obviate urgent and frequent defecations following a sphincter-saving rectal excision. Physiologic characteristics of the colonic J-pouch were compared with those of the traditional straight anastomosis and related to clinical function. METHOD: Patients with total mesorectal excision for carcinoma were randomized to either a straight (n=23) or a colonic pouch anastomosis (n=23). The patients were examined before and at one year after surgery (n=42), which included laboratory studies, and a questionnaire regarding anorectal function was completed. RESULTS: Preoperative compliance of the rectum was restored after surgery in the pouch group, 2.9 (2.2–3.4) ml/cm H ₂ O, but there was a significant decrease after surgery in the straight anastomosis group, 1.9 (1.1–2.3) P <0.001 (median (interquartile range)). Sphincter pressures in both groups were similar. In a multiple regression analysis, high compliance was associated with favorable clinical function, and hypermotility of the anal canal was associated with adverse clinical function. CONCLUSIONS: Colonic pouch-anal anastomosis restores neorectal compliance, which is important for good function after low anterior resection. Presence of an unstable internal sphincter is a negative factor for clinical function in both straight and pouch anastomoses.Supported by the Research Funds of the University Hospital in Linköping and the County of Östergötland.     

Surgical treatment and role of dynamic defecography in impaired evacuation after ileal pouch-anal anastomosis

PURPOSE: Patients with an ileal pouch-anal anastomosis may develop impaired evacuation of the pouch. A new surgical approach and the role of dynamic defecography in such patients are highlighted. METHODS: Five patients with ileal pouch-anal anastomosis were assessed clinically and with dynamic defecography before and after reoperation. RESULTS: In one patient an extensive approach with complete pouch mobilization, stenoplasty of a pouch outlet stenosis, shortening of the rectal remnant, and renewed pouch-anal anastomosis were needed; in three patients, a long and angulated efferent limb was shortened by transabdominal techniques (stenoplasty or a newly developed technique with a linear stapler), and in one patient a pouch inlet stenosis was corrected. In all patients, impaired emptying was cured; in all patients, obstructive abdominal pain improved considerably. CONCLUSIONS: Dynamic defecography is indispensable for tailoring surgical treatment. Effective transabdominal shortening of the efferent limb can be performed with the aid of a linear stapler.     

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

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

Alteration in intestinal permeability after ileal pouch-anal anastomosis

PPURPOSE: The physiologic changes that occur when the small bowel is used as a reservoir, as in the ileal pouchanal anastomosis, are poorly understood. Alterations in bowel permeability, which may lead to bacterial translocation that could result in illness or dysfunction of the pouch, may be one such consequence of the pouch procedure. METHODS: Whole-bowel permeability was evaluated in patients with and without the pouch through the use of an orally consumed nonmetabolizable sugar clearance technique. Patients in whom the ileal pouchanal anastomosis was performed for ulcerative colitis (17 patients) and patients with familial polyposis (7 patients) were compared with normal healthy volunteers (10 patients) and patients with ulcerative colitis with and without curative colectomy and ileostomy (6 and 5 patients, respectively). RESULTS: Measured by this technique, no differences were noted in bowel permeability between the volunteers and patients with ulcerative colitis, even after colectomy and ileostomy (1.7±0.4 in normal healthy volunteers, 1.8±0.5 in patients with ulcerative colitis without stoma, and 1.4±0.2 in patients with ulcerative colitis with ileostomy). The group of patients with an ileal reservoir, however, had a significantly increased index of measured bowel permeability (3.5±0.5 in patients with ulcerative colitis and 5.1±0.7 in patients with familial polyposis; P<0.05 by analysis of variance compared with normal healthy volunteers and patients with ulcerative colitis with or without ileostomy). CONCLUSION: The exact site, cause, and consequence of this possible alteration of bowel permeability are unclear but appear to be related to the presence of the pouch and are not caused by the underlying pathologic diagnosis.Poster presentation at the meeting of The American Society of Colon and Rectal Surgeons, Boston, Massachusetts, May 12 to 17, 1991. Winner of the New Jersey Society of Colon and Rectal Surgeons Award, 1991.