Anal transitional zone cancer after restorative proctocolectomy and ileoanal anastomosis in familial adenomatous polyposis: report of two cases

PURPOSE: Restorative proctocolectomy with ileal pouch-anal anastomosis is accepted as the surgical treatment of choice for many patients with familial adenomatous polyposis. The risk of cancer developing in the ileal pouch after this surgery is unknown. Cancer may arise from the ileal pouch after restorative proctocolectomy, but that arising from the anal transitional zone has not been documented in familial adenomatous polyposis. We report two cases of this cancer from the anal transitional zone in patients with familial adenomatous polyposis, with a review of the literature. METHODS: All patients with familial adenomatous polyposis treated with restorative proctocolectomy and ileal pouch-anal anastomosis in The Cleveland Clinic were included in the study. Patients whose surveillance biopsy of the anal transitional zone revealed invasive adenocarcinoma were studied. RESULTS: Among a total of 146 patients with familial adenomatous polyposis who underwent restorative proctocolectomy and ileal pouch-anal anastomosis from 1983 to 2001 in our institution, none developed cancer of the anal transitional zone at up to 18 years of follow-up. However, there were two patients, both of whom underwent surgery elsewhere but who were followed up here, who developed invasive adenocarcinoma of the anal transitional zone. In one of them, cancer was diagnosed three years after a double-stapled ileal pouch-anal anastomosis, whereas in the other, cancer occurred eight years after a straight ileoanal anastomosis with mucosectomy.CONCLUSIONS: Cancer may develop in the anal transitional zone after restorative proctocolectomy with ileal pouch-anal anastomosis for familial adenomatous polyposis. Long-term surveillance of the anal transitional zone needs to be emphasized.     

Anal Transitional Zone Cancer After Restorative Proctocolectomy and Ileoanal Anastomosis in Familial Adenomatous Polyposis

PURPOSE: Restorative proctocolectomy with ileal pouch-anal anastomosis is accepted as the surgical treatment of choice for many patients with familial adenomatous polyposis. The risk of cancer developing in the ileal pouch after this surgery is unknown. Cancer may arise from the ileal pouch after restorative proctocolectomy, but that arising from the anal transitional zone has not been documented in familial adenomatous polyposis. We report two cases of this cancer from the anal transitional zone in patients with familial adenomatous polyposis, with a review of the literature. METHODS: All patients with familial adenomatous polyposis treated with restorative proctocolectomy and ileal pouch-anal anastomosis in The Cleveland Clinic were included in the study. Patients whose surveillance biopsy of the anal transitional zone revealed invasive adenocarcinoma were studied. RESULTS: Among a total of 146 patients with familial adenomatous polyposis who underwent restorative proctocolectomy and ileal pouch-anal anastomosis from 1983 to 2001 in our institution, none developed cancer of the anal transitional zone at up to 18 years of follow-up. However, there were two patients, both of whom underwent surgery elsewhere but who were followed up here, who developed invasive adenocarcinoma of the anal transitional zone. In one of them, cancer was diagnosed three years after a double-stapled ileal pouch-anal anastomosis, whereas in the other, cancer occurred eight years after a straight ileoanal anastomosis with mucosectomy. CONCLUSIONS: Cancer may develop in the anal transitional zone after restorative proctocolectomy with ileal pouch-anal anastomosis for familial adenomatous polyposis. Long-term surveillance of the anal transitional zone needs to be emphasized.     

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.     

Ileal pouch anal anastomosis with modified double-stapled mucosectomy-the experience in China

AIM:To investigate the feasibility and long-term functional outcome of ileal pouch-anal anastomosis with modified double-stapled mucosectomy.METHODS:From January 2002 to March 2011,fourtyfive patients underwent ileal pouch anal anastomosis with modified double-stapled mucosectomy technique and the clinical data obtained for these patients were reviewed.RESULTS:Patients with ulcerative colitis(n = 29) and familial adenomatous polyposis(n = 16) underwent ileal pouch-anal anastomosis with modified doublestapled mucosectomy.Twenty-eight patients underwent one-stage restorative proctocolectomy,ileal pouch anal anastomosis,protective ileostomy and the ileostomy was closed 4-12 mo postoperatively.Two-stage procedures were performed in seventeen urgent patients,proctectomy and ileal pouch anal anastomosis were completed after previous colectomy with ileostomy.Morbidity within the first 30 d of surgery occurred in 10(22.2%) patients,all of them could be treated conservatively.During the median follow-up of 65 mo,mild to moderate anastomotic narrowing was occurred in 4 patients,one patient developed persistent anastomotic stricture and need surgical intervention.Thirtyfive percent of patients developed at least 1 episode of pouchitis.There was no incontinence in our patients,the median functional Oresland score was 6,3 and 2 after 1 year,2.5 years and 5 years respectively.Nearly half patients(44.4%) reported "moderate functioning",37.7% reported "good functioning",whereas in 17.7% of patients "poor functioning" was observed after 1 year.Five years later,79.2% of patients with good function,16.7% with moderate function,only 4.2% of patients with poor function.CONCLUSION:The results of ileal pouch anal anastomosis with modified double-stapled mucosectomy technique are promising,with a low complication rate and good long-term functional results.     

Ileal Pouch–Anal Anastomosis–Vaginal Fistula: A Review

BACKGROUND Fistula between an ileal pouch and the vagina is an uncommon complication of ileal pouch–anal anastomosis. Its optimal management has not been determined because of its low incidence.METHODS The literature describing such fistulas was reviewed to determine the incidence, cause, and appropriate investigation and repair of these lesions. A literature search was performed with the PubMed, MEDLINE, and EMBASE databases. Through this search we located English-language articles from 1970 to 2003 on pouch-vaginal fistulas following ileal pouch–anal anastomosis. References from these articles were searched manually for further references.RESULTS AND CONCLUSION Pouch-vaginal fistula occurs in 6.3 (range, 3.3–15.8) percent of female patients with an ileal pouch–anal anastomosis. Sepsis and technical factors are the most common contributors. It is the cause of considerable morbidity. Management depends on the level of the fistula, the amount of pelvic scar tissue, and previous treatments. An algorithm for surgical treatment is suggested.Reprints are not available.     

Anal Canal Pressure After Ileal Pouch–Anal Anastomosis with Strengthened Internal Anal Sphincter

INTRODUCTION The aim of sphincter-saving operative techniques and creation of intestinal reservoirs is to improve the quality of life for patients with restorative proctocolectomy.METHODS In this study, 48 consecutive patients (19 males and 29 females of ages between 19 and 55 years; mean age, 35.52 years) with ulcerative colitis and familial adenomatous polyposis underwent ileal pouch–anal anastomosis after proctocolectomy in 1986 to 2002. In 26 patients (54.17 percent of the cases), 10 males and 16 females, ileal pouch–anal anastomosis was performed after a modified surgical technique for strengthening the internal anal sphincter by creation of a smooth muscle cuff through plication of a mucosectomized segment of residual rectum. Basal resting anal canal pressure and pressure after voluntary contraction were recorded preoperatively, one month after surgery, and every six months for two years.RESULTS One month after the operation manometric results showed significantly higher values of resting pressure in patients with a plicated rectal segment than values measured preoperatively (P < 0.001). This effect was absent after the standard ileal pouch–anal anastomosis. With the rectal plication technique, basal pressure increased from a preoperative value of 69 ± 6 mmHg up to 80 ± 6 mmHg at the end of the second postoperative year (P < 0.001).CONCLUSIONS We concluded that ileal pouch–anal anastomosis with rectal plication perhaps improved sphincter function. The operative technique did not affect anal squeeze pressure. Patients quality of life was improved for those undergoing the modified ileal pouch–anal anastomosis.     

Adenocarcinoma in the Anal Transitional Zone After Ileal Pouch for Ulcerative Colitis

This article reports the seventh known case of adenocarcinoma arising in or adjacent to an ileal pouch after proctocolectomy for ulcerative colitis. It is the second reported case of adenocarcinoma in the anal transitional zone in this setting. A literature review is presented of the six previous cases published, and on the wider subject of how to best manage the anal transitional zone. It is concluded that this is a rare, but catastrophic, event with a potentially poor prognosis and can occur late (more than a decade) after the original surgery. All ileal pouches performed for ulcerative colitis should be followed for extended periods. The development of dysplasia necessitates close follow-up, including regular biopsies, and local excision and pouch advancement can manage persistent dysplasia. When operating for dysplasia or cancer, biopsies of the anal transitional zone should be performed or consideration given to mandatory mucosectomy.     

Anal sphincter function after intersphincteric resection and stapled ileal pouch-anal anastomosis

This study was done to determine the effect of the direct ileal pouch-anal anastomosis upon pressure and sensory components of the anal canal and ileal pouch. These findings were related to postoperative continence. Thirty-three patients with ileal pouch-anal anastomosis (25 continent, eight with episodic minor incontinence) were studied 3±0.3 and 25±5 months after ileostomy takedown. The maximum resting pressure in the anal canal was significantly lower in patients with an imperfect result (35±5 mm Hg) than in continent patients (44±5 mm Hg) (P<0.05). Postoperatively the maximum squeeze anal pressure was slightly greater in continent than in incontinent patients (99±8 mm Hg vs.87±7 mm Hg) (P>0.05). The postoperative recto-(ileo-)anal inhibitory reflex was present in 27 percent. The linear correlation between strength of rectal (ileal) distension and depth resp. duration of internal sphincter relaxation as preoperatively observed disappeared postoperatively in every group of patients. Simultaneous measurements of pouch and anal pressure in patients with imperfect results revealed a reduced positive pouch anal pressure gradient compared to the continent group. This low pouch-anal pressure gradient is thought to be responsible for the increased incidence of soiling in some of our patients.     

Adenocarcinoma of the ileoanal pouch for ulcerative colitis—a complication of severe chronic atrophic pouchitis?

Background The appearance of a carcinoma in the ileal pouch after restorative proctocolectomy with ileal pouch–anal anastomosis (IPAA) for ulcerative proctocolitis is rare. Most of these adenocarcinomas previously described in literature develop from residual viable rectal mucosa. We report a case of an adenocarcinoma arising in all probability from the ileal pouch after malignant transformation of the ileal pouch mucosa based on a chronic atrophic pouchitis.Patient and methods A 34-year-old man developed an adenocarcinoma after a double-stapled ileorectal J-pouch for ulcerative colitis (UC) proceeded from malignant ileal transformation. Before surgery, he had a 20-year history of UC refractory to medical therapy, but no occurrence of backwash ileitis, dysplasia or colitis-associated illness. He experienced severe pouchitis after IPAA since the ileostomy closure. Carcinoma was ensured by endoscopy, and the patient underwent an abdominoperineal pouch extirpation combined with excision of perirectal tissues and anal canal. Histology after surgery showed a pT4,pN2(4/16)pM0,G3 adenocarcinoma with global severe chronic atrophic pouchitis (CAP), villous atrophy and malignant ileal transformation. No metaplasia of the rectal mucosa was found, not even malignant epithelial transformation of the anal canal.Conclusion This case suggests that a malignant transformation of the ileal pouch mucosa may occur as a pure complication of severe CAP, even in the absence of backwash ileitis or a previous history of cancer. The absence of metaplasia of the rectal mucosa revealed the passage from CAP to dysplastic epithelium and to cancer. A multifactorial development of carcinogenesis is supposed, but we emphasize the importance of severe CAP, and that careful surveillance is needed in patients after IPAA. We must submit that this is just a case report and cannot stand for general cancer development in ulcerative colitis, but it may point out the risk factor of chronic inflammation and leads the surgeon to skillful working when building the pouch.     

Endoscopic closure instead of surgery to close an ileal pouch fistula with the over-the-scope clip system

An ileal pouch fistula is an uncommon complication after an ileal pouch anal anastomosis. Most patients who suffer from an ileal pouch fistula will need surgical intervention. However, the surgery can be invasive and has a high risk compared to endoscopic treatment. The over-the-scope clip(OTSC) system was initially developed for hemostasis and leakage closure in the gastrointestinal tract during flexible endoscopy. There have been many successes in using this approach to apply perforations to the upper gastrointestinal tract. However, this approach has not been used for ileal pouch fistulas until currently. In this report, we describe one patient who suffered a leak from the tip of the "J" pouch and was successfully treated with endoscopic closure via the OTSC system. A 26-year-old male patient had an intestinal fistula at the tip of the "J" pouch after an ileal pouch anal anastomosis procedure. He received endoscopic treatment via OTSC under intravenous anesthesia, and the leak was closed successfully. Endoscopic closure of a pouch fistula could be a simpler alternative to surgery and could help avoid surgeryrelated complications.     

Integrity of the Anal Sphincters After Pouch-Anal Anastomosis: Evaluation With Three-Dimensional Endoanal Ultrasonography

PURPOSE The aim of the present study was to assess the integrity of the anal sphincters after handsewn pouch-anal anastomosis performed with the help of a Scott retractor. For this purpose the anal sphincters were visualized with three-dimensional endoanal ultrasonography.METHODS Patients undergoing a colonic pouch-anal anastomosis or an ileal pouch-anal anastomosis were included. Before and six months after the procedure, the length and volume of both sphincters were assessed with three-dimensional endoanal ultrasonography, and anal manometry was performed. Continence scores were determined using the Fecal Incontinence Severity Index (FISI).RESULTS Fifteen patients with a colonic pouch and 13 patients with an ileal pouch were examined. Six months after the procedure, three-dimensional endoanal ultrasonography showed significant alterations of the internal anal sphincter in eight patients with a colonic pouch-anal anastomosis (53 percent) and in eight patients with an ileal pouch-anal anastomosis (62 percent). These alterations were characterized by asymmetry or thinning. No defects were seen in the colonic pouch group, but, in two patients with an ileal pouch, a small defect in the internal anal sphincter was found. A decrease in internal anal sphincter volume was seen only in patients with a colonic pouch-anal anastomosis (P = 0.009). In both groups the length of the internal anal sphincter and the length, thickness, and volume of the external anal sphincter remained the same. After the procedure a reduction of maximum anal resting pressure was found in both groups (colonic pouch: P < 0.001, ileal pouch: P = 0.001). Maximum anal squeeze pressure was reduced in only patients with an ileal pouch-anal anastomosis (P = 0.006). The observed alterations of the internal anal sphincter and the manometric findings showed no correlation with the postoperative Fecal Incontinence Severity Index scores.CONCLUSION Handsewn pouch-anal anastomosis, performed with the help of a Scott retractor, only rarely leads to internal anal sphincter defects, but three-dimensional endoanal ultrasonography shows alterations of the internal anal sphincter in 57 percent of the patients. No correlation was observed between these alterations and the functional outcome.Read at the meeting of the Netherlands Association of Gastroenterology (NVGE), Veldhoven, The Netherlands, October 7 and 8, 2004.Reprints are not available.     

Anal sphincteroplasty for incontinence after ileal pouch-anal anastomosis

PURPOSE: This report reviews two patients who underwent anal sphincteroplasty to improve continence after ileal pouch-anal anastomosis (IPAA). METHODS: A retrospective study of two patients was performed. RESULTS: Two patients underwent anal sphincteroplasty after IPAA for incontinence, one diagnosed preoperatively and one postoperatively. Both had had previous anal surgery. Satisfactory continence was achieved in both cases, despite modest changes in manometric studies. CONCLUSION: Anal sphincteroplasty should be considered after IPAA. The value of anorectal manometry in this situation is equivocal.     

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.     

Dysplasia of the anal transitional zone after ileal pouch-anal anastomosis: results of prospective evaluation after a minimum of ten years

PURPOSE: Stapling of the ileal pouch-anal anastomosis with preservation of the anal transitional zone remains controversial because of concerns about the potential risk of dysplasia and cancer. The natural history and optimal treatment of anal transitional zone dysplasia ten or more years after surgery are unknown. This study establishes the risk of dysplasia in the anal transitional zone and the outcome of a conservative management policy for anal transitional zone dysplasia, with a minimum of ten years follow-up after ileal pouch-anal anastomosis. METHODS: A total of 289 patients undergoing anal transitional zone–sparing stapled ileal pouch-anal anastomosis for inflammatory bowel disease between 1986 and 1990 were studied. Patients undergoing anal transitional zone–sparing ileal pouch-anal anastomosis who were studied with serial anal transitional zone biopsies for at least ten years postoperatively were included (n = 178). Median follow-up was 130 (range, 120–157) months. RESULTS: Anal transitional zone dysplasia developed in 8 patients 4 to 123 (median, 9) months after surgery. There was no association with gender, age, preoperative disease duration, or extent of colitis, but the risk of anal transitional zone dysplasia was significantly associated with cancer or dysplasia as a preoperative diagnosis or in the proctocolectomy specimen. Dysplasia was high grade in two patients and low grade in six. Two patients with low-grade dysplasia on two or more occasions after detection of low-grade dysplasia underwent completion mucosectomy and perineal pouch advancement with neo–ileal pouch-anal anastomosis. One patient with high-grade dysplasia on two occasions was to undergo completion mucosectomy, but this was not technically feasible. Partial mucosectomy with vigorous anal transitional zone biopsy was performed with close postoperative surveillance. Biopsies were negative for dysplasia. The second recently diagnosed patient with high-grade dysplasia underwent examination under anesthesia with negative anal transitional zone biopsies and will be kept under close surveillance. No cancer in the anal transitional zone was found during the study period. The 4 other patients with low-grade dysplasia on 1 or 2 occasions were treated expectantly and have been dysplasia free for a median of 119 (range, 103–133) months. CONCLUSIONS: Anal transitional zone dysplasia after stapled ileal pouch-anal anastomosis is infrequent and is usually self-limiting. Anal transitional zone preservation did not lead to the development of cancer in the anal transitional zone with a minimum of ten years of follow-up. Long-term surveillance is recommended to monitor dysplasia. If repeat biopsy confirms persistent dysplasia, mucosectomy with perineal pouch advancement and neo–ileal pouch-anal anastomosis is recommended.     

Functional outcome after restorative proctocolectomy

Incontinence and pouchitis are complications that affect most patients who have undergone restorative proctocolectomy. Incontinence, with particular regard to night leakage, is related to the combination of poorly functioning ileal reservoir and poor anal sphincter function. Pouchitis, the major late complication of restorative proctocolectomy, is quite similar to the previous inflammatory bowel disease. Pouchitis has an important impact on functional results after restorative proctocolectomy, causing a significant increase in defecation frequency, pain on evacuation, urgency, watery bowel movements, bloody diarrhea, anal irritation and stool leakage. In particular, chronic pouchitis can cause distress, anxiety and disappointment for patients needing continuous treatment. The influence of anal sphincter and ileal pouch function on clinical outcome after ileal pouch-anal anastomosis (IPAA) is reviewed, together with the correlation between ileal pouch function and pouchitis. The possible correlation between pouchitis and long-term functional outcome after restorative proctocolectomy is examined. Received: 28 May 1998 / Accepted in revised form: 22 September 1999     

Vaginal Delivery After Ileal Pouch-Anal Anastomosis: A Word of Caution

PURPOSE This study was designed to evaluate the impact of childbirth on anal sphincter integrity and function, functional outcome, and quality of life in females with restorative proctocolectomy and ileal pouch-anal anastomosis.METHODS The patients who had at least one live birth after ileal pouch-anal anastomosis were asked to return for a comprehensive assessment. They were asked to complete the following questionnaires: the Short Form-36, Cleveland Global Quality of Life scale, American Society of Colorectal Surgeons fecal incontinence severity index, and time trade-off method. Additionally, anal sphincter integrity (endosonography) and manometric pressures were measured by a medical physician blinded to the delivery technique. Anal sphincter physiology also was evaluated with electromyography and pudendal nerve function by nerve terminal motor latency technique.RESULTS Of 110 eligible females who had at least one live birth after ileal pouch-anal anastomosis, 57 participated in the study by returning for clinical evaluation to the clinic and 25 others by returning the quality of life and functional outcome questionnaires. Patients were classified into two groups: patients who had only cesarean section delivery after ileal pouch-anal anastomosis (n = 62) and patients who had at least one vaginal delivery after ileal pouch-anal anastomosis (n = 20). The mean follow-up from the date of the most recent delivery was 4.9 years. The vaginal delivery group had significantly higher incidence of an anterior sphincter defect by anal endosonography (50 percent) vs. cesarean section delivery group (13 percent; P = 0.012). The mean squeeze anal pressure was significantly higher in the patients who had only cesarean section delivery (150 mmHg) after restorative proctocolectomy than patients who had at least one vaginal delivery (120 mmHg) after restorative proctocolectomy (P = 0.049). Quality of life evaluated by time trade-off method also was significantly better in the cesarean section delivery group (1) vs. vaginal delivery group (0.9; P < 0.001).CONCLUSIONS The risk of the sphincter injury and quality of life measured by time trade-off method are significantly worse after vaginal delivery compared with cesarean section in patients with ileal pouch-anal anastomosis. In the short-term, this does not seem to substantially influence pouch function or quality of life; however, the long-term effects remain unknown, thus obstetric concern may not be the only factor dictating the type of delivery in this group of patients. A planned cesarean section may eliminate these potential and factual concerns in ileal pouch-anal anastomosis patients.Podium presentation at the meeting of The American Society of Colon and Rectal Surgeons, Dallas, Texas, May 8 to 13, 2004.     

Functional outcomes in patients with mucosal ulcerative colitis after ileal pouch-anal anastomosis by the double stapling technique

PURPOSE: The aim of this study was to evaluate any differences in functional outcome in patients with mucosal ulcerative colitis after restorative proctocolectomy and ileal pouch-anal anastomosis with use of the double stapling technique relative to the type of tissue in the stapled doughnut. METHODS: Between September 1988 and June 1997, the pathology of all patients with mucosal ulcerative colitis who underwent ileal pouch-anal anastomosis with use of the double stapling technique were reviewed. Information was obtained regarding the tissue types in the distal tissue rings (doughnuts) obtained from the stapled ileal pouchanal anastomosis. The level of anastomosis was classified according to the type of tissue in the distal doughnut: Group I- patients in whom the anal transitional zone was removed and the distal doughnut included squamous epithelium or transitional epithelium and Group II- patients in whom the anal transitional zone was preserved because the distal doughnut revealed only columnar epithelium. Functional outcomes were assessed and compared by detailed questionnaires mailed to all patients at least one year after ileal pouch-anal anastomosis surgery. RESULTS: Distal doughnuts were obtained from the stapled ileal pouch-anal anastomosis in 222 patients with mucosal ulcerative colitis. Follow-up data at a mean of 38 (range, 12-132) months were obtained in 138 (62.2 percent) patients, including 72 males, with a mean age of 46.9 (range, 13-79) years. Group I consisted of 40 patients (29 percent; 35 (25.4 percent) who had squamous epithelium and 5 (3.6 percent) who had transitional epithelium in the distal tissue rings). Group II consisted of 98 patients (71 percent) with columnar epithelium in the distal tissue rings. Age at diagnosis and operation, duration of disease, length of follow-up, and stage of pouch surgery were similar in the two groups. Incontinence scores, frequency of bowel movement, use of a protective pad, discrimination between gas and stool, use of antidiarrheals, life-style alteration, and patient satisfaction showed similar functional results between the two groups. CONCLUSIONS: The tissue type in the stapler distal doughnut did not greatly influence functional outcome. Failure to identify a relationship may attest to the variable height and composition of the anal transitional zone.     

Inferior reach of ileal reservoir in ileoanal anastomosis

A possible technical problem encountered when performing ileoanal anastomosis with reservoir is the occurrence of tension when the reservoir is drawn to the anal canal. An anatomic study was performed to assess the gain of caudad reach that can be obtained by dissection of the mesentery root and vascular divisions applied to S- and J-shaped reservoirs, in association with angiographic control of terminal ileum vascularization. The study confirms the clinical experience that caudad reach of ileal reservoirs can be critical in some cases. Complete dissection of the root of the mesentery is a poor lengthening technique, the limiting factor being tension of the superior mesenteric artery. It is simple, however, and should be performed systematically because it can provide 1 or 2 useful centimeters of caudad reach. Division of the ileocecal pedicle is a safe, reproducible, efficient lengthening procedure that can serve all types of reservoirs. In this study, it gave a 5 cm or more gain in caudad reach in 80 percent of the cases, with a slight advantage to the S-shaped reservoir. Distal division of the superior mesenteric pedicle seems more hazardous and can serve only the J-shaped reservoir. For J-shaped reservoirs, maximum caudad reach was achieved when the pouch was built over the most inferior ileal point, which should be checked prior to the procedure, not judged according to predefined measures. The angiographic study showed that, in 38 percent of the cases, cecal vessels participated in vascularization of the last centimeters of the terminal ileum by means of recurrent ileal arteries, which, in 28 percent of the cases, provided exclusive blood supply to this area. Vascularization of the terminal ileum can and should be carefully preserved.     

Adenocarcinoma Arising from the Rectal Stump Eleven Years after Excision of an Ileal J-Pouch in a Patient with Ulcerative Colitis: Report of a Case

Adenocarcinomas in relation to the ileal J-pouch after restorative proctocolectomy for ulcerative colitis have been recently reported with increasing frequency. All previously reported cases have occurred in patients with their ileal pouch in situ. We report a case of adenocarcinoma in the anal canal 11 years after removal of a failed ileal J-pouch. Mucosectomy had been performed at the restorative proctocolectomy. The anus had been left in place at the pouch excision because of severe fibrosis in the pelvis. If it is decided to remove an ileal pouch permanently, a total abdominoperineal excision should be performed, particularly in patients with risk factors for cancer development. Reprints are not available.     

Whitehead's hemorrhoidectomy. A useful surgical procedure in selected cases

At the present time Milligan-Morgan's operation is the most diffusely employed and is widely considered to be the most effective of the various surgical techniques for the treatment of hemorrhoids. In this study we report our experience with Whitehead's radical hemorrhoidectomy. In a 5-year period, 1450 patients with hemorrhoids were treated at our Coloproctologic Unit. We routinely carry out the Milligan-Morgan operation. Nevertheless, in 26 patients the Milligan-Morgan operation was judged to be impossible to perform, in that the prolapsed hemorrhoids were completely irreducible and it was not possible to distinguish and separate the three piles. These patients thus underwent Whitehead's radical hemorroidectomy. All the patients who underwent Whitehead's operation were discharged within the fifth post-operative day. No episodes of incontinence were observed in any patient. The patients were followed for three years after the operation. In only one case did we verify an anal substenosis three months after the operation, which resolved after the use of anal dilators for one month. The stenosis did not recur in the course of follow-up. There were no cases of mucosal ectropion. In conclusion, the type of hemorrhoidectomy which a surgeon performs is primarily based on the surgeon's experience and training. Nevertheless, a competently performed Whitehead's hemorrhoidectomy can give satisfying results. These results are explained by improved knowledge of the anatomy of the anal region and a more accurate surgical technique. On the basis of our experience we believe that Whitehead's hemorrhoidectomy still has its place in selected cases with precise indications. Received: 20 March 2001 / Accepted in revised form: 9 May 2001