[Treatment of low rectovaginal fistula by pulling down a rectal mucosal curtain]

The most delicate stage in the repair of low rectovaginal fistulae is closure of the rectal opening. To the numerous and complex procedures proposed, the authors oppose a simple technique which consists of separating the rectal mucosa, which can then be pulled down like a curtain to effectively and completely obturate the opening without attending to the muscular breach. This technique has been successfully used in 9 cases of low recto-vaginal fistulae of obstetrical or infectious origin.

Replacement of colonic mucosa by free and pedicled grafts of ileal mucosa in the dog

Mucosal proctectomy and ileo-anal anastomosis is a relatively new operation in the treatment of patients with ulcerative colitis. The diseased rectal mucosa is removed and gastrointestinal continuity is restored by replacing it with full thickness ileum. The main disadvantage of the operation is frequency of bowel action and in an attempt to resolve this problem the feasibility of replacing colonic mucosa with grafts of ileal mucosa alone was explored. Both free and pedicled autografts of ileal mucosa were grafted into isolated loops of canine colon, denuded of mucosa and submucosa. All the free grafts failed to survive (eight dogs) and histological examinations confirmed graft rejection. All the pedicled grafts (seven dogs) were successful and retained the histological characteristics of normal ileum. Net movement and bidirectional transport of water and electrolytes were measured in six dogs with pedicled grafts and in four control dogs with intact full thickness ileal loops. Whereas the control loops absorbed water and electrolytes, the grafted loops secreted water, sodium, and potassium and absorbed significantly less chloride. The mucosa of the colon can thus be replaced successfully by grafts of ileal mucosa provided that an intact blood supply is preserved. The capacity and sensation of the neorectum after mucosal proctectomy may be improved if mucosal grafts were used instead of full thickness ileum. Before this procedure could be used in man, however, practical problems would have to be overcome and the secretion of water and electrolytes corrected.

[Studies on total colectomy, mucosal proctectomy and ileoanal anastomosis (ileoanostomy)]

Studies have been made in order to establish a practical operative procedure of the ileoanostomy as well as to understand its postoperative pathophysiology using 45 patients including 34 with familial polyposis and 11 with ulcerative colitis those which have been followed up for 1 to 4 years. Three major technical problems here with challenged are how to minimize the complications, how to improve the bowel function and how to simplify the procedure. Our J-pouch method was found to have better bowel function compared with those without a pouch and those with H-pouch and also considered to be superior to S-pouch, with its consistent spontaneous evacuation and with a simpler construction. The length of rectal cuff was found to be able to be minimized down to just above the levator muscle without disturbing the bowel function, based on our experiences on two polyposis cases with rectal cancers. The short rectal cuff of about 7-6 cm was considered to be the method of choice for eliminating the cuff abscess in addition to routine use of a diverting ileostomy, and for technical simplification. Ano-abdominal rectal mucosectomy at prone-jack-knife position is recommended to achieve further technical feasibility. The pathophysiological studies including anorectal manometry, intestinal transit time, physical, chemical and bacteriological analysis of the stool, water absorption of the ileal neorectum as well as the systemic metabolic studies supported favorable clinical result of our method. Ileoanostomy by our principle consisting of J-pouch, short cuff and loop-ileostomy, was concluded to be a break through to avoid an abdominal ileostomy after total proctocolectomy.

Straight ileoanal anastomosis v ileal pouch--anal anastomosis after colectomy and mucosal proctectomy

The postoperative results of 50 patients who underwent straight ileoanal anastomosis after total colectomy and mucosal proctectomy were compared with those of 74 patients who underwent ileal pouch--anal anastomosis. No deaths occurred. Of the straight ileoanal anastomoses, 32% failed because of sepsis or diarrhea and necessitated abdominal ileostomy; only 1.3% failed in the pouch-anal group (P less than .05). Stool frequency among patients followed up for three months or more (straight ileoanal, n = 30; pouch-anal, n = 33) was less in the pouch-anal group (mean +/- SEM, 7 +/- 1 stools per 24 hours) than in the straight ileoanal group (11 +/- 1/24 hr, P less than .01). Major nocturnal incontinence was also less in the pouch-anal group than in the straight ileoanal group (0% v 20%), and patient satisfaction was better, as measured on a scale of 1 (very poor functional result) to 10 (excellent result) (pouch-anal score, 9; straight ileoanal score, 6; P less than .02). We concluded that ileal pouch-anal anastomosis resulted in less diarrhea, better continence, and an improved quality of life when compared with straight ileoanal anastomosis.

[Septic complications after total colectomy, excision of the rectal mucosa ileoanastomy and its prevention--with special reference to pelvic sepsis]

Forty-two patients had total colectomy, excision of th rectal mucosa and ileoanastomy for adenomatosis coli or ulcerative colitis. The essential operative management for prevention of pelvic sepsis are 1) intraoperative bowel irrigation with antimicrobes, 2) creation of temporary defunctioning ileostomy, 3) effective drainage of the rectal cuff. With these methods pelvic sepsis developed in ten out of forty contaminated case. Whereas in one contaminated case both pelvic sepsis and wound infection developed. Age of the patients, the presence of underlying diseases, type of reservoir and surgeon's experience had no correlation with the incidence of pelvic sepsis, however the short rectal cuff seemed significant for its prevention. The stenosis of the transposed ileum had developed in two cases, one of which case had recurrence of pelvic sepsis after closure of ileostomy. One patient had chronic fistula between transposed ileum and perineum after removal of the transperineal drainage. These complications are very difficult to manage. Three patients had closure of ileostomy with satisfactory result. Proctoscopic examination were essential to identify with anastomotic break down and pus discharge. Irrigation of the transposed ileum with antimicrobes for aerobes and anaerobes should be started after diagnosis. Incision and drainage were necessary when irrigation failed to heal cuff abscess.

Mucosal proctectomy without reservoir

Mucosal proctectomy with endorectal pull-through allows the removal of all colonic mucosa with preservation of continence. This operation was performed in 19 patients with familial polyposis coli and ulcerative colitis. A temporary loop ileostomy was used to defunctionalize the anastomosis. Intestinal continuity was restored in 17 of the 19 patients. Mean duration of follow-up was 29 months. All patients are continent, and the mean number of bowel movements per 24 hours is 6. Follow-up barium studies revealed a gradual dilatation of the terminal ileum within the rectal cuff which accounts for the decrease in the number of bowel movements. This operation eliminates the risk of carcinoma without compromising sphincter function.

Endorectal pull-through operation in adults after colectomy and excision of rectal mucosa

Ileal endorectal pull-through can be performed in adults after abdominal colectomy and excision of rectal mucosa. The procedure requires a painstaking dissection of the mucous membrane of the rectum to ensure cure of the polyposis or ulcerative colitis for which it is carried out. Some cases of ulcerative colitis are inappropriate for this dissection, and Crohn's disease prohibits the use of this operation. Fifteen operations in adults are described herein. Certain technical maneuvers have been of help to us and these are described. We have favored a diverting ileostomy maintained for 3 months. A pouch, positioned in the rectum, has hastened the return toward normal control. Sphincter control and responses have been uniformly good. Dilatations and sphincter exercises are routinely employed. Strictures are not rare but are amenable to correction by digital stretching.

The endorectal pull-through for the management of ulcerative colitis in children and adults

Between June 1977 and November 1981, 26 children and adults with ulcerative colitis have undergone a total colectomy, an endorectal dissection of the rectal mucosa, and an ileoanostomy. A combined abdominoperineal approach was used to perform the operation, and the mucosal-submucosal rectal tube was dissected out intact from the abdominal approach. Every patient survived the operation and showed marked clinical improvement presumably due to resection of the diseased colon. Three patients developed intestinal obstruction that was successfully treated with an enterolysis. A rectal cuff abscess and a retroperitoneal abscess were the only other complications. The postoperative stooling pattern of each patient was obtained through detailed interviews. All the patients were continent during the day and at night one month after surgery. Twenty-two patients had a median stool frequency of seven per 24 hours one month after surgery. At one year, the average number of stools was seven per day. Six patients experienced a stool frequency of seven per 24 hours two years after surgery. The results with this series of patients had encouraged the authors to continue to recommend this approach to children and adults with ulcerative colitis, since it offers an alternative lifestyle that is more attractive to certain patients than the presence of an abdominal stoma.

Preservation of anorectal continence following total colectomy

The search for continence in the surgical management of ulcerative colitis has resulted in the evolution of a method that has yielded gratifying results in the last 18 patients. The disease process is removed; all patients are continent; they have no postoperative perineal excoriation; the frequency of stools is not excessive and the patients are returning to work or to school within three weeks following ileostomy closure. Their ages were eight to 52 years. The procedure consists of a total of colectomy with mucosal proctectomy, ileoanal anastomosis and construction of a terminal ileal, pelvic reservoir. A proximal ileostomy diverts the fecal stream until healing is complete. The authors are now recommending the operation be considered for patients of all ages who require surgery for chronic ulcerative colitis as well as polyposis.

[Total colectomy, rectomucosectomy, and ileoanal anastomosis with the ileum reservoir in treatment of ulcerative colitis]

An operation avoiding a permanent ileostomy is described for patients with ulcerative colitis. The colon and upper half of the rectum are excised and the remaining inflamed mucosa is stripped from the rectal stump down to the dentate line of the anal canal. After excision of all diseased tissue, a reservoir is constructed from the terminal 40 cm of the small intestine. An ileoanal anastomosis via the peranal approach is then carried out. Six patients have been treated, five of whom were followed up for 2-21 months (mean 11 months). One patient died 3 weeks after the operation. The other five are currently well, with no disturbance of urinary or sexual function. The average frequency of evacuation is 5 times in 24 h. Three of these evacuate the reservoir spontaneously and one routinely uses a catheter. (One patient still has an ileostomy). Fecal continence is complete in all during the day and night.

Rectal, bladder and sexual function after mucosal proctectomy with and without a pelvic reservoir for colitis and polyposis

Sexual, bladder and rectal function have been assessed prospectively in a group of patients undergoing mucosal proctectomy, primarily for ulcerative colitis. The function of the rectum and ‘neo-rectum’ was studied before and 3 months (on average) after operation in 18 patients. Intestinal continuity was restored by means of ileo-anal anastomosis; in addition to ileo-anal anastomosis, a pelvic reservoir (MP + RES) was constructed in 10 patients, while ileo-anal anastomosis alone (MP + IAA) was used in the remaining 8 patients. Thirteen of these patients have been studied for a minimum of 4 months after closure of the defunctioning ileostomy.

No evidence of impotence or of bladder dysfunction due to trauma to pelvic autonomic nerves was noted. Evidence of impairment of function of the internal anal sphincter was observed soon after operation in 16 of the 18 patients (P < 0·05). However, reflex function of the external anal sphincter could still be elicited in over 70 per cent of patients who were tested 3 months after operation. The functional results of patients after MP + RES were significantly better than those of patients who had undergone MP + IAA. Thirteen months (on average) after closure of the ileostomy, the maximum capacity and compliance of the ‘neo-rectum’ in patients after MP + RES (423 ± 87 ml and 14 ± 7 ml/cm H2O respectively) were significantly greater than in patients after MP + IAA (181 ± 103 ml and 4 ± 3 ml/cm H2O respectively; P < 0·05). A significant correlation between the capacity of the ‘neo-rectum’ and the frequency of defecation was noted. The results of the present study support the suggestion that a pelvic reservoir should be fashioned in adults undergoing mucosal proctectomy and ileo-anal anastomosis for inflammatory bowel disease.

Endorectal ileoanal anastomosis

In 1933, Nissen performed the first ileoanal anastomosis. Since then, ileoanal anastomosis has enjoyed only periodic popularity because numerous postoperative problems, primarily as a result of infection and incontinence, plagued the procedure. In recent reports, however, better postoperative results have been detailed which stem not only from improved surgical technique and better selection of patients but also from increased understanding of the physiologic mechanisms by which fecal continence is achieved. At operation, meticulous hemostasis and asepsis, accurate en bloc mucosal dissection and effective drainage each contribute to good functional results and the minimization of complications. In addition, patients who manifest evidence of dysfunction of anal sphincters, who are elderly or obese or who have Crohn's disease should not be candidates for ileoanal anastomosis. Finally, if the anal sphincters are intact, reliable ileal reservoir function, achieved by passive dilation, balloon distention or surgical construction of a pouch, may be the most important determinate of excellent clinical results after ileoanal anastomosis.

A technique for transduodenal sphincteroplasty

A technique for transduodenal sphincteroplasty is presented. T-tube decompression of the common bile duct and subphrenic space drainage are routinely avoided. To date, results in 123 consecutive patients have been excellent. The single most troublesome wound complication, duodenal fistula, had been avoided in the most recent 68 patients by colonic or omental onlay of serosa.

Ileoanal anastomosis in the adult

Of 50 adults with chronic ulcerative colitis, familial polyposis or Crohn's disease undergoing colectomy, excision of the rectal mucosa, endorectal ileoanal anastomosis and protective proximal ileostomy, 42 subsequently had restoration of fecal continuity. Observation for six to 36 months revealed that anastomotic strictures or fecal urgency and frequency developed in 13 of the 42 patients. Most of these patients had undergone operation early in the series. All 13 patients required abandonment of the neorectum. Thirty of 39 evaluable patients were continent, averaged eight bowel movements per day and could distinguish between gas and stool. Thirty patients preferred life with an ileoanal anastomosis to that with an ileostomy. We concluded that ileoanal anastomosis is a viable alternative for some adults requiring proctocolectomy.

Artificial sphincters as surgical treatment for experimental massive resection of small intestine

A modification of the technique of Schiller, DiDio, and Anderson was adopted by extending removal of the longitudinal layer of the muscular coat to the entire perimeter of a segment of the small intestine in dogs, resulting in the construction of artificial sphincters, to assist animals undergoing enterectomy. The creation of one or two artificial sphincters prolonged the survival of dogs undergoing massive resection of the small intestine (87.5 percent of the total length).

An ultrastructural study of enteric serosa after surgical management

The surface topography of rabbit enteric serosa was studied with a scanning electron microscope before and after surgical manipulation and after pretreatment with polyvinylpyrrolidone, an experimental antiadhesion agent. Results indicated that the serosal surface is characterized by an intertwined three-dimensional lattice of collagen like material which was remarkably altered by simple handling. Pretreatment with polyvinylpyrrolidone reduced this alteration, but polyvinylpyrrolidone itself has an adverse effect upon serosal topography. This study has provided novel insight into the fine structure of the intestinal serosa and has demonstrated alterations in this structure after simple operative handling. It has been shown that polyvinylpyrrolidone, although offering some protection, altered the fine latticework that covers the serosal surface. In addition, this study has demonstrated the usefulness of the scanning electron microscope in defining serosal damage and evaluating new therapeutic antiadhesion agents.

Physiologic aspects of continence after colectomy, mucosal proctectomy, and endorectal ileo-anal anastomosis

We examined the physiology of continence in 12 patients at least four months after colectomy, mucosal proctectomy, and endorectal ileo-anal anastomosis for ulcerative colitis and familial polyposis. The mean fecal output (+/-SEM) was 598 +/- 60 gm, passed as 12 +/- 4 movements/24 hr, of which 4 +/- 1 were passed at night. The patients were generally continent during the day and could distinguish gas from stool, but 11 of 12 leaked stools at night. Anal sphincter resting pressures (71 +/- 8 cm H2O) and squeeze pressures (171 +/- 15 cm H2O) of patients were similar to those of ten healthy controls (P greater than 0.05), although the rectal inhibitory reflex was absent in the patients. After operation, the distal bowel had a pressure-volume curve of greater slope (0.15 +/- 0.05 ml/cm H2O) than it had in controls (0.07 +/- 0.01 ml/cm H2O, P less than 0.05) and a lesser maximum capacity (patients, 248 +/- 31 ml; controls, 406 +/- 26 ml; P less than 0.05). The greater the capacity of the neorectum, the fewer was the number of bowel movements/day (r = 0.91, P less than 0.001). We concluded that the operation preserved the anal sphincter, although it decreased the capacity and compliance of the distal bowel and impaired continence.

Preserving the ascending colon as an alternative surgical option in ulcerative colitis

Six patients with ulcerative colitis were studied to assess the histologic appearance of the ascending colon which was preserved at the initial operation performed more than ten years previous. Inflammatory cells were increased in all patients, but ulceration was not present microscopically. Most patients had less than five bowel movements a day. Because of good long term survival of the mucosa, wider use of a surgical approach is proposed, based upon excising the colonic mucosa most prone to ulceration and metabolic derangement. The procedure entails subtotal colectomy, mucosectomy of the rectal mucosa and preservation of the ascending colon as a neorectum. Prime advantages are the lack of a stoma and fewer bowel movements than result from other operations.