Mucosal proctectomy using an ultrasonic scalpel

Mucosal proctectomy is becoming the operation of choice in the surgical treatment of patients with ulcerative colitis and familial polyposis coli. Dissection of the rectal mucosa and submucosa from the underlying muscularis is often difficult and, in some instances, impossible to perform. The feasibility of using an ultrasonic device to perform mucosal protectomy was studied in eight dogs. This technique produced coagulative necrosis of the mucosa and muscularis mucosa with marked edema and congestion of the submucosa. The muscularis propria remained intact. Complete destruction of the distal 7 cm of rectal mucosa required a total duration of exposure to the ultrasonic probe of at least 12 minutes. In another five dogs, total colectomy was performed above the area of the mucosal proctectomy followed by endorectal pull-through of the ileum. Follow-up studies revealed healing of the ileonal anastomosis without retraction or stricture. This technique should allow mucosal proctectomy to be performed in those patients in whom standard dissection is not possible due to fibrosis of the submucosal plane.

Endorectal ileal pullthrough procedure after chemical debridement of the rectal mucosa

The technical difficulty of removing the intact rectal mucosa without damaging the rectal muscularis and anorectal sphincter mechanism when there is extensive inflammation has prompted evaluation of techniques other than direct surgical stripping. The present study was done to evaluate the histopathologic effectiveness of chemical debridement of the rectal mucosa in dogs with 0.5 N sodium hydroxide solution and 1 per cent acetic acid. Repeated exposure of the mucosa to sodium hydroxide solution on three consecutive days produced a second degree burn of the mucosa leading to sloughing without appreciably injuring the underlying muscularis. Minimal inflammation or hemorrhage was observed four and eight weeks after removal of the rectal mucosa and endorectal ileal pullthrough using both light and scanning electron microscopy. Excellent healing occurred between the ileal pullthrough segment and the rectal muscularis without evidence of abscess. Anorectal manometric studies showed minor changes in a comparison of the preoperative and four week postoperative tractings. Chemical debridement of the rectal mucosa appears to be a helpful adjunct to mechanical stripping in situations in which the mucosa is extensively inflamed or tenaciously adherent to the muscularis, or both, when endorectal ileal pullthrough is the desired operation.

Preservation of anal function after total excision of the anal mucosa for Bowen's disease

Six women with Bowen's disease of the anogenital area were treated by total excision of the anal mucosa, perianal skin and, in some cases, partial vulvectomy. Two patients had foci of microinvasive squamous carcinoma. Adequate tumor margins were determined by frozen sections. The resulting mucosal and cutaneous defects were grafted with medium split-thickness skin grafts applied to the anal canal and sutured circumferentially to the rectal mucosa. Grafts were held in place by a finger cot inserted in the anal canal and stuffed with cotton balls. Patients were constipated five or six days with codeine. The skin grafts healed per primam. One additional patient was similarly treated for a chronic herpetic ulceration of the anus and healed. Contrary to dire predictions, all patients were able to distinguish between gaseous and solid rectal contents and sphincter function was preserved. In one patient, Bowen's disease has recurred in the grafted perianal skin.

[Treatment with Soave's technic and long-term results in 270 cases of Hirschsprung disease]

The authors present the surgical technique for the correction of Hirschsprung disease following SOAVE's original description. A series of 270 cases observed in 20 years at the Pediatric Surgery Department of the "Instituto Giannina Gaslini" in Genova, Italy, are examined. These cases, all treated by surgery, were followed up in long term for more than one year both clinically and radiologically. Additionally 73 cases treated from 1977 on were also followed up with the aid of ano-rectal electro-manometry. The most recent diagnostic aspects are discussed, such as ano-manometry, and some conclusions are drawn about long term results.

A new type of continent ileostomy. Results of an animal study

Kock's continent ileostomy is a well-established technique, however, it is technically difficult to construct and has a high incidence of complications. This study evaluates a new type of mucosal valve constructed in continuity with an intestinal reservoir. The valve is created along the antimesenteric border of the efferent limb 0.5 cm distal to the reservoir. The seromuscular layer is "stripped" from the mucosal layer for 50 per cent of the bowel circumference and then excised. The remaining seromuscular borders are then sutured to the apex of the pouch and along the antimesenteric border of the afferent limb. In this way the valve is created and, upon distention of the afferent limb and apex of the pouch, the valve closes. In seven dogs such a continent ileostomy was constructed and all were clinically continent. The reservoirs were intubated through the ileostomy two to three times a day. The mean volume aspirated was 143 ml/day. After eight weeks, radiographic and volume-pressure studies were performed. Prior to sacrifice, increasing volumes of barium were instilled into each pouch via the afferent limb and radiographs were taken: these studies confirmed the continence in all seven ileostomies. Following this the reservoirs were intubated and the instilled barium was aspirated. Then Ringer's solution was instilled into each pouch with continuous intrapouch pressure measurements. The pressure remained at 0 cmH2O until a mean volume of 243 ml was exceeded. The mean volume at which incontinence occurred was 415 ml.

Endorectal ileoanal anastomosis with isoperistaltic ileal reservoir after colectomy and mucosal proctectomy

Forty-nine patients with chronic ulcerative colitis refractory to medical therapy and four with multiple polyposis have undergone total colectomy, mucosal protectomy, and endorectal ileal pull-through with ileoanal anastomosis at the UCLA Medical Center during the past 12 years (mean age, 19.4 years). Thirty-eight patients underwent second-stage closure of the ileostomy with construction of a side-to-side isoperistaltic ileal reservoir (mean, 6 months) after the ileal pullthrough operation. The anastomosis extended over a 20-30 cm distance and the lower end was placed within 6-8 cm of the ileonanal anastomosis. Transient reservoir inflammation, which occurred in half of the patients, was reduced by the use of oral metranidazole and was rarely found 6 months after operation. No patients died during the early or late post-operative periods. Cuff abscess in two patients and obstruction of the ileal reservoir outlet have required takedown of the reservoir (two patients) or temporary ileostomy (three patients). Of the 38 patients who have undergone lateral ileal reservoir construction, 33 have achieved a good to excellent result with complete continence and an average of five stools per 24 hours after 6 months. At least 12 patients now participate in competitive athletics; normal sexual activity has been achieved in all but one patient. Seven patients await construction of the reservoir. Although a technically difficult operation, the long-term results (mean, 19.4 months) indicate that the pullthrough operation is a good alternative to standard proctocolectomy.

Eversion technique for distal mucosal proctectomy in ulcerative colitis: a preliminary report

A technique is described for assisting the performance of distal mucosal proctectomy in ulcerative colitis by peranal eversion of the lower rectum. The ease, accuracy and expedition of the mucosal excision have been impressive. In 9 of 16 patients having this procedure as part of an ileo-anal anastomosis (with a pelvic ileal reservoir) the functional results seemed to be similar to those obtained in 14 patients submitted to the same operation but with an endocavitary technique of rectal mucosectomy.

The triangular island skin flap for treatment of anal ectropion

Another method for repair of anal ectropion is reported. Two triangular island flaps, deeply based, are advanced medially to cover the excised area, thus resurfacing the anal canal with normal skin. The technique is recommended because of its simplicity, reliability, and satisfactory results.

The effects on pelvic visceral function of anal sphincter ablating and anal sphincter preserving operations for cancer of the lower part of the rectum and for benign colo-rectal disease

The effects on pelvic visceral function of radical operations for carcinoma of the lower part of the rectum and of operations for inflammatory bowel disease have been determined by studying bladder, sexual and rectal function. Denervation of the bladder was diagnosed in 15% of patients who had undergone sphincter-saving resection of the rectum for carcinoma and in 19% of patients who had undergone abdominoperineal excision of the rectum. In the remaining patients, temporary, less severe, degrees of impairment of bladder function were noted. Abnormalities of function were found on urodynamic testing of patients with denervation of the bladder which explained, in part, the propensity of such patients to develop incontinence of urine. Partial recovery of function was noted in the long term in patients with denervation of the bladder and evidence consistent with regeneration of autonomic nerves was obtained on histological examination of biopsies from the bladders of such patients. In patients who had undergone conventional proctectomy for inflammatory bowel disease, impairment of bladder and sexual function was observed. In contrast, no evidence of damage to pelvic autonomic nerves was found in patients who underwent selective mucosal proctectomy. Mucosal proctectomy and ileo-anal anastomosis in patients with ulcerative colitis did impair ano-rectal reflex function; nevertheless, most patients were continent. Patients in whom, in addition to mucosal proctectomy and ileo-anal anastomosis, a pelvic ileal reservoir had been constructed had better rectal function than patients who lacked such a reservoir.

Healing of experimental defects on the stomach: influence of autologous and heterologous materials

This study was undertaken to evaluate the influence of various autologous and heterologous structures on gastric defect healing. In 210 rats, standard gastric defects were closed using the following structures as patches: (1) pedicled colonic patches, (a) mucosal layer to lumen, and (b) peritoneal surface to lumen; (2) leiomuscular colonic buttons; and (3) lyophilized bovine tendon collagen sponges. The specimens were removed from the defect areas at standard time intervals ranging from 2 to 12 months after surgery; the samples were then examined by light microscopy (hematoxylin-eosin; Azan Mallory; Grimelius methods) and by transmission and scanning electronmicroscopy. The colonic mucosa appeared to be the most resistant of the structures to gastric secretions; it showed no mucosal disruption during the entire period of observation and also underwent a progressive gastric-like morphological transformation. In all the other cases, the healing process involved the initial development of granulation tissue followed by scar tissue with gastric mucosa growing over the scar tissue to fill the defects.

Total colectomy with mucosal protectomy and ileoanal anastomosis--an important surgical option in the aviator with premalignant disease of the colon

Total proctocolectomy with cutaneous ileostomy has been the standard therapy for many years for premalignant mucosal diseases of the colon, such as ulcerative colitis and familial polyposis. While this procedure relieves the patient of the risk of malignancy, it leaves him with the problem of the management of the ileostomy as well as exposing him to the risk of damage to the nerve supply of the bladder and genitalia during the dissection. Within the military population, the ileostomy is a particularly devastating problem as it disqualifies the individual from worldwide duty and requires him to meet a Medical Evaluation Board for discharge from the service. Over the last several years, total colectomy with mucosal proctectomy and ileoanal anastomosis (TCMPIA) has emerged as a viable surgical alternative in these conditions. The benefits of this procedure in the military population are multiple. It allows the individual to continue on active duty, fulfilling his desire to pursue his career as well as keeping the position filled for the military. The time and cost of a medical board are avoided, the military's investment in the individual's training is protected, and the need to train a new individual for the position is avoided.

Fate of the rectal mucosa after rectal mucosectomy and ileoanal anastomosis

The aim of our study was to determine if the rectal mucosa regenerates after rectal mucosectomy and endorectal ileoanal anastomosis for chronic ulcerative colitis. Such regenerated rectal mucosa could be the site of recurrent disease, leading to complications of the operation, and potential malignant degeneration. Pathologic specimens of the ileoanal anastomosis, surrounded by rectal muscular cuff, were obtained from eight patients who required takedown of their ileoanal anastomosis between one and 18 months after construction. Reepithelialization of the rectal cuff was not observed. In two patients, small islets of rectal mucosa and anal glands were identified. In all patients, the rectal muscularis propria was adherent to the serosa of the ileum by fibrous reaction. Three patients were diagnosed, both clinically and pathologically, as having chronic ulcerative colitis at the original ileoanal operation, but features suggestive of Crohn's disease were noted in the subsequently resected neo-rectum. Our observations suggest that, although isolated rectal mucosal cells may remain after mucosectomy, extensive rectal mucosal regeneration does not occur, thus minimizing the risk of recurrent disease and potential malignant change. Failure of an ileoanal anastomosis is therefore most likely related either to technical factors or to the presence of unsuspected Crohn's disease.

Intestinal plication in the treatment of atresia

Twelve infants with jejunal atresia were managed by plication of the dilated proximal bowel and end-to-oblique anastomosis. The technique is simple and very effective in preventing functional obstruction of the dilated bowel, and it preserves the mucosal absorptive surface. It is easier to perform and seems to allow earlier return of function than resection or tapering of the dilated jejunum.

[Complete duplication of the small intestine in childhood]

The article reports on two cases of complete duplication of the small intestine in an infant of 7 months of age (female) and a boy aged 3 1/2 years. The almost complete lining of the duplicated small intestine with gastric mucosa resulted in massive haemorrhages. These haemorrhages, in conjunction with ileus, were the indications for an operation. Mucosectomy was performed in the region of the duplication. Such removal of the mucosa is recommended in complete duplication of the small intestine and in partial tubular forms.

[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.