Comparison of the function of triplicated and duplicated pelvic ileal reservoirs after mucosal proctectomy and ileo-anal anastomosis for ulcerative colitis and adenomatous polyposis

A systematic review and meta-analysis comparing adverse events and functional outcomes of different pouch designs after restorative proctocolectomy

AIM

There is no consensus as to which ileoanal pouch design provides better outcomes after restorative proctocolectomy. This study compares different pouch designs.

METHOD

A systematic review of the literature was performed. A random effects meta-analytical model was used to compare adverse events and functional outcome.

RESULTS

Thirty comparative studies comparing J, W, S and K pouch designs were included. No significant differences were identified between the different pouch designs with regard to anastomotic dehiscence, anastomotic stricture, pelvic sepsis, wound infection, pouch fistula, pouch ischaemia, perioperative haemorrhage, small bowel obstruction, pouchitis and sexual dysfunction. The W and K designs resulted in fewer cases of pouch failure compared with the J and S designs. J pouch construction resulted in a smaller maximum pouch volume compared with W and K pouches. Stool frequency per 24 h and during daytime was higher following a J pouch than W, S or K constructions. The J design resulted in increased faecal urgency and seepage during daytime compared with the K design. The use of protective pads during daytime and night-time was greater with a J pouch compared to S or K. The use of antidiarrhoeal medication was greater after a J reservoir than a W reservoir. Difficulty in pouch evacuation requiring intubation was higher with an S pouch than with W or J pouches.

CONCLUSION

Despite its ease of construction and comparable complication rates, the J pouch is associated with higher pouch failure rates and worse function. Patient characteristics, technical factors and surgical expertise should be considered when choosing pouch design.

Proctocolectomy and Ileostomy for Ulcerative Colitis: The Longer Term Story

Elective surgery for ulcerative colitis usually involves the removal of the entire large bowel with either a conventional ileostomy or the formation of an ileoanal pouch anastomosis. Seventy patients undergoing a one stage elective total proctocolectomy and ileostomy between 1976 (the first year an ileoanal pouch was carried out in this hospital) and 1986 have been studied. We have confirmed that proctocolectomy and ileostomy for ulcerative colitis is not the trouble free operation many presume it to be when considering the alternative of an ileoanal pouch.

Review of our ileal pouch experience in the light of literature

OBJECTIVE

Retrospective proctocolectomy is a distinguished, sphincter saving treatment used for the treatment of ulcerative colitis and FAP disease. We aimed to evaluate ileal pouch interventions performed at our clinic and their results in the light of literature.

MATERIAL AND METHODS

Medical records of 35 restorative proctocolectomy and J pouch ileo-anal anastomosis surgeries performed at Necmettin Erbakan University, Meram School of Medicine between the years 2006-2013 were retrospectively examined. The patients were assessed according to their age, gender, length of hospital stay, diagnosis, follow-up duration and pouch-related complications. All patients were contacted by phone and they were scheduled for controls at the outpatient clinic.

RESULTS

Nineteen patients were male (54%) and 16 were female (46%). Their mean age was 45 years (21-74). The mean length of hospital stay was 11 (5-20) days. Twenty two (63%) patients were operated on due to FAP, 12 (34%) due to synchronous rectum cancer and colon tumor or polyp, and one (3%) due to ulcerative colitis. All patients received J pouch and protective ileostomy. After the closure of ileostomy, two cases were identified to have J pouch fistulas. The patients were followed up for 6 months to 7 years. They were contacted by phone and they were questioned about their active complaints, number of defecations, urinary and sexual dysfunctions. It was identified that they had 5 (3-8) defecations per day on average and that 4 (11%) cases had one nocturnal defecation. No pouchitis was identified in the follow-up endoscopic examinations.

CONCLUSION

Restorative proctocolectomy and ileo-anal anastomosis technique is a surgical procedure that can be performed with low rates of morbidity and mortality, including the elderly.

Morbidity of loop ileostomy closure after restorative proctocolectomy for ulcerative colitis and familial adenomatous polyposis: a systematic review

BACKGROUND

Temporary loop ileostomy is a routine procedure to reduce the morbidity of restorative proctocolectomy. However, morbidity of ileostomy closure could reduce the benefit of this concept. The objective of this systematic review was to assess the risks of ileostomy closure after restorative proctocolectomy for ulcerative colitis or familial adenomatous polyposis.

MATERIALS AND METHODS

Publications in English or German language reporting morbidity of ileostomy closure after restorative proctocolectomy were identified by Medline search. Two hundred thirty-two publications were screened, 143 were assessed in full-text, and finally 26 studies (reporting 2146 ileostomy closures) fulfilled the eligibility criteria. Weighted means for overall morbidity and mortality of ileostomy closure, rate of redo operations, anastomotic dehiscence, bowel obstruction, wound infection, and late complications were calculated.

RESULTS

Overall morbidity of ileostomy closure was 16.5 %, there was no mortality. Redo operations for complications were necessary in 3.0 %. Anastomotic dehiscence occurred in 2.0 %. Postoperative bowel obstruction developed in 7.6 %, with 2.9 % of patients requiring laparotomy for this complication. Wound infection rate was 4.0 %. Hernia or bowel obstruction as late complications developed in 1.9 and 9.4 %, respectively.

CONCLUSION

The considerable morbidity of ileostomy reversal reduces the overall benefit of temporary fecal diversion. However, ileostomy creation is still recommended, as it effectively reduces the risk of pouch-related septic complications.

Comparison of long-term outcomes of S and J pouches and continent ileostomies in ulcerative colitis patients with restorative proctocolectomy-experience in subspecialty pouch center

BACKGROUND

There are no published studies comparing pouch configurations and long-term adverse outcomes.

AIM

To evaluate outcomes of ulcerative colitis (UC) patients undergoing restorative proctocolectomy with S-, J- pouches or continent ileostomy (CI).

METHODS

We conducted a historical cohort study from the prospectively maintained Pouch Registry. Demographic and clinical variables were evaluated with univariate and multivariable analyses.

RESULTS

Fourty-five patients with S pouches and 36 with CI (33 K pouches and 3 Barnett continent ileal reservoirs) were compared with 215 J pouches serving as controls (ratio 1:2.5). In multivariable analysis, patients with S pouches were 93% less likely to develop chronic antibiotic-refractory pouchitis (CARP) than subjects with J pouches (odds ratio [OR]=0.07; 95% confidence interval: <0.001, 0.54; p<0.001). However, no significant difference in the frequency of CARP was found between the CI and J pouch groups (OR=0.68; 95% confidence interval: 0.17, 2.00, p=0.40). Patients with S pouches were 8 times more likely (95% confidence interval: 3.7, 17.5; p<0.001) and patients with CI 5.6 had times more likely (95% confidence interval: 2.4, 13.3; p<0.001) to have pouch surgery-related complications than those with J pouches. There was no difference in the rate of CD of the pouch, pouch-associated hospitalization and pouch failure between the S- pouch, CI and J- pouch groups.

CONCLUSIONS

Patients with J pouches appeared to have a greater risk for chronic pouchitis than those with S-pouches and but had a lower risk for developing pouch surgery-related complications than those with S pouches or CI.

Evolution of the restorative proctocolectomy and its effects on gastrointestinal hormones

Gastrointestinal (GI) peptide hormones are chemical messengers that regulate secretory, mechanical, metabolic, and trophic functions of the gut. Restorative proctocolectomy (RPC) or resection of the colon and rectum with maintenance of intestinal continuity through the construction of an ileal pouch reservoir and preservation of the anal sphincters has become the standard of care for the surgical treatment of ulcerative colitis and familial adenomatous polyposis. The manipulation of the digestive system to create the ileal pouch involves altering gut-associated lymphoid tissue among other anatomic changes that lead to changes in GI peptides. In addition, the ileal pouch epithelium responds to a wide variety of stimuli by adjusting its cellularity and function. These adaptive mechanisms involve systemic factors, such as humoral and neural stimuli, as well as local factors, such as changes in intestinal peristalsis and intraluminal nutrients. There have been conflicting reports as to whether the alterations in GI hormones after RPC have actual clinical implications. What the studies on alterations of GI peptides' response and behavior after RPC have contributed, however, is a window into the possible etiology of complications after pouch surgery, such as pouchitis and malabsorption. Given the possibility of pharmacologically modifying GI peptides or select components of adaptation as a therapeutic strategy for patients with ileal pouch dysfunction or pouchitis, a clear understanding of human pouch mucosal adaptation is of paramount importance. In this review, we summarize the evolution of the RPC and its effects on the GI hormones as well as their possible clinical implications.

Meta-analysis of short-term and long-term outcomes of J, W and S ileal reservoirs for restorative proctocolectomy

OBJECTIVE

The choice of ileal pouch reservoir has been a contentious subject with no consensus as to which technique provides better function. This study aimed to compare short- and long-term outcomes of three ileal reservoir designs.

METHOD

Comparative studies published between 1985 and 2000 of J, W and S ileal pouch reservoirs were included. Meta-analytical techniques were employed to compare postoperative complications, pouch failure, and functional and physiological outcomes. Quality of life following surgery was also assessed.

RESULTS

Eighteen studies, comprising 1519 patients (689 J pouch, 306 W pouch and 524 S pouch) were included. There was no significant difference in the incidence of early postoperative complications between the three groups. The frequency of defecation over 24 h favoured the use of either a W or S pouch [J vs S: weighted mean difference (WMD) 1.48, P < 0.001; J vs W: WMD 0.97, P = 0.01]. The S pouch was associated with an increased need for pouch intubation (S vs J: OR 6.19, P = 0.04). The use of a J pouch was associated with a significantly higher prevalence of use of anti-diarrhoeal medication (J vs S: OR 2.80, P = 0.01; J vs W: OR 3.55, P < 0.001).

CONCLUSION

All three reservoirs had similar perioperative complication rates. The S pouch was associated with the need for anal intubation. There was less frequency and less need for antidiarrhoeal agents with the W rather than the J pouch.

The impact of the fecal stream and stasis on immunologic reactions in ileal pouch after restorative proctocolectomy for ulcerative colitis: a prospective, pilot study

OBJECTIVE

The etiology of pouch inflammation after restorative proctocolectomy is unknown. The fecal stream and immunological reactions are potential pathological factors. This study was performed to examine the impact of the fecal stream and stasis on immunological reactions in the pouch.

METHODS

Patients who underwent a restorative proctocolectomy with a covering ileostomy for ulcerative colitis were studied. Mucosal biopsy specimens were obtained from both the pouch and the proximal ileum at the time of ileostomy closure, and 3, 6, and 12 months after ileostomy closure. As a control group, normal ileal biopsies were obtained from patients with colonic polyps.

RESULTS

At the time of ileostomy closure, mucosal interleukin-1beta, interleukin-6, interleukin-8, and tumor necrosis factor-alpha levels in the pouch and the proximal ileum were not significantly different from those in the normal control group. At 3 months after ileostomy closure, the mucosal cytokine levels in the pouch increased significantly compared with those at ileostomy closure, and their levels were significantly higher than those in the proximal ileum. At 6 and 12 months after ileostomy closure, the mucosal cytokine levels in the pouch did not change significantly compared with those at 3 months after ileostomy closure. The mucosal cytokine levels in the proximal ileum did not change significantly during the entire study.

CONCLUSIONS

The immunological reactions in the pouch occurred soon after ileostomy closure, and continued for at least 1 yr. The fecal stream and stasis play an important part in the pathogenesis of immunological reactions in the ileal pouch.

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.

Ileo-anal S-Pouch reconstruction in patients with total colonic aganglionosis after failed pull-through procedure

Total colonic aganglionosis (TCA) occurs in 3% to 12% of Hirschsprung's disease patients. Although numerous surgical techniques have been utilized for the treatment of these patients, little information is available regarding optimal surgical management of their frequent complications or failured procedures. The ileoanal S pouch (IASP) technique has been utilized in the treatment of children with familial adenomatous polyposis and ulcerative colitis. The authors present the results of salvage IASP in 3 TCA patients who had poor results after total colectomy and Soave pull-through.

Surgery for ulcerative colitis

The type of surgery performed for UC varies from patient to patient and must take into account the nutritional status and health of the patient, the presence of dysplasia or cancer, the desire of the patient to maintain continence, the preoperative anorectal function, the degree of confidence in the diagnosis of UC, and the technical constraint because of certain body habituses. A total proctocolectomy is the surgical procedure of choice for UC. A restorative proctocolectomy is the preferred surgical approach that not only cures the patient of the disease and prevents the development of colorectal cancer, but also maintains continence with an improved quality of life.

Salvage abdominal surgery in patients with a retained rectal stump after restorative proctocolectomy and stapled anastomosis

BACKGROUND

The introduction of surgical stapling instruments has widened the use of restorative proctocolectomy. Too high a distal transection of the rectum can, however, produce a retained rectal stump, which may cause symptoms. A study of the operative and functional data in a consecutive series of patients undergoing salvage surgery for retained rectal stump was undertaken.

METHODS

Twenty-five patients referred between January 1990 and September 2000 for pouch dysfunction were identified as having a retained rectal stump. Twenty-two underwent abdominoanal revision. The hospital notes were reviewed and function was assessed during outpatient visits, by postal questionnaire and by telephone interview.

RESULTS

Median operating time was 225 (range 170-340) min and median hospital stay was 15 (range 8-48) days. There was no operative death. Five pouches were excised. Seventeen patients were available for functional assessment. Median follow-up was 22.5 (range 4-114) months. Median 24-h frequency before and after operation was 12 (range 4-20) and 6 (range 3-12) respectively, and median night-time frequency was 4 (range 0-8) and 0.5 (range 0-4) respectively. Fifteen patients reported marked subjective improvement in pouch function and quality of life.

CONCLUSION

Major revisional surgery for symptomatic retained rectal stump after restorative proctocolectomy with stapled anastomosis was successful in 15 of 22 patients. These results are worse than the outcome following first-time restorative proctocolectomy with anastomosis constructed at the anal level. Pouch-rectal anastomosis should be avoided.

Functional outcome after restorative panproctocolectomy for ulcerative colitis decreases an otherwise enhanced quality of life

BACKGROUND

Restorative panproctocolectomy is a favoured operation for ulcerative colitis, but altered bowel habit may adversely affect overall quality of life.

METHODS

Specific and generic quality of life questionnaires and an instrument to award money for continuing disability based on government guidelines were sent to 103 patients who had curative surgery for ulcerative colitis between 1995 and 1997. Seventy-one patients returned completed questionnaires: 30 with an ileostomy (representing incontinence and abnormal body image), 11 with a Koch pouch (representing continence and abnormal body image) and 30 with a pelvic pouch (representing continence and normal body image).

RESULTS

Patients valued the disability of having an ileostomy similar to that for a Koch pouch or a pelvic pouch: pound 40 000, pound 30 000 and pound 40 000 respectively (P = 0. 97). There was no sex difference. Body image measured with a visual analogue scale (least = 1, worst = 10) was worst with the ileostomy and Koch pouch (8 each) and best with a pelvic pouch (5) (P = 0.06). However, pelvic pouches scored significantly worse than an ileostomy with regard to altered bowel emptying (pelvic pouch, 8; Koch pouch, 7; ileostomy, 5) (P = 0.01).

CONCLUSION

Poor function after pelvic pouch surgery offsets any advantage in body image over an ileostomy. Thus, overall quality of life and perceived monetary damage were the same for the two operations. Improved pelvic pouch function is likely to be reflected in better quality of life after restorative panproctocolectomy.

Surgical options in ulcerative colitis

The length of ileum used rather than pouch configuration per se is related to eventual functional outcome: A pouch constructed from 15- to 20-cm limbs is ideal. One-stage procedures appear feasible in those patients who are not malnourished or taking steroids and in whom a tension-free anastomosis may be achieved. Because most of our patients do not satisfy these criteria, single-stage IPAA is rarely used at the Mayo Clinic. The decision to excise the ATZ should relate to the risk of developing subsequent neoplasia. All patients with FAP should have a mucosectomy performed. Patients with CUC who do not have a mucosectomy should have life-long surveillance. Indeed, an argument can be made that all patients should undergo surveillance after IPAA. The decision to staple the anastomosis impacts little on eventual functional outcome but does preserve the ATZ with the attendant risk of recurrent disease, polyps, and neoplasia. When cancer is a presenting feature, the decision to perform IPAA should be based on the stage of the tumor and the subsequent need for radiation therapy. Patients with early-stage tumors not requiring adjuvant radiation therapy attain long-term function comparable to that of patients who have had an IPAA for benign disease.

Long-term causes of death following ileal pouch-anal anastomosis

PURPOSE

The aim of this study was to identify the overall long-term causes of death in a large series of patients who were undergoing proctocolectomy with ileal pouch-anal anastomosis (IPAA).

METHODS

Records of patients who underwent proctocolectomy with IPAA at the Mayo Clinic affiliated hospitals between January 1981 and October 1994 were reviewed to determine overall mortality, cause, and timing of death.

RESULTS

A total of 1,603 patients underwent proctocolectomy with IPAA reconstruction (1,407 for chronic ulcerative colitis (CUC), 187 for familial polyposis (FAP), and 9 for other diagnoses). Thirty-two patients have died, with an overall mortality rate of 2 percent. Mean age at time of death was 40 (23-60) years. There was no significant difference in overall mortality between patients with CUC and patients with FAP. Three deaths occurred postoperatively (0.2 percent) because of pulmonary embolism, perforated gastric ulcer, and subarachnoid hemorrhage. Late deaths occurred in 29 patients (1.8 percent), 10 months to 10.4 years after the operation. The most common cause of late death was cancer, including colon and rectal carcinoma (10 patients), hematologic malignancies (4 patients), cholangiocarcinoma (3 patients), and germ-cell carcinoma (1 patient). Four patients died from unrelated sepsis, two died following myocardial infarction, two patients died from complications of subsequent orthopedic surgery, and one patient died of cirrhosis. Two additional patients committed suicide. No late deaths were directly attributable to the IPAA procedure.

CONCLUSIONS

Proctocolectomy with IPAA is a safe procedure. Operative mortality is low, and late deaths are related to carcinogenic and extracolonic manifestations of underlying or unrelated coexisting diseases and events.

Outcome of restorative proctocolectomy with ileal reservoir for ulcerative colitis: comparison of distal colitis with more proximal disease

BACKGROUND

An increasing number of patients with severe or refractory ulcerative colitis involving only the rectum and sigmoid colon are being offered restorative proctocolectomy with ileal reservoir but very few data are available concerning the outcome for these patients.

AIM

This study was designed to compare the outcome of ileal pouch procedures for distal ulcerative colitis with procedures performed for more extensive disease.

PATIENTS

A consecutive series of 177 patients undergoing restorative proctocolectomy for ulcerative colitis between January 1984 and December 1994.

METHODS

Data were collected prospectively in a dedicated ileal pouch database and included demographic details, indication for surgery, surgical procedures performed, early (< 30 days) and late morbidity, functional outcome, and histopathology.

RESULTS

There was no mortality in the series. The incidence and range of early morbidity (< 30 days) and the functional outcome (daytime stool frequency, nocturnal frequency, and the incidence of incontinence) were similar for all groups. Log rank analysis of Kaplan-Meier estimates showed no significant difference between groups in the likelihood of developing pouchitis (p > 0.2).

CONCLUSIONS

Patients undergoing restorative proctocolectomy for distal colitis experience a similar outcome to patients with more extensive disease. These data refute the hypothesis that pouchitis is more common in patients with total colitis.

Simple radiographic evaluation of ileoanal pouch volume

PURPOSE

Total colectomy and mucosal protectomy with ileal reservoir and anal pull-through is used in the treatment of ulcerative colitis or familial polyposis, with one complication being frequent bowel movements. A simple radiographic test to predict frequency of bowel movements and measure spasticity was evaluated.

METHODS

Fourteen patients underwent evaluation after ileal reservoir and anal pull-through J-pouch construction. Barium sulfate suspension was instilled into the pouch via the anus in the standing position until reflux flowed into the small intestine proximal to the pouch and patients felt the urge to defecate. Total volume infused (VOLtot), volume to reflux (VOLrflx), and volume voided (VOLvoid) were measured.

RESULTS

VOLvoid and the "voiding efficiency" (VOLvoid/VOLtot) correlated significantly with stool frequency (R=-0.744, P<0.002 and R=-0.754, P<0.002, respectively). Time from operation was correlated with VOLvoid and stool frequency (R=-0.723, P<0.003 and RO.573, P<0.032, respectively).

CONCLUSIONS

The addition of quantitative measurements to this radiographic test gives useful information about pouch performance. Furthermore, the data imply that spasticity, as measured by voiding quantum and efficiency, rather than actual pouch volume is a major determinant of bowel movement frequency.

Effect of intervention in inflammatory bowel disease on health-related quality of life: a critical review

Health-related quality of life (HRQOL) is a quantitative measurement of subjective perception of health state, including emotional and social aspects. It can be reliably measured with several valid instruments. Previous reviews of the literature suggested inadequate attention to HRQOL in studies of interventions in inflammatory bowel disease.

PURPOSE

This study was undertaken to assess the current status of the quality of measurement of HRQOL in studies of inflammatory bowel disease and to review the clinical conclusions warranted by the literature.

METHOD

Medicine was searched for articles relating to ulcerative colitis, Crohn's disease, or inflammatory bowel disease and quality of life since 1981. The articles found were reviewed for citations of further articles. The adequacy of HRQOL measure was assessed and graded, and the study design was categorized to assess the strength of the literature on the whole.

RESULTS

A trend was found toward higher quality of HRQOL measurement in the period 1988 to 1994 compared with 1981 to 1987. Most of the improvement was because of increased use of standardized and multidomain but unvalidated and unpublished questionnaires for measurement.

CONCLUSIONS

Confidence in the following clinical conclusions in studies of surgical interventions in inflammatory bowel disease is limited by study design: that pelvic pouch is not inferior to ileostomy, that specific domains of HRQOL are differentially affected by different surgical procedures, and (with less confidence) that surgery is helpful in Crohn's disease. Medical studies have demonstrated that high quality HRQOL measures can be integrated into randomized, prospective trials. Clinically equivalent treatments have shown differential effects or HRQOL: 9 mg daily of budesonide is superior to 15 mg, and hydrocortisone foam enemas are superior to prednisolone. Home parenteral nutrition has received modest support, limited again by study design. It is recommended that standard tests of HRQOL be used to increase comparability of studies and to increase the quality of this literature in general. In particular the Inflammatory Bowel Disease Questionnaire, Rating Form of Inflammatory Bowel Disease Concerns, and Direct Questioning of Objectives are recommended.

Physiology of ileal pouch-anal anastomosis. Current concepts

PURPOSE

Increasing experience with ileal pouch-anal anastomosis (IPAA) associated with increasing knowledge about anorectal physiology has lead to a large number of publications. The purpose of this review is to evaluate the current understanding of fecal continence as revealed by the evolution of the ileoanal procedure.

METHODS

Review of the literature covering the most important physiologic parameters involved in fecal continence was undertaken.

RESULTS

Rectoanal inhibitory reflex is probably absent after IPAA but is preserved when distal anorectal mucosa is spared. Anal resting pressure decreases but is less affected when the internal anal sphincter is less traumatized. Squeeze pressure is not importantly affected, and the importance of reservoir function as a determinant of stool frequency is emphasized. IPAA does not affect the coordination between pouch and anal canal motility in the majority of cases. Normal continence is preserved, even during the night, by preserving a gradient of pressure between the pouch and anal canal.

CONCLUSIONS

Physiologic concepts are well established, but controversies about the continence mechanism related to IPAA remain. The IPAA procedure has allowed discrimination of details about the function of multiple structures involved in fecal continence.

Synchronous proctocolectomy and ileoanal pouch formation and the risk of Crohn's disease

There is controversy on the advisability of one-stage proctocolectomy and the formation of an ileoanal pouch. Accurate preoperative diagnosis is essential to avoid the error of constructing a pouch in a patient with Crohn's disease. Twenty-four consecutive patients undergoing subtotal colectomy for inflammatory bowel disease were reviewed. All patients had been treated with systemic steroids, 23 were on 5-aminosalicylates and 11 on azathioprine. The preoperative diagnoses, based on a combination of clinical features, colonoscopy, barium enema and biopsy histology, were ulcerative colitis (19), Crohn's disease (four) and inflammatory bowel disease (unclassified) (one). The final diagnosis was made on histological examination of the resected specimen. A discrepancy between initial and final diagnosis occurred in eight patients. In three, the diagnosis was changed from ulcerative colitis to Crohn's disease. Three preoperative diagnoses of Crohn's disease were changed to ulcerative colitis (one), Behçet's disease (one) and diverticulitis (one) on final histology. These data suggest that caution should be exercised in performing synchronous proctocolectomy with the formation of an ileoanal pouch.

Update on the surgical management of ulcerative colitis and ulcerative proctitis: current controversies and problems

: The surgical management of ulcerative colitis has been revolutionized in recent years by the development of the ileal pouch-anal procedure. Although it is now the operation of choice for most patients, there remain several controversies. A variety of designs of ileal pouch are available each with advantages and disadvantages. The technique used to anastomose the pouch to the anal canal is also open to debate with some surgeons favoring distal mucosectomy with eradication of all disease and others choosing to perform a stapled anastomosis to achieve better functional results. The main concern for gastroenterologists, however, is the risk of development of pouchitis. The etiology, diagnosis, and treatment of this condition will also be discussed in this review as well as the more classical options for the surgical treatment of ulcerative colitis.

Functional assessment of ileal pouch-anal anastomotic techniques

BACKGROUND

Recent advances in ileal pouch-anal anastomotic (IPAA) technique include the substitution of a double stapled anastomosis for a mucosectomy and hand-sewn pouch-anal anastomosis, and the use of staples to construct a "J" shaped pouch rather than a hand-sewn "S" pouch in most cases.

METHOD

To determine the impact these technical changes have had on pouch function, 235 IPAA patients with 15 to 155 months of follow-up (mean 70 months) were interviewed by telephone concerning pouch function and quality of life. Categorical responses were then evaluated by contingency table analysis to detect differences between mucosectomy (n = 157) and nonmucosectomy (n = 80) groups, and between J pouch (n = 50), S pouch with mucosectomy (n = 137), and S pouch nonmucosectomy (n = 30) subgroups. An index encompassing nine functional measures was used to quantify the overall impact of technique changes (optimal score 100).

RESULTS

Stool frequency for mucosectomy patients was 7.2 movements/24 hours, compared to 7.1 for nonmucosectomy patients. Elimination of a mucosectomy dramatically reduced nocturnal major incontinence (P < 0.001), nocturnal minor incontinence (P < 0.001), daytime minor incontinence (P = 0.03), and day-time pad use (P = 0.002). Nonmucosectomy patients had a better functional index score than had patients with an S pouch, even when only data from nonmucosectomy patients were analyzed (J = 95.5, S = 91.8, P = 0.009).

CONCLUSIONS

Avoidance of a mucosectomy in the performance of an ileal pouch-anal anastomosis does not influence stool frequency but does significantly improve fecal continence and introduces no detectable morbidity associated with the retained rectal mucosa.

A method for predicting the volume of an ileo-anal pouch

Functional outcome following restorative proctocolectomy depends, in part, on the volume of the pouch. This study investigates the relationship between the length of ileum and volume of saline required to distend the ileum to a set pressure, and the possibility of predicting the volume of an ileoanal pouch using these measurements. Measurements were made on the ileum of 8 mongrel dogs. There was a linear relationship between the length of ileum and volume of saline infused to produce an intraluminal pressure of 20 mmHg (r = 0.94-0.99). However, the capacity of ileum varied widely from animal to animal (100 cc of saline filled 15.5 cm to 43 cm of ileum). Twenty-four pouches (15J, 9S) were constructed from segments of ileum of known capacity. The capacity of a J pouch was 1.71 +/- 0.11 times greater than the capacity of the original length of bowel and an S pouch had a capacity 2.14 +/- 0.25 times greater. These changes in capacity are similar to a theoretical calculation of change in volume of ileum after pouch construction. This technique is a simple, quick method of predicting the volume of an ileo-anal pouch which will be useful in a clinical trial to compare function of pouches of different volumes.

Pelvic ileal reservoirs: the options

Restorative proctocolectomy has become an established surgical option for patients with chronic ulcerative colitis and familial adenomatous polyposis. However, despite a large number of different reservoir designs there is so far no acknowledged ideal configuration. This paper reviews the advantages and disadvantages of the different types of pelvic ileal reservoir so far studied.

The ileal pouch operation for ulcerative colitis

Ileal pouch-anal anastomosis cures chronic ulcerative colitis with an acceptable perioperative morbidity and mortality. The great majority of patients achieve satisfactory continence with an excellent quality of life. However, continence is not perfect, and fecal soilage is a troublesome problem for a small number of patients. Moreover, as many as one third of patients develop pouchitis, for which an effective means of long-term prevention or treatment has yet to be developed. Finally, controversial issues such as optimal pouch design or technique of anastomosis will be resolved only when long-term follow-up of randomized trials has been completed.

Function of ileal J pouch-anal anastomosis in patients with familial adenomatous polyposis

Pouch function after proctocolectomy and ileal J pouch-anal anastomosis was assessed at 1 and 5 years in 41 patients with familial adenomatous polyposis. The mean(s.d.) stool frequency per 24 h decreased from 4.4(1.7) to 3.9(1.8) (P < 0.05), the mean(s.d.) nocturnal stool frequency fell from 0.6(1.0) to 0.3(0.6) (P < 0.05), and the number of patients having nocturnal bowel movements decreased from 16 to seven (P < 0.05). At 5 years, only one patient still followed a strict diet (versus ten at 1 year, P < 0.05) and only two needed antidiarrhoeal medication (versus ten at 1 year, P < 0.05). There were no episodes of pouchitis or late reservoir-related complications. The function of ileal pouch-anal anastomosis improves over time in patients with familial adenomatous polyposis.

Previous subtotal colectomy with ileostomy and sigmoidostomy improves the morbidity and early functional results after ileal pouch-anal anastomosis in ulcerative colitis

The aim of this work was to study the effects of previous subtotal colectomy (STC) with ileostomy and sigmoidostomy on the outcome of ileal J-pouch-anal anastomosis (IPAA) in patients with acute ulcerative colitis. Between 1983 and 1991, we conducted a prospective, nonrandomized study of 156 patients who underwent IPAA in our center. Fifty-five patients (34.3 percent) had undergone STC with ileostomy and sigmoidostomy for either severe acute colitis (36.5 percent of cases) or nonresolving acute colitis (63.5 percent) up to six months before IPAA with covering ileostomy. There were no perioperative deaths; six patients (11 percent) developed complications requiring reoperation (three cases of pelvic sepsis, two occlusions, and one stenosis of the ileostomy). IPAA was successfully carried out at a later stage in all cases. The results of IPAA in these patients were compared with those in 78 patients who underwent the classical two-stage IPAA procedure. The rates of pelvic sepsis and postoperative occlusion were lower in the subgroup of patients who underwent the three-step procedure. Three months after closure of the ileostomy, the mean number of daily stools was significantly lower in the patients who had undergone prior STC (5.09 vs. 5.9), but there was no significant difference between the two groups with regard to diurnal and nocturnal continence, the need to wear a pad, discrimination between gas and stools, or the use of antidiarrheal medication. In addition, there was no significant difference at one year in terms of functional parameters. We conclude that STC is a simple and safe procedure for the treatment of a severe attack of colitis and that it does not compromise the results of later IPAA. Because it does not increase the morbidity of subsequent IPAA and is associated with more rapid functional recovery, STC appears to be suitable for the treatment of patients with nonresolving acute colitis before the onset of malnutrition or steroid dependency.

Comparison of triplicated (S) and quadruplicated (W) pelvic ileal reservoirs. Studies on manovolumetry, fecal bacteriology, fecal volatile fatty acids, mucosal morphology, and functional results

Capacity and compliance, efficiency of evacuation, fecal bacteriology, fecal volatile fatty acids, mucosal morphology, and functional outcome were studied in 20 patients with triplicated (S) and 20 patients with quadruplicated (W) reservoirs after ileal pouch-anal anastomosis. Compared with patients with S reservoirs, patients with W reservoirs were found to have greater efficiency of evacuation of radiolabeled synthetic stool [97% (91%-98%) vs. 74% (62%-89%); P less than 0.05], and their reservoirs were more capacious [350 mL (320-400 mL) vs. 228 mL (175-290 mL); P less than 0.01] and compliant [16.0 mL/cm H2O (13.8-19.0 mL/cm H2O) vs. 12.3 mL/cm H2O (7.4-14.6 mL/cm H2O); P less than 0.01]. Effluent from S reservoirs contained significantly greater numbers of bacteroides (P less than 0.05) and concentrations of acetic and propionic acids (P less than 0.05) than effluent from W reservoirs. The degree of mucosal inflammation and villous atrophy in each design of reservoir was not significantly different. The ratio of anaerobes to aerobes in pouch effluent was significantly correlated with the degree of mucosal inflammation (rs = 0.433; P = 0.035). Fecal volatile fatty acids were significantly correlated with the percentage of stool retained after defecation and degree of mucosal inflammation. The frequency of bowel action was significantly less in patients with W reservoirs than in patients with S reservoirs [3.5/day (3-4/day) vs. 6.0/day (4-7/day); P less than 0.01]. The results indicate marked differences between these two ileal reservoir designs.

Clinical and functional outcome after restorative proctocolectomy

Restorative proctocolectomy and ileal pouch-anal anastomosis (IPAA) has been carried out on 88 patients since 1982. Three different pouch designs (J, S and W) were used. Ten pouches had to be removed. Detailed analysis was performed on 61 patients (J = 23, S = 15, W = 23) whose pouches had been functioning for at least 6 months. There was no significant difference in surgical complications before or after ileostomy closure between pouch designs but the hospital stay was greater after construction of an S pouch (P less than 0.05). There were no significant differences in stool frequency, degree of continence or urgency between the three types. Twelve patients with J pouches required antidiarrhoeal medication compared with only one with S and five with W pouches. Only seven patients with S pouches could defaecate spontaneously compared with 22 with W pouches and all patients with J pouches (P less than 0.001). Twenty-five of 29 patients who had preservation of the anal transition zone had perfect continence compared with 23 of 32 with a mucosal proctectomy (P = n.s.). Pouchitis occurred in 13 patients, all of whom had ulcerative colitis. In a subgroup of 23 patients, pouch evacuation was assessed scintigraphically. There was no difference in pouch capacity or total volume evacuated, but spontaneous evacuation was better in J and W pouches compared with S pouches.

Stapled ileoanal anastomosis for ulcerative colitis and familial polyposis without a temporary diverting ileostomy

Between March 1989 and August 1990, we performed 21 stapled J pouch ileonal procedures (20 ulcerative colitis [UC], 1 familial polyposis [FP]) without an ileostomy in 19, of whom 13 were taking prednisone and eight underwent semi-emergent surgery for uncontrollable bleeding. During the same time, an additional four patients required a standard ileonal procedure. The results of anal manometry and clinical function were compared to 25 patients who had previously undergone mucosal stripping and a sutured J pouch ileoanal anastomoses with a temporary diverting ileostomy between October 1982 and August 1990. During this same time period, an additional 19 patients underwent an anti-peristaltic reversed J pouch and 18 an S pouch, for a total of 83 ileoanal procedures. The reversed J pouch had a lower stool frequency than a standard J pouch but had an unacceptable incidence of complications and problems with pouch emptying. The S pouch had a stool frequency similar to the standard J pouch but provided greater length in patients with a short mesentery. Stapled J pouch ileoanal patients had a better (p less than 0.02) maximum and sphincter resting pressure (46 +/- 11 versus 34 +/- 12 mmHg), fewer (p less than 0.05) night-time accidents (22% versus 68%), daytime (17% versus 55%) or night-time (28 versus 61%) spotting, or use of a protective pad at night (11% versus 42%) than nonstapled J pouch ileoanal patients. Stool frequency was similar in the two groups. All but one UC patient had residual disease at the anastomosis. Anal mucosa between the dentate line and stapled anastomosis was 1.8 +/- 1.3 cm (range, 0 to 3.5 cm). Complications in the nonstapled J pouch group included 4 pouches excised (2 for complications, 2 for excessive stool frequency), 1 pelvic abscess, 2 stenosis requiring dilation under anesthesia, 1 enterocutaneous fistula after ileostomy closure, 1 ileostomy site hernia, and 2 small bowel obstructions. Of the 65 patients who underwent ileostomy closure in the entire series, 8 (12%) developed a complication requiring surgical intervention. Complications in the stapled group included 1 anastomotic leak, 1 pouch leak, and 1 pelvic abscess. Patients were managed successfully with drainage (all 3) and diverting ileostomy (1). One patient developed stenosis requiring dilation under anesthesia. The stapled J pouch ileoanal anastomosis is a simpler, safer procedure with less tension than a standard handsewn J pouch but leaves a very small cuff of residual disease. It provides significantly better stool control and may obviate the need for an ileostomy with its complications.

Correlation between laboratory findings and clinical outcome after restorative proctocolectomy: serial studies in 20 patients with end-to-end pouch-anal anastomosis

Clinical function and anorectal physiological function were assessed and correlated in 20 patients with ulcerative colitis before restorative proctocolectomy and 3, 7, and 12 months after operation. The entire anal sphincter was preserved by means of a stapled pouch-anal anastomosis. Before operation, the median resting anal pressure was 79 cmH2O (interquartile range 70-89 cmH2O), the rectoanal inhibitory reflex was present in all patients and anorectal 'sampling' was noted in 16 of 20 patients. Three months after operation, resting anal pressure was 68 cmH2O (range 50-87 cmH2O) (P less than 0.001), the reflex was present in only three patients (P less than 0.001) and sampling was observed in one patient. After 7 months, resting anal pressure was 76 cmH2O (range 64-89 cmH2O), the reflex was present in 11 patients and sampling was observed in nine patients. At 12 months, resting anal pressure was 84 cmH2O (range 66-94 cmH2O), the reflex was present in 19 patients and sampling was observed in 17 patients. The compliance and capacity of the reservoir increased significantly. Ability to discriminate flatus from faeces was associated with return of the rectoanal reflex and sampling.

Factors affecting anal continence after restorative proctocolectomy

The aim of this multicentre study was to define the incidence of disordered continence after restorative proctocolectomy and ileoanal reservoir with respect to some factors which may influence the postoperative soiling rate. Two hundred and seven patients underwent the operation, 156 had their ileostomy closed and were all available for a functional assessment. Minor leakage was observed in 26.9% of cases, whereas 1.9% complained of troublesome faecal soiling. None had gross faecal incontinence. Patients over 45 years had significantly more soiling than those younger (45% vs 24%, p less than 0.05). Soiling was more prevalent in those with ulcerative colitis than with other diseases (35% vs 18% p less than 0.05). The soiling rate decreased after the first postoperative year from 34% to 21% (p less than 0.05). A bowel frequency higher than 5 evacuations/24 hours increased soiling from 20% to 48% (p less than 0.01). Pouchitis doubled the soiling rate from 26% to 50% (p less than 0.05) without there being any difference in sphincter function. Soiling was not significantly related to staged procedure, J-pouch, perineal complications or a long rectal cuff. Careful preoperative evaluation of the anal sphincter should be performed in older patients operated on for colitis as they are likely to leak during the first year following restorative proctocolectomy, especially in cases with diarrhoea or pouchitis.

The stapled ileal pouch--anal anastomosis. A randomized study comparing two different pouch designs

Thirty patients were operated on with restorative proctocolectomy with an end-to-end ileal pouch-anal anastomosis constructed by double stapling (STP). Pouches were randomized to either J type or K type (folded by the principles used for the Kock continent ileostomy). Manovolumetric and functional results were compared. Patients were followed up for at least 6 months. K pouches acquired a significantly larger volume than the J-configurated pouches, and at 6 months the mean +/- SD volumes amounted to 361 +/- 59.8 ml versus 283 +/- 43.0 ml (p less than 0.01) with a concomitant reduction in 24-h frequency (4.4 +/- 1.5 versus 5.8 +/- 1.9; p less than 0.05). The initial postoperative mean reduction of resting anal pressure amounted to 33%. which was similar to that observed in a group of matched historical controls operated on with endoanal mucosectomy and hand-sutured pouch-anal anastomosis. Compared with these controls STP patients showed a superior overall functional result, most marked in the early postoperative period.

Pouch size: the important functional determinant after restorative proctocolectomy

Sixty-seven patients with a J-shaped ileonanal pouch were studied over a 2-year period with regular recording of sphincter and pouch characteristics and analysis of their role in functional outcome. Although there was a 27 per cent permanent reduction in resting anal pressure (RAP) (P less than 0.001), two-thirds of the patients still had a RAP within the normal range. The mean(s.d.) pouch volume increased during the first year from 132(46) ml to 282(85) ml. RAP was not related to functional outcome and preoperative RAP was not predictive of subsequent function. Large pouch volume and compliance correlated with low defaecation frequency (range of r = 0.27-0.36; P less than 0.05) and good overall function (r = 0.37-0.56; P less than 0.01). The initial pouch volume was predictive of subsequent overall function. The ileal length used for pouch construction predicted subsequent pouch volume (r = 0.48; P less than 0.001) and to some extent functional outcome (r = 0.28-0.37; P less than 0.05). However, the studied variables accounted for only 21 per cent of the total variance of functional outcome.

Restorative proctocolectomy: a procedure for the district general hospital?

Restorative proctocolectomy is widely regarded as the surgical procedure of choice for patients with ulcerative colitis or familial adenomatous polyposis, the majority being carried out within specialised regional centres. The use of this procedure outside such centres has been investigated by reviewing the results from a District General Hospital (DGH) over the 8 year period 1981-1989. Seventeen patients (11 male and 6 female with a median age of 36 years) underwent total colectomy and ileoanal anastomosis with formation of a pelvic reservoir (TC-IA). Fourteen had ulcerative colitis (UC), 2 familial adenomatous polyposis (FAP) and one a colonic and rectal cancer. Three pouch designs were used ("S" in 7, "J" in 8 and "W" in 2) with no operative or perioperative deaths. Further laparotomy was required in two patients for adhesions and pelvic sepsis. Functional results were assessed in 16 patients at a mean of 5 years after surgery. The median daily stool frequency was 5 (range 2-6). Twelve of the 16 patients defaecate spontaneously, 2 regularly self-catheterized and 2 do so occasionally. None of the patients is incontinent of formed or liquid stool but one has occasional soiling. These results suggest that TC-IA may be satisfactorily performed outside a specialised unit.

Anal canal mucosa in restorative proctocolectomy for ulcerative colitis

In an attempt to improve continence after restorative proctocolectomy, ileal reservoir-anal anastomosis at the level of the anorectal junction has been advocated. This procedure preserves the entire mucosa of the anal canal. The histological appearances of the anal mucosa have been examined in 16 consecutive patients undergoing restorative proctocolectomy for ulcerative colitis. In 14 patients there was chronic inflammation characteristic of ulcerative colitis. Four patients had moderate dysplasia and in one of these patients an unsuspected adenocarcinoma of the anal canal extending down to the level of the dentate line was present. We believe that the anal mucosa should always be removed down to the level of the dentate line in restorative proctocolectomy for ulcerative colitis.

Multivariate analysis of factors influencing the results of restorative proctocolectomy

Univariate and multivariate analyses have been used to assess the influence of 14 variables on the results of 65 consecutive ileoanal pouch procedures over 5 years. There were nine failures requiring intubation, ileostomy or pouch excision. There was a significant association between failure and pelvic sepsis (P less than 0.05, n = 8), endoanal mucosectomy (P less than 0.05, n = 7), preservation of a long rectal cuff (P less than 0.05, n = 5) and lack of experience with the operation (P less than 0.05, n = 8). Of 49 patients with preoperative evidence of ulcerative colitis, three are now known to have Crohn's disease. Functional outcome was significantly impaired in patients who developed pelvic sepsis (P less than 0.01) or a postoperative fistula (P less than 0.05), and who had an endoanal mucosectomy (P less than 0.05). Success with ileoanal pouch reconstruction increases with experience. Avoidance of sepsis is associated with a lower failure rate, improved functional results and reduced hospital stay. Preliminary colectomy is also advised to exclude Crohn's disease if the diagnosis is in question.

Changes in the absorption of bile acids after total colectomy in patients with an ileostomy or pouch-anal anastomosis

Bile acid absorption was investigated using 75Se Taurohomocholate (SeHCAT) in controls and patients who had undergone total colectomy with either conventional ileostomy or pouch-anal anastomosis for ulcerative colitis or adenomatous polyposis. Whole-body retention of SeHCAT after 168 hours was greater in the controls than the patients who had undergone colectomy (P less than .05). Retention of SeHCAT did not differ significantly between patients with an ileostomy and patients with pouch-anal anastomosis, but patients with an ileostomy and ileal resection of more than 20 cm retained less SeHCAT than patients with a pouch-anal anastomosis (P less than .01). Analysis of fecal bile acids from ileostomies and pouches showed that bacterial metabolism of primary conjugated bile acids was greater in patients with a pouch. It was concluded that bile acid absorption was not significantly impaired by construction of a pouch compared with conventional ileostomy, but bacterial metabolism of bile acids was greater in the pouches.

Small intestinal obstruction complicating ileal pouch-anal anastomosis

Small bowel obstruction remains the most common complication after proctocolectomy with ileal pouch-anal anastomosis. Of 626 patients who underwent this operation between January 1981 and October 1986 for ulcerative colitis (544 patients), familial adenomatous polyposis (72 patients), or indeterminate colitis (ten patients), 17% developed small bowel obstruction, 7.5% of whom required surgical intervention. The obstruction occurred either before or after closure of the temporary ileostomy. Patients who had a temporary Brooke ileostomy were more likely to develop obstruction (four of 32 patients, 12.5%) than those who had a loop ileostomy (25 of 564 patients, 4.6%) (p = 0.07). Also, patients who had had previous operations were at greater risk of obstruction (8.5%) than those who had not (2.2%) (p less than 0.04).