Pouch size: the important functional determinant after restorative proctocolectomy

Ileal pouch-anal anastomosis in ulcerative colitis: outcomes, functional results, and quality of life in patients with more than 10-year follow-up

PURPOSE

Ileal pouch-anal anastomosis (IPAA) has become the surgical procedure of choice for patients with ulcerative colitis (UC). IPAA was incorporated into our institution in 1984, and thereafter, more than 200 procedures have been performed. The functional results and morbidity of this surgery have been reported previously. However, long-term functional outcomes and quality of life have not been evaluated.

METHODS

As a cohort study, we identified all consecutive patients who underwent IPAA for UC between 1984 and 2017 and selected those with more than 10-year follow-up. Demographic data, morbidity, and pouch survival information were obtained. Long-term functional results and quality of life were evaluated through an e-mail survey using the Öresland score and the Cleveland Global Quality of Life scales, respectively.

RESULTS

Of 201 patients, 116 met the inclusion criteria. Median follow-up was 20 (10-34) years. Early post-operative complications (30 days) were observed in 19 (16.4%) patients and 66 (56.9%) presented adverse events. The IPAA preservation rate at 10 and 20 years was 96.5% and 93.1%, respectively. Long-term functional scores presented a median of 6 (1-15) points. IPAA function was satisfactory in 11 (20.0%) patients, acceptable in 18 (32.7%), and deficient in 26 (47.3%). The median score for global quality of life was 0.8 (0.23-1.0) points.

CONCLUSION

IPAA as treatment for UC meets the expectations of cure of the disease, maintaining adequate long-term intestinal functionality associated with a good quality of life in most patients.

Anorectal Function After Ileo-Rectal Anastomosis Is Better than Pelvic Pouch in Selected Ulcerative Colitis Patients

BACKGROUND

With a lifelong perspective, 12% of ulcerative colitis patients will need a colectomy. Further reconstruction via ileo-rectal anastomosis or pouch can be affected by patients' perspective of their quality of life after surgery.

AIM

To assess the function and quality of life after restorative procedures with either ileo-rectal anastomosis or ileal pouch-anal anastomosis in relation to the inflammatory activity on endoscopy and in biopsies.

METHOD

A total of 143 UC patients operated with subtotal colectomy and ileo-rectal anastomosis or pouches between 1992 and 2006 at Linköping University Hospital were invited to participate. Those who completed the validated questionnaires (Öresland score, SF-36, Short Health Scale) were offered an endoscopic evaluation including multiple biopsies. Associations between anorectal function and quality of life with type of restorative procedure and severity of endoscopic and histopathologic grading of inflammation were evaluated.

RESULTS

Some 77 (53.9%) eligible patients completed questionnaires, of these 68 (88.3%) underwent endoscopic evaluation after a median follow-up of 12.5 (range 3.5-19.4) years after restorative procedure. Patients with ileo-rectal anastomosis reported better overall Öresland score: median = 3 (IQR 2-5) for ileo-rectal anastomosis (n = 38) and 10 (IQR 5-15) for pouch patients (n = 39) (p < 0.001). Anorectal function (Öresland score) and endoscopic findings (Baron-Ginsberg score) were positively correlated in pouch patients (tau: 0.28, p = 0.006).

CONCLUSION

Patients operated with ileo-rectal anastomosis reported better continence compared to pouches. Minor differences were noted regarding the quality of life. Ileo-rectal anastomosis is a valid option for properly selected ulcerative colitis patients if strict postoperative endoscopic surveillance is carried out.

Ileal-anal pouches: A review of its history, indications, and complications

The ileal pouch anal anastomosis (IPAA) has revolutionised the surgical management of ulcerative colitis (UC) and familial adenomatous polyposis (FAP). Despite refinement in surgical technique(s) and patient selection, IPAA can be associated with significant morbidity. As the IPAA celebrated its 40^th anniversary in 2018, this review provides a timely outline of its history, indications, and complications. IPAA has undergone significant modification since 1978. For both UC and FAP, IPAA surgery aims to definitively cure disease and prevent malignant degeneration, while providing adequate continence and avoiding a permanent stoma. The majority of patients experience long-term success, but “early” and “late” complications are recognised. Pelvic sepsis is a common early complication with far-reaching consequences of long-term pouch dysfunction, but prompt intervention (either radiological or surgical) reduces the risk of pouch failure. Even in the absence of sepsis, pouch dysfunction is a long-term complication that may have a myriad of causes. Pouchitis is a common cause that remains incompletely understood and difficult to manage at times. 10% of patients succumb to the diagnosis of pouch failure, which is traditionally associated with the need for pouch excision. This review provides a timely outline of the history, indications, and complications associated with IPAA. Patient selection remains key, and contraindications exist for this surgery. A structured management plan is vital to the successful management of complications following pouch surgery.

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.

Determinants of optimal bowel function in ileal pouch-anal anastomosis - physiological differences contributing to pouch function

BACKGROUND

Variability in functional outcome after ileal-pouch anal anastomosis (IPAA) is to a large extent unexplained. The aim of this study was to perform multiple physiological and biochemical tests including an endoscopic examination with histology on IPAA patients with well and poorly functioning pouches to determine factors, or combinations thereof, contributing to functional outcome.

METHODS

All patients with ulcerative colitis undergoing restorative proctocolectomy between 2000 and 2013 (N = 108) were interviewed using a pouch functioning score. The best and worst functioning quartiles were invited to undergo examination with a barostat measuring pouch volume at preset variable distension pressures, and a pouch endoscopy.

RESULTS

Forty five of 58 eligible patients agreed to participate. The most significant physiological parameter differing between the well and poorly functioning pouches was pouch volume at first sensation, urge and discomfort (p value <.001). Urge volumes were 213 (CI 171-256) ml for poorly and 352 (CI 305-401) ml for well functioning pouches. Pouchitis episodes were negatively correlated to function. The poorly functioning patients had a higher prevalence of histological signs of inflammation and hand-sewn anastomosis, and a longer remaining rectal cuff, however, nonsignificant. The pouch pressure at sensation thresholds did not differ between the groups.

CONCLUSIONS

Pouch volume is the most dominant predictor of pouch function in this study. The present comprehensive study of a multitude of different factors that possibly could be contributing to functional outcome, failed to shed much further light on the functional variability among pouch patients. The pouch physiology remains to a large extent unexplained.

Postoperative changes of manometry after restorative proctocolectomy in Korean ulcerative colitis patients

AIM

To investigate the changes of postoperative anal sphincter function and bowel frequency in Korean patients with ulcerative colitis (UC).

METHODS

A total of 127 patients with UC who underwent restorative proctocolectomy (RPC) during 20 years were retrospectively analyzed. The parameters of anal manometry and bowel frequency were compared according to the 6-mo intervals until 24 mo postoperatively. Manometry was used to measure the maximal squeezing pressure (MSP) and maximal resting pressure (MRP).

RESULTS

MSP decreased after surgery until 6 mo (157 to 142 mmHg); thereafter, it improved and was recovered to and maintained at the preoperative value at 12 mo postoperatively (142-170 mmHg, P < 0.001). Although the decreased MRP (65 to 56 mmHg) improved after 18 mo (62 mmHg), it did not completely recover to the preoperative value. The decreased rectal capacity after surgery (90 to 82 mL) gradually increased up to 150 mL at 24 mo. Although bowel frequency showed significant gradual decreases at each interval, it was stabilized after 12 mo postoperatively (6.5 times/d).

CONCLUSION

Postoperative changes of manometry and bowel frequency after restorative proctocolectomy in Korean patients with UC were not different from those in Western patients with UC.

[The technique of restorative proctocolectomy with ileal J‑pouch : Standards and controversies]

BACKGROUND

Restorative proctocolectomy (RPC) is the standard of care in the case of medically refractory disease and in neoplasia in ulcerative colitis (UC).

OBJECTIVES

This review aims at providing an overview of the current evidence on standards, innovations, and controversies with regard to the surgical technique of RPC.

RESULTS

RPC is the standard of care in the surgical management of UC refractory to medical treatment and in neoplasia. Due to its simplicity and good functional outcomes, the J‑pouch is the most used pouch design. RPC is usually performed as a two-stage procedure. In the presence of risk factors, a three-stage procedure should be performed. The technically more demanding mucosectomy and hand sewn anastomosis does not seem to result in a better oncologic outcome than stapled anastomosis. Functional results appear marginally better after stapled anastomosis, but the rectal cuff should not exceed 2 cm in this reconstruction. The laparoscopic approach is at least as good as the open approach. For the new, innovative surgical approaches such as robotics and transanal surgery, only feasibility but no advantages have yet been demonstrated.

CONCLUSION

The evidence in regard to controversial points remains limited.

Restorative proctocolectomy with two different pouch designs: few complications with good function

AIM

The object of this study was to compare function and quality of life after restorative proctocolectomy (RPC) with ileal pouch-anal anastomosis (IPAA) surgery having two different pouch designs.

METHOD

Patients having RPC in an academic unit from 2000 who had had the loop-ileostomy closed by June 2013 were identified from the hospital medical records. They were sent a questionnaire regarding quality of life and interviewed using a pouch function score (PFS) described by Oresland (score 0-16, higher scores denote worse function).

RESULTS

One hundred and three patients underwent surgery, of whom 56 had a J-pouch design and 47 a K-pouch design, this being a double-folded Kock pouch without the nipple valve. No patients have had the pouch removed or defunctioned due to failure at a mean of 8 years. The reoperation rate was 11.6%. The mean PFS was 5.43 and 5.27 for J- and K-pouches, respectively (P = 0.766). More patients with a J-pouch reported a social handicap due to poor bowel function (P = 0.041). Patients with a PFS ≥ 8 had a poorer quality of life. A score of ≥ 8 was reported by 16% of K-pouch and 25% of J-pouch patients (P = 0.29).

CONCLUSION

RPC is a safe procedure with a low complication rate and good functional outcome. Small improvements in function have an impact on a patient's quality of life. Although the J-pouch is the most commonly used, the K-pouch has some advantages. Other pouch designs deserve further evaluation.

Scintigraphic Small Intestinal Transit Time and Defaecography in Patients with J-Pouch

Objective methods for examination of pouch function are warranted for a better understanding of the functional result and treatment of dysfunction. The objective of this study was to evaluate the results of scintigraphic intestinal transit time and defaecography compared to the results of pouch function, mucosal condition and a questionnaire on quality of life (QoL). This cross-sectional study included 21 patients. Scintigraphic transit time and defaecography was determined with the use of Tc-99m. Pouch function was assessed by number of bowel movements, pouch volume, and continence. Pouch mucosal condition was evaluated by endoscopy and histology. Median transit time was 189 min (105-365). Median ejection fraction at defaecography (EF) was 49% (3-77) and 62% (17-98) after first and second defecation. Median pouch volume was 223 mL (100-360). A median daily stool frequency of nine (4-25) was reported and three (14%) patients suffered from daytime incontinence. No patients had symptomatic or endoscopic pouchitis; however, the histology showed unspecific inflammation in 19 (90%) patients. There was no correlation between transit time, evacuation fraction (EF) and pouch function in univariate analysis. However, we found a high body mass index (BMI) and a low bowel movement frequency to be associated with a longer transit time by multivariate analysis. Scintigraphic determination of transit time and defaecography are feasible methods in patients with ileal pouch anal anastomosis, but the clinical relevance is yet doubtful.

A reappraisal of the ileo-rectal anastomosis in ulcerative colitis

Colectomy is still frequently required in the care of ulcerative colitis. The most common indications are either non-responding colitis in the emergency setting, chronic active disease, steroid-dependent disease or neoplastic change like dysplasia or cancer. The use of the ileal pouch anal anastomosis has internationally been the gold standard, substituting the rectum with a pouch. Recently the use of the ileorectal anastomosis has increased in frequency as reconstructive method after subtotal colectomy. Data from centres using ileorectal anastomosis have shown the method to be safe, with functionality and risk of failure comparable to the ileal pouch anal anastomosis. The methods have different advantages as well as disadvantages, depending on a number of patient factors and where in life the patient is at time of reconstruction. The ileorectal anastomosis could, together with the Kock continent ileostomy, in selected cases be a complement to the ileal pouch anal anastomosis in ulcerative colitis and should be discussed with the patient before deciding on reconstructive method.

Minimal invasive surgery: NOSE and NOTES in ulcerative colitis

BACKGROUND

In patients with ulcerative colitis (UC), laparoscopic pelvic dissection for IPAA is not always straightforward: often, a hand-assistance incision is used to complete the proctectomy, lengthening operative times. Hybrid NOSE and NOTES are emerging as an alternative approach to conventional laparoscopy. We believe that UC patients could benefit from this new hybrid approach in three ways: by easing the proctectomy as performed down to up, avoiding additional incisions and decreasing surgical times. We present the short-term outcomes of our series.

METHODS

All patients with UC who required IPAA were enrolled in a single-arm prospective study (July 2011 to March 2014). A three-step procedure was performed. The first step: laparoscopic colectomy (with transanal removal of the colon) and temporary ileostomy. The second step: "down-to-up" proctectomy (with transanal removal of the rectum) and IPAA with a covering ileostomy. We combined simultaneously transanal and laparoscopic approach. The third step: ileostomy closure. Functional outcomes were assessed 3 months after third step.

RESULTS

Eighteen patients were enrolled. Two patients are waiting to complete the second stage, and 16 underwent all surgical steps. Twelve have been evaluated with functional scores. For the first step, the mean operative time was 162.2 min (SD 40.5) and 170 min (SD 50.1) for the second one. The median hospital stay was 6 days (IQR 5-14.75) for the first step and 5.5 (IQR 5-9.75) for the second one. No major complications occurred. Twenty-four-hour defecation frequency was 5.5 per day (SD 1.7), 0.5 per night. Seventy-five percentage of patients may retain stools for more than 30 min; the mean value of Oresland score was 4.7 and Wexner score 1.4.

CONCLUSIONS

This is a safe and feasible technique to treat UC patients with good short-term outcomes. Long-term outcomes and controlled trials are needed.

Reoperative inflammatory bowel disease surgery

With the advent of restorative proctocolectomy or ileal pouch-anal anastomosis (IPAA) for ulcerative colitis (UC), not only has there been potential for cure of UC but also patients have enjoyed marked improvements in bowel function, continence, and quality of life. However, IPAA can be complicated by postoperative small bowel obstruction, disease recurrence, and pouch failure secondary to pelvic sepsis, pouch dysfunction, mucosal inflammation, and neoplastic transformation. These may necessitate emergent or expeditious elective reoperation to salvage the pouch and preserve adequate function. Local, transanal, and transabdominal approaches to IPAA salvage are described, and their indications, outcomes, and the clinical parameters that affect the need for salvage are discussed. Pouch excision for failed salvage reoperation is reviewed as well. Relaparotomy is also frequently required for recurrent Crohn's disease (CD), especially given the nature of this as yet incurable illness. Risk factors for CD recurrence are examined, and the various surgical options and margins of resection are evaluated with a focus on bowel-sparing policy. Stricturoplasty, its outcomes, and its importance in recurrent disease are discussed, and segmental resection is compared with more extensive procedures such as total colectomy with ileorectal anastomosis. Lastly, laparoscopy is addressed with respect to its long-term outcomes, effect on surgical recurrence, and its application in the management of recurrent CD.

Differences in ano-neorectal physiology of ileoanal and coloanal reconstructions for restorative proctectomy

OBJECTIVE

Restorative proctectomy with straight coloanal anastomosis (CAA) and restorative proctocolectomy with ilealpouch-anal anastomosis (IPAA) are options for maintaining bowel integrity after rectal resection. The aim of this study was to compare clinical function and anorectal physiology in patients treated with CAA and IPAA.

METHOD

Three-dimensional vector-manometry and neorectal volumetry were performed in straight CAA [53 patients (34 male)] and IPAA [61 patients (39 male)] for ulcerative colitis. Function was assessed using a 14 day incontinence diary.

RESULTS

Function was similar in both groups, but neorectal compliance and threshold volumes for sensation, urge and maximum tolerated volume (MTV) were significantly higher after IPAA than after CAA. Mean pressure, vector volume and sphincter symmetry at rest were significant determinants of continence in both groups but squeeze pressure did not correlate significantly with function in either group. Threshold volume, MTV, and compliance were significantly correlated with frequency of defecation in patients with IPAA but not with CAA.

CONCLUSION

A strong consistent resting anal sphincter pressure is one determinant of continence after both IPAA and CAA. Squeeze pressures do not influence the functional result. In IPAA but not CAA, the neorectum has a reservoir function which correlates with the postoperative frequency of defaecation.

The role of pouch compliance measurement in the management of pouch dysfunction

PURPOSE

Ileal pouch anal anastomosis is an established option for patients who require total proctocolectomy and restoration of bowel continuity. However, the functional results are not always good and low pouch compliance has been suggested as one possible cause. We aimed to review the results of pouch compliance tests over 11 years to assess whether measuring pouch compliance is a useful diagnostic tool to guide management of pouch dysfunction.

METHODS

The results of pouch compliance tests performed between 1996 and 2007 together with the details of symptoms, treatments and outcome were reviewed.

RESULTS

One hundred and forty-one pouch compliance tests were performed. There was no difference in pouch compliance between those with overt pathology (pouchitis, pelvic sepsis or anastomotic stricture) and those with idiopathic pouch dysfunction. In this second group, there was no difference in pouch compliance between patients with and without each of the symptoms of increased defaecatory frequency, incontinence and evacuation difficulties. The results of the compliance testing did not influence the clinical decision making on idiopathic pouch dysfunction (p=0.77) nor diverted pouches (p=0.07).

CONCLUSIONS

Measuring pouch compliance does not offer new information accounting for idiopathic pouch dysfunction and has little influence on the clinical management.

Pouch design and long-term functional outcome after ileal pouch-anal anastomosis

BACKGROUND

Functional outcome is of utmost importance after ileal pouch-anal anastomosis. Although pouch design and construction of the anastomosis are known technical determinants of function, there are few long-term results. This retrospective study evaluated functional outcome for two different pouch designs, and for handsewn versus stapled pouch-anal anastomoses.

METHODS

The analysis included 412 patients who had either a J or K pouch (double-folded J pouch), of whom 123 had a J pouch (96 handsewn and 27 stapled) and 289 had a K pouch (95 handsewn and 194 stapled). Functional outcome was evaluated by a mailed questionnaire to achieve an Oresland score (0 to 15; 15 worst).

RESULTS

Mean functional scores were 6.1 for J pouches and 4.9 for K pouches (P < 0.001). Regression analysis showed that reservoir design and age at surgery were predictors of functional outcome (P < 0.001). A higher proportion of patients with a J pouch and handsewn anastomosis than with a K pouch and stapled anastomosis had a score of 8 or more, a level previously demonstrated to impact negatively on quality of life (32 versus 16 per cent; P = 0.006).

CONCLUSION

The K pouch was associated with a better long-term functional outcome than the J pouch in this patient population.

Medical management of patients with ileal pouch anal anastomosis after restorative procto-colectomy

Restorative procto-colectomy with ileal pouch anal anastomosis has become the most common elective surgical procedure for patients with ulcerative colitis and is becoming popular in those with familial adenomatous polyposis coli. The procedure itself is primarily carried out in specialist surgical centres but an increasing number are being performed and followed up in district general hospitals. These patients are now filtering through general surgical and gastroenterology clinics and are frequently seen in primary care. Pouchitis, an inflammatory condition of the ileal pouch, has become the third most important form of inflammatory bowel disease. As research develops in this area, other complications are being found. The aim of this review is to provide an up-to-date, evidence-based approach to the clinical management of these patients.

Ileal pouch dysfunction: diagnosis and management

Restorative proctocol ectomy is the elective surgical procedure of choice for most patients who have ulcerative colitis or familial adenomatous polyposis. This major advance has offered an alternative to permanent ileostomy in these patients.

Long-term function and manovolumetric characteristics after ileal pouch–anal anastomosis for ulcerative colitis

Background

Long-term pouch function and physiological characteristics after ileal pouch–anal anastomosis (IPAA) are poorly described. The aim of this study was to undertake a prospective investigation of long-term pouch function and manovolumetric characteristics.

Methods

Forty-two patients with a median follow-up of 16 years after IPAA were included. Function was assessed using a questionnaire and a score was calculated ranging from 0 to 15 (15 being the worst). Manovolumetry was performed and pouchitis recorded. A paired analysis was conducted, as the results were compared with previous data for each patient.

Results

The median functional score was 3·5 (range 0–10) at 2 years and 5 (range 1–11) at 16 years (P = 0·013). Resting anal canal pressures were higher (P &lt; 0·001) and squeeze pressures lower (P = 0·008) at long-term follow-up. Ileal pouch volumes at distension pressures of 10, 20 and 40 cmH2O were diminished at 16 years (P &lt; 0·001, P = 0·005 and P = 0·058 respectively). The volume and pressure for first sensation and urge to defaecate were reduced. Increased age correlated positively with a poor functional score. A history of pouchitis did not affect functional or physiological characteristics.

Conclusion

Ileal pouch function declines in the long term. The reasons are unclear, but the ageing process may have an impact.

Long-Term Functional Outcome of Colonic J-pouch Reconstruction After Low Anterior Resection for Rectal Cancer

PURPOSE

To evaluate the long-term functional outcome of colonic J-pouch reconstruction after low anterior resection (LAR) for rectal cancer in a prospective study.

METHODS

We compared the functional outcome of 46 patients who underwent J-pouch reconstruction (J-group) and 49 patients who underwent straight anastomosis (S-group) after LAR for rectal cancer. We evaluated clinical function using a 17-item questionnaire about different aspects of bowel function. Physiologic reservoir function was evaluated by manovolumetry.

RESULTS

Among the patients with an ultralow anastomosis (<or=4 cm from the anal verge), those in the J-group had fewer bowel movements during the day and at night, and less urgency, soiling, protective pad use, incontinence, and dissatisfaction with bowel function than those in the S-group. Among the patients with a low anastomosis (5-8 cm from the verge), those in the J-group had fewer bowel movements at night, and less urgency and soiling than those in the S-group. Moreover, reservoir function (reflected by the maximum tolerable volume, threshold volume, and compliance) was better in the J-group than in the S-group in both the ultralow and low anastomosis groups.

CONCLUSION

J-pouch reconstruction after low anterior resection creates a better stool reservoir than straight anastomosis, especially when the anastomosis is less than 4 cm from the anal verge, resulting in a better quality of life 3 years after rectal cancer resection.

Salvage surgery after restorative proctocolectomy

BACKGROUND AND METHOD

Restorative proctocolectomy is now the elective surgical procedure of choice for most patients with ulcerative colitis or familial adenomatous polyposis. Complications may lead to failure, defined as removal of the reservoir with establishment of a permanent ileostomy or long-term diversion. Failure may be avoided for some patients by salvage surgery. The causes of failure are identified in this article and the procedures adopted to treat them are defined; a review of the literature was carried out to determine the effectiveness of the procedures.

RESULTS

Failure after restorative proctocolectomy results from complications, which may occur indefinitely during follow-up to a cumulative rate of about 15 per cent at 10-15 years. Sepsis accounts for over 50 per cent of these complications. Abdominal salvage procedures are successful in 20 to over 80 per cent of patients but the rate of salvage is dependent on the duration of follow-up, which might explain this variance. Local procedures are successful in 50-60 per cent of patients with pouch-vaginal fistula. Poor function accounts for about 30 per cent of failures. Abdominal salvage for outlet obstruction and low pouch capacitance results in satisfactory or acceptable function in up to 70 per cent of patients. There is no effective surgical salvage for pouchitis.

CONCLUSION

Salvage surgery must be discussed carefully with the patient, who should be made aware of the possible complications and the prospect of success, which is less than that in the general population of patients undergoing ileoanal pouch surgery.

Prospective evaluation of ileoanal pouch characteristics measured by barostat

PURPOSE

The aim of this study was to evaluate pouch sensory and motor characteristics prospectively during the first postoperative year and to compare those with rectal characteristics.

METHODS

Twelve patients with an ileoanal J-pouch were studied at 3 and 12 months postoperatively. The results were compared with those obtained in 12 healthy controls. Visceral compliance was assessed using an electronic barostat by a pressure distention procedure, during which sensitivity was also scored by visual analog scales. The response to a meal was assessed during set pressure.

RESULTS

During the first postoperative year, pouch compliance increased significantly from 7.2 +/- 0.6 to 10.7 +/- 0.9 ml/mmHg (rectal compliance 10.6 +/- 1.1 ml/mmHg). The increase in pouch compliance significantly influences the 24-hour stool frequency (P = 0.42). Visceroperception scores remained unchanged. Postprandial decrease in intrabag volume was more pronounced in patients (45 +/- 13 percent at 3 months, 32 +/- 15 percent at 12 months) than in controls (9 +/- 6 percent, < 0.05), and residual postprandial bag volumes were significantly lower in patients at 3 months compared with patients at 12 months.

CONCLUSIONS

Ileoanal pouch compliance increases significantly during the first postoperative year to values in the range of rectal compliance. The increase in pouch compliance is related to a decrease in 24-hour stool frequency. Postprandial bag volumes increase during the first postoperative year but remain significantly smaller than in the rectum. Pouch sensitivity does not change.

Gut transit time after ileal pouch-anal anastomosis using a radiopaque marker

PURPOSE

The aim of this study was to determine the contribution of gastrointestinal motility to bowel function and the pathogenesis of pouchitis after ileal pouch-anal anastomosis.

METHODS

Gastrointestinal transit time was assessed by a radiopaque marker technique in 32 patients with ulcerative colitis.

RESULTS

Small intestinal transit time and pouch emptying time were 4.1 +/- 2 hours and 4.1 +/- 2.5 hours, respectively. There was no significant difference in pouch emptying time between patients with and without pouchitis. When only patients with acute pouchitis that responded to metronidazole were analyzed, there was a trend toward a prolonged pouch emptying time compared with those without pouchitis (P = 0.095). Whole gut transit time was inversely correlated with 24-hour stool frequency in patients without pouchitis (r = -0.63, P < 0.005). In the analysis of regional transit time, only small intestinal transit time was inversely correlated with 24-hour stool frequency (r = -0.472, P < 0.05). Significant prolongation of small intestinal transit time was demonstrated in patients over a period of 41 months (the median time) after ileostomy closure compared with those whose pouches had been functioning for 6 to 41 months (5.4 +/- 1.7 hours vs. 3.1 +/- 1.3 hours, P < 0.005).

CONCLUSIONS

There was an association between small intestinal motility and bowel frequency. Further investigation is necessary in the pathogenesis of acute pouchitis regarding the relationship between delayed pouch emptying and subsequent development of mucosal inflammation.

Ileoanal pouch function is related to postprandial pouch tone

BACKGROUND

Functional impairments are frequently observed in patients with an ileoanal pouch. Meal ingestion increases pouch tone and motility. Little is known, however, about the influence of meal-stimulated pouch characteristics on pouch function. The aim was to characterize basal and postprandial pouch motor and sensory characteristics in relation to clinical pouch function in patients with an ileoanal pouch.

METHODS

Nineteen patients with an ileoanal pouch, without faecal incontinence but with either a high stool frequency (n = 8) or an adequate stool frequency (n = 11), underwent pressure distension of the pouch, by which pouch compliance and sensitivity characteristics were assessed using an electronic barostat. A set pressure procedure was performed to assess the influence of a meal on pouch tone and motility.

RESULTS

Mean(s.d.) compliance was 10(6) and 11(4) ml/mmHg in the groups with poor and adequate pouch function respectively (P not significant). Mean(s.d.) visual analogue scale scores (0-10 cm) for urge at the highest pressure of 28 mmHg were 2.3(1.0) versus 2.3(2.4) cm respectively (P not significant); those for pain were 0.8(1.0) versus 0.5(0.7) (P not significant). Postprandially mean(s.d.) pouch volume decreased by 70(24) per cent in the group with poor pouch function and 29(25) per cent in the group with adequate pouch function (P < 0.01). The frequency and amplitude of phasic pouch contractions increased significantly postprandially, but no differences in motility characteristics were observed between the two groups.

CONCLUSION

In patients with uniform pouch design and follow-up after pouch construction, pouch compliance and sensitivity were no different between patients with normal and high stool frequency; however, postprandial pouch tone was increased significantly in patients with a high stool frequency.

Key factors influencing bowel function after ileal W-pouch anal anastomosis: a spectral analysis of W-pouch motor activity

Restorative proctocolectomy with ileal pouch anal anastomosis (IPAA) has become the standard surgical procedure for ulcerative colitis (UC). The purpose of this study was to determine which factors are important to achieve good anal continence after IPAA in terms of the motor activity and pressure-volume relationship. A total of 17 patients with UC who underwent IPAA were evaluated. The internal ileal pouch pressure was transanally measured with and without volume-loading of the pouch which induces the urge to evacuate. The maximum tolerable volume (MTV), first urge volume (FUV), and ileal pouch compliance were calculated and the internal ileal pouch pressure records were subjected to spectral analysis for intensive evaluation of the intraluminal pressure waves. The FUV, correlation of the compliance of the FUV with MTV, and the remaining volume up to the MTV (RVMTV) were analyzed. Compliance of the FUV was significantly correlated with the RVMTV (r = 0.736, P < 0.01). The frequency of the phasic waves in the pouch decreased with length of follow up, reflecting improved function (r = -0.588, P < 0.05). The findings of this intensive analysis of manometric measurement indicate that the key factors in postoperative pouch function are RVMTV and the frequency of phasic waves in the W-pouch.

A comparison of the effect of loperamide in oral or suppository form vs placebo in patients with ileo-anal pouches

OBJECTIVE

The effect of the anti-diarrhoeal drug, loperamide hydrochloride, on bowel function in patients with an ileo-anal pouch was studied by means of a blinded, three-tailed, case-controlled and randomized crossover trial, using a daily dose of 12 mg in either oral (4 mg t.d.s.) or suppository (6 mg b.d.) form.

PATIENTS AND METHODS

Daily stool frequency was recorded in a diary and an objective measure of pouch motor function was obtained at the end of each treatment phase. Ten subjects (seven males, three females) aged 23-50 years (median 38 years) were studied 9-48 months (median 27 months) after ileostomy closure. Eight pouches had been constructed for ulcerative colitis and two for familial adenomatous polyposis (9J, 1W).

RESULTS

Mean daily stool frequency during the oral loperamide phase was lower than during both the placebo (P=0.05) and suppository (P < 0.02) phases. Stool frequency did not differ significantly between placebo and suppository phases. There was a strong inverse correlation between mean daily stool frequency and pouch capacity (r=-0.82 after both oral and suppository phases). Large isolated pouch contractions were evident in five of eight subjects studied; suppression was observed in two of the five after oral loperamide and in three of the five after loperamide suppositories. Rhythmic pouch contractions were seen in four subjects and suppression was evident after loperamide suppositories (but not after oral loperamide) in three. A daily oral dose of 12 mg loperamide significantly lowered stool frequency in pouch patients and modified some aspects of pouch contraction. Loperamide suppositories produced more prominent suppression of pouch contractions but did not lower stool frequency.

CONCLUSION

This suggests that the beneficial effect of oral loperamide is primarily due to its action on intestine proximal to the pouch itself.

Rectal compliance as a routine measurement: extreme volumes have direct clinical impact and normal volumes exclude rectum as a problem

PURPOSE

The clinical impact of rectal compliance and sensitivity measurement is not clear. The aim of this study was to measure the rectal compliance in different patient groups compared with controls and to establish the clinical effect of rectal compliance.

METHODS

Anorectal function tests were performed in 974 consecutive patients (284 men). Normal values were obtained from 24 controls. Rectal compliance measurement was performed by filling a latex rectal balloon with water at a rate of 60 ml per minute. Volume and intraballoon pressure were measured. Volume and pressure at three sensitivity thresholds were recorded for analysis: first sensation, urge, and maximal toleration. At maximal toleration, the rectal compliance (volume/pressure) was calculated. Proctoscopy, anal manometry, anal mucosal sensitivity, and anal endosonography were also performed as part of our anorectal function tests.

RESULTS

No effect of age or gender was observed in either controls or patients. Patients with fecal incontinence had a higher volume at first sensation and a higher pressure at maximal toleration (P = 0.03), the presence of a sphincter defect or low or normal anal pressures made no difference. Patients with constipation had a larger volume at first sensation and urge (P < 0.0001 and P < 0.01). Patients with a rectocele had a larger volume at first sensation (P = 0.004). Patients with rectal prolapse did not differ from controls; after rectopexy, rectal compliance decreased (P < 0.0003). Patients with inflammatory bowel disease had a lower rectal compliance, most pronounced in active proctitis (P = 0.003). Patients with ileoanal pouches also had a lower compliance (P < 0.0001). In the 17 patients where a maximal toleration volume < 60 ml was found, 11 had complaints of fecal incontinence, and 6 had a stoma. In 31 patients a maximal toleration volume between 60 and 100 ml was found; 12 patients had complaints of fecal incontinence, and 6 had a stoma. Proctitis or pouchitis was the main cause for a small compliance. All 29 patients who had a maximal toleration volume > 500 ml had complaints of constipation. No correlation between rectal and anal mucosal sensitivity was found.

CONCLUSION

Rectal compliance measurement with a latex balloon is easily feasible. In this series of 974 patients, some patient groups showed an abnormal rectal visceral sensitivity and compliance, but there was an overlap with controls. Rectal compliance measurement gave a good clinical impression about the contribution of the rectum to the anorectal problem. Patients with proctitis and pouchitis had the smallest rectal compliance. A maximal toleration volume < 60 ml always led to fecal incontinence, and stomas should be considered for such patients. A maximal toleration volume > 500 ml was only seen in constipated patients, and therapy should be given to prevent further damage to the pelvic floor. Values close to or within the normal range rule out the rectum as an important factor in the anorectal problem of the patient.

Myoelectric and motor activity after proctocolectomy and ileal pouch-anal anastomosis in dogs

BACKGROUND

The aim of this study was to investigate the motor function of the ileoanal pouch and to evaluate its coordination with proximal small-intestine motility.

METHODS

Proctocolectomy and ileal J pouch-anal anastomosis were performed in 12 dogs. Motility was recorded by serosal electrodes and strain gauge transducers.

RESULTS

Transmission of the migrating motor complex (MMC) on the pouch appeared in only 37 of 109 measurements. On the ascending limb there was a constant irregular activity with no MMC detectable. Motility pattern of the pouch did not change postprandially. Spontaneous defecation always appeared independently from MMC transmission without an increase of electrical or mechanical activity or endoluminal pouch pressure.

CONCLUSIONS

Ileal pouch motility is independent from motility patterns of the proximal intestine. Its random contractile activity might provide storage function and make the pouch act as a functional reservoir. Intrinsic pouch motility is not responsible for pouch evacuation under physiologic conditions.

Long-term functional outcome and quality of life after stapled restorative proctocolectomy

OBJECTIVE

To evaluate prospectively long-term quality of life and functional outcome after restorative proctocolectomy (RPC) with ileal pouch-anal anastomosis, and to evaluate and validate a novel quality-of-life indicator in this group of patients.

SUMMARY BACKGROUND DATA

Restorative proctocolectomy with ileal pouch-anal anastomosis is now the preferred option when total proctocolectomy is required for ulcerative colitis or familial adenomatous polyposis, but long-term data on functional outcome and quality of life after the procedure are lacking.

METHODS

Patients (n = 977) who underwent RPC with stapled anastomosis for colitis or polyposis coli and who were followed for > or =12 months were included. Quality of life, fecal incontinence, and satisfaction with surgery were prospectively evaluated by structured interview or questionnaire for 1 to 12 years after surgery (median 5.0). Quality of life was scored using the Cleveland Global Quality of Life (CGQL) instrument (Fazio Score). This is a novel score developed over the past 15 years by the senior author. Quality of life was also evaluated in a subgroup of patients with the Short Form 36 (SF-36). The CGQL was validated by determining its reliability, responsiveness, and validity as well as its correlation with the SF-36 score.

RESULTS

Postoperative quality of life as measured by SF-36 was excellent and compared well with published norms for the general U.S. population. The CGQL was found to be reliable, responsive, and valid, and there was a high correlation with the SF-36 scores. Using the CGQL, quality of life was shown to increase after the first 2 years after surgery, and there was no deterioration thereafter. The prevalence of perfect continence increased from 75.5% before surgery to 82.4% after surgery, and although this deteriorated somewhat >2 years after surgery, it was no worse than preoperative values. Ninety-eight percent of patients would recommend the surgery to others.

CONCLUSIONS

Long-term quality of life after ileal pouch surgery is excellent and the level of continence is satisfactory. This surgery is an excellent long-term option in patients requiring total proctocolectomy. The CGQL is a simple, valid, and reliable measure of quality of life after pelvic pouch surgery and may well be applicable in many other clinical conditions.

Long-term functional outcome and quality of life after stapled restorative proctocolectomy

OBJECTIVE

To evaluate prospectively long-term quality of life and functional outcome after restorative proctocolectomy (RPC) with ileal pouch-anal anastomosis, and to evaluate and validate a novel quality-of-life indicator in this group of patients.

SUMMARY BACKGROUND DATA

Restorative proctocolectomy with ileal pouch-anal anastomosis is now the preferred option when total proctocolectomy is required for ulcerative colitis or familial adenomatous polyposis, but long-term data on functional outcome and quality of life after the procedure are lacking.

METHODS

Patients (n = 977) who underwent RPC with stapled anastomosis for colitis or polyposis coli and who were followed for > or =12 months were included. Quality of life, fecal incontinence, and satisfaction with surgery were prospectively evaluated by structured interview or questionnaire for 1 to 12 years after surgery (median 5.0). Quality of life was scored using the Cleveland Global Quality of Life (CGQL) instrument (Fazio Score). This is a novel score developed over the past 15 years by the senior author. Quality of life was also evaluated in a subgroup of patients with the Short Form 36 (SF-36). The CGQL was validated by determining its reliability, responsiveness, and validity as well as its correlation with the SF-36 score.

RESULTS

Postoperative quality of life as measured by SF-36 was excellent and compared well with published norms for the general U.S. population. The CGQL was found to be reliable, responsive, and valid, and there was a high correlation with the SF-36 scores. Using the CGQL, quality of life was shown to increase after the first 2 years after surgery, and there was no deterioration thereafter. The prevalence of perfect continence increased from 75.5% before surgery to 82.4% after surgery, and although this deteriorated somewhat >2 years after surgery, it was no worse than preoperative values. Ninety-eight percent of patients would recommend the surgery to others.

CONCLUSIONS

Long-term quality of life after ileal pouch surgery is excellent and the level of continence is satisfactory. This surgery is an excellent long-term option in patients requiring total proctocolectomy. The CGQL is a simple, valid, and reliable measure of quality of life after pelvic pouch surgery and may well be applicable in many other clinical conditions.

Enlargement of colonic pouch after proctectomy and coloanal anastomosis: potential cause for evacuation difficulty

PURPOSE

Although the functional outcome after low anterior resection for rectal cancer using colonic J-pouch reconstruction is superior to that using conventional straight reconstruction, the one drawback of colonic J-pouch reconstruction is difficulty with evacuation. Recently it has been suggested that construction of a larger colonic J-pouch causes the evacuation difficulty. The purpose of this study was to elucidate the cause of evacuation difficulty with colonic J-pouch reconstruction.

METHODS

We compared pouchography of 26 patients with 10-cm colonic J-pouch reconstructions (10-J group) and 27 patients with 5-cm colonic J-pouch reconstructions (5-J group) at three months, one year, and two years after surgery. Functional assessments were performed one year postoperatively. Clinical function was evaluated using a questionnaire. Evacuation function was evaluated by the balloon expulsion and saline evacuation tests.

RESULTS

The greatest width of the pouch in the 10-J group in the anteroposterior view was significantly greater than that in the 5-J group at all three measurement times (3 months, 4.9 vs. 4 cm; P = 0.0011; 1 year, 9 vs. 5.6 cm; P < 0.0001; 2 years, 9.2 vs. 5.8 cm; P < 0.0001). The value in the 10-J group at one year after surgery was 1.9 times that at three postoperative months; in the 5-J group this ratio was 1.4. There was a significant difference between these ratios (P < 0.0001). No significant difference existed between the values at two years and one year after surgery in either the 10-J or the 5-J group. An evacuation difficulty was significantly more common in the 10-J group than the 5-J group. Evacuation function in the 10-J group was significantly inferior to that in the 5-J group.

CONCLUSIONS

The evacuation difficulty observed in patients with larger colonic J-pouch reconstructions is associated with excessive distention of the pouch occurring within one year of surgery.

Effects of loperamide on ileoanal pouch function

BACKGROUND

Opioid analogues are used to manage increased bowel frequency in patients with an ileoanal reservoir. The aim of the study was to determine the clinical efficacy of loperamide in patients with an ileoanal reservoir and to assess its effect on pouch motility.

METHODS

Fourteen patients with a pouch who had normal pouch emptying and anal function were studied. Ambulatory pouch and anal motility, and stool weights, were recorded for 24 h while taking no medication and for 24 h while receiving 8 mg loperamide. In a second analysis, patients were divided on the basis of bowel frequency into those with 4 or fewer motions (good function; n=6) and those with more than 6 per day (poor function; n=8), to determine any differential effects of loperamide.

RESULTS

Loperamide decreased median bowel frequency (no loperamide 5.5 versus loperamide 4.0, P=0.03) and 24-h stool weight (610 g versus 413 g, P=0.03) but not individual stool weights. Patients with poor function had both higher bowel frequency (8.0 versus 3.5 per 24 h, P=0.004) and higher stool weight (728 g versus 430 g, P=0.05) with no treatment than those with good function. High-amplitude pouch pressure waves were greater in number before defaecation in patients with poor function and did not decrease with loperamide, in contrast to patients with good function. Pouch baseline pressure decreased after defaecation to a similar extent in both groups and was not affected by loperamide.

CONCLUSION

Loperamide 8 mg per day reduces bowel frequency by reducing total stool weight, not individual stool weights. In patients with good function it also affects pouch motility. High bowel frequency is associated with increased pouch high-pressure waves.

The physiology of ileo-anal pouch function

Even excellent clinical function after ileo-anal pouch construction is associated with a variety of physiological abnormalities. Small bowel intestinal motility is essentially normal but the ileal reservoir serves to markedly suppress the ileal motor response both to progressive distension by intestinal contents and to transmitted myoelectrical complexes. As a result, the healthy pouch can accommodate a large volume of intestinal content before the rising baseline pressure and the appearance of large isolated contraction waves produce an urge to defecate. Evacuation in the normal pouch patient is rapid and highly efficient and is achieved by means of the Valsalva maneuver without any evidence of significant intestinal propulsion. External anal sphincter function is fully preserved but internal anal sphincter function is significantly impaired in the immediate postoperative period. Recovery occurs over the next 6 to 12 months but is often incomplete. Bacterial overgrowth in the pouch and prepouch ileum is almost universal and results in the premature deconjugation of primary bile salts and accumulation of secondary bile salts within the pouch. These produce morphologic changes in the ileal mucosa, and their excretion in pouch effluent gradually depletes the bile salt pool. Anerobic organisms also bind with vitamin B12 and the vitamin B12-intrinsic factor complex, resulting in subtle but measurable reductions in vitamin B12 levels in pouch patients. Finally, anerobic fermentation of mucus and undigested carbohydrate results in excessive quantities of short chain fatty acids within the pouch lumen. The clinical significance of these substances is unclear, but they may have an adverse action on both ileal mucosal and smooth muscle function. In essence, however, the pouch surgeon can maximize the likelihood of good clinical function by constructing a large capacity pouch, by avoiding surgery in patients with clearly deficient anal sphincter mechanisms, and by careful attention to pouch-anal anastomotic technique.

Physiologic evaluation and surgical management of failed ileoanal pouch

BACKGROUND

Following proctocolectomy and ileal pouch-anal anastomosis, a small percentage of patients will have poor functional results attributable to pouchitis or anastomotic or septic complications. Additionally, functional failures can occur secondary to limited pouch capacity and compliance. We present five such patients managed with operative conversion to W-ileal pouch-anal anastomosis and examined physiologic parameters important for improving functional results.

METHODS

Five female patients (mean age, 30 (range, 24-39) years) with poorly functioning J-ileal pouch-anal anastomoses were referred for evaluation with symptoms of high stool frequency and incontinence problems. Three had severe nocturnal incontinence, and the remaining two patients experienced minor nocturnal incontinence. Preoperative and postoperative evaluation included barium pouch studies, flexible sigmoidoscopy, anal manometry, evacuation volume, and pouch compliance. Pouch-to-anal pressure gradients were calculated. To improve reservoir capacity and compliance, all five patients underwent conversion to W-ileal pouch-anal anastomoses.

RESULTS

Twenty-four hour and nocturnal stool frequencies decreased from 13.8+/-1.7 and 3+/-1.3 to 5.8+/-0.3 and 0.3+/-0.2 postconversion (P < 0.05). Mean pouch evacuation volume increased from 83+/-27 to 290+/-29 ml postoperatively (P < 0.05). Pouch compliance increased from 2.7+/-0.5 mmHg/ml to 7.7+/-0.6 mmHg/ml postconversion (P < 0.05). Improvement in postconversion stool frequency correlated with an increase in pouch evacuation volume (r=-0.87). All patients reported improved day and nocturnal continence, despite no significant change between preoperative and postoperative anal manometric pressures. Improved continence correlated with a significant widening of the pouch-to-anal pressure gradients, which increased from 5 to 25 mmHg at 150 ml following pouch conversion.

CONCLUSIONS

Poorly functioning ileal reservoirs secondary to limited capacity and compliance can be successfully managed with conversion to W-ileal pouch-anal anastomosis. The increased pouch capacity is associated with improvement in compliance and widening of the pouch-to-anal pressure gradients, providing excellent functional results.

USE OF ANORECTAL MANOMETRY FOR OBJECTIVE ASSESSMENT OF ANORECTAL FUNCTION AFTER POUCH ILEOANAL ANASTOMOSIS

Sixteen patients of ulcerative colitis and two of familial adenomatous polyposis were subjected to anorectal manometry, a minimal of three months after Pouch Ileo-Anal Anastomosis and closure of ileostomy. Using a perfusion catheter the parameters measured were resting anal pressure (RAP), maximum squeeze pressure (MSP), pouch volume and compliance at maximum tolerated volume. Subjective evaluation included anal continence and frequency of stools. The subjective functional results after surgery were then correlated with the objective findings of manometry. 4/18 patients (22%) had nocturnal incontinence only, while one patient (5%) had incontinence both by day and night. Frequency of stools was < 8/day in 10/18 patients (55%). Only 1/5 patients (20%) with incontinence had anal sphincter pressures greater than the controls while only 3/13 continent patients (22%) had anal sphincter pressures less than the controls. The study shows that low anal sphincter pressures are associated with post-operative incontinence and that there is a correlation between decreased frequency of stools and increased pouch volume as well as pouch compliance.

Is age relevant to functional outcome after restorative proctocolectomy for ulcerative colitis?: prospective assessment of 122 cases

OBJECTIVE

Restorative proctocolectomy for mucosal ulcerative colitis is well established. However, the effect of age on physiologic sphincter parameters is poorly understood. Our objective was to determine whether age at the time of restorative proctocolectomy correlates with physiologic changes.

SUMMARY BACKGROUND DATA

In the approximately 20 years during which restorative proctocolectomy has been performed for ulcerative colitis, the indications have changed. Initially, the procedure was recommended only in patients under approximately 50 years. However, the procedure has been considered in older patients because of the increasing age of our population, the increasing frequency of recognition of patients during the "second peak" of mucosal ulcerative colitis, and the decreasing morbidity rates, due to the learning curve and to newer techniques, such as double-stapling. Few authors have presented data analyzing the effects of this operation in older patients.

METHODS

One hundred twenty-two patients who had undergone a two-stage restorative proctocolectomy for mucosal ulcerative colitis were divided into three groups according to age: group I (>60 years), 11 men, 6 women; group II (40-60 years), 29 men, 18 women; and group III (<40 years) 29 men, 29 women. The patients were prospectively evaluated using anal manometry and subjective functional results. Comparisons were made before surgery, after colectomy and before closure of ileostomy, and at 1 or more years after surgery.

RESULTS

There were no significant differences among the groups relative to manometric results, frequency of bowel movements, incontinence scores, or overall patient satisfaction. The postoperative mean and maximum resting pressures were significantly reduced (p < 0.001), and conversely the sensory threshold (p < 0.005) and capacity (p < 0.001) were increased in all groups up to 1 year after surgery. There were no statistically significant changes in the squeeze pressure or length of the high-pressure zone in any group at any point in time. After surgery, the mean and maximum resting pressures had returned to 80% of their original values.

CONCLUSION

Although anorectal function is transiently somewhat impaired after restorative proctocolectomy, the impairment is not an age-related phenomenon.

Influence of ileal pouch capacity and anal sphincteric function on the clinical outcome after ileal pouch-anal anastomosis

This study was designed to determine the influence of ileal pouch capacity and anal sphincteric function on the clinical outcome after ileal pouch-anal anastomosis. A total of 24 patients who had undergone ileal pouch-anal anastomosis (J pouch) for ulcerative colitis were studied. The 24-hour stool frequency was found to be inversely correlated with the sensitivity threshold volume (STV), maximal tolerance volume (MTV), and distensibility, but was independent of the maximal resting pressure and maximal squeeze pressure. Patients experiencing nocturnal fecal incontinence had maximal resting pressures that were significantly lower than those of nocturnally continent patients. Among the patients with fecal incontinence, those with frequent soiling had lower resting pressures, STV, and distensibility than the patients with intermittent spotting. In addition, the STV in patients needing nocturnal evacuation were lower than those of patients who did not evacuate after falling asleep. The conclusions are as follows. Both stool frequency and the need for nocturnal pouch evacuation correlated directly with pouch volume. Anal incontinence was more common in patients with low internal sphincteric function. In addition, frequent and gross nocturnal incontinent patients demonstrate a worse function in both the anal sphincter and reservoir than those with intermittent spotting.

Restorative proctocolectomy in children and adolescents

Children and adolescents with colitis present specific problems for surgeons. There has been a fashion, particularly in North America, for restoring continuity after colectomy by a direct ileo-anal anastomosis. The authors reviewed their experience with restorative proctocolectomy with ileal reservoir (RPC) in patients under 18 years of age to evaluate the outcome and to discuss the problems and challenges associated with the procedure in this age group. Fifteen patients (6 boys, 9 girls) were operated on between 1984 and 1995. The diagnoses included 12 patients with ulcerative colitis (UC), two with familial adenomatous polyposis (FAP), and one with total colonic neuronal dysplasia. The median age of the patients at the time of ileal pouch formation was 15 years, and follow-up data were available for all patients at a median of 43 months. Ten patients with UC underwent pouch surgery 4 to 14 months after initial total abdominal colectomy (7 for acute severe disease, 3 for chronic disease). Four patients (2 with chronic UC, 2 with FAP) underwent primary RPC. There were no deaths in this series. Three (20%) patients suffered serious early morbidity (pouch hemorrhage, pelvic sepsis, severe psychological crisis). Late morbidity included three patients who had small bowel obstruction, one who required laparotomy, two who required pouch revision, and five of 12 (42%) patients with UC who presented with a documented episode of pouchitis between 2 and 72 months after ileostomy closure. All patients had acceptable bowel frequency and quality of continence. This experience suggests that RPC provides an important surgical option for children and adolescents with UC or FAP.

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.

Stenosis of the pouch anal anastomosis following restorative proctocolectomy

PURPOSE

To compare the incidence of stenosis after hand-sewn and stapled ileoanal anastomosis. Stenosis of the ileoanal anastomosis occurs in 5-16% of patients undergoing a restorative proctocolectomy but the incidence using a stapled technique is unknown.

METHODS

Between 1976 and 1990, 266 patients underwent restorative proctocolectomy or proctectomy at one hospital. In two hundred and eighteen the anastomosis was hand sewn and stapled in 48 (single 33; double 15).

RESULTS

Stenosis occurred in 31 (14.2%) of the hand-sewn and in 19 (39.6%) of the stapled anastomoses. This difference was highly significant (P < 0.001). Stenosis was not related to the size of the staple head used or to the stapling technique. There was no relationship between the development of stenosis and pelvic sepsis. Twenty six (hand-sewn 16, stapled 10) of the 48 patients with stenosis needed dilatation under general anaesthetic.

CONCLUSION

Stapled anastomoses may result in a high incidence of anastomotic stenosis.

High dose loperamide suppositories: a novel approach for improving clinical function after restorative proctocolectomy

The effect of loperamide suppositories on patients following restorative proctocolectomy was studied by means of a randomized, double-blind, crossover trial comparing active suppositories (20 mg b.d. x 1 week) with placebo. Ten patients (8 male, 2 female; 7 J pouch, 3 W pouch; 8 ulcerative colitis, 2 familial adenomatous polyposis) were studied 3-60 months (median, 31.5) after ileostomy closure. Ages ranged from 24 to 63 years (medium, 41.5). All patients kept a diary of their bowel habits and eight underwent a standardized test of pouch compliance. Urgency volume (UV) and maximum tolerable volumes (MTV) and the volume at onset of large isolated pouch contractions (LIC) were recorded. Statistical analysis was by the Wilcoxon test for paired data. Mean daily stool frequency during the placebo phase ranged from 3.7 to 7.8. It was reduced during the active phase in only seven patients (P > 0.1) but was reduced in all six patients whose placebo phase stool frequency was five or more. Urgency volume was increased by use of active suppositories in six of the eight patients tested (P > 0.01). There was no consistent effect on MTV. Large isolated pouch contractions were not seen in either test in one patient. In all of the remaining seven patients LIC were recorded after the placebo phase. After the active phase LIC first appeared at higher volumes in three but were not seen at all in four patients. High dose loperamide suppositories suppress pouch contractions and tend to lower stool frequency especially when high initially. They represent a novel therapeutic approach to high stool frequency in pouch patients.

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.

Breath hydrogen analysis in patients with ileoanal pouch anastomosis

The possible influence on functional outcomes of hydrogen production in the ileoanal pouch after restorative proctocolectomy was investigated by means of lactulose H2 breath tests. Eight of 15 patients had significant increases in breath hydrogen after 10 g lactulose. One patient declined to participate in further investigations, the remaining seven responders had no evidence of small bowel bacterial overgrowth after glucose H2 breath tests. The ability to produce hydrogen by anaerobic fermentation of lactulose in the pouch was unrelated to the age of the patients or of the pouch. Seven of eight responders had successive breath tests after ingestion of lactulose 20 g and wheat starch 100 g. Five of seven had significant increases after lactulose but none after wheat starch. The overall function of the pouch continence, spontaneity of defecation, and 24 hour stool frequency was significantly better in responders than in non-responders. The absence of H2 production of 100 g wheat starch may indicate either increased absorption or defective fermentation.

Physical health status in young subjects after colectomy: an application of the Roy model

The aim of this study was to describe the long-term physical health status after colectomy in 30 young subjects with ulcerative colitis, 11 of whom had ileostomies. The subjects, aged between 14 and 31 years of age, were assessed post-operatively for their physical health status. In assessing physiological adaptation in these subjects four basic needs were the foci: nutrition, elimination, activity and rest, and protection. Adaptation problems related to nutrition, elimination, activity/rest and protection were found in four, 17, 17 and three subjects respectively. Nine out of 30 had pain that influenced their daily life. Six out of 30 subjects had no adaptation problems at all. Nineteen subjects found their health to be 'excellent' or 'good' despite the adaptation problems reported.

Recovery of the internal anal sphincter and continence after restorative proctocolectomy

The internal anal sphincter (IAS) was assessed prospectively using electromyography and manometry in 66 patients (48 men) undergoing restorative proctocolectomy to determine its role in the gradual return of continence. Twenty-nine patients received a J pouch and 37 a W reservoir. Some 38 pouches (J, ten; W, 28) were hand-sewn (mucosal proctectomy with endoanal anastomosis) and 28 (J, 19; W, nine) stapled (end-to-end pouch-anal anastomosis 1 cm above the dentate line). Twelve patients underwent a one-stage procedure (all J pouches), while the remainder had a covering loop ileostomy. Each patient was reassessed immediately after restorative proctocolectomy and again at 7 days, 1 month, 4 months, 9 months and 18 months after pouch formation. Internal sphincter electromyographic activity was greatly reduced after pouch-anal anastomosis (median preoperative frequency 0.51 Hz versus immediate postoperative frequency 0.21 Hz, P < 0.003) and gradually recovered from 4 months after surgery. At 18 months, measurements of IAS function had not fully recovered to preoperative values (median frequency 0.31 Hz; P < 0.03). Resting anal pressures (median preoperative value 99 cmH2O) decreased by over 50 per cent after surgery (median immediate postoperative resting pressure 44 cmH2O) and recovered gradually but incompletely (median pressure at 18 months 63 cmH2O). Eleven patients reported leakage in the follow-up period. The median (range) resting pressure in these patients (54 (40-71) cmH2O) was not significantly different at 9 months from that of those who were continent either before or after operation (59 (46-68) cmH2O). Prolonged recordings in patients with faecal leakage revealed evidence of high-pressure pouch waves that overwhelmed anal sphincter pressures and coincided with leakage. These episodes were most common during sleep, when anal sphincter activity was reduced.

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.