Pelvic ileal reservoirs: the options

Functional outcome and quality of life after transanal minimal invasive pouch surgery

PURPOSE

To investigate functional outcomes and quality of life (QoL) after restorative proctocolectomy (RPC) using transanal minimal invasive surgery (TAMIS).

METHOD

The study consists of two sub-studies. A cohort study comprised 98 consecutive patients, who underwent TAMIS RPC. These patients were the first at our department to undergo TAMIS RPC. We collected information about surgery, complications, postoperative morbidity and mortality ≤ 30 days, and pouch problems. Patients were also invited to participate in a case-control study in which the patients would respond to three different questionnaires, the Inflammatory Bowel Disease Questionnaire (IBDQ), the Short Form-36 General Health Questionnaire (SF-36), and questions from the Pouch Dysfunction Score. We compared the responding TAMIS RPC patients to a Danish national cohort (0-10 years from RPC, n = 514) of patients having RPC between 1980 and 2010. We compared functional outcomes and QoL.

RESULTS

Four (4%) of the TAMIS patients had an anastomotic leak; none of these required re-operation with removal of the pouch. Anastomotic leak was treated with antibiotics and drain. Out of the four leaks, only one ended up with a permanent stoma; all others had their stoma reversed successfully. The TAMIS patients had the same number of bowel movements as the patients in the Danish national cohort study. The same was seen with regard to incontinence. We had no conversions in our series of TAMIS procedures.

CONCLUSION

The TAMIS technique shows acceptable outcomes, both in regard to postoperative complications and also functional outcome and QoL.

Pouchitis: Clinical Features, Diagnosis, and Treatment

Procto-colectomy with an ileal pouch anal anastomosis is the procedure of choice for ulcerative colitis patients that require colectomy. Pouchitis is a non-specific inflammation of the ileal reservoir, and the most common, inflammatory and long-term, complication after pouch surgery for ulcerative colitis. The aetiology is still unknown, but many risk factors have been individuated. Pouchitis can be classified based on aetiology, duration, clinical course, and response to antibiotic therapy. Accurate diagnosis and classification is the key factor for an adequate management, and exclusion of secondary causes of pouchitis is pivotal. Most of the patients consistently respond to antibiotic therapy, but management of the subgroup of patients with chronic-antibiotic-resistant-pouchitis is still challenging, being this entity one of the major causes of pouch failure.

An Update on the Medical Management of Inflammatory Pouch Complications

Total proctocolectomy with ileal pouch-anal anastomosis is the surgical procedure of choice for patients with medically-refractory ulcerative colitis or ulcerative colitis with associated dysplasia. Although most patients after ileal pouch-anal anastomosis experience good functional outcomes, a number of complications may develop. Of the long-term complications, pouchitis is most common. Although most respond to antibiotic treatment, some patients develop chronic pouchitis, leading to substantial morbidity and occasionally pouch failure. In patients with pouchitis who are not responsive to conventional antimicrobial therapy, secondary causes of chronic pouchitis need to be considered, including Crohn's disease of the pouch. In recent years, more literature has become available regarding the medical management of chronic pouchitis and Crohn's disease of the pouch, including the use of newer biologic agents. We herein provide a concise review on inflammatory complications involving the ileal pouch, including a focused approach to diagnosis and medical management.

Twenty years of restorative proctocolectomy with ileal pouch anal anastomosis in Beaumont Hospital

INTRODUCTION

An ileal pouch anal anastomosis (IPAA) is the treatment of choice in selected patients to restore intestinal continuity following proctocolectomy. Data on IPAA in the Republic of Ireland is lacking, and surgery for IPAA has evolved over time. The aim of this retrospective study was to report our institutional outcomes from IPAA over a 20-year period.

METHODS

Data were retrospectively collated from consecutive primary IPAA cases between 1998 and 2017 at Beaumont Hospital. Patient demographics and operative approach were examined, and pouch failure was estimated using the Kaplan-Meier method.

RESULTS

Ninety-five patients underwent IPAA over the study period with a mean follow-up of 9.4 ± 5.6 years. The mean age at IPAA was 35.9 ± 10.0 years, and 58.9% were male. The majority were performed in 3 stages (78.9%), were performed to treat ulcerative colitis (66.3%), were of a J-pouch configuration (96.8%), and had a stapled anastomosis (70.5%). On follow-up, 28.4% reported experiencing at least 1 episode of pouchitis and the 10-year pouch failure rate was 14%. In the last decile of the study period, the mean number of IPAA performed per year increased to 10.5 ± 2.1 (P = 0.013), the age of IPAA formation reduced (P = 0.049), and the proportion completed in a minimally invasive manner increased (P < 0.001).

CONCLUSIONS

Acceptable long-term outcomes were observed by our institution. A recent increase in institutional volume, reduction in patient age, and increase in the proportion of cases performed laparoscopically have been identified.

Redo ileal pouch-anal anastomosis: outcomes from a case-controlled study

AIM

To assess short- and long-term outcomes of redo ileal pouch-anal anastomosis (redo-IPAA) for failed IPAA, comparing them with those of successful IPAA.

METHOD

This was a case-control study. Data were collected retrospectively from prospectively maintained databases from two tertiary care centres. Patients who had a redo-IPAA between 1999 and 2016 were identified and matched (1:2) with patients who had a primary IPAA (p-IPAA), according to diagnosis, age and body mass index.

RESULTS

Thirty-nine redo-IPAAs (16 transanal and 23 abdominal procedures) were identified, and were matched with 78 p-IPAAs. After a mean follow-up of 56 ± 51  (2.6-190) months, failure rates after transanal and abdominal approaches were 50% and 15%, respectively. Reoperation after the transanal approach was higher than after p-IPAA (69% vs 7%; P < 0.001). No differences were noted between the abdominal approach for redo-IPAA and p-IPAA in terms of morbidity (61% for redo-IPAA vs 38% for p-IPAA; P = 0.06), major morbidity (9% vs 8%; P = 0.96), anastomotic leakage (13% vs 10%; P = 0.74), mean daily bowel movements (6 vs 5.5; P = 0.68), night-time bowel movements (1.2 vs 1; P = 0.51), faecal incontinence (13% vs 7%; P = 0.40), urgency (31% vs 27%; P = 0.59), use of anti-diarrhoeal drugs (47% vs 37%; P = 0.70), mean Cleveland Global Quality-of-Life score (7 vs 7; P = 0.83) or sexual function.

CONCLUSION

The abdominal approach for redo-IPAA is justified in cases of pouch failure because it achieves functional results comparable with those observed after p-IPAA, without higher postoperative morbidity. The transanal approach should be chosen sparingly.

A Comprehensive Approach to Pouch Disorders

Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the surgical procedure of choice for patients with medically refractory ulcerative colitis (UC) or indeterminate colitis, UC with colonic dysplasia or neoplasia, and familial adenomatous polyposis. In general, patients experience good function outcomes and quality of life with an IPAA. Although pouchitis is the most well-recognized and frequent complication after IPAA, a number of additional inflammatory, postsurgical, structural, neoplastic, and functional complications may occur, resulting in pouch dysfunction. We herein provide a comprehensive review of pouch function and an approach to diagnosis and management of pouch complications.

Update on medical and surgical options for patients with acute severe ulcerative colitis: What is new?

Acute severe ulcerative colitis (UC) is a highly morbid condition that requires both medical and surgical management through the collaboration of gastroenterologists and colorectal surgeons. First line treatment for patients presenting with acute severe UC consists of intravenous steroids, but those who do not respond require escalation of therapy or emergent colectomy. The mortality of emergent colectomy has declined significantly in recent decades, but due to the morbidity of this procedure, second line agents such as cyclosporine and infliximab have been used as salvage therapy in an attempt to avoid emergent surgery. Unfortunately, protracted medical therapy has led to patients presenting for surgery in a poorer state of health leading to poorer post-operative outcomes. In this era of multiple medical modalities available in the treatment of acute severe UC, physicians must consider the advantages and disadvantages of prolonged medical therapy in an attempt to avoid surgery. Colectomy remains a mainstay in the treatment of severe ulcerative colitis not responsive to corticosteroids and rescue therapy, and timely referral for surgery allows for improved post-operative outcomes with lower risk of sepsis and improved patient survival. Options for reconstructive surgery include three-stage ileal pouch-anal anastomosis or a modified two-stage procedure that can be performed either open or laparoscopically. The numerous avenues of medical and surgical therapy have allowed for great advances in the treatment of patients with UC. In this era of options, it is important to maintain a global view, utilize biologic therapy when indicated, and then maintain an appropriate threshold for surgery. The purpose of this review is to summarize the growing number of medical and surgical options available in the treatment of acute, severe UC.

Controversies in J Pouch Surgery for Ulcerative Colitis: A Focus on Handsewn Versus Stapled Anastomosis

The accepted current standard for treatment of medically refractory ulcerative colitis is total proctocolectomy with an ileal pouch-anal anastomosis for restoration of continence. There are 2 techniques by which the anastomosis can be performed, including handsewn and stapled. Handsewn anastomosis with mucosectomy was the first method described; however, it has been associated with significant incontinence. The double-stapled anastomosis was developed in response to improve postoperative function. Controversy remains as to which technique is superior as both have disadvantages. This review article addresses differences between the 2 methodologies in relation to postoperative complications, anorectal physiology, functional outcomes, and oncological safety.

Male issues of the ileal pouch

: Restorative proctocolectomy with ileal pouch-anal anastomosis is the standard surgical treatment modality for patients with ulcerative colitis who require colectomy. There are special issues related to male gender. We performed systemic literature review on the topic, incorporating the experience in our specialized Center for Ileal Pouch Disorders, and provide recommendations for the identification and management for the gender-specific issues in male patients with ileal pouches. Chronic pouchitis, particularly ischemic pouchitis, anastomotic leak, and presacral sinus are more common in male patients than their female counterparts. Sexual dysfunction can occur after pouch surgery, particularly in those with pouch failure. Diagnosis and management of benign and malignant prostate diseases can be challenging due to the altered pelvic anatomy from the surgery. Digital rectal examination for prostate cancer screening is not reliable. Transpouch biopsy of prostate may lead to pouch fistula or abscess. Pelvic radiation therapy may have an adverse impact on the pouch function. In conclusion, sexual dysfunction and enlarged prostate can occur in patients with the ileal pouch. The measurement of serum prostate-specific antigen is a preferred method for the screening of prostate cancer. If biopsy of the prostate is needed, the perineal route is recommended. The risk for pouch dysfunction and the benefit for oncologic survival of pelvic radiation for prostate cancer should be carefully balanced.

Volvulus of ileal S-pouch: A rare complication of ileal pouch anal anastomoses

INTRODUCTION

Ileal pouch anal anastomosis (IPAA) after total proctocolectomy is a frequently performed surgery for medically refractory ulcerative colitis (UC). Volvulus of the ileal pouch as a complication of IPAA is extremely rare. We present a case of volvulus of S-type ileal pouch.

PRESENTATION OF CASE

A 28 year old male, with history of total proctocolectomy with IPAA for severe UC in 2009 presented with signs of bowel obstruction. Emergency laparotomy was done and a volvulus of the S-type ileal pouch was derotated and pouchpexy done.

DISCUSSION

The IPAA has a wide spectrum of complications, with obstruction of proximal small bowel occurring frequently. Volvulus of the ileal pouch is extremely rare with only 3 reported cases. Early diagnosis and intervention is important to salvage the pouch. Computed tomography (CT) may aid the diagnosis in stable patients.

CONCLUSION

The diagnosis of ileal pouch volvulus although rare, should be kept in mind when dealing with patients complaining of recurrent obstruction following IPAA.

Ileal j pouch complications and surgical solutions: a review

Ileal pouch-anal anastomosis is currently accepted as the standard method to restore continence after total proctocolectomy for medically refractory ulcerative colitis and familial adenomatous polyposis. Ileal pouches offer improved quality of life and high patient satisfaction; however, there are many pouch-related complications due to the original disease process and change in anatomy. This is a review article of the common and some rare surgical complications after J pouches, which can be subdivided into the septic and nonseptic categories. Septic-related complications include anastomotic leak, abscess, and fistulas, whereas common nonseptic-related complications include small bowel obstruction, strictures, Crohn's disease, pouchitis, and cuffitis. Rare nonseptic complications to be discussed are prolapse, volvulus, and neoplasia.

Ileal pouch anal anastomosis: analysis of outcome and quality of life in 3707 patients

BACKGROUND

Ileal pouch anal anastomosis (IPAA) is the treatment of choice for chronic, medically refractory mucosal ulcerative colitis, indeterminate colitis, familial adenomatous polyposis (FAP), and a select group of patients with Crohn's disease.

AIM

: We report outcomes, complications, and quality of life (QOL) in a cohort of 3707 patients treated at our institution from January 1984 to March 2010.

METHODS

Data were collected from a prospectively maintained database and chart review of 3707 consecutive primary IPAA cases. Patient demographics, postoperative complications, functional outcomes, and QOL data were available. Follow-up consisted of clinical examination with assessment of pouch function and QOL.

RESULTS

A total of 3707 patients underwent primary pouch and 328 underwent redo pouch surgery. Postoperative histopathological diagnoses were mucosal ulcerative colitis (n = 2953, 79.7%), indeterminate colitis (n = 63, 1.7%), FAP (n = 223, 6%), Crohn's disease (n = 150, 4%), cancer/dysplasia (n = 97, 2.6%), and others (n = 221, 6.0%). Early perioperative complications were encountered in 33.5% of patients with a mortality rate of 0.1%. Excluding pouchitis, late complications were experienced by 29.1% of patients. Of those patients who had IPAA at our institution, pouch failure occurred in 197 patients (5.3%). During a median follow-up of 84 months, 119 patients (3.2%) required excision of the pouch, 32 (0.8%) had a nonfunctioning pouch, and 46 patients (1.2%) had redo IPAA. Functional outcomes and QOL were good or excellent in 95% of patients and similar in each histopathological subgroup.

CONCLUSIONS

IPAA is an excellent option for patients with MUC, IC, FAP, and select patients with Crohn's disease.

Evaluating pouch problems

IPAA is a technically demanding procedure that requires appropriate skills and expertise. Adverse sequelae of IPAA are common. Accurate diagnosis and classification of pouch disorders and associated complications are important for proper management and prognosis. Based on presenting symptoms, appropriate and combined diagnostic modalities should apply. A multidisciplinary approach involving gastroenterologists, colorectal surgeons, gastrointestinal pathologists, and gastrointestinal radiologists is advocated for diagnosis and treatment of pouch disorders.

Intraoperative, postoperative and reoperative problems with ileoanal pouches

BACKGROUND

Proctocolectomy with ileal pouch-anal anastomosis (IPAA) has been developed and refined since its introduction in the late 1970s. Nonetheless, it is a procedure associated with significant morbidity. The aim of this review was to provide a structured approach to the challenges that surgeons and physicians encounter in the management of intraoperative, postoperative and reoperative problems associated with ileoanal pouches.

METHODS

The review was based on relevant studies identified from an electronic search of MEDLINE, Embase and PubMed databases from 1975 to April 2011. There were no language or publication year restrictions. Original references in published articles were reviewed.

RESULTS

Although the majority of patients experience long-term success with an ileoanal pouch, significant morbidity surrounds IPAA. Surgical intervention is often critical to achieve optimal control of the situation.

CONCLUSION

A structured management plan will minimize the adverse consequences of the problems associated with pouches.

Nutrition considerations surrounding restorative proctocolectomy

Restorative proctocolectomy with ileal pouch-anal anastomosis has become the surgical treatment of choice for patients with ulcerative colitis and familial polyposis coli syndromes. Pouch construction uses the distal 30-40 cm of ileum, and there exists a potential for postoperative nutrition consequences. These include vitamin B(12) deficiency, iron deficiency, bile acid malabsorption, and abnormalities of trace elements, fluids, and electrolytes. Patients who have undergone an ileal pouch-anal anastomosis procedure often describe specific food sensitivities that may require diet alteration, even more so than do patients with permanent ileostomy. There may be roles for postoperative probiotic supplementation in an attempt to decrease the rate of "pouchitis" and appropriate preoperative nutrition support to minimize the risk of perioperative complications.

Early experience with laparoscopic ileal pouch-anal anastomosis for ulcerative colitis

The purpose of this study was to describe our minimally invasive technique and outline perioperative and medium-term outcomes in patients undergoing laparoscopic ileal pouch-anal anastomosis (LIPAA) for ulcerative colitis. Data were obtained from a prospectively collected database of 13 LIPPA procedures performed for ulcerative colitis between May 1994 and November 2000. Medium-term quality-of-life follow-up was obtained by telephone interview. Eight males and five females had an LIPAA performed, all of whom had previously undergone total abdominal colectomy with ileostomy. Median operative time was 255 minutes (range, 200-398 minutes) with one conversion (8%) due to adhesions. There were no deaths or intraoperative complications; however, six patients experienced seven postoperative complications within 30 days of final closure of defunctioning ileostomy (two leaks, two wound infections, one pulmonary embolus, and two reoperations for small bowel obstruction). Median length of stay was 7 days (range, 5-13 days). Median follow-up was 24 months (range, 6-66 months). The median number of day and night bowel movements was 6.0 (range, 3-10) and 1.0 (range, 0-3), respectively, with five patients requiring medication to control frequency. None had incontinence of stool or retrograde ejaculation; however, one had occasional incontinence of gas, three had occasional nocturnal soiling, and one was impotent. Three patients (23%) had pouchitis, all treated successfully with oral antibiotics. All patients were satisfied with the outcome of their operation and all preferred their pouch to previous ileostomy. Patients reported their overall social, emotional, and physical well being to be satisfactory to excellent. Results of the SF-36, a generic quality-of-life survey, were similar to those from studies of patients following an open pelvic pouch procedure. The LIPAA is technically feasible in experienced centers. We believe that the technique is still evolving and that more time and experience is required to refine the procedure.

Comparative anatomical study of division of the ileocolic pedicle or the superior mesenteric pedicle for mesenteric lengthening

BACKGROUND

Lengthening of the mesentery by vascular division may be necessary to perform an ileal pouch-anal anastomosis without tension. The aim of this study was to compare, in fresh cadavers, the increase in mesentery length after division of the ileocolic pedicle (ICP) and the superior mesenteric pedicle (SMP).

METHODS

Total colectomy was performed in 12 fresh cadavers, which were then randomly divided into two groups. Pouch-anal anastomosis was performed with division of the ICP in one group of six cadavers and with division of the SMP in the other. The ileum was measured and the increase in length was recorded and compared statistically.

RESULTS

The mean(s.d.) increase in length was 3.0(0.8) cm after ICP division and 6.5(1.1) cm after SMP division (P < 0.001). The distance between the end of the ileum and the point giving the greatest length was 25.5(5.0) cm in the ICP group and 46.8(4.2) cm in SMP group (P < 0.001).

CONCLUSION

In fresh cadavers, the increase in mesenteric length was greater after SMP division than after ICP division, but if pouch-anal anastomosis is performed a short segment of small bowel must be removed.

Retocolectomia total e anastomose íleo-anal com reservatório ileal: experiência de 16 anos

O reservatório ileal pélvico tem sido a melhor opção cirúrgica para a retocolite ulcerativa (RCU) e polipose adenomatosa familiar (PAF). Desde 1983 esta técnica vem sendo empregada, e o objetivo deste trabalho é apresentar revisão desta casuística, analisando seus resultados e seus pontos controversos. Setenta e três pacientes, com média de idade de 34,6 (13-63) anos e com predomínio do sexo feminino (42 pacientes, 56,7%) se submeteram ao procedimento para tratamento de RCU (46 pacientes - 63,0%) e PAF(27 - 37,0%). Foram utilizadas as seguintes variantes técnicas: em S, de grande tamanho e ramo eferente longo (oito); em S pequeno e ramo eferente reduzido (22); em "dupla câmara" (20); em J (23). Todos os procedimentos foram seguidos da construção de ileostomia de proteção. De 1993 em diante, todos os pacientes tiveram a arcada do colo direito preservada. Setenta pacientes têm pelo menos um ano de pós-operatório e 61 têm dois anos ou mais com média de 7,01 (1-16) anos. Foram consideradas complicações precoces aquelas que ocorreram até o 30º dia de pós- operatório e tardias, após esse tempo. Resultados funcionais foram analisados após um ano do fechamento da ileostomia. Ocorreram 35 complicações precoces em 22 pacientes e 39 complicações tardias em 35 pacientes. Vinte e cinco pacientes não apresentaram complicações. As principais complicações foram: obstrução intestinal (19,1 %), fistulizações cutâneas, com vagina ou trato urinário (10,9%), isquemia de reservatório (parcial ou total), (9,5%), e ileíte do reservatório (pouchitis) (6,8%). Nove pacientes (12,3%) têm ileostomia funcionante, sendo que sete pacientes têm ainda o reservatório mantido no lugar e dois tiveram-no ressecado. A mortalidade diretamente relacionada ao procedimento foi em dois pacientes, mas outros quatro pacientes evoluíram tardiamente ao óbito, por causas como desnutrição crônica e tumor de cerebelo. Em conclusão, apesar da morbidade e da existência ainda de questões controversas, as perspectivas tardias têm sido animadoras e têm estimulado a indicação deste tipo de procedimento.

A comparison of function and patient satisfaction after restorative proctocolectomy for ulcerative colitis (UC) and familial adenomatous polyposis (FAP)

OBJECTIVE

[corrected] Function after restorative proctocolectomy for UC and FAP varies. We assessed function, satisfaction and social activity in patients with ileal pouch-anal anastomosis and explored possible factors associated with poor function.

PATIENTS AND METHODS

We reviewed all case notes and sent postal questionnaires to 145 patients (121 UC, 24 FAP).

RESULTS

One hundred and twenty questionnaires were returned (98 UC and 22 FAP). The complication rate, particularly pouch failure, was higher in the UC group (UC 18·8%, FAP 8%). Functional outcome was similar: 74% of UC patients and 68% of FAP patients had an acceptable result. Although social activity was similar in the UC and FAP groups, satisfaction with the outcome was much less in the FAP group.

CONCLUSION

Patients, particularly with FAP, who are asymptomatic need to be told about the functional outcome they can expect, particularly bowel frequency and soiling. Restorative proctocolectomy may not be the best option for all FAP patients.

Outcome after ileoanal anastomosis in pediatric patients with ulcerative colitis

BACKGROUND

To review the outcome after restorative proctocolectomy among children and adolescents with ulcerative colitis at a pediatric inflammatory bowel disease center.

METHODS

The records of all patients with ulcerative colitis undergoing colectomy and ileoanal anastomosis at The Hospital for Sick Children, Toronto, Canada, were reviewed. Questionnaires concerning functional results were sent to patients with restored transanal defecation.

RESULTS

Seventy three patients (mean age, 13.2 years; range, 2.6-18.8 years) underwent ileoanal anastomosis (19 straight ileoanal anastomosis, 41 J pouch, 13 S pouch) between January 1980 and June 1995 and were observed 5.8+/-3.3 years. The ileoanal anastomosis is nonfunctional in 19 (26%) patients. Excision rates according to type of restorative procedure were J pouch, 7% (3 of 41); S pouch, 32% (4 of 13); and straight ileoanal anastomosis, 32% (6 of 19). Failure was usually attributable to intractable diarrhea among patients with straight ileoanal anastomosis but was caused by anastomotic leak or pelvic-perianal sepsis among patients with pouch procedures. Failure rates did not vary with age at ileoanal anastomosis. Among patients retaining ileoanal continuity, continence problems reported in the questionnaire were frequent and tended to be more extreme among younger patients. Overall, 90% of respondents reported satisfaction with the functional outcome of the restorative operation.

CONCLUSIONS

The success rate of the ileoanal anastomosis/J-pouch procedure is comparable to that in adult series. The ileoanal anastomosis/J-pouch procedure is the operation of choice for children and adolescents who want ileoanal continuity restored after colectomy for ulcerative colitis.

Disconnection, pouch revision and reconnection of the ileal pouch-anal anastomosis

The aim of this retrospective study was to determine the outcome of patients with a dysfunctional pelvic ileal reservoir in whom disconnection of an ileal pouch-anal anastomosis (IPAA), pouch revision and reanastomosis had been carried out. There were 23 patients (15 women). At the revision operation functional problems were found to be due to a long efferent spout (nine patients), sepsis and/or fistula (four), a redundant blind limb (three), a twisted pouch (three), anastomotic problems (three) or no reservoir (one). The pouch was salvaged in 16 patients and a new pouch was constructed in seven. The pouch-anal anastomosis was resutured in 22 patients and stapled in one. Postoperative complications (all minor) occurred in six patients. Two patients underwent two revision of IPAA. At a median follow-up of 5 (range 1-10) years, 11 patients reported good to excellent function, five reported fair function and one reported recurrent pouchitis. Revision surgery was unsuccessful in six of 23 patients (three had gross incontinence, two excessive bowel movements and one Crohn's disease), and they subsequently underwent pouch excision. It is concluded that revision of an ileal reservoir and IPAA can be undertaken safely with good results in carefully selected patients.

Effect of terminal ileal transposition on intestinal absorption following proctocolectomy

A terminal ileal transposition procedure, in which a distal jejunal segment is interposed between the terminal ileum and the anus following proctocolectomy, is described. Adult mongrel dogs had either terminal ileal transposition (n = 5) or ileoanal anastomosis (n = 6) following two-stage proctocolectomy. Untreated dogs were used as controls (n = 7). Twelve weeks after the second-stage operation, a perfusion study was performed. After terminal ileal transposition the transposed terminal ileum showed a high absorptive capability for sodium, chloride and bile acids (P < 0.05, P < 0.05 and P < 0.001 respectively). After ileoanal anastomosis the absorptive capability of the terminal ileum was not enhanced significantly. In the mid-jejunum, the absorption of bile acids, chloride and glucose was enhanced (all P < 0.05) only after terminal ileal transposition. Terminal ileal transposition improves the absorptive capability of the terminal ileum and the mid-jejunum compared with conventional ileoanal anastomosis in this model.

Ileal pouch-anal anastomoses complications and function in 1005 patients

BACKGROUND

Restorative proctocolectomy and ileal pouch-anal anastomosis (IPAA) has become an established surgery for patients with chronic ulcerative colitis and familial adenomatous polyposis.

PURPOSE

The authors report the results of an 11-year experience of restorative proctocolectomy and IPAA at a tertiary referral center.

METHODS

Chart review was performed for 1005 patients undergoing IPAA from 1983 through 1993. Preoperative histopathologic diagnoses were ulcerative colitis (n = 858), familial adenomatous polyposis (n = 62), indeterminate colitis (n = 75), and miscellaneous (n = 10). Information was obtained regarding patient demographics, type and duration of diseases, previous operations, and indications for surgery. Data were collected on surgical procedure and postoperative pathologic diagnosis. Early (within 30 days after surgery) and late complications were noted. Follow-up included an annual function and quality-of-life questionnaire, physical examination, and biopsies of the pouch and anal transitional zone.

RESULTS

Of the 1005 patients (455 women), postoperative histopathologic diagnoses were as follows: ulcerative colitis (n = 812), familial adenomatous polyposis (n = 62), indeterminate colitis (n = 54), Crohn's disease (n = 67), and miscellaneous (n = 10). During a mean follow-up time of 35 months (range 1-125 months), histopathologic diagnoses were changed for 25 patients. The overall mortality rate was 1% (n = 10 patients, early = 4, late = 6); one death (0.1%) was related to pouch necrosis and sepsis. The overall morbidity rate was 62.7% (1218 complications in 630 patients; early, n = 27.5%; late, n = 50.5%). Septic complication and reoperation rates were 6.8% and 24%, respectively. The ileal pouch was removed in 34 patients (3.4%), and it is nonfunctional in 11 (1%). Functional results and quality of life were good to excellent in 93% of the patients with complete data (n = 645) and are similar for patients with ulcerative colitis, familial adenomatous polyposis, indeterminate colitis, and Crohn's disease. Patients who underwent operations from 1983 through 1988 have similar functional results and quality of life compared with patients who underwent operations after 1988.

CONCLUSION

Restorative proctocolectomy with an IPAA is a safe procedure, with low mortality and major morbidity rates. Although total morbidity rate is appreciable, functional results generally are good and patient satisfaction is high.

Harry E. Bacon Oration. Comparison of the functional results of restorative proctocolectomy for ulcerative colitis between the J and W configuration ileal pouches with sutured ileoanal anastomosis

PURPOSE

This study was designed to compare function of patients who had undergone reconstruction following proctocolectomy for ulcerative colitis using the J or W configuration ileoanal pouch.

METHODS

Of 126 patients who underwent restorative proctocolectomy between January 1981 and March 1993, 101 had surgery for ulcerative colitis. Eighty-seven of these patients were available for review by personal or postal interview. All operative procedures were performed by one surgeon. The group comprised 35 W-pouches and 52 J-pouches.

RESULTS

More patients with a J-pouch had a stool frequency of greater than 8 per 24 hours (P = 0.044), and they were also more likely to use a perineal pad (P = 0.019). No difference in the rates of nocturnal stool frequency, fecal incontinence, or use of constipating agents between the two pouch designs was found. Significantly more patients with a J-pouch have had episodes of pouchitis (P = 0.001). Of the total patient group 91.9 percent felt that restorative proctocolectomy had improved their quality of life.

CONCLUSION

Minor differences in the function of the W configuration ileoanal pouch and the J configuration ileoanal pouch are demonstrated in this study.

Acute pouchitis and deficiencies of fuel

PURPOSE

Acute pouchitis is a troublesome complication after restorative proctocolectomy. Deficiency of fuel, especially short chain fatty acids (SCFA), produced by anaerobic bacterial fermentation of saccharides, is implicated in ulcerative and diversion colitis. Our hypothesis was that SCFA deficiency occurs in acute pouchitis, and correction of the deficiency is associated with resolution of pouchitis.

METHODS

Thirty-two patients were studied, 10 with histologically confirmed acute pouchitis and 22 with healthy pouches. Stool concentrations of SCFA (acetic, propionic, butyric, and valeric acids) were determined by gas-liquid chromatography. Quantitative bacteriologic studies of stool were carried out, and four-quadrant pouch biopsies were assessed by a pathologist who was unaware of the clinical state. Patients with pouchitis were treated for six weeks with metronidazole and given dietary advice to increase their intake of fermentable saccharides.

RESULTS

Stool concentrations of SCFA were significantly less in pouchitis patients compared with patients with healthy pouches (340 mumol/g (range, 124-492) vs. 93 (range, 44-136) P < 0.01). No differences in anaerobic or aerobic counts were seen. Resolution of pouchitis was associated with a significant increase in SCFA, but anaerobic counts fell.

CONCLUSION

Deficiency of SCFA is implicated in acute pouchitis.

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.