Proctocolectomy and ileoanal anastomosis with J-shaped or S-shaped ileal pouch

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.

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

OBJECTIVE

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

METHOD

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

RESULTS

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

CONCLUSION

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

Lengthening of small bowel mesentery: stepladder incision technique

The surgical option of choice in most patients with mucosal ulcerative colitis or familial adenomatous polyposis is restorative proctocolectomy with ileal pouch anal anastomosis. The tension-free anastomosis is one of the most critical steps but may be technically difficult or impossible in some patients because of shortened small bowel mesentery. Various techniques have been described to increase the length of small bowel mesentery. These techniques usually involve selective division of mesenteric blood vessels and meticulous dissection. We describe a new technique of stepladder transverse, transmesenteric incisions in the avascular windows of small bowel mesentery. This provides additional small bowel length without compromising blood supply to the pouch and a simple and safe method of increasing the length of small bowel mesentery. To date, no complications have been reported using this technique.

Long-term outcomes of the ileal pouch anal anastomosis: the association of bowel function and quality of life 5 years after surgery

INTRODUCTION

Previous studies have reported that mean health related quality of life (HRQL) levels generally attain normalcy following construction of an ileal pouch anal anastomosis (IPAA). It appears inconsistent, however, that these normal HRQL levels are achieved while bowel function (BF) scores generally remain statistically worse than "normal" (e.g., 4-8 stools/day, possible anal leakage, diaper usage). To investigate this inconsistency, the current study attempts to determine if any statistical associations are present between HRQL and BF, specifically in the long term. Multivariate regression analyses are performed using each of 8 individual HRQL domains against the full model of BF characteristics.

METHODS

All patients more than 5 years status post an ileal pouch anal anastomosis (IPAA) procedure for familial adenomatous polyposis (FAP) at a single institution were studied. FAP was chosen because patients are routinely asymptomatic preoperatively. BF (e.g., stool frequency, anal leakage) and HRQL (using the 8 health domains of the SF-36) were assessed by patient interview. Student's t tests and full model multivariate regression analyses were used to analyze associations between BF and HRQL.

RESULTS

The sample included 25 patients (14 male). Mean age was 39 years, mean follow-up time was 11 years. Although mean scores for the 8 individual HRQL domains were not statistically different from the general United States population, regression analyses of the different domains did demonstrate significant associations with varying levels of BF. While controlling for age and gender, the analyses show that the physical function domain is improved with the ability to pass flatus independent of stool, and physical role and mental health domains are improved with decreased stool frequency. The social function domain is improved with increased stool retention time, while the perception of general health is improved with less diaper usage and less sexual dysfunction.

CONCLUSIONS

This study shows that a statistically significant association between HRQL levels and BF is present. Of the numerous BF characteristics tested, five appear to be of greater importance with regard to certain HRQL domains. This finding may have clinical implications concerning pouch construction and surgical technique. Methodologically, this study demonstrates that merely using mean levels to describe HRQL may not elucidate meaningful relationships between important clinical outcomes, such as function and HRQL.

Efficacy of the straight endorectal pull-through in the management of familial adenomatous polyposis--a 16-year experience

From 1979 to 1995, 27 patients who had familial adenomatous polyposis (FAP) were treated at the authors' institution. Most patients (n = 23) presented as a result of a previous family history of FAP. Eighteen patients presented with symptomatic colonic disease that included bloody stools (n = 14), diarrhea (n = 10), and abdominal pain (n = 6). Treatment consisted of a total colectomy, rectal mucosectomy, and straight endorectal pull-through (ERPT) in 26 of 27 patients. One patient preferred to undergo an ileoanal J pouch reconstruction. A temporary diverting loop ileostomy was performed in 25 patients and closed at an average of 100 days after the ERPT. Follow-up has been achieved in 100% of the patients and ranges from 6 to 182 months with an average of 48 months. Postoperative complications included partial bowel obstruction (two patients, one requiring enterolysis); and mild pouchitis (one patient). Two of the 27 patients required proctectomy and permanent ileostomy procedures, one for rectal cancer that was present microscopically in the initial rectal specimen from the ERPT and the other because of recurrent anastomotic complications. No patient required revision of the straight pull-through to a pouch or takedown of the pull-through as a result of persistent diarrhea or dissatisfaction. All of the patients are continent, and 80% deny any soiling during bouts of gastroenteritis. The mean number of bowel movements reported was 10 per day at the first postoperative clinic visit with a gradual decreased to six per day after 2 years. Initial use of bulking (62%) and antimotility agents (88%) decreased significantly over the course of follow-up to 29% and 67%, respectively at the most recent follow-up (average, 48 months) of each patient. Pelvic sepsis, which occurs in 8% of most series of patients who have pouches, did not occur in any of our patients. Pouchitis, a common complication with pouches (23%), occurred in only one of the patients and was mild and easily treated medically. This series demonstrates that total colectomy with rectal mucosectomy and straight ERPT eliminates the risk of colorectal cancer and achieves continence with a low complication rate and excellent functional results and patient satisfaction.

Prospective analysis of perioperative morbidity in one hundred consecutive colectomies for ulcerative colitis

BACKGROUND

This study was undertaken to evaluate prospectively the indications for surgical treatment and perioperative morbidity for patients with idiopathic ulcerative colitis (UC).

METHODS

Between January 1985 and August 1994, 145 patients were referred to the senior author (F.M.) for treatment of UC. Data were prospectively collected. One hundred patients have completed all stages of their surgical treatment and have been followed up for at least 1 year. These 100 patients form the basis of this study.

RESULTS

Thirty patients underwent a proctocolectomy with end-ileostomy in one (25) or two (5) stages. Seventy patients underwent a restorative proctocolectomy with ileal J-pouch anal anastomosis in either one (2), two (37), or three stages (31). In total 100 patients underwent 204 procedures. Failure of medical treatment was by far the most common indication. The initial colectomy was performed electively in 61 patients and urgently in the remaining 39. The rate of perioperative complications for elective and urgent colectomy was 26% and 44%, respectively (p < 0.05).

CONCLUSIONS

The overall perioperative morbidity rate remains high and almost doubles for urgent cases. Reducing the need for urgent procedures by earlier elective colectomy may allow for a reduction in perioperative morbidity.

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.

Lengthening of the mesentery using the marginal vascular arcade of the right colon as the blood supply to the ileal pouch

PURPOSE

Creation of a safe ileal pouch requires a tension-free anastomosis. The aim of this study was to evaluate a technical procedure that increases the length of the mesentery while preserving the blood supply to the ileal pouch.

HYPOTHESIS

Preservation of the marginal vascular arcade (MVA) of the right colon will allow ligation of more mesenteric vessels and increase the mesenteric length.

METHODS

Six fresh cadavers were dissected. Measurement of the apex of the terminal ileum was done in relation to the pubic symphysis. Measurements were taken after 1) complete mobilization of the terminal ileum, right colon, and hepatic flexure; 2) vascular ligation between colon wall and the MVA, preserving the latter from the right branch of the middle colic artery to the ileal branch of the ileocolic artery (ICA); 3) ligation of the distal third of the superior mesenteric artery; 4) ligation of the ICA at its origin; 5) ligation of the right colon artery; and 6) division of the terminal ileal mesentery.

RESULTS

This technique enabled complete division of the terminal ileal mesentery, adding a mean additional 3.6 (range, 2.5 - 5.0) cm (36.5 +/- 16.5 percent) in length to the mesentery, compared with superior mesenteric artery, ICA, and right colic artery ligation.

CONCLUSION

Patients who have a shorter mesentery and concern of excessive mesenteric tension should have colectomy performed, preserving the MVA from the middle colic artery to the ileal branch of the ICA. The preserved MVA can be a reliable alternative blood supply to the pouch if more mesenteric vessel ligations are necessary.

Quality of life after total proctocolectomy and ileal J-pouch-anal anastomosis

We investigated the daily life and opinions of patients after total proctocolectomy and ileal J-pouch-anal anastomosis. Eighty patients answered a questionnaire, completed Cattell's anxiety scale, and recorded bowel function for one month. Both colitis and polyposis patients defecated five times daily, had 1.6 episodes of nocturnal motions weekly, and soiled twice weekly. However, colitis patients were more satisfied with their bowel function and surgical outcome than were polyposis patients. This difference had a close relationship to the personality factors of ego strength and frustration. All patients with either disease who defecated less than three times daily, had no nocturnal motions, and had no soiling showed normal ego strength and frustration and were completely satisfied with their bowel status and operation. In contrast, patients defecating more than seven times daily or more than once per week nocturnally and soiling more than four times weekly had high frustration and were dissatisfied. Thus, satisfaction with surgery correlated not only with the objective outcome but also with personality and lifestyle.

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

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

Quality of life after restorative proctocolectomy

An audit of 18 patients whom the author managed by abdominal colectomy, rectal mucosectomy and ileo-anal reservoir anastomosis was undertaken to assess the resulting quality of life. Sixteen patients had ulcerative colitis and two had familial adenomatous polyposis. In each case, a temporary loop ileostomy was performed at the time of reservoir construction. The minimum time since stoma closure was 12 months. The mean number of daily evacuations after stoma closure was eight (range: 4-15). Six patients usually had daytime soiling and eight overnight soiling. Nine patients always wore a perineal pad. Six patients had significant urgency of defecation and 15 patients took medication to reduce bowel frequency. Anorectal problems were noted by all but one of the 18 patients. However, of 14 patients who had lost time from work prior to operation, 12 have returned to uninterrupted employment. Of 11 patients who were unable to travel because of colitis symptoms, eight have no restrictions postoperatively. Twelve patients noted that their diets were more varied since surgery. Of fourteen patients who had restricted sex lives because of colitis symptoms, 11 were subsequently not restricted. On the other hand, during the 3 months the ileostomy was required, sexual activity was restricted in all but one patient. Other aspects of life also restricted by the stoma were sporting activity (14) and social life (15). Improvement followed stoma closure. Overall, the patients graded the success of the reservoir surgery as excellent (7), very good (3), good (2), satisfactory (4), poor (0), or prefer ileostomy (2). Thirteen patients believed their total lifestyle had improved.(ABSTRACT TRUNCATED AT 250 WORDS)

Endoscopic assessment of acute inflammation of the ileal reservoir after restorative ileo-anal anastomosis

Forty-seven patients, undergoing ileo-anal anastomosis for ulcerative colitis (42) or familial polyposis (5), were endoscopically examined after protective ileostomy or after restorative ileo-anal anastomosis. The neorectum and the ileum above were examined in all cases and multiple biopsies were taken. No symptoms of pouch inflammation were found in 41 subjects; 80.5% of these had non-macroscopic lesions and 19.5% had focal lesions such as congestion, petechiae, mucous hypersecretion (5), or single ulcers (3). None of these developed pouchitis. Pouchitis was observed in the other six subjects, who all underwent surgery for ulcerative colitis and developed 14 clinical episodes of pouchitis during the follow-up. In these cases the entire neorectum mucosa was always affected by the lesions which, in 50%, also extended to the ileum above. The most common endoscopic features (71.4%) were congestion, potechiae, oozing areas, mucous hypersecretion, and multiple superficial ulcers. In half the remaining cases (14.3%) the neorectum showed the features, described above, while the upper ileum was affected by deep round or irregular ulcers within normal mucosa; Crohn's disease was excluded in these cases. In the remaining 14.3%, pouchitis showed a pseudomembranous feature. In our experience, the endoscopic pattern of pouchitis is polymorphic. Although an ulcerative colitis-like feature prevails, pseudomembranous and Crohn's ileitis-like features may also be present.

Ileoanal anastomosis with interposition of the ileal 'Kock pouch'. Preliminary results

For patients needing proctocolectomy, there are several alternatives available today for the previously dominating conventional ileostomy. Currently, the ileal pouch-anal anastomosis attracts major interest. Various reservoir procedures have been proposed, but the ideal reservoir design is still debated. The double-folded ileal reservoir (Kock pouch) has a large capacity, low pressure, and is expandable. It is successfully used for the construction of continent ileostomies, continent urostomies, and for replacing the urinary bladder by connecting the reservoir to the urethra. In view of these facts, it was decided to interpose the Kock pouch between the ileum and the anus after colectomy and mucosal proctectomy in a small number of patients, and to study and evaluate its merits in this position. Six consecutive patients formed the study group. Three months after ileostomy closure the stool frequency was 4 every 24-hours, range 3 to 5, and remained so during the follow-up period. All patients could sleep through the night without bowel movements or soiling. None of the patients used pads. The capacity of the reservoir increased from a mean of 100 ml preoperatively to 550 ml one year after ileostomy closure. The large reservoir capacity and the low pressure can explain the good functional results.

Quality of life after Brooke ileostomy and ileal pouch-anal anastomosis. Comparison of performance status

Although the clinical results of Brooke ileostomy are good, patients are permanently incontinent of stool and gas. Alternative operations designed to restore enteric continence, such as ileal pouch-anal anastomosis, must not only be as safe and effective as Brooke ileostomy, but should provide an improved quality of life in order to establish long-term acceptability. Ileal pouch-anal anastomosis has been performed safely and good functional results have been reported. The quality of life after ileal pouch-anal anastomosis, however, has not been documented. Two hundred ninety-eight ileal pouch patients and 406 Brooke ileostomy patients who had the operations performed for chronic ulcerative colitis or familial adenomatous polyposis formed the basis of the study. After adjusting for age, diagnosis, and reoperation rate, logistic regression analysis of performance scores in seven different categories was used to discriminate between operations. Median follow-up was longer in Brooke ileostomy patients than in ileal pouch patients (104 months vs. 47 months, respectively), and Brooke ileostomy patients were slightly older (38 years vs. 32 years). A great majority of patients in each group were satisfied (93% Brooke ileostomy; 95% ileal pouch-anal anastomosis). Thirty-nine per cent of Brooke ileostomy patients, however, desired a change in the type of ileostomy they had. At 47 months, ileal pouch patients had a median of 5 stools per day and 1 at night, 77% did not experience any daytime incontinence, while 22% reported occasional spotting. In each performance category, the performance score discriminated between operations, with the probability of having had an ileal pouch-anal anastomosis operation increasing with improvement in performance scores (p less than 0.05). We concluded that after ileal pouch-anal anastomosis, patients experienced significant advantages in performing daily activities compared to patients with Brooke ileostomy and thus may experience a better quality of life. These results help further to establish ileal pouch-anal anastomosis as a safe, attractive, and valid alternative to Brooke ileostomy.