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Ashitomi Y, Oshio H, Yano M, Okazaki S, Motoi F. Laparoscopic Proctocolectomy With Transanal Total Mesorectal Excision for Ulcerative Colitis. Cureus 2021; 13:e19720. [PMID: 34934583 PMCID: PMC8684528 DOI: 10.7759/cureus.19720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/18/2021] [Indexed: 11/06/2022] Open
Abstract
Transanal total mesorectal excision (TaTME) refers to endoscopic retrograde total mesorectal excision and is becoming increasingly popular worldwide. TaTME improves surgical manipulation and minimizes the risk of local recurrence of rectal cancer by ensuring circumferential resection margins. TaTME is mainly indicated for patients in whom transabdominal approaches are expected to be technically challenging. We extended the indications for TaTME to include surgery for ulcerative colitis lesions that might be cancerous in the rectum. Here, we report a case of proctocolectomy with TaTME for ulcerative colitis. A 38-year-old woman who was receiving treatment for ulcerative colitis underwent a biopsy for random samples from the transverse colon to the rectum. Histopathological findings revealed noninvasive dysplasia with p53 overexpression, suggestive of cancer. We extended the indication of TaTME to surgery for ulcerative colitis. We formed two surgical teams and performed laparoscopic proctocolectomy with TaTME simultaneously. This simultaneous operation reduced the duration of the procedures in the present case. The patient was discharged without any complications and underwent loop ileostomy closure four months postoperatively. The patient recovered without significant loss of the anal sphincter function and is doing well four months after the second surgery. We propose laparoscopic proctocolectomy with TaTME to be conducted simultaneously by two teams as a safe and effective technique that is associated with a shorter operation time than that reported previously. Additionally, TaTME was useful in confirming the appropriate dissection layer as well as in surgical manipulation. Hence, TaTME could serve as a useful therapeutic option for ulcerative colitis surgery.
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Affiliation(s)
- Yuya Ashitomi
- First Department of Surgery, Yamagata University, Faculty of Medicine, Yamagata, JPN
| | - Hiroshi Oshio
- First Department of Surgery, Yamagata University, Faculty of Medicine, Yamagata, JPN
| | - Mitsuhiro Yano
- Department of Surgery, Nihonkai General Hospital, Yamagata, JPN
| | - Shinji Okazaki
- First Department of Surgery, Yamagata University, Faculty of Medicine, Yamagata, JPN
| | - Fuyuhiko Motoi
- First Department of Surgery, Yamagata University, Faculty of Medicine, Yamagata, JPN
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Melvin JC, Harms BA, Heise CP, Leverson GE, Carchman EH. The Optimal Ileal Pouch: Physiologic Parameters Significantly Correlate with Overall Pouch Function. J Gastrointest Surg 2021; 25:1280-1286. [PMID: 32367282 DOI: 10.1007/s11605-020-04617-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Accepted: 04/16/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND Ileal pouch function is affected by several patient factors and pouch physiology. The significance of pouch physiology on optimal pouch function has not been well characterized. The purpose of this study was to examine specific post-ileal pouch anal anastomosis (IPAA) physiologic parameters to determine impact on pouch function and quality of life. METHODS Patients undergoing proctocolectomy with IPAA for ulcerative colitis were examined. Post-IPAA compliance, pouch anal pressure gradient (PAPG), and function were assessed 6-8 months postoperatively. Compliance was calculated as change in volume divided by change in pressure. PAPG was calculated as the difference between anal pressure and intra-pouch pressure at a fixed volume. Pouch function evaluation included stool frequency and episodes of incontinence. Quality of life was evaluated using the Rockwood Fecal Incontinence Quality of Life Scale. RESULTS A total of 125 patients were investigated. Post-IPAA resting anal pressure averaged 58.1 ± 15 mmHg. Mean volume and intra-pouch pressure at evacuation were 245 mL and 33.9 mmHg, respectively. Compliance averaged 11.2 mmHg/mL with a mean PAPG of - 29.3 mmHg. Compliance and PAPG correlated with 24-h (p = 0.003, p = 0.004) and nighttime stool frequency (p = 0.04, p = 0.03). Daytime continence was impacted by compliance (p = 0.04), PAPG (p = 0.02), and resting anal pressure (p = 0.02). CONCLUSION This unique evaluation reveals a significant correlation between IPAA physiologic properties and function. Optimal function and quality of life depend in part on maintaining optimal pouch compliance and pressure differentials between the pouch and anal canal, defined by the pouch anal pressure gradient.
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Affiliation(s)
- Joseph C Melvin
- Section of Colon and Rectal Surgery, University of Wisconsin-Madison, Madison, WI, USA.
- Associates in Colon and Rectal Surgery, MountainStar Healthcare, St. Mark's Colon and Rectal Surgery Residency, Salt Lake City, UT, USA.
| | - Bruce A Harms
- Section of Colon and Rectal Surgery, University of Wisconsin-Madison, Madison, WI, USA
| | - Charles P Heise
- Section of Colon and Rectal Surgery, University of Wisconsin-Madison, Madison, WI, USA
| | - Glen E Leverson
- Section of Colon and Rectal Surgery, University of Wisconsin-Madison, Madison, WI, USA
| | - Evie H Carchman
- Section of Colon and Rectal Surgery, University of Wisconsin-Madison, Madison, WI, USA
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Simillis C, Afxentiou T, Pellino G, Kontovounisios C, Rasheed S, Faiz O, Tekkis PP. A systematic review and meta-analysis comparing adverse events and functional outcomes of different pouch designs after restorative proctocolectomy. Colorectal Dis 2018; 20:664-675. [PMID: 29577558 DOI: 10.1111/codi.14104] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2017] [Accepted: 03/12/2018] [Indexed: 02/08/2023]
Abstract
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.
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Affiliation(s)
- C Simillis
- Department of Colorectal Surgery, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK.,Department of Surgery and Cancer, Imperial College, London, UK
| | - T Afxentiou
- Department of Colorectal Surgery, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - G Pellino
- Department of Colorectal Surgery, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - C Kontovounisios
- Department of Colorectal Surgery, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK.,Department of Surgery and Cancer, Imperial College, London, UK
| | - S Rasheed
- Department of Surgery and Cancer, Imperial College, London, UK
| | - O Faiz
- St Mark's Academic Institute, Surgical Epidemiological Trials and Outcomes Centre, London, UK
| | - P P Tekkis
- Department of Colorectal Surgery, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK.,Department of Surgery and Cancer, Imperial College, London, UK
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M'Koma AE, Longo WE. Postoperative liver enzyme abnormalities are related to staged restorative proctocolectomy. Int J Colorectal Dis 2007; 22:283-8. [PMID: 16583192 DOI: 10.1007/s00384-006-0130-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/01/2006] [Indexed: 02/08/2023]
Abstract
BACKGROUND Transient homeostatic derangements are found after major abdominal and pelvic surgery. We observed elevated liver function tests (LFTs) after restorative proctocolectomy (RPC). This study was undertaken to determine the etiology and implications of elevated LFTs before RPC and postoperatively. METHODS One hundred and thirty-four RPC-patients were prospectively evaluated for LFT abnormalities. Patients were assigned to two groups: hand-sewn ileal-reservoir after mucosoproctocolectomy (n=83) or stapled anastomosis (n=9), both with loop ileostomy and stapled anastomosis without loop ileostomy (n=42). Serum alanine-aminotransferase (ALAT) and alkaline phosphatases (ALP) were assessed preoperatively, 1-10 weeks postoperatively before loop ileostomy closure and 1-10 weeks after ileostomy closure. These findings were correlated with anesthesia time, transfused blood volume, perioperatively administered drugs, and length of the diverted bowel while having a loop ileostomy. RESULTS A large number of patients showed initial elevated serum ALAT and ALP levels, suggesting liver cell damage. There was a substantial and significant increase in ALAT and ALP in the first postoperative week. The values normalized within 2 weeks for the group without loop ileostomy, but not until after loop ileostomy closure in first group. A significant correlation as to length of diverted bowel (<0.05) while having a loop ileostomy was noted. When the length of diverted bowel was more than 105 cm, liver enzymes were higher than baseline levels (p<0.05) until after closure. CONCLUSIONS Patients may develop elevated LFTs after RPC; however, its etiology and significance remains unclear. A loop ileostomy with RPC seemed to delay the normalization. Consideration of further diagnostic imaging may be indicated to exclude other liver pathology such as sclerosing cholangitis.
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Affiliation(s)
- Amosy E M'Koma
- Department of Surgery, Center for Surgical Sciences (CFSS), Karolinska Institute, Karolinska University Hospital, Huddinge, Sweden.
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5
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M'Koma AE. Serum biochemical evaluation of patients with functional pouches ten to 20 years after restorative proctocolectomy. Int J Colorectal Dis 2006; 21:711-20. [PMID: 16437210 DOI: 10.1007/s00384-005-0076-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/07/2005] [Indexed: 02/05/2023]
Abstract
BACKGROUND Restorative proctocolectomy with an ileal pouch-anal anastomosis is a surgical treatment of choice for ulcerative colitis and familial adenomatous polyposis (FAP). Pouchitis is a significant enigmatic morbidity. In the long-term, these patients, we anticipated, would experience biochemical profiling alterations after years of retaining functionally acceptable pouches. This pilot study was aimed at assessing results of essential biochemical variables more than 10 years after surgery. METHODS The investigation was carried out in 91 patients; 39 were women. Eight-eight had ulcerative colitis, while three had FAPs. The hand-sewn ileal reservoirs after mucoso-proctocolectomy were 66 S and 25 J. The analyses were compared short-term vs long-term. Patients were investigated and were their own control. RESULTS Long-term, incidence of acute and chronic pouchitis was 2 and 13%. Eleven and 4% of patients had hypomagnesaemia and hypocalcaemia. Mean levels were significantly enhanced (p<0.01 and p<0.0002). Hypomagnesaemia corresponded to episodes of pouchitis and was corrected with oral magnesium and antibiotics. Hypoferric anaemia was diagnosed in 7% and treated with oral iron tablets. Chronic pouchitis and recurrent pouch mucosa bleeding were the cause. Hypohemoglobinemia and hypocyanocobalaminemia were noted in 5% and 5%, respectively. Erythrocyte sedimentation rate and white blood cells were supra-normal in 13 and 10%, which corresponded with pouchitis. A significant (p<0.03) steady rise of mean serum immunoglobulin G without correlation to pouchitis was noted. CONCLUSION Long-term functional results did not deteriorate. Pouchitis was a significant enigmatic morbidity. Severe or chronic pouchitis complicated hypoferric and vitamin B(12) anemia and hypomagnesaemia.
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Affiliation(s)
- Amosy Ephreim M'Koma
- Center for Surgical Sciences, Department of Surgery, Karolinska University Hospital, SE-141 86 Huddinge, Stockholm, Sweden.
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Chaudhry R. USE OF ANORECTAL MANOMETRY FOR OBJECTIVE ASSESSMENT OF ANORECTAL FUNCTION AFTER POUCH ILEOANAL ANASTOMOSIS. Med J Armed Forces India 1998; 54:121-122. [PMID: 28775443 DOI: 10.1016/s0377-1237(17)30499-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
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.
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Affiliation(s)
- Rajan Chaudhry
- Classified Specialist (Surgery & GI Surgeon), Command Hospital (Southern Command), Pune 411040
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7
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Takao Y, Gilliland R, Nogueras JJ, Weiss EG, Wexner SD. Is age relevant to functional outcome after restorative proctocolectomy for ulcerative colitis?: prospective assessment of 122 cases. Ann Surg 1998; 227:187-94. [PMID: 9488515 PMCID: PMC1191234 DOI: 10.1097/00000658-199802000-00006] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
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.
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Affiliation(s)
- Y Takao
- Department of Colorectal Surgery, Cleveland Clinic Florida, Fort Lauderdale 33309, USA
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8
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Thompson-Fawcett MW, Mortensen NJ. Anal transitional zone and columnar cuff in restorative proctocolectomy. Br J Surg 1996; 83:1047-55. [PMID: 8869301 DOI: 10.1002/bjs.1800830806] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
The popularity of double stapling the ileal pouch-anal anastomosis probably owes more to the technical ease it brings than to histological considerations or functional results. It is preservation of a 'columnar cuff' of mucosa, rather than the restricted site of the anal transitional zone, that should be the focus of research with respect to long-term risk of malignancy and inflammatory complications. If cancer is present in colon that has been removed for ulcerative colitis, there is a 25 per cent incidence of dysplasia in the columnar cuff in the short term. In other circumstances, those who are spared from carcinoma by colectomy are likely to have a similar risk of developing dysplastic change in the columnar cuff with longer follow-up. Double stapling the pouch-anal anastomosis and preserving the anal canal mucosa improves function, but long-term surveillance of the columnar cuff is then required, including biopsies.
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Abstract
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.
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Affiliation(s)
- R Goes
- Department of Surgery, University of Southern California, Los Angeles, USA
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10
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Staniunas RJ, Keck JO, Counihan T, Marcello P, Barrett RC, Oster M, Roberts PL, Schoetz DJ, Murray JJ, Veidenheimer MC. State of the defunctionalized sphincter in patients undergoing ileoanal pouch anastomosis. Dis Colon Rectum 1995; 38:458-61. [PMID: 7736874 DOI: 10.1007/bf02148843] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
PURPOSE Our aim was to determine manometric status and functional outcome of the ileoanal pouch procedure in a subset of patients with defunctionalized anal sphincters as a result of long-term fecal diversion. METHODS The anal manometric profiles of 12 patients defunctionalized for one year or more were compared with 26 patients with nondefunctionalized anal sphincters. Functional data were obtained from the Lahey Clinic Ileoanal Pouch Registry. RESULTS Preoperative manometric data revealed a mean resting pressure of 91.5 mmHg in the nondefunctionalized group vs. 68.7 mmHg in the defunctionalized group; mean squeezing pressure was 171.7 mmHg (nondefunctionalized group) vs. 102.3 mmHg (defunctionalized group); and squeezing pressure volume was 1,283,000 mmHg3 (nondefunctionalized group) vs. 585,000 mmHg3 (defunctionalized group). Functionally both groups had a mean of 6.1 bowel movements in a 24-hour period and could defer defecation for a mean of 2 hours. Leakage occurred in 22 percent of the defunctionalized group and 17 percent of the nondefunctionalized group (P = 0.35). CONCLUSION Despite physiologic perturbations, the long-term, defunctionalized anal sphincter can adequately support a restorative procedure without regard to timing of pouch creation.
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Affiliation(s)
- R J Staniunas
- Department of Colon and Rectal Surgery, Lahey Clinic, Burlington, Massachusetts 01805, USA
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Jorge JM, Wexner SD, James K, Nogueras JJ, Jagelman DG. Recovery of anal sphincter function after the ileoanal reservoir procedure in patients over the age of fifty. Dis Colon Rectum 1994; 37:1002-5. [PMID: 7924704 DOI: 10.1007/bf02049312] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
PURPOSE This study was undertaken to postoperatively assess the progression of anal sphincter function and clinical outcome in patients > or = 50 years old (Group I) compared with those < 50 years old (Group II). METHODS Clinical data were assessed after ileostomy closure by a questionnaire. These data were compiled to obtain an incontinence score, which ranged from 0 (perfect continence) to 20 (total incontinence). Anorectal manometry was performed preoperatively (MN1) and postoperatively, before (MN2) and after (MN3) ileostomy closure. Wilcoxon and paired t-test were used to compare the clinical and functional results, respectively. RESULTS Group I consisted of 22 patients (mean age, 56 years) and Group II, 50 patients (mean age, 32 years). No differences were found relative to either preoperative pressures or clinical outcome. However, both the mean and high resting pressures were significantly lower in Group I at the MN2 examination. CONCLUSION The effect on anal sphincters of ileoanal reservoir in patients over the age of 50 years is similar to that noted in younger patients. Transient impairment of internal anal sphincter function observed after ileoanal reservoir is more severe in older patients (P = 0.01). However, as in younger patients, it does completely recover after ileostomy closure.
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Affiliation(s)
- J M Jorge
- Department of Colorectal Surgery, Cleveland Clinic Florida, Fort Lauderdale
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Deen KI, Hubscher S, Bain I, Patel R, Keighley MR. Histological assessment of the distal 'doughnut' in patients undergoing stapled restorative proctocolectomy with high or low anal transection. Br J Surg 1994; 81:900-3. [PMID: 8044617 DOI: 10.1002/bjs.1800810636] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
A non-randomized prospective study of 38 patients, 32 with ulcerative colitis and six with familial adenomatous polyposis (FAP), who underwent high or low anal transection during stapled restorative proctocolectomy was undertaken. The median (range) height of the staple line 6 months after operation was 5.2 (3.2-6.0) cm after high transection compared with 2.9 (1.8-3.6) cm after low transection. Nineteen of 20 patients after high anal transection had columnar epithelium in the distal 'doughnut' versus 16 of 18 after low transection. Active colitis was present in 12 of 19 'doughnuts' in patients with high anal transection and columnar mucosa and in seven of 16 after low transection. Nine patients (high transection two, low transection seven; P < 0.05) had striated muscle in the stapled distal 'doughnut'. Dysplasia was found in the resected colon in one patient with ulcerative colitis and adenocarcinoma in two colectomy specimens (ulcerative colitis, one; FAP, one). No dysplasia or carcinoma was seen in any of the 'doughnuts' from patients with ulcerative colitis. Four patients with FAP (high transection, two; low transection, two) had microadenoma in the distal 'doughnut'. Despite attempts to place a stapled pouch-anal anastomosis below the anal transition zone, it was not possible to remove columnar mucosa completely from the remaining anal canal in most patients (16 of 18). High anal transection and pouch-anal anastomosis should be the preferred option in restorative proctocolectomy, as a dentate-line anastomosis may not fully eliminate columnar epithelium and may involve resection of some of the external sphincter.
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Affiliation(s)
- K I Deen
- University Department of Surgery, Queen Elizabeth Hospital, Edgbaston, Birmingham, UK
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13
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Jorge JM, Wexner SD, Morgado PJ, James K, Nogueras JJ, Jagelman DG. Optimization of sphincter function after the ileoanal reservoir procedure. A prospective, randomized trial. Dis Colon Rectum 1994; 37:419-23. [PMID: 8181400 DOI: 10.1007/bf02076184] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
PURPOSE Impairment of sphincter function in patients who undergo ileoanal reservoir is usually most severe immediately after ileostomy closure. Therefore, a prospective, randomized trial was undertaken to assess the potential value of preileostomy closure sphincter-strengthening exercises to improve early functional outcome. METHODS Patients were randomized either to a control group (Group 1) or to undergo a five-week pelvic floor exercise program (Group 2). An incontinence score from 0 to 20 was used to clinically assess the functional results. Anorectal manometric assessment included: high-pressure zone length, mean resting pressure, highest resting pressure, mean squeezing pressure, and highest squeezing pressure. The paired t-test was used to compare the functional results preoperatively and at the time of ileostomy closure. This time corresponded to the conclusion of the exercise program or the equivalent time period for the control group. RESULTS Twenty-six patients who underwent double-stapled ileoanal reservoir between July 1991 and June 1992 were studied. They included 16 males and 10 females with a mean age of 38 (range, 17-69) years. When both evaluations were compared, the mean incontinence score decreased from 0.2 to 2.8 (delta = 2.6) in Group 1 and from 0.2 to 2.0 (delta = 1.8) in Group 2 (P = 0.07). None of the changes between the preoperative and postoperative clinical and physiologic evaluations were statistically significant (P > 0.05). CONCLUSION Sphincter-strengthening exercises before ileostomy closure did not minimize the transient impairment of functional results.
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Affiliation(s)
- J M Jorge
- Department of Colorectal Surgery, Cleveland Clinic Florida, Fort Lauderdale
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14
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Annibali R, Oresland T, Hultén L. Does the level of stapled ileoanal anastomosis influence physiologic and functional outcome? Dis Colon Rectum 1994; 37:321-9. [PMID: 8168410 DOI: 10.1007/bf02053591] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
PURPOSE The aim of this investigation was to ascertain how the length of anal canal preserved above the dentate line in stapled end-to-end ileoanal anastomosis influenced late outcome. METHODS Two groups, high cuff group and low cuff group of nine subjects with stapled anastomosis, matched for sex, age, pouch configuration, and mean follow-up, representing the highest (median, 2.5 cm) and lowest (median, 0.7 cm) anal cuff lengths in our series, were selected. Physiologic and functional parameters were appraised preoperatively, at the time of ileostomy closure, and at 1, 3, 6, and 12 months after reestablishment of intestinal continuity. RESULTS At one year, the drop in mean anal canal resting pressure was 13 percent in the high cuff group (not significant) and 31 percent in the low cuff group (P < 0.05); mean maximum squeezing pressure did not differ significantly from preoperative values in both groups. The mean volume of the ileal pouch was higher in the low cuff group at all insufflation pressures. The rectoanal inhibition reflex reappeared in four high cuff group patients and in none of the low cuff group patients. Mean distention pressure (cm H2O) and volume (ml) eliciting urge sensation were 80 and 360 in the low cuff group compared with 40 and 240 in the high cuff group (P < or = 0.05). Daytime bowel movements and night incontinence were significantly better in the low cuff group. No statistical differences were observed for night stool frequency, daytime incontinence, pad use (day and night), discrimination between gas and feces, ability to defer evacuation, and difficulty in emptying the pouch. CONCLUSION Patients with stapled anastomoses and a low rectal cuff length, despite presenting lower anal resting pressure and absence of rectoanal inhibition reflex, had a better functional outcome in terms of continence than those with a high cuff length.
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Affiliation(s)
- R Annibali
- Department of Surgery II, Sahlgrenska Sjukhuset, Göteborg, Sweden
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Sun WM, Read NW, Katsinelos P, Donnelly TC, Shorthouse AJ. Anorectal function after restorative proctocolectomy and low anterior resection with coloanal anastomosis. Br J Surg 1994; 81:280-4. [PMID: 8156360 DOI: 10.1002/bjs.1800810244] [Citation(s) in RCA: 26] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Anorectal manometry and electromyography were studied in 17 patients before and after restorative proctocolectomy with stapled pouch-anal anastomosis, in ten patients before and after low anterior resection with stapled coloanal anastomosis, and in 35 normal controls. More than 80 per cent of patients in both groups developed abnormal oscillation of anal pressure after operation (amplitude 15-60 (median 25) cmH2O, frequency 4-10 (median 8) per min) and showed no anal relaxation in response to intermittent neorectal distension. All patients lost discriminative rectal sensation and none could perceive a normal desire to defaecate. Patients with postoperative soiling had a greater amplitude of anal pressure oscillation and lower minimum basal pressure, although those who underwent coloanal anastomosis had a greater risk of incontinence because of large asynchronous oscillations in neorectal pressure. The common pathophysiological features after restorative proctocolectomy and coloanal anastomosis probably relate to damage to the autonomic and enteric nerve supplies. The presence of an unstable internal anal sphincter may be an important cause of postoperative nocturnal incontinence.
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Affiliation(s)
- W M Sun
- Gastrointestinal Motility Unit, Northern General Hospital, Sheffield, UK
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16
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Hallgren T, Fasth S, Delbro D, Nordgren S, Oresland T, Hultén L. Possible role of the autonomic nervous system in sphincter impairment after restorative proctocolectomy. Br J Surg 1993; 80:631-5. [PMID: 8518909 DOI: 10.1002/bjs.1800800530] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Peroperative manometry was performed in 12 patients operated on with endoanal proctectomy and a hand-sewn pouch-anal anastomosis and in 12 in whom proctectomy was performed entirely from above, with the ileal pouch stapled to the top of the anal canal. Results from both groups showed that division of the superior rectal artery reduced the median (95 per cent confidence interval (c.i.)) resting anal pressure from 77.5 (69.9-83.3) mmHg to 64.5 (55.2-70.0) mmHg (P < 0.01). Complete rectal mobilization to the pelvic floor decreased resting pressure by an additional 22 per cent, to a median of 50.0 (95 per cent c.i. 40.1-53.5) mmHg (P < 0.01). After completion of anastomosis, irrespective of the operative technique used, a further decline in median pressure to 35.0 (95 per cent c.i. 26.0-47.7) mmHg could be demonstrated (P < 0.05). This study indicates that anal sphincter pressure is reduced to a similar extent after hand-sewn and stapled anastomoses. Injury to the autonomic nervous supply to the anal sphincter mechanism might be the major cause for this reduction.
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Affiliation(s)
- T Hallgren
- Department of Surgery II, University of Göteborg, Sahlgrenska sjukhuset, Sweden
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17
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Pescatori M. The results of pouch surgery after ileo-anal anastomosis for inflammatory bowel disease: the manometric assessment of pouch continence and its reservoir function. World J Surg 1992; 16:872-9. [PMID: 1462622 DOI: 10.1007/bf02066984] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Anal sphincter function after restorative proctocolectomy has mainly been investigated by anal manometry. A significant decrease of basal pressure up to 45%, has been recorded postoperatively, possibly due to sphincter stretch during endoanal mucosectomy. Both abdominal mucosectomy and anastomosis at the level of the anorectal ring have been reported to prevent anal sphincter damage and lead to better continence. The striated sphincter is not significantly affected by the surgical procedure. Pouch-anal inhibitory reflex is partly maintained in the presence of a rectal cuff which leaves the ganglionic plexus unaltered; a satisfactory continence is also retained in the absence of the reflex when the rectum is totally excised. Pouch capacity, compliance and motility have been investigated by endoluminal balloon and probes. Pouch emptying has been studied by a "porridge" test, by a semi-solid medium labelled with technetium-99, and by other methods. A more effective storage function is achieved by large capacity reservoirs which lower the bowel frequency. The motor response to pouch distension, to a meal, and to pharmacological stimuli is usually counteracted by sphincter contraction. Ileal hypermotility may lead to fecal leakage mainly in the presence of weak sphincters. Poor pouch emptying may be related to an anal stricture.
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Affiliation(s)
- M Pescatori
- Istituto di Clinica Chirurgica, Università Cattolica, Roma, Italy
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Wexner SD, James K, Jagelman DG. The double-stapled ileal reservoir and ileoanal anastomosis. A prospective review of sphincter function and clinical outcome. Dis Colon Rectum 1991; 34:487-94. [PMID: 1645246 DOI: 10.1007/bf02049935] [Citation(s) in RCA: 59] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Fifteen consecutive patients (nine males and six females) who underwent construction of a double-stapled ileoanal reservoir (DS-IAR) were prospectively evaluated. Mean and maximal resting pressures preoperatively, before ileostomy closure, and at 12 months, were 53 and 84 mm Hg, 39 and 62 mm Hg, and 62 and 81 mm Hg. Mean and maximal squeeze pressures at those same time periods were 96 and 153 mm Hg, 111 and 173 mm Hg, and 95 and 168 mm Hg. There were no significant decreases in either resting or squeeze pressure between preoperative values and those obtained 12 months after surgery. However, the length of the high pressure zone decreased from 3.8 cm preoperatively to 2.3 cm at 12 months. This reflects the sacrifice of the cephalad 1.5 cm of the internal anal sphincter necessary to effect this anastomosis at a mean of 1.4 cm from the dentate line. However, this maneuver did not result in poor continence. Eleven patients whose ileostomies were closed for a mean of 9 months, ranging from 3 to 15 months, were evaluated regarding functional outcome. Only one patient had any incontinence and this patient had incomplete circular-stapled tissue rings, which necessitated transanal suture repair of the anastomotic defect. Similarly, three of the four patients who sometimes or rarely use a pad at night had transanal-suture reinforcement. Ten of the 11 patients never wear a pad during the day. No pelvic or perianal sepsis occurred. Stratified squamous epithelium was found in 6 of the 13 distal stapler "donuts" that were examined. In addition, 10 patients underwent biopsy of the tissue immediately caudad to the circular staple line at the time of ileostomy closure; in five, only stratified squamous epithelium was noted. The DS-IAR is associated with excellent objective physiologic and subjective functional results.
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Affiliation(s)
- S D Wexner
- Department of Colorectal Surgery, Cleveland Clinic Florida, Fort Lauderdale 33309
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Abstract
Between January 1982 and March 1990, 106 patients underwent restorative proctocolectomy in eight separate surgical departments. The indication for operation was ulcerative colitis in 86%, familial adenomatous polyposis in 12% and megacolon in 2%. The age at operation was 33 +/- 2 years (mean +/- sem) (range 15-55 years). There were no perioperative deaths. The principal causes of post-operative morbidity were intra-abdominal sepsis (15%), anastomotic stricture (10%) and intestinal obstruction (8%). Intestinal continuity has been restored in 99 patients. All were grossly continent, but 32% experienced occasional soiling. The mean stool frequency was 5/day and 1/night. The overall failure rate was 6%. Eighty-nine percent of patients were happy with the outcome. We conclude that restorative proctocolectomy is safe and provides acceptable functional results. It should be the operation of choice in most patients with ulcerative colitis or familial adenomatous polyposis.
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