Randomized, controlled trial to compare the J-pouch and W-pouch configurations for ulcerative colitis in the maturation period

Surgical Options for Appropriate Length of J-Pouch Construction for Better Outcomes and Long-term Quality of Life in Patients with Ulcerative Colitis after Ileal Pouch-Anal Anastomosis

Background/Aims

Total proctocolectomy with ileal pouch-anal anastomosis (IPAA) is widely accepted as a radical surgery for refractory ulcerative colitis (UC). Definite results on the appropriate pouch length for an evaluation of the risk-to-benefit ratio regarding technical complications and long-term quality of life (QOL) are still scarce.

Methods

Data on UC patients who underwent IPAA from 2008 to 2022 in four well-established pouch centers affiliated to China UC Pouch Center Union were collected.

Results

A total of 208 patients with a median follow-up time of 6.0 years (interquartile range, 2.3 to 9.0 years) were enrolled. The median lengths of the patients' short and long pouches were 14.0 cm (interquartile range, 14.0 to 15.0 cm) and 22.0 cm (interquartile range, 20.0 to 24.0 cm), respectively. Patients with a short J pouch configuration were less likely to achieve significantly improved long-term QOL (p=0.015) and were prone to develop late postoperative complications (p=0.042), such as increased defecation frequency (p=0.003) and pouchitis (p=0.035). A short ileal pouch was an independent risk factor for the development of late postoperative complications (odds ratio, 3.100; 95% confidence interval, 1.519 to 6.329; p=0.002) and impaired longterm QOL improvement (odds ratio, 2.221; 95% confidence interval, 1.218 to 4.050, p=0.009).

Conclusions

The length of the J pouch was associated with the improvement in long-term QOL and the development of late post-IPAA complications. A long J pouch configuration could be a considerable surgical option for pouch construction.

ECCO Topical Review Optimising Reporting in Surgery, Endoscopy, and Histopathology

BACKGROUND AND AIMS

Diagnosis and management of inflammatory bowel diseases [IBD] requires a lifelong multidisciplinary approach. The quality of medical reporting is crucial in this context. The present topical review addresses the need for optimised reporting in endoscopy, surgery, and histopathology.

METHODS

A consensus expert panel consisting of gastroenterologists, surgeons, and pathologists, convened by the European Crohn's and Colitis Organisation, performed a systematic literature review. The following topics were covered: in endoscopy: [i] general IBD endoscopy; [ii] disease activity and surveillance; [iii] endoscopy treatment in IBD; in surgery: [iv] medical history with surgical relevance, surgical indication, and strategy; [v] operative approach; [vi] intraoperative disease description; [vii] operative steps; in pathology: [viii] macroscopic assessment and interpretation of resection specimens; [ix] IBD histology, including biopsies, surgical resections, and neoplasia; [x] IBD histology conclusion and report. Statements were developed using a Delphi methodology incorporating two consecutive rounds. Current practice positions were set when ≥ 80% of participants agreed on a recommendation.

RESULTS

Thirty practice positions established a standard terminology for optimal reporting in endoscopy, surgery, and histopathology. Assessment of disease activity, surveillance recommendations, advice to surgeons for operative indication and strategies, including margins and extent of resection, and diagnostic criteria of IBD, as well as guidance for the interpretation of dysplasia and cancer, were handled. A standardised report including a core set of items to include in each specialty report, was defined.

CONCLUSIONS

Interdisciplinary high-quality care requires thorough and standardised reporting across specialties. This topical review offers an actionable framework and practice recommendations to optimise reporting in endoscopy, surgery, and histopathology.

Inflammatory bowel disease position statement of the Italian Society of Colorectal Surgery (SICCR): ulcerative colitis

The Italian Society of Colorectal Surgery (SICCR) promoted the project reported here, which consists of a Position Statement of Italian colorectal surgeons to address the surgical aspects of ulcerative colitis management. Members of the society were invited to express their opinions on several items proposed by the writing committee, based on evidence available in the literature. The results are presented, focusing on relevant points. The present paper is not an alternative to available guidelines; rather, it offers a snapshot of the attitudes of SICCR surgeons about the surgical treatment of ulcerative colitis. The committee was able to identify some points of major disagreement and suggested strategies to improve the quality of available data and acceptance of guidelines.

The Association of Coloproctology of Great Britain and Ireland consensus guidelines in surgery for inflammatory bowel disease

AIM

There is a requirement of an expansive and up to date review of surgical management of inflammatory bowel disease (IBD) that can dovetail with the medical guidelines produced by the British Society of Gastroenterology.

METHODS

Surgeons who are members of the ACPGBI with a recognised interest in IBD were invited to contribute various sections of the guidelines. They were directed to produce a procedure based document using literature searches that were systematic, comprehensible, transparent and reproducible. Levels of evidence were graded. An editorial board was convened to ensure consistency of style, presentation and quality. Each author was asked to provide a set of recommendations which were evidence based and unambiguous. These recommendations were submitted to the whole guideline group and scored. They were then refined and submitted to a second vote. Only those that achieved >80% consensus at level 5 (strongly agree) or level 4 (agree) after 2 votes were included in the guidelines.

RESULTS

All aspects of surgical care for IBD have been included along with 157 recommendations for management.

CONCLUSION

These guidelines provide an up to date and evidence based summary of the current surgical knowledge in the management of IBD and will serve as a useful practical text for clinicians performing this type of surgery.

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

AIM

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

METHOD

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

RESULTS

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

CONCLUSION

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

Hormonal contraceptives and venous thromboembolism: Are inflammatory bowel disease patients at increased risk? A retrospective study on a prospective database

Recent studies showed an increased risk of venous thromboembolism (VTE) in patients receiving oral hormonal contraceptives. Inflammatory bowel diseases (IBD) often affect young patients and represent a pro-coagulant condition. This could result from active inflammation, but a potential role for genetic and molecular factors has been suggested. Hormonal contraceptives have also been associated with increased risk of VTE and the risk may be greater in IBD patients that already are in a pro-coagulant status, but no definitive data are available in this population. The purpose of our study was to seek for differences of the risk of VTE in IBD patients receiving hormonal contraceptives compared with controls.

This is a retrospective study. We interrogated a prospectively maintained database of IBD patients observed at our outpatient clinic between 2000 and 2014. All female patients managed conservatively, with no active disease, who were taking oral hormone contraceptives in the study period, were included. Patients observed for other-than-IBD conditions at our Unit and at the Unit of Gynaecology and Obstetrics, receiving contraceptives, served as controls (ratio 1:2). Patients with cancer, those receiving hormonal therapy, and those with known genetic predisposition to VTE were excluded.

We included 146 six IBD patients and 290 controls. One patient in each group developed VTE. Overall, the incidence of VTE associated with oral contraceptives was 0.5%. IBD was associated with increased risk of VTE (OR 1.9, 95% CI 0.12–32.12, p > 0.99). Active smokers since 10 years (17.2%) had higher risks of VTE (OR 8.6, 95% CI 1.16–19.25, p = 0.03).

Our data show that patients with IBD in remission are not at higher risk of VTE due to oral oestrogen-containing contraceptives compared with non-IBD controls. Smokers are at increased risk, irrespective of the baseline disease.

•

Contraceptives do not increase the risk of VTE in IBD patients in remission.

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Irrespective of baseline disease, smoking is associated with VTE.

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IBD patients receiving contraceptives should be encouraged to quit smoking.

A think tank of the Italian Society of Colorectal Surgery (SICCR) on the surgical treatment of inflammatory bowel disease using the Delphi method: ulcerative colitis

The majority of patients suffering from ulcerative colitis (UC) are managed successfully with medical treatment, but a relevant number of them will still need surgery at some point in their life. Medical treatments and surgical techniques have changed dramatically in recent years, and available guidelines from relevant societies are rapidly evolving, providing UC experts with updated and valid practical recommendations. However, some aspects of the management of UC patients are still debated, and the application of guidelines in clinical practice may be suboptimal. The Italian Society of Colorectal Surgery (SICCR) sponsored the think tank in order to identify critical aspects of the surgical management of UC in Italy. The present paper reports the results of a think tank of Italian colorectal surgeons concerning surgery for UC and was not developed as an alternative to authoritative guidelines currently available. Members of the SICCR voted on several items proposed by the writing committee, based on evidence from the literature. The results are presented, focusing on points to be implemented. UC management relies on evaluations that need to be individualized, but points of major disagreement reported in this paper should be considered in order to develop strategies to improve the quality of the evidence and the application of guidelines in a clinical setting.

Outcomes of salvage surgery for ileal pouch complications and dysfunctions. the experience of a referral centre and review of literature

BACKGROUND AND AIMS

Failure rates of restorative proctocolectomy with ileo pouch-anal anastomosis (IPAA) range between 3.5 and 15%. Salvage surgery aims to preserve the pouch and transanal evacuation. We report our experience with salvage, review the outcomes of revisional pouch surgery, and propose a classification of pouch dysfunction.

METHODS

We collected data on patients undergoing pouch salvage surgery between 1987 and 2014 at our hospital. Pre- and post-salvage functional data were assessed. Function at the 3-year follow-up was compared with that of matched IPAA controls (study patients:controls, 1:3).

RESULTS

Considering only patients who underwent primary IPAA at our centre (n = 31), 5-year failure was higher after salvage compared with primary IPAA (28.8 vs 5.7% log rank test, p = 0.005). Overall, we included 39 patients, with eight additional patients who received primary IPAA elsewhere, undergoing 46 procedures. Most patients had a J-pouch (74.4%) and needed salvage for septic complications. A transperineal approach was used in 22 patients, whereas 17 underwent abdominal salvage, with 77.3 and 64.7% success rates, respectively. Minor surgery was effective but required repeated procedures. Overall failure was 28.2% at a median follow-up of 42 (1-153) months. A significant decrease in bowel frequency (p = 0.021) and rate of urgency (p = 0.009) was observed at the 3-year follow-up after salvage in 25 patients available for comparison. Functional results after major salvage procedures were poorer compared with healthy IPAA controls (p = 0.003).

CONCLUSIONS

Salvage surgery is effective and safe in experienced teams, but the 5-year failure rate is higher after salvage than after successful primary pouch surgery. Sepsis brings about a higher risk of failure compared with mechanical causes of dysfunction.

Restorative proctocolectomy with ileal pouch-anal anastomosis is safe and effective in selected very elderly patients suffering from ulcerative colitis

Restorative proctocolectomy (RP) with ileal pouch-anal anastomosis is the mainstay treatment for intractable or refractory ulcerative colitis (UC). Safety and effectiveness of RP in elderly patients are debated. Our aim was to compare surgical outcomes and function of patients undergoing RP over 80-year-of-age with those of younger controls. We retrospectively gathered data of patients receiving RP for UC aged >80 years between January 1990 and December 2012. A control group of younger patients was established for comparison (1:3 ratio). Functional outcomes and satisfaction with surgery 6 and 12 months after ileostomy closure were collected. Ten patients >80-year-old were included (median age 87.5, range 84-90 years). All patients had at least one comorbidity (mean 2.1 ± 1) and were receiving medications for concomitant diseases. Half of them received a 3-stage procedure. Neither death nor major perioperative complications were observed. One patient (10%) required readmission for dehydration 2 weeks after RP with loop-ileostomy. Thirty younger patients (median age 34.3, range 25-52 years) served as controls. All patients had their ileostomy closed within 3 months from RP. At 6 month follow-up, elderly patients had more nocturnal seepage, antidiarrhoeals intake, and a trend toward more frequent day-time incontinence. At 12-month follow-up differences were less apparent. Only nocturnal seepage was higher in elderly. All patients retained their pouch and would have undergone surgery again. RP is feasible in selected advanced age patients, and functional results are comparable to younger patients.

The ideal ileal-pouch design: a long-term randomized control trial of J- vs W-pouch construction

BACKGROUND

The IPAA has become established as the preferred technique for restoring intestinal continuity postproctocolectomy. The ideal pouch design has not been established. W-pouches may give better functional results owing to increased volume, whereas the J-pouch's advantage is its straightforward construction. We report short- and long-term results of an randomized control trial designed to establish the ideal pouch.

DESIGN

Ninety-four patients were randomly assigned to J- and W-pouches (49:45) and assessed at 1 and 8.7 years postoperatively. Assessment was questionnaire based and designed to assess pouch function and patient quality of life.

RESULTS

Eighty-five percent of patients were followed up at 1 year, and 68% were followed up at 8.7 years. At 1 year, there was a significant difference in 24-hour bowel movement frequency J- vs W-pouches 7 vs 5(p < 0.001) and in daytime frequency J- vs W-pouches 6 vs 4 (p < 0.001), with no difference in nocturnal function. At 9-year follow-up, function had equilibrated between the 2 groups: 24-hour bowel movement frequency J- vs W-pouches 6.5 vs 6 (p = 0.36), daytime frequency 5.5 vs 5 (p = 0.233), and nocturnal function 1 vs 1 (p = 0.987). Mean operating time of J- and W-pouches was 195 and 215 minutes (p < 0.05). All other parameters, pad usage, urgency, incontinence, and quality of life, did not differ significantly between groups.

CONCLUSION

These data demonstrate that the theoretical functional advantage conferred on the W-pouch by its greater volume exists only in the short term and is of little consequence to patients' long-term quality of life. This advantage is attenuated as the pouches mature, resulting in no disparity in pouch function. This, combined with the more consistent, efficient, and easily taught construction of the J-pouch, should conclusively establish it as the optimum ileal-pouch design.

History of and current issues affecting surgery for pediatric ulcerative colitis

Pediatric ulcerative colitis (UC) is reportedly more extensive and progressive in its clinical course than adult UC. Therefore, more aggressive initial therapies and more frequent colectomies are needed. When physicians treat pediatric UC, they must consider the therapeutic outcome as well as the child's physical and psychological development. Mucosal proctocolectomy with ileal J-pouch anal anastomosis is currently recommended as a standard curative surgical procedure for UC in both children and adults worldwide. This procedure was developed 100 years after the first surgical therapy, which treated UC by colon irrigation through a temporary inguinal colostomy. Predecessors in the colorectal and pediatric surgical fields have struggled against several postoperative complications and have long sought a surgical procedure that is optimal for children. We herein describe the history of the development of surgical procedures and the current issues regarding the surgical indications for pediatric UC. These issues differ from those in adults, including the definition of toxic megacolon on plain X-rays, the incidence of colon carcinoma, preoperative and postoperative steroid complications, and future growth. Surgeons treating children with UC should consider the historical experiences of pioneer surgeons to take the most appropriate next step to improve the surgical outcomes and patients' quality of life.

Long-term followup with evaluation of the surgical and functional results of the ileal pouch reservoir in restorative proctocolectomy for ulcerative colitis

Aims. Evaluate the early and long term surgical and functional results of the ileal pouch-reservoir (IPAA) in patients with intractable ulcerative colitis. Material and Methods. Followup of 134 consecutive patients with W-or J-ileal pouch by diseases-specific and general health (SF-36) questionnaire. In the first 44 patients, early and late followup was performed. Results. Followup was performed 7.4 years (0.5-17 years) after construction of W (n = 9) and J (n = 125) ileal pouch, which had similar results. There were 14.9% early and 43.6% late complications with 12.7% early and 19.5% late reoperations. Protecting loop-ileostomy used in 54 patients (43.9%), did not protect against complications. Thirteen reservoirs (9.8%) were resected (n = 8) or deactivated (n = 5) due to functional failure. Operation time, postoperative complications and pouchitis were determinators for reservoir failure and reduced quality of life. The functional results at followup of 44 patients at 2.5 years (0.8-6.7 years) and 11.5 years (8.2-19.2 years) were remarkably similar. Conclusions. IPAA is a good option for most patients when medication fails. 10% experience failure with inferior quality of life. Protective stoma will not reduce failure rates. After an initial time period, reservoir function will not change over time.

Technical aspects of ileoanal pouch surgery

Ileal pouch-anal anastomosis has become the surgical procedure of choice for chronic ulcerative colitis. Since the initial description of the technique, various modifications have facilitated its evolution into a safe operation with excellent long-term outcomes. However, some aspects of the operation remain contentious. Our aim is to describe the technical aspects of ileal pouch-anal anastomosis and review the current literature in the areas of controversy.

The impact of technical factors on outcome of restorative proctocolectomy for familial adenomatous polyposis

PURPOSE

This study was designed to assess the impact of technical factors on functional outcomes and complications in patients undergoing restorative proctocolectomy for familial adenomatous polyposis.

METHODS

This was a descriptive study on 189 patients undergoing restorative proctocolectomy in a single tertiary referral center between 1977 and 2003. Primary outcomes were major complications, pouch function, and neoplastic transformation in the anal transitional zone.

RESULTS

Pouch construction was J-reservoir (60 percent), W-reservoir (34 percent), or S-reservoir (6 percent), with double-stapled (31 percent) or handsewn anastomosis with mucosectomy (69 percent). Overall pouch survival was 96 percent at five years and 89 percent at ten years, with no differences according to pouch design or anastomotic technique. The incidence of pelvic sepsis was unaffected by anastomotic technique (stapled vs. handsewn; 12 vs. 13 percent) or type of reservoir (J- vs. W- vs. S-pouch; 16 vs. 9 vs. 10 percent). Fistula formation was independent of anastomotic technique (stapled vs. handsewn; 8 vs. 8 percent) and type of reservoir (J- vs. W- vs. S-pouch; 9 vs. 7 vs. 0 percent). The night-time and 24-hour bowel frequencies were similar with the two anastomotic techniques and types of reservoirs. The incidence of polyps at the anal transitional zone was lower with handsewn than with stapled anastomosis (19 vs. 38 percent; P=0.047).

CONCLUSIONS

Restorative proctocolectomy in patients with familial adenomatous polyposis has good functional outcomes and an acceptable rate of complications, which are independent of choice of technique. Handsewn ileoanal anastomosis with mucosectomy seems to reduce the incidence of subsequent neoplasia in the anal transitional zone but does not eliminate the risk of cancer.

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.

Ileal pouch-anal anastomosis: the Australasian experience

OBJECTIVE

The aim of this project was to establish and maintain an internet-based database of all ileal pouch procedures performed in major centres in Australasia.

METHOD

The initial three colorectal units contributing data are Auckland, northern Brisbane and Central Sydney Area Health Service. A web-based database was designed. The data collection method was tested on a subgroup of 20 patients to ensure functionality. Data were collected in five main categories: patient demographics, preoperative data, operative details, postoperative complications and functional results.

RESULTS

Initial data are presented for 516 patients [363 J, (70%), 133 W (26%), 16 S pouches (3%)]. There were two deaths within 30 days (0.4%). The anastomotic leak rate overall, in handsewn (HSA) and stapled anastomoses (SA) respectively was 5.0%, 8.5% and 3.3% (P=0.02 for difference HSA vs SA). Incidence of pouchitis was 20% (ulcerative colitis 23%, Crohn's disease 20%, indeterminate colitis 22%, familial adenomatous polyposis 9%). Incidence of anal stricture requiring intervention (11% overall) was significantly greater in HSAs than in SAs (16%vs 9%, P=0.02). Incidence of small bowel obstruction at any time postoperatively was 16%. Functional data were available for 234 patients. The median frequency of bowel actions during waking hours was significantly less in W pouches than in J pouches (four vs five, P=0.0005).

CONCLUSION

A national web-based database has been developed for access by all Australasian colorectal units. Initial Australasian data compare favourably with other international studies. Pouchitis continues to be a long-term problem. The leak rate and rate of late anal stricture requiring a procedure are higher if the anastomosis is handsewn rather than stapled. Functional results are better with the W pouch than with the J pouch.

The role of scintigraphic defecography in the assessment of bowel function after restorative proctocolectomy for ulcerative colitis

BACKGROUND

The aim of the study was to evaluate the efficiency of defecation in patients with ileal pouch for ulcerative colitis by using the mean of scintigraphic defecography.

METHODS

Sixteen patients were classified into two groups according to the presence of good (group A) or poor (group B) pouch function. Emptying efficiency was calculated by scintigraphic defecography and measured as percentage of evacuation. This involves the use of up to 200 ml of an artificial stool made up of methyl cellulose paste labeled with 180 MBq of technetium-99 m (Tc-99 m) methylene diphosphonate. Potential causes of increased frequency in the absence of additional associated symptoms of dysfunction were excluded in all patients. Maximum tolerated volume (MTV) and balloon expulsion tests were also performed on all patients.

RESULTS

No patient in both groups showed evidence of organic pouch dysfunction. Percentage of emptying was higher in patients of group A (n=6) than in group B (n=10) (81+/-9 vs 71+/-9%, respectively, P<0.05; correlation, -0.51, P<0.04). Mean MTV was similar in the two groups (group A: 361+/-118 ml and group B: 338+/-77 ml, P=0.7). Results of the balloon expulsion test were normal in all patients except for one individual in group B.

CONCLUSION

In patients with ileal pouch for ulcerative colitis, increased frequency of defecation without any evidence of pouch dysfunction may be correlated with an alteration of emptying efficiency. Scintigraphic defecography is appropriate to use for investigation of this condition with no disadvantages for the patients.

Distal cT2N0 rectal cancer: is there an alternative to abdominoperineal resection?

PURPOSE

Patients with cT2N0 distal rectal cancer do not require adjuvant therapy. However, when a patient refuses an abdominoperineal resection (APR), is there an alternative? The purpose of this trial is to determine whether preoperative external-beam radiation therapy can increase the rate of sphincter preservation for patients with distal cT2N0 adenocarcinoma of the rectum.

PATIENTS AND METHODS

Between April 1988 and October 2003, 27 patients with distal rectal adenocarcinoma staged T2 by clinical and/or endorectal ultrasound who were judged by the operating surgeon to require an APR were treated with preoperative pelvic radiation alone (50.4 Gy). Surgery was performed 4 to 7 weeks later. If pathologic positive pelvic nodes were identified, postoperative adjuvant chemotherapy was recommended. The median follow-up was 55 months (range, 9 to 140 months).

RESULTS

The pathologic complete response rate was 15% and 78% of patients underwent a sphincter-sparing procedure. The crude incidence of local failure for patients undergoing a sphincter sparing procedure was 10% and the 5-year actuarial incidence was 13%. The actuarial 5-year survival for patients undergoing sphincter preservation was as follows: disease-free, 77%; colostomy-free, 100%; and overall, 85%. Using the Memorial Sloan-Kettering Cancer Center sphincter function score, 54% of those undergoing a sphincter-sparing procedure had good/excellent bowel function at 12 to 24 months after surgery, and 77% had good/excellent function at 24 to 36 months after surgery.

CONCLUSION

Our data suggest that for patients with cT2N0 distal rectal cancer who require an APR, preoperative pelvic radiation improves sphincter preservation without an apparent compromise in local control or survival.

A new operative technique for restorative proctocolectomy: the endorectal pull-through combined with a double-stapled ileo-anal anastomosis

BACKGROUND

In children, restorative proctocolectomy is usually accomplished by a rectal mucosectomy followed by a hand-sewn ileo-anal anastomosis+/-ileal pouch. In certain patients, a hand-sewn anastomosis can be technically difficult. This led us to develop a new technique that combines endorectal mucosectomy with a double-stapled ileo-anal anastomosis.

METHODS

After colectomy, an ileal J-pouch is constructed. The head of the circular stapler is placed in the apex of the pouch and secured. An endorectal mucosectomy is completed from the abdomen to approximately 1.5 cm above the dentate line. The rectal mucosal/submucosal tube is everted onto the perineum. A transverse stapler is positioned 1.5 cm above the dentate line on the perineum and fired. The circular stapler is inserted transanally and the trocar advanced through the transverse staple line until the head and anvil are mated and then fired. A loop ileostomy is constructed.

RESULTS

Thirteen patients, with a mean age of 12.3 years, have undergone endorectal mucosectomy with a double-stapled anastomosis without major complication. The operative time averaged 280+/-70 minutes. The mean 24-hour stool frequency, with 9 months' follow-up, was 6.8+/-3.2, of which 1+/-0.7 were at night.

CONCLUSIONS

The combination of endorectal mucosectomy with a double-stapled anastomosis is a new approach for patients requiring restorative proctocolectomy. In our early experience, this technique was completed with a low complication rate and excellent functional results.

A study of the complications and pelvic visceral function after restorative proctocolectomy and W pouch construction

OBJECTIVE

Aspects of ileal pouch surgery remain controversial. The authors' single practice experience of 107 operations illustrates many of them. It was hoped that its study would contribute usefully to the debate.

PATIENTS AND METHODS

Details of all 107 restorative proctocolectomies carried out since the operation was started in Gloucester in 1984 until the study period ended have been kept prospectively. All patients had proctectomy by mesorectal dissection, and 106 had W pouch restoration. Four suffered functional failure requiring reversion to ileostomy and three patients have died. The remaining 99 were sent a questionnaire concerning pelvic visceral function and evidence of pouchitis. Records of all but one of the patients have been reviewed.

RESULTS

Surgical morbidity was low with neither chronic pelvic sepsis, pouch related fistula, pouch haemorrhage nor pouch ischaemia. Mucosectomised patients had similar bowel control to the stapled group. The policy change from routine to selective protective ileostomy proved satisfactory. W pouch function was found to be comparable to that reported from major J pouch series, although anti-diarrhoeal usage was reduced, and was not influenced by either gender, age or time since surgery.

CONCLUSION

None of the following reasonably intuitive assumptions seem supported by our findings: that mesorectal excision necessarily poses a greater danger to pelvic visceral function than close rectal dissection, that the greater capacity of W pouches will be reflected in markedly less frequency, that mucosectomy would impair anal control, or that a defunctioning ileostomy is a mandatory precaution. Pouch frequency is less if wind can be passed separately; otherwise functional outcome seems determined by other, non-technical, factors.