Endorectal ileal pullthrough operation with ileal reservoir after total colectomy

Complications in children with ulcerative colitis undergoing ileal pouch-anal anastomosis

Total colectomy with ileal pouch-anal anastomosis (IPAA) is considered the standard procedure for the surgical management of ulcerative colitis. Despite the widespread utility of the procedure, as many as 75% of patients who undergo IPAA, experience at least 1 complication. This review highlights difficult intraoperative scenarios and complications of pouch surgery in children, including intraoperative, postoperative, and functional complications. Intraoperative scenarios include insufficient mesenteric length and positive leak tests. Postoperative complications include surgical site infection, anastomotic leak, stricture, fistula, pouchitis, small bowel obstruction, and pouch failure. Less common complications include afferent limb syndrome, pouch prolapse, and superior mesenteric artery syndrome. Functional complications include incontinence, impaired quality of life, infertility, and sexual dysfunction. Despite complications, most patients are satisfied with their outcomes and report an improvement in their lifestyle.

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 results of restorative proctocolectomy for ulcerative colitis

To study the long-term effects of restorative proctocolectomy with J-pouch for ulcerative colitis 100 consecutive patients were examined a mean of 5.6 years after ileal pouch-anal anastomosis (IPAA). Seventy-three percent of patients were on steroids and 22% had a preceding severe attack of colitis before IPAA. The overall early and late complication rates were 40% and 33%, respectively. Failure rate was 5% and all failures requiring pouch excision occurred within the first three postoperative years. Pouchitis (36%) was the commonest late complication. A preceding severe attack of colitis was an important prognostic sign of late anastomotic complications, troublesome incontinence and ultimate failure. The daily mean stool frequency varied from 4.5 to 6.9. After a short learning period continence-stabilised and minor incontinence was common (57%). The majority of patients (72%) were either very satisfied or had no problems in daily activities after IPAA. Ten patients were dissatisfied after surgery due to obvious medical reasons in most of them.

[The expanded ileal pouch as a reservoir in continence preserving proctocolectomy. An experimental study on the pig]

Silicone balloons were inserted into bypassed segments of terminal ileum of five mini-pigs. The balloons were expanded over a period of 3 months, thereby creating pouches with a mean volume of 700 cm3 (a 9.5-fold increase). Functional proctocolectomy was performed and the bypassed segment was than placed in continuity with its terminal end at the previous site of the anus, thus creating a neorectum. One year later, the three pigs were still alive. They were continent and stool frequency was 2-3 times a day. The final mean volume of the pouch was still 360 cm3, corresponding to a 5.7-fold increase. At the end of the experiment significant hypertrophy of the bowel wall thickness was observed compared to the controls. The rectal X-ray contrast study demonstrated a new rectal reservoir without fistula or stenosis.

New rectum and new anal canal: two cases of ileal reservoir-cutaneous anastomosis

Two patients who had total proctocolectomy for ulcerative colitis 4 and 10 years ago respectively have each been given a new rectum and anal canal, the lower end of a J ileal reservoir being brought through the pelvic floor muscles and joined to a skin wound made in the perineum.

Ileoproctostomy with J-pouch: use of the Swenson pull-through for reconstruction after proctocolectomy for ulcerative colitis

Continence can be preserved by several operations following proctocolectomy for ulcerative colitis. The Swenson procedure, used for congenital megacolon, may be applied for reconstruction following proctocolectomy for other colonic disease. Rectal eversion and resection to the dentate line obviates the need for mucosectomy and permits ileoanal anastomosis with excellent exposure. Two girls, 9 and 11 years of age, underwent proctocolectomy, formation of an ileal J-pouch, and a Swenson pull-through with ileoanal anastomosis. One year following closure of diverting ileostomies, both children have 2 to 3 continent bowel movements daily with very rare nocturnal soiling. Anal manometry is normal. The application of this method for ileoanal anastomosis may broaden the choice of operations for selected children requiring proctocolectomy.

Ileal "J" pouch-anal anastomosis. Clinical outcome

One hundred eighty-eight patients undergoing abdominal colectomy with distal mucosal proctectomy and endorectal ileal pouch-anal anastomosis were reviewed to assess long-term functional results and to identify factors that might influence them. There was no postoperative mortality, but 10 patients (5.3%) required permanent ileostomy because of postoperative complications or the development of unsuspected Crohn's disease. Immediate postoperative complications, including pelvic sepsis, small bowel obstruction requiring surgery, anastomotic stricture, and ileostomy dysfunction, were observed in 11%, 9%, 14% and 9% of patients, respectively. No males were impotent but nine (9%) developed retrograde ejaculation. Pouchitis occurred in 8% of patients. Among 157 patients assessed at least 60 days after ileostomy closure (mean +/- SD, 375 +/- 216 days), all evacuated their neorectum spontaneously, and stool frequency was 6.0 +/- 2.6 daily and 1.2 +/- 1.3 nightly. While continence was generally good, 2.5% of patients during waking hours and 4.5% during sleep had occasional frank soilage. Moreover, seepage was noted in 25 and 47% of patients during daytime and nighttime, respectively. Both stool frequency and degree of continence improved with time. Patients less than 50 years of age and those with polyposis coli had fewer stools and better continence than those older than 50 or those with ulcerative colitis. It is concluded that ileal "J" pouch-anal anastomosis can be performed safely and will provide acceptable anorectal function without late deterioration.

Continence following ileo-anal anastomosis with an antiperistaltic terminal ileal segment

The procedure of total colectomy, excision of the rectal mucosa and ileo-anal anastomosis with or without a proximal small intestinal reservoir has been described as a method of treating patients with ulcerative colitis and familial polyposis coli. The purpose of constructing a terminal ileal reservoir is to reduce the severe diarrhoea which often occurs following ileo-anal anastomosis. It is suggested that the use of a single antiperistaltic segment for this purpose would reduce the diarrhoea, and provide continence. This has been tested in the dog and the results are reported in this publication.

A muscle ablation sphincter to prevent diarrhea after total colectomy in puppies: a preliminary report

Many adjunctive surgical techniques have been proposed to decrease diarrhea following total colectomy with an ileoanal anastomosis. A previously proposed method of longitudinal muscle ablation in canine small intestine to produce an "artificial sphincter" and increase transit time after massive small bowel resections has been applied to puppies who have had a total abdominal colectomy and ileoproctostomy. Total abdominal colectomy with ileoproctostomy at the level of the peritoneal reflection was performed in 6 mongrel puppies, aged 6-8 weeks. Two control puppies died within 2 weeks of the procedure with overwhelming diarrhea. Four experimental animals had "sphincters" (circumferential excision of a 1 cm length of longitudinal muscle) placed 5 cm proximal to the ileoproctostomy anastomosis. The puppies with colectomy plus sphincter were followed from 14 months to two years postoperatively and had intestinal transit times of 3-4 1/2 hours comparable to unoperated littermates. Intermittent postoperative barium enemas were performed and gross and histologic examination of the sphincters were carried out at necropsy. This muscle ablation technique when used in puppies with total abdominal colectomy and ileoproctostomy controls diarrhea, allows survival with normal growth and does not result in proximal small bowel enteritis.

Endorectal ileal pullthrough with isoperistaltic ileal reservoir for colitis and polyposis

Seventy-eight patients with ulcerative colitis refractory to medical therapy and eight with colonic polypisis have undergone total colectomy mucosal proctectomy, endorectal ileal pull-through with ileoanal anastomosis, and diverting ileostomy at the UCLA Medical Center during the past 7 years. Seventy-seven patients underwent a second stage operation with construction of a lateral isoperistaltic ileal reservoir, 12 to 30 cm long, and closure of the ileostomy. A reservoir 10 to 15 cm long appears optimal for children, and one 20 cm long appears to function best for adults. Major complications were either related to obstruction of the reservoir outlet from leaving a rectal muscle cuff longer than 6 cm, and/or constructing the reservoir too long in the early experience (16 patients), or from cuff abscesses (four patients). Out of the 77 patients, these problems led to reservoir removal in three, temporary ileostomy in eight, and reservoir revision in 16. Persistent cuff abscess was the cause for reservoir removal in two of four patients. Continence was achieved in all patients within 2 weeks. Good to excellent results were obtained in 65 patients. At one year, 78% were completely continent during the day, 18% had minor seepage, and four per cent had occasional soiling. Frequency of defecation in patients without complications, or those surgically corrected, was seven per 24 hours within 3 months. There were no deaths. Six patients were found to have unsuspected cancer at operation. No patient experienced bladder dysfunction or abnormal sexual function. Although a technically difficult operation, the long-term results indicate that the pullthrough operation is a good alternative to proctocolectomy with ileostomy.

Myoelectric and motor activity of the terminal ileum after pelvic pouch for ulcerative colitis

The electrical and motor activity of the terminal ileum after proctocolectomy and ileoanal reservoir was evaluated in seven patients who had undergone surgery for ulcerative colitis. Recordings were carried out with an intraluminal probe under fasting conditions, during stepwise distention of the pouch, in the postprandial state and after administration of Prostigmine and bisacodyl. Ileal sensitivity was also studied. Phase III of the interdigestive myoelectric motor complex, when detectable (four patients), was characterized by regular spike bursts superimposed on slow waves at a frequency of 9 cycles per minute. Two different types of motor patterns were observed: short phasic waves lasting 2 to 6 seconds and long tonic waves lasting up to 2 minutes. In most cases, the amplitude and frequency of the pressure events were higher in the efferent limb than in the reservoir. Electrical activity of the surrounding rectal muscle and striated sphincters was also recorded. When distended to the maximum tolerable volume, the reservoir showed spike bursts propagated aborally at a frequency of 15 per minute, leading to large propulsive waves. An overall increase of spike activity was observed after a meal, which did not affect the slow waves. Neostigmine caused an irregular increase of electrical and motor activity, more evident in the efferent limb. Bisacodyl, used to test the functional integrity of the myenteric plexus, elicited strong propulsive contractions and urgency. Leakage did not occur frequently either at rest or under stimuli. Onset of sensation was elicited with volumes of 271 +/- 149 ml (Mean +/- SD) in the reservoir and 17 +/- 6 ml in the efferent loop of small bowel (P less than 0.001).

IN CONCLUSION

1) most of the electrical and motor properties of the terminal ileum are retained after surgery; 2) due to its large capacity, the reservoir acts as a storage organ; and 3) overall motility is reduced in the pouch when compared with the distal ileum and propulsion in the triple-loop system is opposed by the activity of the anal sphincters.

Endorectal ileal pull-through for ulcerative colitis and polyposis in children

The marked reluctance to leaving a permanent ileostomy in a child is understandable; too often, however, before surgical therapy is accepted, the patient is permitted to decline to a hopeless state from which restoration is virtually impossible without operation. Endorectal ileal pull-through provides an attractive alternative. From 1972 to 1982 at Children's Hospital, G. Gaslini Institute, Genoa, nine patients with ulcerative colitis and eight patients with familial polyposis received this operation. Results are encouraging and support the more frequent use of this alternative.

Colectomy and endorectal ileal pull-through with lateral ileal reservoir for ulcerative colitis and polyposis in children

Nineteen children with chronic ulcerative colitis refractory to medical therapy and one with multiple polyposis, all under 20 years of age, underwent total colectomy, mucosal proctectomy, and endorectal ileal pull-through with ileoanal anastomosis at the UCLA Medical Center during a 4 1/2-year period (mean age, 14.4 years). Seventeen patients underwent second-stage closure of the ileostomy with construction of a side-to-side isoperistaltic ileal reservoir (mean, 6 months) after the ileal pull-through operation. The anastomosis extended over a 20- to 30-cm distance and the lower end was placed within 6 to 8 cm of the ileoanal anastomosis. Transient reservoir inflammation, which occurred in more than half of the patients, was reduced by the use of oral Metranidazole and was rare 6 months postoperation. Cuff abscess in one patient did not respond to long-term antibiotics and required ileostomy as well as eventual takedown of the reservoir. Two patients developed obstruction of the ileum below the reservoir due to an extended distance between the reservoir and anal anastomosis, requiring transient ileostomy. Fourteen of the 17 children who have undergone lateral reservoir construction have achieved a good-to-excellent result, with complete continence and an average of five stools per 24 hours after 6 months. Seven of the 14 now participate in competitive athletics. Three children await construction of the reservoir.

Endorectal ileoanal anastomosis with isoperistaltic ileal reservoir after colectomy and mucosal proctectomy

Forty-nine patients with chronic ulcerative colitis refractory to medical therapy and four with multiple polyposis have undergone total colectomy, mucosal protectomy, and endorectal ileal pull-through with ileoanal anastomosis at the UCLA Medical Center during the past 12 years (mean age, 19.4 years). Thirty-eight patients underwent second-stage closure of the ileostomy with construction of a side-to-side isoperistaltic ileal reservoir (mean, 6 months) after the ileal pullthrough operation. The anastomosis extended over a 20-30 cm distance and the lower end was placed within 6-8 cm of the ileonanal anastomosis. Transient reservoir inflammation, which occurred in half of the patients, was reduced by the use of oral metranidazole and was rarely found 6 months after operation. No patients died during the early or late post-operative periods. Cuff abscess in two patients and obstruction of the ileal reservoir outlet have required takedown of the reservoir (two patients) or temporary ileostomy (three patients). Of the 38 patients who have undergone lateral ileal reservoir construction, 33 have achieved a good to excellent result with complete continence and an average of five stools per 24 hours after 6 months. At least 12 patients now participate in competitive athletics; normal sexual activity has been achieved in all but one patient. Seven patients await construction of the reservoir. Although a technically difficult operation, the long-term results (mean, 19.4 months) indicate that the pullthrough operation is a good alternative to standard proctocolectomy.

The lateral reservoir technique of ileal endorectal pull-through for ulcerative colitis and familial polyposis in children

Total abdominal colectomy and endorectal ileal pull-through have been widely used in children as a definitive continence-preserving procedure for ulcerative colitis (UC) and familial polyposis (FP). Controversy exists in regards to the results achieved with the various techniques utilized to accomplish this procedure, including straight ileal pull-through, pull-through with balloon dilatation of the lower ileal segment, and the construction of a variety of ileal reservoirs: S-shaped, J-shaped, or lateral. We have utilized the two-stage lateral reservoir approach advocated by Fonkalsrud et al, on a total of 12 patients, aged 1 to 17 years, including ten patients with UC and two with FP. Twelve patients have undergone stage 1 and seven of these stage 2. Numerous complications of stage 1 occurred early in the series, including breakdown of the ileoanal anastomosis, 3 patients; cuff abscess, 2 patients; postoperative intestinal obstruction, 2 patients; and intraabdominal abscess, 1 patient. All have fully recovered. The last six stage 1 procedures have been without complications. Five of the seven stage 2 patients are now well, continent, and having four to six controlled bowel movements a day 1 to 2 years postoperatively. Two patients are using small amounts of Immodium and Metamucil. One patient has developed marked dilatation of the pouch at 8 months postoperatively with episodic "pouchitis" requiring operative revision and diversion. One stage 2 patient suffered numerous complications including spontaneous perforation of the reservoir 2 months postoperatively, eventually leading to re-creation of a permanent ileostomy and removal of the pouch. Five patients await further treatment. The lateral reservoir technique is capable of producing a satisfied and continent patient; however, the potential technical problems and early complications are significant. The occurrence of delayed "pouchitis" is worrisome. Although the initial results with the lateral reservoir technique appear encouraging, further longterm evaluation is necessary.

Mucosal proctectomy without reservoir

Mucosal proctectomy with endorectal pull-through allows the removal of all colonic mucosa with preservation of continence. This operation was performed in 19 patients with familial polyposis coli and ulcerative colitis. A temporary loop ileostomy was used to defunctionalize the anastomosis. Intestinal continuity was restored in 17 of the 19 patients. Mean duration of follow-up was 29 months. All patients are continent, and the mean number of bowel movements per 24 hours is 6. Follow-up barium studies revealed a gradual dilatation of the terminal ileum within the rectal cuff which accounts for the decrease in the number of bowel movements. This operation eliminates the risk of carcinoma without compromising sphincter function.

Comparison of endorectal ileal pullthrough following colectomy with and without ileal reservoir

In an experimental study, 18 dogs underwent total colectomy, mucosal proctectomy, and endorectal ileal pullthrough with ileoanal anastomosis. In 6 dogs, no internal reservoir was constructed (NR). In 6 additional dogs, an S-shaped ileal reservoir (SR) was constructed immediately above the peritoneal reflection. In 6 other dogs, a side-to-side ileal reservoir (SS) of 15-cm length was constructed above the peritoneal reflection. At 12 wk postoperatively, there was a 231% increase in volume of the SS reservoir, whereas the SR increased 85% and the NR increased 78%. Dogs with NR experienced high stool frequency with low water absorption and minimal dilatation. Dogs with SR experienced dilatation rapidly, reducing stool frequency but causing stasis and moderate to severe inflammation of the ileal mucosa. Dogs with SS of at least 15-cm length enlarged sufficiently to reduce stool frequency and increase water absorption slightly without causing stasis or appreciable inflammation.

Endorectal ileal pullthrough with ileal reservoir for ulcerative colitis and polyposis

Total colectomy, mucosal proctectomy, and endorectal ileal pullthrough operations were performed in 29 patients (mean age 16.8 years) with ulcerative colitis or polyposis during the past 10 years. The immediate and long-term results achieved after use of a lateral internal ileal reservoir 25 to 30 cm long in 15 patients were superior to those after construction of an S-shaped reservoir (5 patients) or when no ileal reservoir was used (3 patients). A completely diverting ileostomy was used for approximately 4 months to minimize complications. A mean of four continent bowel movements per 24 hours has been achieved within 4 weeks in patients with lateral reservoirs; all have returned to school or work within 4.5 weeks. The absence of mortality and the low morbidity suggest that the endorectal pullthrough with ileal reservoir should be the primary operation early in the course of ulcerative colitis refractory to medical therapy.

Endorectal ileal pullthrough with lateral ileal reservoir for benign colorectal disease

Eight patients with ulcerative colitis and one with multiple polyposis have undergone total colectomy, mucosal proctectomy, endorectal ileal pullthrough with ileoanal anastomosis, and a diverting ileostomy at UCLA Hospital during a two-year period. Five of the patients underwent construction of side-to-side ileal reservoirs and closure of the cutaneous ileostomies within six months. Wound complications were uncommon compared with the previous clinical experience with an S-shaped ileal reservoir. Each of the five patients has complete fecal continence with an average of four bowel movements per 24-hour period. A temporary diverting ileostomy and transcutaneous reservoir catheter for irrigation help to minimize complications. Construction of an ileal reservoir proximal to the endorectal ileal pullthrough segment provides a better opportunity for fecal storage than if no reservoir is used because it reduces defecatory urgency and frequency as well as perineal inflammation. The lateral ileal reservoir produces less stasis and achieves a more regular defecatory pattern than the S-shaped reservoir. Favorable clinical experience with the lateral internal ileal reservoir and ileoanal anastomosis in five patients who had ulcerative colitis or multiple polyposis suggests that further clinical application in selected patients is warranted.

Continent ileoanal endorectal pull-through

Five patients with familial polyposis coli, ages 13 through 21 yr, were given the choice of permanent reservoir-type ileostomy or ileoanal endorectal pull-through to prevent cancer of the colon. Total colectomy and an ileoanal endorectal pull-through was uniformly chosen and was performed using the principles described by Boley and Soavè. The post-operative courses were characterized by a transition from 8 to 10 liquid stools per day and up to 3 incontinent nocturnal stools, to a bowel pattern of 2 to 4 continent semi-liquid stools without nocturnal soiling by 1 mo. Defecograms at 1 mo revealed excellent sphincter function and mild reservoir dilatation of the ileum. These observations have convinced us that this is the operative management of choice for familial polyposis.

Total colectomy, mucosal proctectomy, and ileoanal anastomosis

A safe and practical procedure for total colectomy and mucosal proctectomy with ileoanal anastomosis has been developed and performed by us on 11 patients with adenomatosis coli and two patients with ulcerative colitis. The major features of the operative procedure are 1) total removal of the rectal mucosa to just above the dentate line; 2) preservation of anorectal function by a long rectal cuff procedure achieved by rectal mucosal excision from a level just below the sacral promontory, using a rectal internal stent and gauze packing techniques for rectal mucosal stripping, with, in some patients, an ileal reservoir added; and 3) prevention of pelvic sepsis by intraoperative rectal irrigation, rectal cuff drainage, and a temporary defunctioning loop ileostomy. Of six patients with at least three months of follow-up after reconstruction, each has returned to normal life, averaging two to seven semiformed stools each day. A side-to-end ileoanal anastomosis with a low-lying, loop-type ileal reservoir provided the best functional results.

Rectal mucosal replacement

Preservation of the rectum in chronic ulcerative colitis or familial polyposis conserves continence at the risk of recurrent disease or malignant change. Replacement of rectal mucosa with a graft of ileum in these benign colonic mucosal diseases conserves fecal continence without the threat of continuing disease or the development of carcinoma. Rectal mucosal replacement with construction of a rectal reservoir includes total colectomy, removal of the rectal mucosa-submucosa and its replacement with an ileal graft. A rectal reservoir is constructed when intestinal continuity is restored. Twenty-nine patients have undergone rectal mucosal replacement; 12 for familial polyposis and 17 for ulcerative colitis. Twenty-five patients have had intestinal continuity restored. Patients have been followed from three months to seven years after the restoration of intestinal continuity. Twenty-three patients have a satisfactory result. Fecal continence has been preserved. Patients pass an average of six stools in a 24 hour period.