The critical level for preservation of continence in the ileoanal anastomosis

Guidelines for the management of postoperative soiling in children with Hirschsprung disease

Although most children with Hirschsprung disease ultimately achieve functional and comfortable stooling, some will experience a variety of problems after pull-through surgery. The most common problems include soiling, obstructive symptoms, enterocolitis, and failure to thrive. The purpose of this guideline is to present a rational approach to the management of postoperative soiling in children with Hirschsprung disease. The American Pediatric Surgical Association Hirschsprung Disease Interest Group engaged in a literature review and group discussions. Expert consensus was then used to summarize the current state of knowledge regarding causes, methods of diagnosis, and treatment approaches to children with soiling symptoms following pull-through for Hirschsprung disease. Causes of soiling after pull-through are broadly categorized as abnormalities in sensation, abnormalities in sphincter control, and "pseudo-incontinence." A stepwise algorithm for the diagnosis and management of soiling after a pull-through for Hirschsprung disease is presented; it is our hope that this rational approach will facilitate treatment and optimize outcomes.

Restorative proctocolectomy and ileal pouch-anal anastomosis in children

PURPOSE

This study was designed to evaluate the results of restorative proctocolectomy with distal rectal mucosectomy and ileal pouch-anal anastomosis in children.

METHODS

This study is a retrospective review of 100 consecutively referred children (<18 years old) who underwent reconstruction with a J-pouch of ileum and preservation of the transitional anorectal epithelium by the same two-surgeon team. Temporary diverting ileostomy was used. The main outcome measures were daytime and nocturnal fecal continence, bowel movements per day, and complications including pouchitis, ileoanal stricture, or postoperative small-bowel obstruction.

RESULTS

Average age of the 100 children (48 males/52 females) was 13.2 years (range, 2.95-17.99). All 25 children with familial adenomatous polyposis had proctocolectomy and reconstruction performed simultaneously. Of 75 children with ulcerative colitis, 50 (67%) had their colectomy followed by reconstruction after an interval ranging from 2 months to 4.4 years. Median postoperative follow-up was 2.6 years. Daytime fecal continence was achieved in 98 children, although 4 reported rare accidents. Nighttime continence was achieved in 93 children, of whom 14 reported rare accidents. The average frequency of bowel movements was 5.43/day (+/-2.22). Only one child with polyposis had pouchitis. Of 75 children with ulcerative colitis, 35 had symptoms consistent with pouchitis; of these 35 children, 10 required prolonged treatment. The most frequent postoperative complication was ileoanal stricture requiring operative dilatation and/or anoplasty (18 children). Bowel obstruction requiring surgery occurred in 18 children. One child eventually required pouchectomy for probable Crohn's disease.

CONCLUSIONS

Excellent results can be achieved with restorative proctocolectomy in children with respect to fecal continence and stool frequency. However, with ulcerative colitis, a substantial risk of pouchitis remains.

Ileal pouch-anal anastomosis for ulcerative colitis: technical considerations

Total colectomy with ileal pouch-anal anastomosis has emerged as the preferred surgical treatment for ulcerative colitis. The operation has evolved over the last few decades. Various technical issues are discussed, including types of reservoir, options for mesenteric lengthening, method and level of ileoanal anastomosis (hand-sewn versus stapled), and rationale for staging. Anticipated postoperative problems and strategies for management are discussed.

Surgery for inflammatory bowel disease

Ulcerative colitis is potentially cured by total excision of the colon and rectum. Crohn's disease is an unremitting condition in which operations are frequently multiple and in which the minimum amount of bowel possible should be excised.

Restorative proctocolectomy with ileal pouch-anal anastomosis in very young patients with refractory ulcerative colitis

BACKGROUND/PURPOSE

Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the standard surgical treatment for ulcerative colitis (UC). The purpose of the current study was to determine the outcome of very young patients (< or =10 years of age) with UC undergoing IPAA.

METHODS

Between 1978 and 2002, 13 patients 10 years of age or younger underwent IPAA for management of UC at the authors' institution. Charts were reviewed for patient characteristics, and a standardized telephone interview was performed.

RESULTS

Average age at diagnosis was 4.0 years (range, 1.0 to 8.4 years), and patients underwent IPAA at a mean of 6.8 years (range, 3.7 to 10.8 years). Pancolitis was present in 100%. The mean follow-up was 9.1 years (1.0 to 16.1 years), the average number of stools per day was 5 (3 to 8). All patients are continent while awake. Pouchitis was documented in 9 patients (75%). All patients or their parents rated the outcome of their procedures as "excellent."

CONCLUSIONS

When compared with older children, very young patients with UC tend to have more frequent total colonic involvement and a greater frequency of pouchitis after IPAA. The functional outcome and patient/family satisfaction with the procedure endorse IPAA as an attractive procedure even in the very young population with UC.

Quality of life in patients undergoing ileal pouch-anal anastomosis at the University of Cincinnati

BACKGROUND

In 1978, Drs. Fischer and Martin were among the first to preserve anorectal continence and create a pelvic reservoir in adult patients, in what has become the ileal pouch-anal anastomosis (IPAA).

METHODS

Here we review our institutions' experience with 379 of these procedures from 1978 to present. To assess the specific health concerns of patients with ulcerative colitis (UC) and familial adenomatous polyposis (FAP) and determine the effects of IPAA on health-related quality of life, we evaluated patients with the SF-36, the Rating Form of Inflammatory Bowel Disease Patient Concerns (RFIPC), time trade-off questions, and a gamble question.

RESULTS

IPAA patients did not differ from the general population in seven of eight general health categories assessed by the SF-36. When compared with the UC population as a whole using the RFIPC they had reduced concerns in almost all areas. In addition, time trade-off and gamble questions indicated that these patients, as a group, are willing to accept a significant risk of dying in order to achieve their results of the IPAA.

CONCLUSIONS

This high level of satisfaction has led to the referral of patients who would not have otherwise considered a procedure requiring permanent ileostomy.

Ileal pouch anal anastomosis without ileal diversion

OBJECTIVE

To evaluate continued experience with a one-stage stapled ileoanal pouch procedure without temporary ileostomy diversion.

SUMMARY BACKGROUND DATA

Most centers perform colectomy, proctectomy, and ileal pouch anal anastomoses (IPAA) with a protective ileostomy. Following a previous report, the authors performed 126 additional stapled IPAA procedures for ulcerative colitis and familial adenomatous polyposis, of which all but 2 were without an ileostomy. Outcomes in these patients question the need for temporary ileal diversion, with its complications and need for subsequent surgical closure.

METHODS

Two hundred one patients underwent a stapled IPAA since May 1989, 192 as a one-stage procedure without ileostomy, and 1 with a concurrent Whipple procedure for duodenal adenocarcinoma. Patient charts were reviewed or patients were contacted by phone to evaluate their clinical status at least 1 year after their surgery.

RESULTS

Among the patients who underwent the one-stage procedure, 178 had ulcerative colitis (38 fulminant), 5 had Crohn's disease (diagnosed after IPAA), 1 had indeterminate colitis, and 8 had familial adenomatous polyposis. The mean age was 38 +/- 7 (range 7--70) years; there were 98 male patients and 94 female patients. The average amount of diseased tissue between the dentate line and the anastomosis was 0.9 +/- 0.1 cm, with 35% of the anastomoses at the dentate line. With 89% follow-up at 1 year or more (mean 5.1 +/- 2.4 years) after surgery, the average 24-hour stool frequency was 7.1 +/- 3.3, of which 0.9 +/- 1.4 were at night. Daytime stool control was 95% and night-time control was 90%. Only 2.3% needed to wear a perineal pad. Average length of hospital stay was 10 +/- 0.3 days, with 1.5 +/- 0.5 days readmission for complications. Abscesses or enteric leaks occurred in 23 patients; IPAA function was excellent in 19 of these patients (2 have permanent ileostomies). In patients taking steroids, there was no significant difference in leak rate with duration of use (29 +/- 8 with vs. 22 +/- 2 months without leak) or dose (32 +/- 13 mg with vs. 35 +/- 3 mg without leak). Two (1%) patients died (myocardial infarction, mesenteric infarction).

CONCLUSIONS

The triple-stapled IPAA without temporary ileal diversion has a relatively low complication rate and a low rate of small bowel obstruction, provides excellent fecal control, permits an early return to a functional life, and can be performed in morbidly obese and older patients.

Restorative proctocolectomy in children with ulcerative colitis utilizing rectal mucosectomy with or without diverting ileostomy

BACKGROUND

Controversies continue concerning the best way to perform restorative proctectomy (RP) for ulcerative colitis (UC). Can rectal mucosectomy and hand-sewn ileoanal anastomosis (IAA) withstand the challenge posed by extrarectal dissection with a double-stapled technique and no mucosectomy? Is a diverting ileostomy mandatory after RP?

METHODS

The authors describe 30 consecutive children with UC who underwent RP with rectal mucosectomy and hand-sewn IAA. The authors assess the results and compare the first 14 patients (group 1) treated with temporary diverting ileostomies with the next 16 consecutive patients (group 2) without diverting ileostomies.

RESULTS

The average age (13.8 years in group 1 v 10.4 in group 2), duration of illness before resection (3.2 years in group 1 v 1.5 in group 2), and gender breakdown (10 of 14 were girls in group 1, 10 of 16 were girls in group 2) were similar between the two groups. Outcome was not significantly different between the two groups. Average bowel movements per 24-hour period was 5.5 in group 1 and 4.2 in Group 2. Occasional nighttime staining occurred in two patients in group 1 and five in group 2. No one suffered daytime staining in group 1, and one patient had occasional daytime staining in group 2. Average quality of life (on a scale of 0 to 5) as assessed by the patients or parents was 4.4 in group 1 and 4.9 in group 2. There were 10 total complications in group 1. One child required a permanent stoma for ileoanal separation. Two patients required reoperations for complications caused by the diverting ileostomy. The single instance of peritonitis was in group 1 caused by anastomotic leak after ileostomy closure. There were five total complications in group 2, of which, two required temporary stomas for ileoanal separations.

CONCLUSIONS

RP with rectal mucosectomy and hand-sewn IAA in children with UC provides good functional results. Peritonitis did not occur in the absence of diversion. Eliminating routine diverting ileostomy avoids the considerable complications and morbidity from the stoma and its closure.

Incidence of dysplasia in pelvic pouches in pediatric patients after ileal pouch-anal anastomosis for ulcerative colitis

BACKGROUND

The purpose of this study was to evaluate the incidence of dysplasia and the mucosal adaptation patterns of pelvic pouches in children and adolescents who had undergone ileal pouch-anal anastomosis for ulcerative colitis.

METHODS

Between 1982 and 1996, 176 pediatric patients with ulcerative colitis underwent ilial pouch-anal anastomosis. Seventy-six patients were followed up after surgery at the Cleveland Clinic. Pouch biopsy specimens were reviewed for dysplasia and to determine mucosal adaptation patterns. Fifty-eight of the 76 patients had an average of three mucosal biopsies during a mean follow-up of 5 years. Demographic and surgical data were abstracted from archives of medical records. All previously obtained pouch biopsy specimens were re-evaluated by a single pathologist to ensure standardized interpretation.

RESULTS

No dysplasia was identified in screening specimens of 76 children and adolescents including 5 patients who showed dysplasia in resected colon specimens. The pattern of mucosal adaptation was categorized using previously reported criteria. Type A was defined as normal mucosa or mild villous atrophy with no or mild inflammation. Type B mucosa showed transient atrophy with temporary moderate inflammation followed by normalization of architecture. Type C mucosa was defined as a pattern of persistent atrophy with severe inflammation. In the study cohort, the patterns of mucosal adaptation, type A (56.9%; n = 33), type B (32.8%; n = 19), and type C (10.3%; n = 6), were comparable with those reported in adults. The rate of pouch failure and diagnosis of Crohn's disease were similar in each group and were not related to the specific adaptation pattern. Most of the patients with type C mucosa had clinical symptoms of pouchitis requiring periodic antibiotic therapy. No dysplasia was identified in any biopsy specimen reviewed.

CONCLUSIONS

Similar morphologic changes can be seen in ileal pouches in pediatric and adult patients. There seemed to be no increased risk of dysplasia in children and young adults who had undergone ilial pouch-anal anastomosis surgery for ulcerative colitis during a 5 year follow-up. Because the long-term risk of development of dysplasia is unknown, an initial screening should be performed 5 years after the creation of a pelvic pouch in children or when the total disease duration exceeds 7 years. Once identified, patients with Type C mucosa should have annual screening for dysplasia until further data become available.

Outcome after ileoanal anastomosis in pediatric patients with ulcerative colitis

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

All mechanical low rectal anastomosis in children

PURPOSE

The aim of this study is to demonstrate the feasibility and usefulness of mechanical suturing in children for low rectal anastomosis.

METHODS

The study group includes 31 children operated on from January 1993 to July 1996 by the same senior surgeon, performing the modified Duhamel procedure for Hirschsprung's disease in 17 children, intestinal neuronal dysplasia in seven, and the Knight-Griffen procedure in seven pediatric patients with chronic ulcerative colitis.

RESULTS

In all the cases the technique of "viscero-synthesis" was performed using the mechanical stapler. A circular stapler has been used for the end-to-end and the end-to-side anastomosis between the anal canal or the back wall of the rectum with the pulled viscus, while a linear endoscopic stapler (GIA) has been used for the consolidation of the rectocolic wall in the modified Duhamel technique.

CONCLUSIONS

The results obtained demonstrate that the mechanical staplers in children are safe and effective in low rectal anastomosis, sparing operative time and reducing the risk of anastomotic dehiscence; however, the size of circular instruments limits its use in neonates and small infants.

Restorative proctocolectomy in children and adolescents

Children and adolescents with colitis present specific problems for surgeons. There has been a fashion, particularly in North America, for restoring continuity after colectomy by a direct ileo-anal anastomosis. The authors reviewed their experience with restorative proctocolectomy with ileal reservoir (RPC) in patients under 18 years of age to evaluate the outcome and to discuss the problems and challenges associated with the procedure in this age group. Fifteen patients (6 boys, 9 girls) were operated on between 1984 and 1995. The diagnoses included 12 patients with ulcerative colitis (UC), two with familial adenomatous polyposis (FAP), and one with total colonic neuronal dysplasia. The median age of the patients at the time of ileal pouch formation was 15 years, and follow-up data were available for all patients at a median of 43 months. Ten patients with UC underwent pouch surgery 4 to 14 months after initial total abdominal colectomy (7 for acute severe disease, 3 for chronic disease). Four patients (2 with chronic UC, 2 with FAP) underwent primary RPC. There were no deaths in this series. Three (20%) patients suffered serious early morbidity (pouch hemorrhage, pelvic sepsis, severe psychological crisis). Late morbidity included three patients who had small bowel obstruction, one who required laparotomy, two who required pouch revision, and five of 12 (42%) patients with UC who presented with a documented episode of pouchitis between 2 and 72 months after ileostomy closure. All patients had acceptable bowel frequency and quality of continence. This experience suggests that RPC provides an important surgical option for children and adolescents with UC or FAP.

Does eversion of the anorectum during restorative proctocolectomy influence functional outcome?

PURPOSE

The aim of this study was to determine the effect of eversion of the anorectum during restorative proctocolectomy (RP) for ulcerative colitis on functional outcome.

METHODS

One hundred seventeen patients underwent RP with stapled end-to-end ileal pouch-anal anastomosis (EEA), without resection of the anal mucosa. Sixty-four underwent EEA with eversion of the anorectum, and 53 underwent EEA without eversion. Each patient underwent paired studies of anorectal function before and a median of 12 months after RP.

RESULTS

One year after RP, median (interquartile range) maximum resting pressure was 69 (range, 51-88) cmH2O in those patients who underwent eversion vs. 80 (range, 64-90) cmH2O in patients without eversion (P < 0.04). Threshold sensation in the upper, middle, and lower thirds of the anal canal were 9.1, 7.4, and 6.8 mA after eversion vs. 6.9, 4.9, and 3.8 mA without eversion (P = 0.003, P < 0.001, P < 0.001, respectively). Before operation, all patients had a rectoanal inhibitory reflex; however, after RP, 54 of 64 patients in the eversion group and 50 of 53 patients with a stapled EEA without eversion had an inhibitory reflex (P = not significant). Leakage of mucus was experienced by 11 patients who underwent eversion, compared with 9 patients without eversion. Fifty-six of 64 patients with eversion could defer defecation for more than 30 min compared with 43 of 53 patients without eversion. Twenty-two of 64 patients in the eversion group retained perfect discrimination between flatus and feces compared with 38 of 54 without eversion (P < 0.001). Level of the anastomosis was 1 (range, 0.5-3) cm above dentate line after eversion compared with 1.5 (range, 0-6) cm without eversion.

CONCLUSION

Clinical outcome after RP with eversion was not as good as outcome after stapled EEA without eversion. Such a conclusion requires confirmation in a prospective control trial.

The perfect pelvic pouch--what makes the difference?

The aim of this study was to determine what factors are important for the achievement of perfect anal continence after restorative proctocolectomy. One hundred patients underwent paired studies of anorectal physiology before and one year after restorative proctocolectomy with pelvic ileal reservoir (11 S, 25 J, 64 W) with stapled ileoanal anastomosis, without mucosectomy. Fifty seven patients attained perfect anal continence and were able to discriminate flatus from faeces with such confidence that they were able to release flatus safely without fear of faecal soiling. The remaining 43 patients experienced minor problems in this regard. Four factors were found to correlate significantly with a perfect functional result (median, perfect v imperfect): maximum resting anal pressure (72 v 57 cm H2O, p < 0.02), the sensory threshold in the upper and mid-anal canal (7.3 v 8.6 and 5.3 v 7.0 mA, p < 0.05 and p < 0.02), compliance of the ileal reservoir (12.4 v 7.6 ml/cm H2O, p < 0.01), and the presence of a pouch-anal inhibitory reflex (56 of 57 patients v 29 of 43 patients, p < 0.01). The quality of anal continence depends on several factors: a complaint ileal reservoir, a strong sensitive anal sphincter, and normal reflex coordination of the activities of the reservoir and the sphincter. Excellent pouch-anal coordination is obtainable irrespective of the design of the reservoir, provided that these criteria are satisfied.

Physiology of ileal pouch-anal anastomosis. Current concepts

PURPOSE

Increasing experience with ileal pouch-anal anastomosis (IPAA) associated with increasing knowledge about anorectal physiology has lead to a large number of publications. The purpose of this review is to evaluate the current understanding of fecal continence as revealed by the evolution of the ileoanal procedure.

METHODS

Review of the literature covering the most important physiologic parameters involved in fecal continence was undertaken.

RESULTS

Rectoanal inhibitory reflex is probably absent after IPAA but is preserved when distal anorectal mucosa is spared. Anal resting pressure decreases but is less affected when the internal anal sphincter is less traumatized. Squeeze pressure is not importantly affected, and the importance of reservoir function as a determinant of stool frequency is emphasized. IPAA does not affect the coordination between pouch and anal canal motility in the majority of cases. Normal continence is preserved, even during the night, by preserving a gradient of pressure between the pouch and anal canal.

CONCLUSIONS

Physiologic concepts are well established, but controversies about the continence mechanism related to IPAA remain. The IPAA procedure has allowed discrimination of details about the function of multiple structures involved in fecal continence.

Preservation of complete anal sphincteric proprioception in restorative proctocolectomy: the inhibitory reflex and fine control of continence need not be impaired

This study evaluates whether reflux function of the anal sphincter remains unchanged after restorative proctocolectomy, provided that the sphincter remaining is kept intact, without mucosal stripping or endo-anal anastomosis. Paired tests of anorectal function were performed before, and a median of 6 (range 2-12) months after restorative proctocolectomy with stapled, end to end pouch-anal anastomosis. Beforehand, distension of the rectum with 50 ml of air produced a median (interquartile range) increase in pressure within the rectum of 22 (15-29) cm H2O and reflex inhibition of the anal sphincter from a pressure of 76 (62-106) cm H2O to a pressure of 34 (15-52) cm H2O. After the procedure, distension of the ileal pouch with 50 ml of air produced an increase in pressure within the pouch of only 5 (4-8) cm H2O (p < 0.001 compared with beforehand) and reflex inhibition of the anal sphincter from a pressure of 62 (25-79) cm H2O to 37 (17-68) cm H2O. Maximal reflex inhibition of the upper third if the anal sphincter to a pressure of 26 (15-48) cm H2O was observed when pressure within the pouch increased by 16 (11-22) cm H2O. After restorative proctocolectomy, all patients were continent (two experienced minor nocturnal leakage of mucus) and 25 could discriminate between flatus and faeces. Thus, reflux function was preserved in response to changes in pressure, ensuring that the subtler aspects of anal continence were preserved.

Update on the surgical management of ulcerative colitis and ulcerative proctitis: current controversies and problems

: The surgical management of ulcerative colitis has been revolutionized in recent years by the development of the ileal pouch-anal procedure. Although it is now the operation of choice for most patients, there remain several controversies. A variety of designs of ileal pouch are available each with advantages and disadvantages. The technique used to anastomose the pouch to the anal canal is also open to debate with some surgeons favoring distal mucosectomy with eradication of all disease and others choosing to perform a stapled anastomosis to achieve better functional results. The main concern for gastroenterologists, however, is the risk of development of pouchitis. The etiology, diagnosis, and treatment of this condition will also be discussed in this review as well as the more classical options for the surgical treatment of ulcerative colitis.

Proctocolectomy and quadruple-limb W pouch reconstruction for the management of pediatric ulcerative colitis and familial polyposis

Proctocolectomy with ileal pouch-anal anastomosis (IPAA) has become the procedure of choice for many children with ulcerative colitis and familial polyposis. The modified quadruple-limb (W) IPAA was designed to increase reservoir compliance and capacity, and to improve functional results by decreasing stool frequency. However, only limited information has been reported concerning the technical considerations and functional outcomes from W IPAA modification and utilization in the pediatric population. Additionally, pediatric IPAA physiological adaptation, expressed as IPAA volume/pressure relationships, for any type of IPAA design has not been described. In this report, the authors analyze their functional and physiological results with W IPAA in 19 children undergoing colectomy for ulcerative colitis and familial polyposis. Since 1986, 19 children (5 girls, 14 boys; mean age, 15.3 years [range, 11 to 18 years]) have undergone proctocolectomy with W IPAA for ulcerative colitis (n = 9) and familial polyposis (n = 10). IPAA pressure and volume profiles were measured in 10 patients at 2 and 12 months postileostomy takedown, and in five patients at 3 years. W IPAA compliance was calculated as the change in volume over change in pressure (delta V/delta P). There were no deaths, anastomotic leaks, or pelvic sepsis. The 24-hour stool frequency (mean +/- SEM) decreased significantly (P < or = .05) from 4.6 +/- 0.6 at 2 months to 3.3 +/- 0.1 at 12 months. No nighttime evacuation occurred after 12 months. W IPAA evacuation volume significantly increased (P < or = .05) from 238 +/- 22.9 mL at 2 months to 346 +/- 26.5 mL at 12 months and remained stable thereafter.(ABSTRACT TRUNCATED AT 250 WORDS)

Straight ileo-anal anastomosis with myectomy as an alternative to ileal pouch-anal anastomosis in restorative proctocolectomy

Restorative proctocolectomy with various types of reservoir is widely used in the elective surgery of ulcerative colitis and familial adenomatous polyposis. Both, advantages and disadvantages of this procedure are well known and documented. Straight ileo-anal anastomosis (IAA) yields unsatisfactory clinical results due to the lack of storage capacity of the distal ileum and the frequency of bowel movements related to high pressure ileal waves. In an attempt to create an alternative to the above procedures, we have performed a straight ileo-anal anastomosis with two rectangular (10 cm x 1 cm) myectomies down to 2 cm, above the anastomotic line. The two myectomies are spaced at 120 degrees to each other and to the mesenteric border of the ileal loop. The rationale of this approach is to reduce the peristaltic drive of the ileum by weakening the muscular wall. This study presents the results in three patients operated on with this new method in the last year.

Does the level of stapled ileoanal anastomosis influence physiologic and functional outcome?

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.

Results of mucosal proctectomy versus extrarectal dissection for ulcerative colitis and familial polyposis in children and young adults

Over a 5-year period, the authors examined 30 consecutively treated patients, aged 16 years or younger, who underwent total colectomy and ileal pouch-anal anastomosis, (IPAA) using two different surgical methods. In 16 patients (group I), extrarectal dissection with stapled J pouch and anastomosis was performed. In 14 patients (group II), mucosal proctectomy with hand-sewn S pouch and anastomosis was performed. The mean follow-up period this study was approximately two years (range, 1 to 5 years). With regard to postoperative complications, quality of life, and occurrence of pouchitis, there were no significant differences between the groups. Stool frequency was not significantly different between the two groups, and approached four bowel movements per day at 1 year after surgery. In both groups, daytime continence was achieved by all patients 6 months after surgery. A greater number of patients in group II demonstrated temporary nocturnal leakage than in group I, but this difference was not statistically significant (P = .09). The authors conclude that both methods of IPAA are equally effective in preserving normal sphincter function. In patients with severe rectal inflammation, extrarectal dissection with stapled anastomosis may obviate the need for extended preoperative hyperalimentation or subtotal colectomy, but may carry a small increased risk of recurrent anorectal inflammation. The long-term risk of dysplasia is unknown, but may be slightly higher after extrarectal dissection with stapled anastomosis. Further study of both methods of IPAA is recommended.

Anorectal function in children after ileoanal pull-through

Mucosal proctectomy and ileoanal pull-through is increasingly used in children requiring total colectomy for ulcerative colitis or familial polyposis. Excellent continence can be achieved with this procedure, and it avoids proctocolectomy and permanent ileostomy. We have evaluated prospectively anorectal function in nine consecutively treated children who underwent ileoanal pull-through. Patients were 8 to 17.5 years of age (median, 11.3 years) at the time of surgery; seven had ulcerative colitis, and two had familial polyposis. Anorectal evaluation was performed before colectomy and ileoanal pull-through, following ileoanal pullthrough, after rectal training, and then at yearly intervals. A biofeedback "rectal training" program was instituted 6 weeks after ileoanal pull-through and a contrast study documenting integrity of the pouch. The program consisted of an initial biofeedback session with the motility unit, followed by daily instillations, through a catheter, of progressively larger volumes of water (from 1 to 6 oz, increasing 1 oz per week) into the ileal pouch. Patients were instructed to retain the water and participate in normal activities after the instillation. This protocol acclimated the patient to sensing distension of the pouch and using the sphincters. The follow-up period ranges from 1 to 4.5 years (median, 2.2 years). All patients are continent by day and night. One patient has nocturnal incontinence with episodes of pouchitis. Stool frequency is three to eight movements per day (median, four), with none at night. Preoperative resting rectal sphincter pressures averaged 74.3 +/- 23.1 mm Hg (mean +/- standard deviation), and a maximum squeeze pressure was 93.9 +/- 25.3 mm Hg.(ABSTRACT TRUNCATED AT 250 WORDS)

Stapled ileoanal anastomosis without a temporary ileostomy

Stapled J-pouch ileoanal operations were performed in 75 patients (35 men, 40 women; 72 with ulcerative colitis, 3 with familial polyposis) without an ileostomy in 68 (43 taking prednisone, 12 emergent surgery, 8 completion proctectomy with ileostomy takedown). The seven primary ileostomies were due to technical difficulties in two patients and toxic colitis in four patients. No patients were lost to follow-up. Of patients followed for more than 1 month, 96% had perfect daytime control, 86% had no nocturnal accidents, and 73% had no nocturnal spotting. Mucosa between the dentate line and the anastomosis averaged 1.1 +/- 1.0 cm, with the anastomosis at, or below, the dentate line in 16 patients, of whom 14 had excellent continence. Stools in 24 hours averaged 6.9 +/- 0.3, of which 1.8 +/- 0.2 were at night. Stool frequency was unrelated to gender, anastomotic distance from the dentate line, or age; however, patients 50 years of age or older had more problems with nocturnal fecal control than those younger than 50 years of age. Anastomotic leaks (four), cuff abscess (one), pouch leaks (two), and pelvic abscesses (three) were treated with drainage in all patients and ileostomy in five. Pouchitis occurred in 31% of patients and responded to oral antibiotic therapy. Acute complications were fewer, functional pouches greater, stool control better, and overall hospitalization shorter (all p < 0.01) than those in our 63 patients with a mucosectomy and handsewn ileoanal anastomosis.

The ileal pouch operation for ulcerative colitis

Ileal pouch-anal anastomosis cures chronic ulcerative colitis with an acceptable perioperative morbidity and mortality. The great majority of patients achieve satisfactory continence with an excellent quality of life. However, continence is not perfect, and fecal soilage is a troublesome problem for a small number of patients. Moreover, as many as one third of patients develop pouchitis, for which an effective means of long-term prevention or treatment has yet to be developed. Finally, controversial issues such as optimal pouch design or technique of anastomosis will be resolved only when long-term follow-up of randomized trials has been completed.

The histological pattern and pathological involvement of the anal transition zone in patients with ulcerative colitis

BACKGROUND

The aim was to determine whether the transitional epithelium (TE) of the anal transition zone (ATZ) was involved by chronic ulcerative colitis (CUC) and whether preserving the ATZ preserves the disease.

METHODS

Proctocolectomy specimens from 50 CUC patients and 50 patients with rectal cancer serving as controls were stained with alcian-blue to map the ATZ, and biopsy specimens containing adjacent TE and rectal mucosa were examined.

RESULTS

The mean inflammation score (0, none; 4, severe) in TE of controls was 0.4, whereas in CUC it was 0.5. However, the mean inflammation score of the rectal mucosa within the ATZ was 0.2 in controls and 2.6 in CUC (P < 0.001). Rectal columnar epithelium extended past half of the maximum length of TE in 75% of patients (65-83%; 95% CI) and was within 1 cm of the dentate line in 89% (81%-94%).

CONCLUSIONS

Although the TE of the ATZ was not inflamed, the rectal mucosa within the ATZ was. Moreover, rectal mucosa traversed half of the length of the ATZ in 75% of patients and was within 1 cm of the dentate line in fully 89%. Preserving the ATZ may preserve the disease in the majority of patients with CUC.

Effect of anorectal eversion during restorative proctocolectomy on anal sphincter function

Twenty-six patients underwent restorative proctocolectomy with end-to-end ileal pouch-anal anastomosis, without resection of the anal mucosa, by the eversion technique. Before surgery patients underwent tests of anorectal function. These were repeated a median of 8 (range 3-21) months after operation. The median (range) maximum resting anal pressure was 93 (36-149) cmH2O before and 71 (40-131) cmH2O after operation (P = 0.002). The median (range) maximum squeeze pressure before operation was 136 (73-280) cmH2O; it was 149 (69-290) cmH2O afterwards (P not significant). The median (range) length of the anal sphincter was 3.5 (2.5-4.5) cm before and 3.5 (2.0-4.5) cm after operation (P not significant). Thresholds for sensation in the upper, middle and lower thirds of the anal canal before and after operation were, respectively, 8.7 versus 8.7, 6.8 versus 7.4 and 4.2 versus 6.2 mA (P not significant). All 26 patients were continent, although one experienced minor leakage. Function of the anal sphincter is not significantly impaired by eversion of the rectum and anus during restorative proctocolectomy.

Comparison of triplicated (S) and quadruplicated (W) pelvic ileal reservoirs. Studies on manovolumetry, fecal bacteriology, fecal volatile fatty acids, mucosal morphology, and functional results

Capacity and compliance, efficiency of evacuation, fecal bacteriology, fecal volatile fatty acids, mucosal morphology, and functional outcome were studied in 20 patients with triplicated (S) and 20 patients with quadruplicated (W) reservoirs after ileal pouch-anal anastomosis. Compared with patients with S reservoirs, patients with W reservoirs were found to have greater efficiency of evacuation of radiolabeled synthetic stool [97% (91%-98%) vs. 74% (62%-89%); P less than 0.05], and their reservoirs were more capacious [350 mL (320-400 mL) vs. 228 mL (175-290 mL); P less than 0.01] and compliant [16.0 mL/cm H2O (13.8-19.0 mL/cm H2O) vs. 12.3 mL/cm H2O (7.4-14.6 mL/cm H2O); P less than 0.01]. Effluent from S reservoirs contained significantly greater numbers of bacteroides (P less than 0.05) and concentrations of acetic and propionic acids (P less than 0.05) than effluent from W reservoirs. The degree of mucosal inflammation and villous atrophy in each design of reservoir was not significantly different. The ratio of anaerobes to aerobes in pouch effluent was significantly correlated with the degree of mucosal inflammation (rs = 0.433; P = 0.035). Fecal volatile fatty acids were significantly correlated with the percentage of stool retained after defecation and degree of mucosal inflammation. The frequency of bowel action was significantly less in patients with W reservoirs than in patients with S reservoirs [3.5/day (3-4/day) vs. 6.0/day (4-7/day); P less than 0.01]. The results indicate marked differences between these two ileal reservoir designs.

Colectomy-proctomucosectomy with S-pouch: operative procedures, complications, and functional outcome in 69 consecutive patients

Sixty-nine patients were operated upon in a three-stage procedure. Early complications occurred in 29 percent after colectomy-ileostomy, in 25 percent after proctomucosectomy with ileoanal anastomosis and loop ileostomy, and in 9 percent after closure of loop ileostomy. Only three of these were considered serious. Seventy-one percent of the patients were readmitted into the hospital between the three operations or after the last one. Total hospital stay was 49 days (median); the range was 20 to 345 days. Reconstruction of the reservoir was performed in four patients owing to defecation problems, with satisfying functional results in two patients, while two emptied by catheter. There was no postoperative mortality or pelvic sepsis, and no pouches were excised. Ileostomy was re-established in two patients. At histopathologic re-evaluation of colectomy specimens, the diagnosis was changed from ulcerative colitis to Crohn's disease in three patients and to indeterminate colitis in five. Median follow-up was 4.3 years. Continent anal defecation without ileostomy was achieved in 67 patients (97 percent), with 4.1 bowel movements per day and 0.6 per night. Perfect continence was achieved in 55 percent in the daytime and in 43 percent at night. The low rate of reservoir-threatening complications is attributed to the three-stage procedure and the technical details in the surgical procedures.

Anal sphincter-saving operations for chronic ulcerative colitis

Three anal sphincter-saving operations--ileorectostomy, ileal pouch-anal anastomosis, and ileal pouch-distal rectal anastomosis--are currently being used in the surgical treatment of chronic ulcerative colitis. All three operations remove the disease, or most of it, and yet they maintain transanal defecation, reasonable fecal continence, and a satisfactory quality of life. All three avoid permanent abdominal ileostomy. Ileorectostomy is the easiest to perform, but it leaves residual disease in the remaining rectum and proximal anal canal that may cause symptoms and that may predispose the patient to cancer. In contrast, ileal pouch-anal anastomosis, although a more technically demanding procedure, totally eradicates the colitis. Its main drawbacks--frequent stooling, nocturnal fecal spotting, and pouchitis--are usually satisfactorily treated with loperamide hydrochloride and metronidazole. Ileal pouch-distal rectal anastomosis is somewhat easier to perform than ileal pouch-anal anastomosis and may result in less nocturnal fecal spotting. Like ileorectostomy, however, the operation leaves residual disease in the distal rectum and proximal anal canal. Considering all of these factors, the ileal pouch-anal operation is preferred today for most patients who require surgery for chronic ulcerative colitis.

Complications of endorectal pull-through for Hirschsprung's disease

In 10 years, 57 infants with Hirschsprung's disease underwent endorectal pull-through (ERPT). Postoperatively, 3 patients died. Of the 44 survivors with an intact endorectal anastomosis aged more than 3 years, 23 (52%) had an excellent result, and of the 28 children more than 5 years old, 23 (82%) had a satisfactory result. Of the 53 known survivors of all ages, 18% suffered from diarrhea with intermittent incontinence and 5 (9.4%) had undergone a Duhamel procedure within 4 years of ERPT.

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

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

Prospective randomized trial comparing anal function after hand sewn ileoanal anastomosis with mucosectomy versus stapled ileoanal anastomosis without mucosectomy in restorative proctocolectomy

A prospective randomized trial was performed to compare complications and function after hand sewn ileoanal anastomosis with mucosectomy (group A) with stapled ileoanal anastomosis without mucosectomy (group B) during restorative proctocolectomy. Thirty-two age- and sex-matched consecutive patients under the care of one surgeon were randomized. The median duration of anal dilatation while making the anastomosis was 19 min (range 14-33 min) and 1 min (range 0-39 min) in groups A and B respectively (P less than 0.005). The median level of the anastomosis was at the dentate line (range 0-0.5 cm) in group A and 2 cm above the dentate line (range 0.2-4.0 cm) in group B (P less than 0.005). Seven patients in group A and 11 in group B had at least one postoperative complication (n.s.). One patient in group A and four in group B developed an anastomotic stricture requiring dilatation (n.s.). One patient in group B had the reservoir removed. Function was assessed at a median of 11 months (range 7-15 months) after ileostomy closure in 14 patients in group A, and at a median of 12 months (range 5-17 months) in 14 patients in group B. Median frequency of defaecation per 24 h was 4 in both groups (group A, range 2-7; group B, range 2-10). Night evacuation (greater than once per week) occurred in seven patients in each group. All patients in both groups could delay the desire to defaecate by more than 30 min. Eleven patients in group A and 12 in group B had normal continence. Evidence to date favours a full mucosectomy. Function is not vitiated by this technique and surgical removal of the disease is more complete.

The stapled ileal pouch--anal anastomosis. A randomized study comparing two different pouch designs

Thirty patients were operated on with restorative proctocolectomy with an end-to-end ileal pouch-anal anastomosis constructed by double stapling (STP). Pouches were randomized to either J type or K type (folded by the principles used for the Kock continent ileostomy). Manovolumetric and functional results were compared. Patients were followed up for at least 6 months. K pouches acquired a significantly larger volume than the J-configurated pouches, and at 6 months the mean +/- SD volumes amounted to 361 +/- 59.8 ml versus 283 +/- 43.0 ml (p less than 0.01) with a concomitant reduction in 24-h frequency (4.4 +/- 1.5 versus 5.8 +/- 1.9; p less than 0.05). The initial postoperative mean reduction of resting anal pressure amounted to 33%. which was similar to that observed in a group of matched historical controls operated on with endoanal mucosectomy and hand-sutured pouch-anal anastomosis. Compared with these controls STP patients showed a superior overall functional result, most marked in the early postoperative period.

Proctocolectomy and stapled ileo-anal anastomosis without mucosal proctectomy

The present study compared the outcome of a small series of patients (7 cases) who underwent total proctocolectomy without mucosal proctectomy and stapled ileal pouch-anal anastomosis made at the apex of the anal transitional zone, with our previous experience (17 cases) in which the ileal pouch was anastomosed at the dentate line after mucosectomy. Though not statistically significant, our limited experience showed excellent clinical results with better continence and discriminating ability of flatus from faeces in the former group. The resting anal pressure profile was not changed postoperatively. The operation time was significantly reduced compared with our previous approach which was a time-consuming procedure. There was an indication that risk of complications (pelvic sepsis and haemorrhage) was less.

Incidence of dysplasia in the anorectal mucosa in patients having restorative proctocolectomy

The incidence of dysplasia in the mucosal strippings from the anorectal stump was studied in 132 patients treated by restorative proctocolectomy with ileal reservoir for ulcerative colitis and familial adenomatosis. The anorectal mucosa was stripped from the level of division of the gut tube to the dentate line. Of 118 patients with ulcerative colitis, 12 (10.2 per cent) had dysplasia in some part of the large bowel. Mucosal strippings were examined histologically in 118 cases, of which only three (2.5 per cent) showed dysplasia. There was a correlation between dysplasia and the presence of carcinoma and the duration of the disease in the operative specimen of colon and rectum and also in the anorectal mucosal specimen although the number of patients with carcinoma (eight cases) in this analysis was small. All 14 patients with familial adenomatous polyposis showed large bowel mucosal dysplasia in the operative specimen which was severe in six cases. Anorectal mucosal strippings were examined in these patients and 12 showed dysplasia which was severe in three.

Pouch size: the important functional determinant after restorative proctocolectomy

Sixty-seven patients with a J-shaped ileonanal pouch were studied over a 2-year period with regular recording of sphincter and pouch characteristics and analysis of their role in functional outcome. Although there was a 27 per cent permanent reduction in resting anal pressure (RAP) (P less than 0.001), two-thirds of the patients still had a RAP within the normal range. The mean(s.d.) pouch volume increased during the first year from 132(46) ml to 282(85) ml. RAP was not related to functional outcome and preoperative RAP was not predictive of subsequent function. Large pouch volume and compliance correlated with low defaecation frequency (range of r = 0.27-0.36; P less than 0.05) and good overall function (r = 0.37-0.56; P less than 0.01). The initial pouch volume was predictive of subsequent overall function. The ileal length used for pouch construction predicted subsequent pouch volume (r = 0.48; P less than 0.001) and to some extent functional outcome (r = 0.28-0.37; P less than 0.05). However, the studied variables accounted for only 21 per cent of the total variance of functional outcome.

Internal anal sphincter function after total abdominal colectomy and stapled ileal pouch-anal anastomosis without mucosal proctectomy

A comparison, based on results from anal manometry and continence, was made between eight patients after circular stapled ileal J-pouch-anal anastomosis without mucosectomy (Js) and seven patients after endoanal mucosal proctectomy and hand-sewn ileal pouch-anal anastomosis (Jm). The mean and range from ileostomy closure were 3.5 months (1.5 to 12) and 21.7 months (13 to 32), respectively. The mean maximum resting pressure (MRP) ( +/- SEM and range) was 81.3 mm Hg ( +/- 6.0 and 61 to 112.5) and 50.0 mm Hg ( +/- 6.2 and 17 to 62.5), respectively, for the Js and Jm groups (P less than .003). None of the Js patients experienced leakage or wore a pad, while in the Jm group 14 percent experienced minor leakage during the day and 28 percent at night. Seventy-one percent of the Jm group wore a pad at some point. Anal sphincter resting pressures and continence were better in the Js group. The improvement in MRP resulted from avoidance of injury to the internal and sphincter during dilatation and mucosectomy and the maintenance of a normal anal canal that allowed for proper closure.

Failed ileoanal anastomosis: correlations between clinical function and anal canal neurophysiologic and histologic examinations

Ten patients with an ileoanal anastomosis had conversion to permanent ileostomy 13 (range, 6-29) months after the primary procedure. Causes for reoperation were incontinence in seven patients, unacceptable stool frequency without incontinence in two patients, and atypia in the mucosal remnant with perfect continence in one patient. Stool frequency, continence function, anal canal resting pressure, external anal sphincter (EAS) EMG/pressure relationship (in terms of slope, m), EAS fiber density (FD), and pressure in the distal ileum were registered, and the mucosa and the anal sphincter muscles were examined histologically. There were significant correlations between continence function and EAS changes in terms of both neurophysiologic tests (m and FD) and the histologic picture. The abnormalities in six incontinent patients were consistent with denervation of the EAS. The main reason for fecal leakage in one patient was the high amplitude of pressure waves in the distal ileum. Preservation of mucosal epithelium proximal to the dentate line per se did not seem essential to maintain continence.

Anal sphincter function after colectomy, mucosal proctectomy, and ileoanal anastomosis

Anal sphincter investigations were performed in 41 patients with straight ileoanal anastomosis and in 10 controls. In 20 patients (group I) the mucosal stripping had been performed from the abdominal side, leaving 1-2 cm of distal anal mucosa. In 21 patients (group II) the anal mucosa had been stripped from the perineal side as far as the dentate line. Continence was perfect in all patients in group I and poor in 6 of 17 patients in group II, when examined 12 months after the operation. Anal canal resting pressure was normal in group I. In group II the resting pressure was significantly decreased and correlated to continence function. The maximum anal canal squeeze pressure was the same in the two groups. The slope of the regression line between pressure rise and integrated electromyography proved to be a useful criterion of the external anal sphincter function and was significantly correlated to degree of incontinence. This variable was significantly smaller in group II patients than in group I and controls. Thus, function of the anal sphincters was normal after mucosal proctectomy performed from above with preservation of a mucosal brim. Dysfunction of the internal and external anal sphincter was found after perineal mucosal dissection and was correlated to continence function.

Mucosal proctectomy with straight ileoanal anastomosis. A comparison of two methods

Straight ileoanal anastomosis was performed in 59 patients. In 32 patients (group I) mucosal dissection was performed from above with preservation of a distal mucosal brim. In 27 patients (group II) the mucosectomy was performed to the dentate line--in 26 patients from the perineal side and in 1 patient from the abdominal side. Diverting loop ileostomy was used in group II but not in group I. The results in group II were in every respect inferior to those in group I, with significantly more intestinal obstruction and more conversions to permanent ileostomy because of poor functional results. The patients with ulcerative colitis (UC) in group II had higher stool frequency (10 (6-12) versus 7.3 (5-8) per 24 h; p = 0.01) and significantly less 'neorectal' capacity and distensibility than the UC patients in group I at 12 months after the operation. Anal continence was perfect in group I. In group II, 5 of 15 of the patients had significant incontinence problems 12 months postoperatively. The differences in results are ascribed to the differences in surgical technique between the two groups, and especially to the harmful effect of anal dilatation.

Anal sensation after restorative proctocolectomy for ulcerative colitis

The hypothesis that anal sensation might be better after restorative proctocolectomy with end-to-end ileoanal anastomosis than after mucosal proctectomy with endo-anal anastomosis was tested in this study. Anal sensation was measured in 14 patients before operation, 16 patients after restorative proctocolectomy with end-to-end anastomosis (RP + EEA) and 13 patients after mucosal proctectomy with endo-anal anastomosis 1 cm above the dentate line (MP + EAA). Threshold electrosensitivity was measured in the upper, mid and lower anal canal by means of a bipolar constant current stimulator probe. The 'recto'-anal inhibitory reflex was tested, and the patients' ability to discriminate between flatus and faeces and to release flatus 'safely' was assessed by interview. In the upper anal canal, threshold sensitivity was significantly greater in patients who had undergone MP + EAA than in patients who had undergone RP + EEA (P less than 0.05). In the mid and lower anal canal, electrosensitivity in the three groups of patients did not differ significantly. Twelve patients (75 per cent) regained the 'recto'-anal reflex after RP + EEA, but after MP + EAA only three patients (23 per cent) did so (P less than 0.02). Thirteen patients after RP + EEA could release flatus safely without fear of faecal leakage, compared with only four after MP + EAA (P less than 0.02). The proportions of patients in these two groups who said they were able to discriminate flatus from faeces did not differ significantly. Anal sensation and discriminatory function are significantly better after end-to-end ileoanal anastomosis than after mucosal proctectomy with endo-anal anastomosis.

[Physiologic aspects of postoperative continence following ileoanal anastomosis with and without intrapelvic reservoir]

Clinical and electro-manometric investigations were performed in six patients with ileoanal anastomoses. The results were compared with electromyographic and electrophysiological observations in the literature. It can be shown that decreasing motility, increasing compliance and a normalisation of the frequency of stools is possible after ileoanal as well as after ileo-pouch-anal anastomoses. Following both procedures high amplitude phase waves may persist in the distal and even in the proximal ileum. These waves can be stopped by voluntary contractions of the striated sphincter muscles if the patient becomes aware of them. During the night, however, uncontrolled defecations may occur. Un-isoperistaltic bowel segments will become isoperistaltic a few weeks or months after the operation. However, pouch-anal anastomoses show a better compliance and lower amplitude segmental or peristaltic waves than ileoanal anastomoses.

Preservation of the entire anal canal in conservative proctocolectomy for ulcerative colitis: a pilot study comparing end-to-end ileo-anal anastomosis without mucosal resection with mucosal proctectomy and endo-anal anastomosis

Mucosal proctectomy with endo-anal pull-through anastomosis (MP + PTA) for ulcerative colitis reduces resting anal pressure and low RAP has been found to correlate with minor leakage of faeces or mucus. Our hypothesis was that conservative proctocolectomy with an end-to-end ileo-anal anastomosis (EEA) would result in higher anal pressure and less leakage. Twelve patients were studied after EEA and 24 after MP + PTA: each was in good health several months after operation. After EEA, maximal RAP decreased from a median 90 cmH2O (60-116 cmH2O) to 70 cmH2O (25-104 cmH2O, P less than 0.01), whereas after MP + PTA maximal RAP decreased from 85 cmH2O (70-125 cmH2O) to 40 cmH2O (22-80 cmH2O, P less than 0.003). RAP after EEA was significantly greater than RAP after MP + PTA (P less than 0.001). The pressure profile of the anal sphincter in the EEA group did not differ significantly from that of the pre-operative group at any point from 6 to 1 cm from the anal verge, and the sphincteric high pressure zone averaged 4 cm in length both before and after operation. After MP + PTA, resting anal pressure at stations 1 to 4 cm from the anal verge was significantly less than pre-operative pressure (P less than 0.001) and the sphincteric high pressure zone was only 3 cm in length compared with 4 cm before operation. Anal squeeze pressures were similar in the two groups of patients. After EEA 11 of 12 patients achieved perfect continence, day and night, whereas after MP + PTA 58 per cent of patients experienced minor faecal leakage (P less than 0.01). These findings suggest that the entire anal canal should be kept intact in the course of conservative proctocolectomy for ulcerative colitis.