Effect of anorectal eversion on long-term clinical outcome of restorative proctocolectomy

Surgery for ulcerative colitis

Ulcerative colitis (UC) has a more severe presentation and rapid progression in pediatric patients, resulting in a greater need for surgical intervention compared to adults. Though medical management of UC has advanced with new biologic therapies, surgery continues to play an important role when disease progresses in the form of worsened or persistent symptoms, hemodynamic instability, or sepsis. The goals of surgical management are to restore intestinal continuity with a functional pouch when possible. While the literature has been growing regarding studies of pediatric patients with UC, high level of evidence studies are limited and most recommendations are based on adult studies. Similar to adults, pediatric patients who have ileal pouches created require surveillance for recurrent disease and cancer surveillance. Unique issues for pediatric patients include monitoring of growth and appropriate transition to adult care after adolescence. This review includes indications for surgical management, overview of staged surgical approaches, and the technical details of the three-stage approach.

Rectal eversion and double-stapled ileal pouch anal anastomosis in familial adenomatous polyposis syndrome

INTRODUCTION

Surgery is the only treatment option for familial adenomatous polyposis (FAP). Aim of surgery in FAP is to minimize colorectal cancer risk without need for permanent stoma. There are especially two operation options; Total colectomy with ileorectal anastomosis (IRA) and total proctocolectomy with ileo-pouch anal anastomosis (IPAA). We report here a patient with FAP who had resection via rectal eversion just over the dentate line under direct visualization and ileoanal-J pouch anastomosis by double-stapler technique.

PRESENTATION OF CASE

A 40 yr. old female patient with FAP underwent surgery. Firstly, colon and the rectum mobilized completely, and then from the 10 cm. proximal to the ileo-caecal valve to the recto-sigmoid junction total colectomy was performed. Rectum was everted by a grasping forceps which was introduced through the anus and then resection was performed by a linear stapler just over the dentate line. A stapled J-shaped ileal reservoir construction followed by intraluminal stapler-facilitated ileoanal anastomosis. Follow up at six months anal sphincter function was found normal.

DISCUSSION

There is only surgical management option for FAP patients up to now. Total colectomy with IRA and restorative proctocolectomy with IPAA is surgical options for FAP patients that avoid the need for a permanent stoma. Anorectal eversion may be used in the surgical treatment of FAP, chronic ulcerative colitis and early stage distal rectal cancer patients.

CONCLUSION

J-pouch ileoanal anastomosis can safely be performed by rectal eversion and double stapler technique in FAP patients.

Ileal pouch-anal anastomosis

BACKGROUND

Since 1977, restorative proctocolectomy with ileoanal anastomosis (IAA) has evolved into the surgical treatment of choice for most patients with intractable ulcerative colitis. Construction of an ileal pouch reservoir is now standard, usually in the form of J pouch (IPAA). The aim of this report is to review selection criteria for, and functional outcomes, follow-up and management of complications of IPAA after 30 years of widespread clinical application.

METHODS AND RESULTS

Literature published in English on the clinical indications, surgical technique, morbidity, complications and outcome following IAA and IPAA was sourced by electronic search, performed independently by two reviewers who selected potentially relevant papers based on title and abstract. Additional articles were identified by cross-referencing from papers retrieved in the initial search.

CONCLUSION

The functional results of IPAA are good. Pouchitis, irritable pouch syndrome and cuffitis are specific long-term complications but rarely result in failure. Pouch salvage is possible in selected patients with poor functional outcomes. One-stage operations are increasingly performed.

Manometric study in ulcerative colitis patients with modified ileal pouch--anal anastomosis

BACKGROUND AND AIMS

Sphincter-saving operations and construction of intestinal reservoirs aim at additional improvement quality of life of patients with restorative proctocolectomy. The conventional ileoanal anastomosis affects the function of the anal sphincters. There is a need for operative techniques that provide sufficient intraluminal anal pressure and thus a better postoperative continence and quality of life.

MATERIALS AND METHODS

Ileal pouch-anal anastomosis (IPAA) after restorative proctocolectomy was carried out in 42 consecutive ulcerative colitis patients (age range: 19-55 years and mean age of 35.52 years). There were 17 males (40.48%) and 25 females (59.52%). IPAA was performed at dentate line, according to a standard method, in 20 patients (47.62% of the cases; mean age of 35.20 years), 19 of which were in 1986-1995 and one patient in 1998. In 1996-2002, however, IPAA was performed after plicating the demucosed segment of rectal residual in 22 patients (52.38% of the cases; mean age of 35.82 years). This modification consisted in strengthening the internal anal sphincter by creation of a smooth muscle cuff through plication of a mucosectomized segment of rectal residual. The basal anal-canal and squeeze pressures were recorded prior to the operation as well as 1 month afterwards and then every 6 months for 2 years. Kelly-Hohlschneider's continence scores after Herold's modification were applied in 14 consecutive patients.

RESULTS

Thanks to strengthening the internal anal sphincter by this segment, the basal pressure increased from a preoperative value of 68+/-6 mmHg up to 80+/-6 mmHg at the end of the second postoperative year (P<0.001). This favourable effect could be explained with the additional contractile potential of the plicated rectal segment resulting from the interference of the contractile potential of the internal anal sphincter with that of the smooth muscle cuff.

CONCLUSION

The modified IPAA creates a novel and probably functionally active anatomical substrate. The basal anal-canal pressure is maintained sufficiently high through the tone of the smooth muscle cuff and internal anal sphincter. Our preliminary results suggest that the presented technique for performing IPAA may contribute to better functional results.

Anal canal pressure after ileal pouch-anal anastomosis with strengthened internal anal sphincter

INTRODUCTION

The aim of sphincter-saving operative techniques and creation of intestinal reservoirs is to improve the quality of life for patients with restorative prococolectomy.

METHODS

In this study, 48 consecutive patients (19 males and 29 females of ages between 19 and 55 years; mean age, 35.52 years) with ulcerative colitis and familial adenomatous polyposis underwent ileal pouch-anal anastomosis after proctocolectomy in 1986 to 2002. In 26 patients (54.17 percent of the cases), 10 males and 16 females, ileal pouch-anal anastomosis was performed after a modified surgical technique for strengthening the internal anal sphincter by creation of a smooth muscle cuff through plication of a mucosectomized segment of residual rectum. Basal resting anal canal pressure and pressure after voluntary contraction were recorded preoperatively, one month after surgery, and every six months for two years.

RESULTS

One month after the operation manometric results showed significantly higher values of resting pressure in patient with a plicated rectal segment than values measured preoperatively (P < 0.001). This effect was absent after the standard ileal pouch-anal anastomosis. With the rectal plication technique, basal pressure increased from a preoperative value of 69 +/- 6 mmHg up to 80 +/- 6 mmHg at the end of the second postoperative year (P < 0.001).

CONCLUSIONS

We concluded that ileal pouch-anal anastomosis with rectal plication perhaps improved sphincter function. The operative technique did not affect anal squeeze pressure. Patients quality of life was improved for those undergoing the modified ileal pouch-anal anastomosis.

Stapler-facilitated rectal eversion

Sphincter-preserving procedures have come to play an increasingly important role in colon and rectal surgery. In certain situations, rectal eversion can be an invaluable aid in performing a sphincter-saving operation. We present a new method to evert the rectum using the curved circular stapler.