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PubMed1983

Surgical options in ulcerative colitis.

Five operative options are now available for treatment of ulcerative colitis: (1) proctocolectomy with ileostomy, (2) abdominal colectomy with ileostomy and retention of the rectum, (3) abdominal colectomy with ileorectal anastomosis, (4) proctocolectomy with creation of a continent stoma or conversion of a standard ileostomy after proctocolectomy to a continent stoma, and (5) restorative proctocolectomy. Each procedure has advantages and disadvantages. With careful assessment, the specific needs of each patient can best be met. In many cases a permanent stoma can be avoided. The newer procedures have not been used long enough for long-term effects to be known, and they must be offered with reservation and then only to well-informed, stable, and relatively fit and cooperative patients.

Adult↗
PubMed1992

Use of the de Pezzer catheter to facilitate endoanal pull-through during ileal pouch-anal anastomosis.

Ileal pouch-anal anastomosis is now the treatment of choice for selected patients requiring proctocolectomy for benign mucosal disease of the large intestine. Pelvic sepsis continues to be a major postoperative complication. This is often subsequent to the technical complexity of the intestinal pull-through and ileal pouch-anal anastomosis. We report the use of the de Pezzer catheter to facilitate this often difficult reservoir pull-through during restorative proctocolectomy. This is an inexpensive and simple aid which has consistently helped to decrease operative difficulty, especially where pelvic access is restricted. By enabling the avoidance of clamps and tissue forceps, it has reduced the incidence of contamination and tissue trauma. It has enabled pull-through without undue tension on the reservoir and has facilitated postoperative drainage of the reservoir.

Catheterization↗
PubMed1997

Pneumocystis carinii pneumonia postrestorative proctocolectomy for ulcerative colitis: a role for perioperative prophylaxis in the cyclosporine era? Report of a case and review of the literature.

PURPOSE: Medical management of severe ulcerative colitis has used cyclosporine with increasing frequency as an adjuvant to systemic steroids and mercaptopurine. However, the effects of combined management with cyclosporine and prednisone may lead to significant immune compromise and adversely affect operative morbidity in the event urgent surgery is required. METHODS: A case is reported of a 43-year-old white male who presented with severe ulcerative colitis. The patient had been initially treated with prednisone and cyclosporine for six weeks before surgical intervention. The intractability of his ulcerative colitis caused the patient to present to surgery, where he underwent restorative proctocolectomy. RESULTS: On initial presentation, the patient manifested systemic signs of severe ulcerative colitis with hypoalbuminemia, anemia, and weight loss, despite continuous prednisone and cyclosporine management. Before surgical intervention, a chest x-ray and the patient's respiratory status were normal. A total abdominal colectomy with ileal pouch reconstruction and temporary loop ileostomy were performed without incident. On the fifth postoperative day, the patient developed respiratory failure, which was subsequently diagnosed as Pneumocystis carinii pneumonia. Although ventilator support and both aggressive medical and surgical management eventually resulted in successful outcome, significant perioperative morbidity occurred. CONCLUSIONS: In the era of aggressive medical management for ulcerative colitis with both steroids and cyclosporine, the complications of immunosuppression may be significant, including opportunistic pneumonia. Prophylaxis against P. carinii pneumonia with sulfa antibiotics should be considered, especially in patients for whom proctocolectomy is a potential end point.

Adult↗
PubMed2001

[Possibilities in the preservation and restoration of anal continence].

The preservation of anal continence and the improvement of the patients' quality of life in general are primary objectives of colorectal surgery. Earlier the loss of the entire rectum, colon required a definitive stoma. This review describes surgical procedures designed to preserve anal continence. This paper also describes operative techniques designed to improve impaired sphincter function. Total extirpation of the mesorectum reduces local recurrence of rectal tumours. At the same time, this operation requires formation of the anastomosis low, at the level of the levator muscle. Low colorectal or coloanal anastomoses are associated with higher incidence of suture leakage and poor functional outcome. The distance between anastomosis and anal verge was less than 7 cm in 249 sphincter-sparing rectal resections performed during the examined 6-year period in our institute. Different techniques to perform anastomoses were applied, the prevalence of suture leakage and the functional results are analysed. Restorative proctocolectomy has dramatically improved the treatment of familial polyposis and ulcerative colitis with rectal involvement. Although proctocolectomy is necessary to cure the disease, acceptable faecal continence can be achieved by creating ileoanal anastomosis with ileal reservoir. We discuss our results after 43 operations. Weakness of the sphincter apparatus is the most common cause of continence problems. Occasionally, the sphincter is no longer suitable for reconstruction because of extensive damage or denervation. In such cases, the levator muscles or--if neither these are of acceptable quality--the gluteus maximus muscle can be used to repair the external sphincter. Anterior levator plasty involves tightening the levator plate by suturing its arches together between the rectum and the vagina. This procedure enhances the resistance of the sphincter barrier primarily by increasing functional sphincter length. The functional outcome of this procedure was acceptable in two-thirds of the 52 operations. Post anal repair was performed only in 3 patients. This method comprises reinforcing the levator plate through an access between the external and the internal sphincters. When the levator plate is unsuitable, bilateral gluteus plasty can be performed to increase the strength of sphincter muscles. As the gluteus is a striated muscle it can improve only the of the external sphincter function. Therefore this procedure can restore acceptable continence to hard stool only. This is demonstrated by our clinical experience obtained in 10 patients.

Anal Canal↗
PubMed2006

Adenocarcinoma in an ileoanal pouch formed for ulcerative colitis in a patient with primary sclerosing cholangitis and a liver transplant: report of a case and review of the literature.

This is a report of the first case of adenocarcinoma arising in an ileal pouch after proctocolectomy for ulcerative colitis in a patient who had also undergone orthotopic liver transplantation for primary sclerosing cholangitis. Previously reported cases of adenocarcinoma developing after formation of an ileoanal pouch are reviewed as is the evidence for neoplastic transformation of the ileal mucosa. The risk factors for the development of colorectal cancer in patients with ulcerative colitis and the possibility that these may be risk factors for the development of pouch malignancy are discussed. We conclude that this patient exemplifies a small group of patients who may be at increased risk of developing pouch malignancy and need endoscopic follow-up. There is also the need for longer-term follow-up data to determine the risk of this rare and potentially devastating complication of restorative proctocolectomy.

Adenocarcinoma↗
PubMed2006

Three-step ileal pouch-anal anastomosis under total laparoscopic approach for acute or severe colitis complicating inflammatory bowel disease.

BACKGROUND: A two- or three-step procedure is mandatory for restorative proctocolectomy in patients presenting with severe or acute colitis complicating inflammatory bowel disease (IBD). The aim of this study was to analyze the feasibility of a total laparoscopic approach for consecutive subtotal colectomy (STC) and secondary ileal pouch-anal anastomosis (IPAA). STUDY DESIGN: All patients underwent a three-step procedure that included first, a laparoscopic STC with ileostomy and sigmoidostomy; second, a laparoscopic proctectomy and IPAA, and third, closure of the temporary ileostomy. RESULTS: Eighteen consecutive patients (7 women and 11 men), with a mean age of 39+/-14 years (range 15 to 59 years) were included. Mean lengths of the procedures were 252+/-59 minutes for STC, and 286+/-46 minutes for IPAA, respectively. Two patients (11%) after laparoscopic IPAA required conversion into laparotomy. No patient died postoperatively. Four patients had reoperations after laparoscopic IPAA for intraperitoneal hemorrhage by laparotomy (n=2) and by a transanal approach for anastomotic leakage (n=2). The overall morbidity rate was 33% (12 of 36 procedures). Mean hospital stay was 8+/-2 days after STC, and 10+/-2 days after IPAA. After a mean follow up of 13 months, all patients underwent intestinal continuity restoration. CONCLUSIONS: Our study suggests that a total laparoscopic approach is feasible and safe in inflammatory bowel disease patients with acute or severe colitis, not only for STC but also for IPAA after STC, with no mortality and an acceptable morbidity rate.

Acute Disease↗
PubMed2001

Functional results and visceral perception after ileo neo-rectal anastomosis in patients: a pilot study.

INTRODUCTION: To reduce pouch related complications after restorative proctocolectomy, an alternative procedure was developed, the ileo neo-rectal anastomosis (INRA). This technique consists of rectal mucosa replacement by ileal mucosa and straight ileorectal anastomosis. Our study provides a detailed description of the functional results after INRA. PATIENTS AND METHODS: Eleven patients underwent an INRA procedure with a temporary ileostomy. Anorectal function tests were performed two months prior to and six and 12 months after closure of the ileostomy and comprised: anal manometry, ultrasound examination, rectal balloon distension, and transmucosal electrical nerve stimulation (TENS). Function was subsequently related to the histopathology of rectal biopsy samples. RESULTS: Median stool frequency decreased from 15/24 hours (10-25) to 6/24 hours (4-11) at one year. All patients reported full continence. Anal sensibility, and resting and squeeze pressures did not change after INRA. Rectal compliance decreased (2.1 (0.7-2.8) v 1.5 (0.4-2.2) and 1.4 (0.8-3.7) ml/mm Hg (p=0.03)) but the maximum tolerated volume increased (70 (50-118) v 96 (39-176) (NS) and 122 (56-185) ml (p=0.03)). Decreasing rectal sensitivity was found: the maximum tolerated pressure increased (14 (8-24) v 22 (8-34) (NS) and 26 (14-40) (p=0.02)) and the rectal threshold for TENS displayed a similar tendency. All patients displayed a low grade chronic inflammatory infiltrate in neorectal biopsy samples before closure of the ileostomy, with no change during follow up. CONCLUSIONS: The technique of INRA provides a safe alternative for restorative surgery. Stool frequency after INRA improves with time and seems to be related to decreasing sensitivity and not to histopathological changes in the neorectum. Furthermore, after the INRA procedure, all patients reported full continence.

Adenomatous Polyposis Coli↗
PubMed2004

Endoscopic balloon dilation of ileal pouch strictures.

BACKGROUND: Restorative proctocolectomy with ileal pouch-anal anastomosis is the surgical treatment of choice in patients with ulcerative colitis. Strictures can occur at the inlet and outlet of the pouch. Endoscopic balloon dilation has been successfully used in patients with Crohn's strictures at the small intestine and colon. There are no published trials on endoscopic balloon therapy of ileal pouch strictures. AIM: To evaluate outpatient endoscopic balloon dilation of strictures in ileal pouches. METHODS: Patients underwent nonfluoroscopy-guided, nonsedated, outpatient endoscopic dilations with an 8.6-mm upper endoscope and through-the-scope balloons (size: 11-18 mm). Pre- and posttreatment Pouchitis Disease Activity Index symptom scores (range: 0-6), endoscopic stricture scores based on resistance in passing the endoscope (range: 0-4), and Cleveland Global Quality of Life were compared. RESULTS: Nineteen patients with pouch strictures who had concurrent Crohn's disease of the pouch (n = 11), cuffitis (n = 5), and pouchitis (n = 3), including 14 inlet and 14 outlet strictures, were enrolled. The mean number of strictures for each patient was 1.61 +/- 0.78. All strictures were successfully dilated with the through-the-scope balloon, with a mean of 1.74 +/- 1.19 (range: 1-5) sessions for each patient. Nine patients had a second endoscopy at 8 wk and five patients had a third pouch endoscopy at 16 wk after the initial endoscopic dilation. Endoscopic stricture scores immediately (0.30 +/- 0.47), 8 wk (0.40 +/- 0.51), and 16 wk (0.44 +/- 0.76) after the dilation were significantly improved compared to the predilation stricture scores (2.67 +/- 0.78). The symptom scores and quality-of-life (QOL) scores improved at week 8 and 16 following dilation, with a mean follow-up of 6.10 +/- 5.83 months (2-25 months). No complications were experienced with the procedure. One patient with CD who failed endoscopic and medical therapy underwent pouch resection. CONCLUSION: In conjunction with medical therapy, outpatient endoscopic balloon dilation appears safe and effective in treating pouch inlet and outlet strictures, by relieving symptoms, restoring pouch patency, and improving QOL in the majority of patients.

Adult↗
PubMed2005

Colonic surgery in patients with juvenile polyposis syndrome: a case series.

PURPOSE: Juvenile polyposis syndrome is characterized by multiple hamartomatous polyps in the large intestine. When indicated, the surgical choices in symptomatic juvenile polyposis syndrome patients are colectomy with ileorectal anastomosis or proctocolectomy with pouch. The aim of this study was to evaluate the long-term outcomes of the surgical options in juvenile polyposis syndrome patients who present with symptomatic colonic polyps. METHODS: The charts of all juvenile polyposis syndrome patients who had had at least one colonic operation since 1953 in our institution were reviewed. The following data were abstracted: demographics, the number and site of the polyps, symptoms, the intervals and types of the colonic operation, follow-up, and the patients' current status. RESULTS: There were 13 patients (6 males) with a median age of 10 years (range, 1-50 years) at the time of diagnosis. Patients had colonic (n = 13), rectal (n = 12), and gastric (n = 6) polyps. Rectal bleeding (n = 11) was the most common presenting symptom. Three patients underwent proctectomy as the initial operation. Although a rectum-preserving operation was initially performed in ten patients, a subsequent proctectomy was required in five of them within a median of 9 years (range, 6-34 years). Therefore, eight patients had their rectum removed during the study period; five had an ileal pouch-anal anastomosis, one had a Koch pouch as a restorative surgery, and two had an end ileostomy. No relation was observed between the number of colonic and rectal polyps and the type of surgery or the need for proctectomy. Patients were followed up a median of 3 years (range, 2-24 years) after their ultimate operations. During this period, one patient (20 percent) who underwent restorative proctectomy and 4 patients (80 percent) whose rectums were preserved required multiple endoscopic polypectomies for recurrent polyps in the pouch (first patient) or their rectums (the other four patients). The patient who underwent the Koch procedure required surgery for recurrent polyps in her pouch. CONCLUSIONS: One-half of the patients who initially underwent rectal preservation required subsequent proctectomy. The number of colonic or rectal polyps does not influence the choice of the surgical procedure. Both restorative proctocolectomy and subtotal colectomy with ileorectal anastomosis need endoscopic follow-up because of the high recurrence rates of juvenile polyps in the remnant rectum or pouch.

Adenomatous Polyposis Coli↗
PubMed2003

Quality-of-life assessment of patients after ileal pouch-anal anastomosis for slow-transit constipation with rectal inertia.

PURPOSE: Severe idiopathic constipation with rectal inertia represents a challenging medical problem that, in extremis, might warrant surgery. We studied a group of patients who have undergone proctocolectomy and ileal pouch-anal anastomosis for this problem. The purpose was to assess the functional success of this procedure and its impact on the social function of the patients. METHODS: Patients with functional, intractable constipation have one motion or less per week and are laxative-dependent. The indication for surgery was based on failure of long-term medical therapy. The selection criteria were normal colonoscopy, normal anal manometry and pudendal nerve latency test, and abnormal transit study and abnormal video proctography. The functional outcome after surgery was assessed by anal manometry and stool frequency. Quality of life was analyzed using the Rand health survey 1.0 consisting of a comprehensive questionnaire used preoperatively and postoperatively with emphasis on physical function, role limitation because of functional/emotional problems, social function, pain, and general health. RESULTS: Fifteen patients (14 females) underwent ileal pouch-anal anastomosis over a seven-year period (1993-1999). The mean age was 41 (range, 25-47) years. All had a temporary defunctioning loop ileostomy fashioned, and there were no anastomotic leaks. Two patients required pouch excision within 18 months because of intractable pelvic pain. The mean stool frequency was eight (range, 3-12) per day at the first follow-up. At the second follow-up, this had improved to five (range, 2-6) per day. The mean resting and squeeze anal pressures preoperatively were 82 cm H2O and 104 mmHg, respectively, and were unchanged after surgery. Significant improvement in lifestyle scores were recorded in the categories of physical function, social function, and pain at the first follow-up and in all categories at the second follow-up (P < 0.05). CONCLUSION: Restorative proctocolectomy is an option in selected patients and leads to progressive improvement in quality of life.

Adult↗
PubMed1991

[Continence-preserving proctocolectomy using an ileum-pouch-anal anastomosis].

Between 1985 and 1990 restorative proctocolectomy with ileo-anal anastomosis was performed in 19 patients (in 15 cases for ulcerative colitis, in 2 cases for familial adenomatous polyposis and in 2 cases for multiple synchronous colorectal carcinomas). Restoration of intestinal continuity was performed by ileo-anal J-pouch (j-shaped ileal reservoir) by the method of UTSUNOMIYA. Eleven patients were operated upon in a two-stage procedure and 8 patients in a three-stage procedure. There was no mortality and no pouch had to be removed. Mean bowel frequency is 5-6 times during daytime and 0-once during nighttime, a fact which speaks for the excellent quality of life in these patients.

Adolescent↗
PubMed2004

[Surgical management of inflammatory bowel diseases].

The development of the medical management of the inflammatory bowel disease (IBD-ulcerative colitis, Crohn's disease) has reduced the number of the acute surgical interventions. Beyond the medical treatment the surgical management, the operative modalities, the pre and postoperative care has gone through a lot of changes. They review the different types of surgical alternatives and debating on the advantages and disadvantages, they put emphasis on the different surgical solutions of the Crohn's disease and that of the ulcerative colitis. Among the applied surgical alternatives to the ulcerative colitis they discuss the traditional proctocolectomy with end-ileostomy, the Kock-reservoir (as continent stoma), as well as the restorative proctocolectomy which is sufficient to preserve the anal continence. Principles of the surgery of the Crohn's disease are discussed according to the localisation of the inflammatory process (small bowel, colonic, rectal, anal channel). Because of the predisposition of relapses and the necessity of the successive surgical therapy, the extensive resections should be avoided.

Acute Disease↗
PubMed1987

The pouch as an alternative to permanent ileostomy.

Restorative proctocolectomy has become a realistic alternative to construction of a permanent stoma for patients with ulcerative colitis and familial polyposis coli. The operation restores intestinal continuity but continent patients have to open their bowels 4-5 times during the day, and over half have to rise at night to defaecate. The potential complications are considerable, but their frequency decreases with experience with the operation. This article reviews the place and results of ileoanal pouch anastomosis.

Adult↗
PubMed1990

Conservative proctocolectomy with low transection of the anorectum is a poor alternative to conventional proctocolectomy in inflammatory bowel disease.

The perineal wound is a frequent source of morbidity following proctocolectomy for inflammatory bowel disease. In 8 patients low transection of the anorectum or conservative proctocolectomy has been performed as an alternative to proctocolectomy in order to avoid a perineal wound. All patients passed copious mucoid discharge per anum post-operatively. Five patients required a proctectomy, 2 remain symptomatic and 1 patient has undergone a restorative proctocolectomy. This small series suggests conservative proctocolectomy does not seem to offer any advantage over conventional proctocolectomy in the surgical management of inflammatory bowel disease.

Adult↗
PubMed2006

Laparoscopic surgery in inflammatory bowel disease: is the future already here?

PURPOSE OF REVIEW: Starting from easy operations like the creation of enterostomies, laparoscopic colorectal surgery has developed quickly towards comprehensive procedures like proctocolectomies. Because of their benign character, inflammatory bowel diseases are an ideal indication for laparoscopic surgical approaches. Inflammatory alterations of bowel and mesentery, however, may demand a high level of laparoscopic experience. RECENT FINDINGS: In severe anal Crohn's disease, laparoscopic stoma formation has become a standard procedure for low morbidity and reoperation rates. In comparison with conventional bowel resections for Crohn's disease, shorter times to first postoperative bowel movements and hospital stays have been observed with the laparoscopic approach. Even complex cases with previous surgery and enteric fistulas may be managed laparoscopically with a low complication rate. In ulcerative colitis, experience with laparoscopic restorative proctocolectomy is increasing, and its feasibility has been proven in multiple studies. An elevated risk of complications has been observed with increased body mass index and acute inflammation. Function and quality of life outcomes seem to be equivalent for open and laparoscopic surgery. SUMMARY: Laparoscopic management of Crohn's disease and ulcerative colitis is complex and may be demanding. Its feasibility has been proven in multiple studies and it is offered as a safe and durable alternative for selected patients. The selection criteria are under investigation.

Humans↗
PubMed2003

Risk of rectal cancer in patients after colectomy and ileorectal anastomosis for familial adenomatous polyposis: a function of available surgical options.

PURPOSE: One of the concerns with colectomy and ileorectal anastomosis as a prophylactic procedure for patients with familial adenomatous polyposis is the risk of metachronous rectal cancer, estimated at from 12 to 43 percent. These estimates are based largely on surgeries performed at a time when the only alternative option to ileorectal anastomosis for patients with severe familial adenomatous polyposis was proctocolectomy and ileostomy. This study was designed to test the hypothesis that in the pouch era severe polyposis is now treated by proctocolectomy and ileal pouch-anal anastomosis. Ileorectal anastomosis is performed mostly in mildly affected patients and will therefore carry a very low risk of metachronous rectal cancer. METHODS: Patients undergoing primary prophylactic surgery for familial adenomatous polyposis between 1950 and 1999 were categorized according to the year of their surgery: prepouch era (before 1983) or pouch era (after 1983). Patients undergoing colectomy and ileorectal anastomosis were the focus of the study, and rate of proctectomy and the incidence of rectal cancer were recorded for each group. Data on the severity of the polyposis for each group were abstracted. RESULTS: A total of 197 patients underwent ileorectal anastomosis, 62 in the prepouch era (median follow-up, 212 months; interquartile range, 148 months) and 135 in the pouch era (median follow-up, 60 months; interquartile range, 80 months). Patients in the prepouch era came to surgery at the same median age as those in the pouch era (median age 23.0 years, interquartile ranges 15.5 years for prepouch and 17 years for pouch). Similar proportions of patients in the prepouch era had severe polyposis (49 percent) as in the pouch era (44 percent), although all severely affected patients had an ileorectal anastomosis in the prepouch era vs. 39 percent in the pouch era. Twenty (32 percent) prepouch-era patients underwent proctectomy compared with three (2 percent) pouch-era patients. No pouch-era patient had rectal cancer on follow-up; eight (12.9 percent) prepouch-era patients did. CONCLUSION: Although follow-up is shorter, ileorectal anastomosis for familial adenomatous polyposis performed since 1983 carries a much lower rate of rectal cancer and proctectomy than ileorectal anastomosis performed before this time, when restorative proctocolectomy was not an option. This is related, at least in part, to a greater number of patients with severe polyposis having their rectum initially spared.

Adenomatous Polyposis Coli↗
PubMed1987

Mathematical prediction of ileal pouch capacity.

Restorative proctocolectomy is an operation still in the stage of development. Three main types of ileal pouch construction are used, but the advocacy of each probably arises more from familiarity and convenience than from scientific considerations. Since, other things being equal, pouch capacity can be expected to affect stool frequency, it seemed reasonable to examine calculable pouch capacity geometrically for different methods of construction. A mathematical model was therefore used to compare the double loop ('J') type with the quadruple loop ('W') construction. The W was estimated to have a capacity more than half as great again as the J. Similarly anastomotic methods which encroach on the ileal circumference by creating an inverted edge can be expected to reduce resultant capacity by 10 per cent or more.

Colectomy↗
PubMed1987

Neural control of internal anal sphincter function.

The effect on anal tone of electrical stimulation of the presacral (hypogastric) sympathetic nerves has been studied in eight patients during abdominal rectopexy or restorative proctocolectomy. A sharp fall in anal pressure occurred in seven patients (mean fall 59 cmH2O; range 35-80 cmH2O). In one patient given a beta- and alpha-sympathetic blocking drug (labetalol 200 mg) intra-operatively, the anal pressure decreased by 15 cmH2O. These observations show that stimulation of the presacral sympathetic nerves causes relaxation of the internal anal sphincter and implies that these nerves may induce relaxation of the sphincter in vivo. The pathway of the recto-anal reflex has been studied intra-operatively in three patients undergoing rectal excision. The recto-anal reflex is present after presacral nerve blockade and after full mobilization of the rectum, but is abolished by circumferential rectal myotomy. The reflex has a local intramural pathway. This observation validates the assumption that absence of this reflex is a feature of aganglionosis, as in Hirschsprung's disease.

Adrenergic Fibers↗