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PubMed1989

Clinical results of colectomy for severe constipation.

Subtotal colectomy has been performed in 40 patients with severe constipation. Only one patient was male. Five patients (13 per cent) had a history of a serious psychiatric disorder. Twenty-six patients (65 per cent) could not expel a 100-ml air-filled balloon and 19 patients (48 per cent) had electromyographic evidence of abnormal puborectalis contraction during attempted defaecation before operation. Median preoperative passage of 50 radio-opaque markers over 5 days was 16 per cent. Sixteen patients had had a previous anorectal myectomy to exclude Hirschsprung's disease. Initial resections were subtotal colectomy and ileorectal anastomosis (n = 34), caecorectal (n = 5) or ileosigmoid (n = 1) anastomosis. Secondary operations included restorative proctocolectomy and ileal pouch-anal anastomosis (n = 6) and six patients eventually had an ileostomy. Median bowel frequency per week significantly increased after operation (0.3 (range 0-1) preoperatively to 21 (range 2-70) postoperatively, P less than 0.005), the percentage of patients with abdominal pain fell after operation from 93 to 39 per cent but symptoms of abdominal distension remained the same (86 per cent preoperatively and 82 per cent postoperatively).

Adult↗
PubMed1989

Ileitis and pouchitis after colectomy for ulcerative colitis.

Ileitis can occur after surgical treatment of ulcerative colitis. Following continent ileostomy or restorative proctocolectomy ileitis can become a serious clinical problem and is then known as pouchitis although this condition is yet to be clearly defined. It is likely that pouchitis is the result of an abnormal host response to a change in bacterial flora and that the nature of this host response is related to the underlying pathogenesis of ulcerative colitis. Continued study of the immunological basis of ulcerative colitis is therefore required to solve the problem of pouchitis.

Colectomy↗
PubMed1991

Myectomy reduces ileal motility after ileoanal anastomosis.

The hypothesis tested was that myectomy of the distal ileum would produce a long-lasting decrease in ileal motility, and so render single-lumen ileum more suitable for use as a rectal substitute in the course of restorative proctocolectomy, without the need for a pelvic ileal reservoir. Ileal motility, both spontaneous and in response to intraluminal volatile fatty acids (VFA), was studied after proctocolectomy in 25 female adult beagles, at least 6 months after ileoanal anastomosis alone (IAA, n = 6), IAA with myectomy (n = 8), IAA with myectomy and an ileal valve (n = 5) or IAA with a duplicated (J) ileal reservoir (n = 6). VFA were found to stimulate ileal motility significantly in each group. Myectomy significantly reduced the number of ileal contractions (P less than 0.01), the mean amplitude of contractions (P less than 0.05) and the motility index (P less than 0.01). The addition of the valve to myectomy made no significant difference.

Anal Canal↗
PubMed1992

Reduction of the effluent volume in high-output ileostomy patients by a somatostatin analogue, SMS 201-995.

Twelve ileostomy patients were given subcutaneous SMS 201-995 therapy (100 micrograms t.d.s. for 5 days) in a randomized placebo-controlled trial. All patients had ileostomies constructed 60 cm proximal to the terminal ileum (proximal ileostomy) following restorative proctocolectomy. SMS 201-995 reduced the daily ileostomy output from 997 +/- 52 g to 736 +/- 28 g, P < 0.05, along with a decrease in daily sodium and chloride excretion (sodium: 92.60 +/- 8.51 to 75.22 +/- 8.64 mEq, chloride: 143.46 +/- 8.54 to 113.60 +/- 15.84 mEq; both P < 0.05). There were no significant changes in the plasma levels of glucagon, C peptide, insulin, renin or aldosterone with SMS 201-995 therapy. Patients developed no severe side effects and reported easier management of the ileostomy and a reduction in thirst. Our results suggest a possible clinical role for SMS 201-995 in the management of proximal ileostomy.

Adolescent↗
PubMed1995

Colectomy for acute colitis: is it safe to close the rectal stump?

We report 62 operations for acute colonic inflammatory bowel disease in which the rectal stump was closed. Operative findings were of severe colitis in 46, toxic megacolon in 8 and faecal peritonitis in 8 patients. Histology showed ulcerative colitis in 48, Crohn's disease in 9 and indeterminate colitis in 5 patients. Clinical evidence of stump leakage occurred in only one of 53 patients with a long rectal stump in contrast to 3 of 9 patients who had a short rectal stump. Leaving a very short stump also led to difficulty at subsequent proctectomy in 3 patients and at restorative proctocolectomy in 1 patient. This suggests that careful closure of the rectum above the peritoneal reflection can be a safe means of dealing with the rectal stump after total colectomy and ileostomy for acute colitis.

Acute Disease↗
PubMed1988

Does balloon dilatation and anal sphincter training improve ileoanal-pouch function?

Although patients' satisfaction may be high after restorative proctocolectomy the functional results are still far from perfect. Increased bowel frequency and imperfection in continence are common. Pouch volume and anal sphincter status are important determinants for the outcome. The aim of the present study was to evaluate if balloon dilatation of the pouch and sphincter biofeedback training might improve the results. Forty patients with an ileo-pouch anal anastomosis were randomized into a control and a treatment group. During the interval with a diverting ileostomy, patients in the latter group were subjected to balloon dilatation of the pouch and sphincter biofeedback training by using a manovolumetric technique. All patients were functionally assessed and anorectal manovolumetry performed preoperatively and at regular intervals postoperatively. Follow-up time was at least 12 months. Immediately before ileostomy take down patients in the treatment group showed a significant initial increase in pouch compliance compared with controls. However, a rapid and pronounced increase in pouch volume occurring after ileostomy closure in the control group equalized this initial difference. Anal resting tone and maximum squeezing capacity were at all intervals similar in the two groups. Bowel frequency per 24 h was similar and mucus soiling occurred to a similar extent in both groups, and the overall functional result as assessed according to a scoring system was equal at each interval. Balloon dilatation of the pouch and sphincter exercises appear not to be essential measures in these patients.

Adolescent↗
PubMed1988

Manometric follow-up of anal sphincter function after an ileo-anal pouch procedure.

Between January 1985 and January 1987 restorative proctocolectomy with J-pouch was undertaken in 20 patients with ulcerative colitis. In all patients anal manometry was performed preoperatively, before closure of the temporary ileostomy (mean 3.9 months after operation) and 3,6 and 12 months after the closure of the ileostomy. Preoperatively the basal resting pressure was 60.2 +/- 12 cm water and the maximum squeeze pressure 88.5 +/- 18 cm water. After the operation the respective pressures were 33.2 +/- 8 and 68 +/- 21 cm water, a decrease of 45% (p less than 0.05) and 12% (p less than 0.05), respectively. One year after the closure of the loop ileostomy the basal pressure was 46.2 +/- 9 cm water, which is still 23% lower (p less than 0.05) than preoperatively. At the same time the maximum squeeze pressure was 96.5 +/- 13 cm water, 8% higher (p greater than 0.1) than preoperatively. The continence of the patients at the end of the follow-up was either good (n = 6) or excellent (n = 9). A correlation seemed to exist between sphincter pressures and the degree of continence. It is concluded that the internal anal sphincter suffers damage during the operation and slowly recovers up to 6 months after closure of the covering ileostomy. After that its function usually does not improve and remains at a lower level than preoperatively.

Adult↗
PubMed1992

Clinical implications of jejunoileal diverticular disease.

Congenital and acquired diverticula of the jejunum and ileum in the adult are unusual and occur in approximately 1 percent to 2 percent of the population. They are pulsion diverticula thought to be the result of intestinal dyskinesia. These lesions can produce a significant diagnostic and therapeutic dilemma. They are multiple in the jejunum and solitary distally and are characteristically found in 60- or 70-year-old males. The diagnosis may be confirmed with contrast studies of the small intestine, arteriography, or nuclear scan. Consider these disorders in patients with 1) unexplained gastrointestinal bleeding, 2) unexplained intestinal obstruction, 3) an unexpected cause of acute abdomen, 4) chronic abdominal pain, 5) anemia, or 6) malabsorption. Medical therapy is helpful in controlling diarrhea and anemia, while surgical therapy is reserved for hemorrhage, obstruction, perforation, or failure of medical management. Asymptomatic diverticula discovered on routine contrast studies need not be resected. At surgery, incidental diverticula should be removed when evidence of dilated, hypertrophied loops of small bowel with large diverticula is found. Intraoperative air distention will aid in diagnosis. Resection and primary anastomosis is the preferred treatment for non-Meckelian diverticula. Diverticulectomy is reserved for a Meckel's diverticulum without evidence of ulceration. An incidental Meckel's diverticulum should be removed in the presence of mesodiverticular bands or ectopic tissue. Removal of a Meckel's diverticulum is not advised in the patient with Crohn's disease but may be performed in the patient undergoing restorative proctocolectomy for ulcerative colitis.

Algorithms↗
PubMed1991

Loop ileostomy after ileal pouch-anal anastomosis--is it necessary?

Construction of a loop ileostomy is usually advised in patients having an ileal pouch-anal anastomosis to minimize the complication of chronic pelvic sepsis. Formation and closure of a loop ileostomy was associated with a 41 percent and 30 percent complication rate, respectively, in a prospective series of 34 patients. This morbidity must now be assessed in relation to the benefits of avoiding temporary fecal diversion in restorative proctocolectomy.

Adolescent↗
PubMed2000

Risk factors for rectal cancer morbidity and mortality in patients with familial adenomatous polyposis after colectomy and ileorectal anastomosis.

PURPOSE: The aims of the study were to investigate the effects of ileorectal anastomosis and the follow-up program on rectal cancer morbidity and mortality and to identify risk factors that predict the fate of the rectal stump. METHODS: One hundred ninety-five patients with familial adenomatous polyposis on whom an ileorectal anastomosis was performed between 1957 and the end of 1995 were included. Median follow-up time was 14 (range, 1-39) years. The cumulative risks of rectal cancer and rectal excision were estimated using survival analysis. RESULTS: Eighteen patients (9.2 percent) developed cancer, 17 in the retained colorectal segment and one on the ileal side of the anastomosis, and nine died of their cancer during the study period. The cumulative rectal cancer morbidity and mortality 20 years after ileorectal anastomosis was 12.1 percent (95 percent confidence interval = 5.7-18.5) and 7 percent (95 percent confidence interval = 2-12), respectively. The cumulative age-dependent risk of rectal cancer was 22.9 percent (95 percent confidence interval = 11.4-34.5) and 25.7 percent (95 percent confidence interval = 13.2-38.2) at the ages of 60 and 70 years, respectively. The corresponding cumulative mortality was 11.1 percent (95 percent confidence interval = 2.9-19.3) at the age of 70 years. Patients with dense polyposis at colectomy had an increased risk for cancer in the retained colorectal segment compared with patients with intermediate or sparse polyposis (P = 0.04). Sixty-six patients (34 percent) had their rectum removed, and the cumulative rectal excision rate 35 years after ileorectal anastomosis was 65.5 percent (95 percent confidence interval = 53-78). CONCLUSION: Patients on whom ileorectal anastomosis was performed had, despite the high rectal excision rate, a substantial risk of developing cancer in the retained colorectal segment, with an ensuing high mortality. Our results indicate that patients with dense polyposis should undergo restorative proctocolectomy as primary operation for familial adenomatous polyposis. In younger patients with intermediate or sparse polyposis and good expected follow-up compliance, ileorectal anastomosis still is an alternative.

Adenomatous Polyposis Coli↗
PubMed1983

Evacuation pouchography in the evaluation of ileoanal reservoir function.

Thirty four patients with restorative proctocolectomy and ileoanal pelvic reservoirs were studied by "evacuation pouchography" to determine why only some patients could evacuate spontaneously. The 50 per cent who were able had a significantly shorter distal segment (P less than 0.02) of mean length (8 +/- 3 cm) that filled on straining, compared with those who had to use a catheter to empty the pouch, in whom the distal segment was longer (mean 11 +/- 4 cm) and often failed to fill on straining. The longer the distal segment, the more likely it was to be angulated, causing difficulty in passage of the catheter with possible ulceration and stenosis from minor trauma. Stricturing in the distal segment was associated with minor nocturnal leakage. A short distal segment is recommended to allow spontaneous evacuation and avoid the risks of repeated catheterization.

Adolescent↗
PubMed1987

Perforation of terminal ileal appendage of J-pelvic ileal reservoir.

If, during restorative proctocolectomy, the most distal segment of the terminal ileum is not incorporated into the reservoir during J-pouch construction, it will remain as an appendage and may twist upon itself and obstruct. Two cases in which this resulted in significant complications are described.

Adult↗
PubMed1989

Ileal pouch vaginal fistulas: incidence, etiology, and management.

Some of the initial problems associated with the ileoanal reservoir have been solved. In their place, other complications have been recognized. Among these, the ileal pouch vaginal fistula stands out as a recently recognized difficult management problem. This multicenter study was undertaken to gain insight into the causes for, and treatment of, pouch vaginal fistulas. Cases were gathered from 11 surgical practices throughout North America, in which the ileoanal reservoir procedure is frequently performed. Overall, 304 females had undergone ileoanal reservoir procedures by these surgical groups. Twenty-one patients developed 22 pouch vaginal fistulas for an overall incidence of 6.9 percent. Five additional patients with pouch vaginal fistulas, whose restorative proctocolectomies were done elsewhere, were referred to these surgeons for treatment. The courses of these 26 patients form the basis of this report. This study details the risk factors which predispose in the development of a pouch vaginal fistula, as well as the various treatment options available.

Adolescent↗
PubMed1984

Transmucosal myotomy of the small bowel after ileoanal anastomosis.

Posterior transmucosal myotomy of the small bowel distal to the pelvic pouch was carried out in two patients who underwent restorative proctocolectomy for ulcerative colitis. Painful spasms of the efferent limb and outlet obstruction of the reservoir were the main indications for surgery. Laparotomy was unnecessary, as the operation could be performed either through a transanal route or by means of a rigid sigmoidoscope. Both patients showed marked clinical improvement after myotomy; therefore, it may be considered an effective and safe procedure in the treatment of functional and mechanical disorders of the small intestine above an ileoanal anastomosis.

Adult↗
PubMed1986

Solitary J-pouch ulcer causing pouchitis-like syndrome.

A 37-year-old man with familial polyposis coli who had undergone restorative proctocolectomy with a J-pouch as an ileal reservoir developed a solitary mucosal ulcer in the reservoir, causing a pouchitis-like syndrome. There was no endoscopic evidence of further inflammatory changes of the mucosa. The ulcer healed and symptoms subsided after six weeks of therapy with metronidazole followed by tetracycline. Possible causal and pathogenic factors are considered and discussed. Association of this patient's lesion with the nonspecific mucosal inflammatory process described in pouchitis is suggested by similar clinical manifestations and outcome.

Adult↗
PubMed2006

Differential expression of toll-like receptor 3 and 5 in ileal pouch mucosa of ulcerative colitis patients.

BACKGROUND AND AIMS: The pathogenesis of pouchitis, major complication after restorative proctocolectomy, and ileal J pouch-anal anastomosis (IPAA) in patients with ulcerative colitis (UC) is still unclear. Changes in intraluminal bacterial colonization and correlated changes of pouch mucosa are thought to play an important role. Toll-like receptors (TLRs) as part of the innate immune system are capable of recognizing bacterial antigens. Their activation can lead to secretion of proinflammatory mediators. In this study, TLR2, 3, 4, and 5 expression profiles in the pouch mucosa of patients with UC and IPAA were analyzed and correlated with pouchitis. MATERIALS AND METHODS: Clinical symptoms, endoscopy, and histology were assessed in 35 patients using the Heidelberg Pouchitis Activity Score to classify patients as either having pouchitis or not. TLR mRNA expression in normal ileal mucosa and pouch mucosa was investigated by performing semi-quantitative reverse transcriptase polymerase chain reaction (RT-PCR). The results of RT-PCR were associated with the pouchitis score. RESULTS: In the analysis of all patients, TLR3 expression was decreased significantly whereas TLR5 expression was increased significantly in pouch mucosa compared to normal ileal mucosa (p-values 0.0076 and 0.016, respectively). A more detailed analysis upon dividing the patients into patients with and without pouchitis showed decreased TLR3 expression in the pouch mucosa only of patients without pouchitis (p-value=0.0067). TLR5 expression was increased in the pouch mucosa only of patients with pouchitis (p-value=0.023). No differences in TLR2 and 4 expression were found in either group. CONCLUSION: Differential expression of TLR3 and 5 suggests bacterial involvement in the pathogenesis of pouchitis in patients with UC.

Adult↗
PubMed1997

Laparoscopic surgery for lower gastrointestinal fistulas.

BACKGROUND: Increased experience and improved instrumentation have lead to a reduction in morbidity and a commensurate increase in the spectrum of laparoscopic indications. The purpose of this study was to assess the feasibility of laparoscopic surgery in patients with gastrointestinal fistulas. METHODS: Between March 1993 and March 1995, patients with gastrointestinal fistulas who were laparoscopically treated were analyzed for age, gender, diagnosis, type of procedure, operative time, conversion rate, length of postoperative hospitalization, time until oral intake and return of bowel function, morbidity, and mortality. RESULTS: Ten patients (five females; five males) with a mean age of 49.7 (range 20-86) years were preoperatively diagnosed as having the following fistulas: colocutaneous fistula due to diverticulitis (one), enterocolic fistula (two)-due to Crohn's ileocolitis (one) and due to diverticulitis (one)-pouchvaginal fistula after restorative proctocolectomy for familial adenomatous polyposis (two), colofallopian fistula due to diverticulitis (one), rectourethral fistula due to Crohn's disease (one), high transsphincteric fistula due to perianal Crohn's disease (one), enteroenteric fistula due to Crohn's disease (one), and colovesical fistula due to diverticulitis (one). Procedures performed consisted of sigmoidectomy with coloproctostomy (four), ileocolic resection (two), small-bowel resection with ileostomy (one), and diverting loop ileostomy (three). A complex jejunal enterotomy was noted in one (10%) patient. The mean operative time was 195 (range 75-360) min and mean postoperative hospital stay was 6.1 (range 3-12) days. Two additional cases were converted to open procedures for extensive disease (one) and adhesions (one). The patients started oral intake after a mean of 2.2 (range 1-5) days and bowel function returned after a mean of 3.4 (range 2-7) days. One patient required laparotomy on postoperative day 7 for a malrotated loop ileostomy. CONCLUSIONS: Laparoscopic colorectal surgery is feasible in patients with simple lower gastrointestinal fistulas. The morbidity rate of 10% and length of hospitalization of 6 days are similar to results after laparoscopic procedures for "simpler" colorectal pathology. However, the 30% conversion rate is higher, attesting to the challenging nature of these conditions.

Adult↗
PubMed2005

Endoscopic transanal rectal mucosal ablation in the surgical treatment of ulcerative colitis: preliminary results of a novel technique.

PURPOSE: We describe a new technique that endoscopically eradicates rectal stump mucosa after total colectomy for ulcerative colitis. METHODS: Seven patients (5 males; median age, 56 (range, 36-72) years) underwent attempted endoscopic transanal rectal mucosal ablation using the 28-French-gauge urologic resectoscope, either at the time of total colectomy and ileostomy for failed medical therapy (5 patients) or as an alternative to completion proctectomy (2 patients) with rectal stump discharge. All had declined restorative proctocolectomy. Clinical, endoscopic, and histologic follow-up was undertaken during a mean of 15 (range, 3-28) months. RESULTS: The operative technique evolved during these cases; mucosal ablation was successfully performed leaving a denuded muscular rectal tube in situ in six patients. Mean operative time was 45 minutes. Postoperative endoscopic surveillance has not demonstrated any viable rectal mucosa in these six patients, with only granulation tissue detected histologically. Narrowing of the rectal tube has occurred in two patients. Although all patients report insignificant rectal discharge, urinary and sexual function have remained unchanged. CONCLUSIONS: Diathermy ablation of the rectal mucosa via endoscopic transanal rectal mucosal ablation avoids the complications of pelvic dissection and might offer an effective alternative to proctectomy for ulcerative colitis.

Adult↗