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PubMed1993

A pathophysiologic study of diversion proctitis.

Diversion proctitis occurs with variable frequency after exclusion of the fecal stream. Its importance lies in the inability to differentiate it from other types of proctitis that may result in inappropriate therapy and a reluctance to recommend stoma closure. The effect of fecal diversion (n = 18) and restoration of intestinal continuity (n = 10) on human rectal mucosa in patients without inflammatory intestinal disease has been prospectively evaluated. Fecal diversion was associated with macroscopic inflammation in 55 percent of the patients and histologic inflammation in 72 percent, with a variable incidence of aphthoid ulceration, crypt abscess formation and submucosal nodularity. Restoration of continuity was associated with improvement in histologic features in all patients, but the mucosa returned to normal in only 50 percent of the patients. Onset or resolution of diversion proctitis was not associated with any significant changes in colonic cellular proliferation, glycoprotein synthesis or mucosa-associated or luminal flora. The only diagnostic feature of defunctioned proctitis remains its resolution on reintroducing the fecal stream.

Diagnosis, Differential↗
PubMed2000

Caring for patients with coloanal reservoirs for rectal cancer.

Advances in surgical techniques enable select patients with rectal cancer to have sphincter-saving procedures that restore the continuity of the GI tract, eliminating the need for a permanent colostomy. One of the preferred surgical options is the construction of a coloanal reservoir or colonic J-pouch. This procedure is usually performed in two stages (two surgeries) and involves creating a temporary ileostomy. Patients undergoing treatment for rectal cancer frequently require adjunctive therapy for the disease before and after surgery. They require extensive education and support during the course of treatment and through rehabilitation.

Humans↗
PubMed2002

Rectal washout with cytotoxic solution can be extended to the whole colon.

BACKGROUND: Rectal irrigation with a cytotoxic agent does not kill viable intraluminal cancer cells proximal to the primary tumour. To prevent implantation of these cells at the time of restorative proctectomy, the feasibility of retrograde whole-colon irrigation just before surgery was explored. METHODS: The cytotoxic efficacy of different combinations of povidone-iodine (PVPI) and Gastrografin was tested with the trypan blue exclusion test on a human colon carcinoma cell line (SW620) in vitro. Subsequently, a retrograde whole-colon lavage with PVPI 5 per cent and Gastrografin 12 per cent was performed in 14 euthyroid, non-allergic patients with colorectal cancer using a colostomy irrigation set. Thyroid function and mucosal damage were assessed. RESULTS: It took 2 min and approximately 1 litre of infused solution to reach the caecum in all patients. The solution was 100 per cent tumoricidal in vitro and remained so after colonic irrigation. Total serum tri-iodothyronine (T3) levels decreased and those of reverse T3 increased, but normalized after 1 week. Superficial epithelial desquamation was observed shortly after irrigation; however, complete restoration occurred within 7 days. CONCLUSION: A rectal washout can easily be extended to a retrograde irrigation of the whole colon in elective colorectal cancer surgery. This may help to prevent anastomotic and local recurrence due to implantation of viable exfoliated tumour cells.

Adult↗
PubMed1994

Can (neo)rectal evacuation disorders be treated surgically in inflammatory bowel disease?

Besides the well-known perineal and anal manifestations of inflammatory bowel disease (abscess, ulcers, fissures and fistulae) anal stricture can develop in Crohn's disease. Usually anal dilation under general anaesthesia in one or two procedures is recommended as the treatment of choice. In the Leiden University Hospital 4 patients were seen in the period 1988-1993 with an anal stricture based on Crohn's disease after previous attempts at dilation. On physical examination and anal manometry it was judged that dilation in a single procedure was endangering faecal continence. It was decided to treat the patients with "self dilation" by means of custom made dilators over a period of several months. Three patients are very satisfied with the results and no longer have disordered defaecation. The fourth patient has only recently started this form of treatment but is experiencing clinical improvement. Anal stricture at the site of the anastomosis of the efferent limb of an ileal pouch in patients after restorative panproctocolectomy is most often the cause of obstructed defaecation. However, patients with such a pouch can develop obstructed defaecation caused by an efferent limb of the pouch that is compressed or intussuscepted on defaecation. Four patients with such a disorder were treated with a new operation to prevent repeated damage to the anal sphincter. In this operation the pouch was opened at the top and a stapling device was used to fuse the efferent limb with the pouch.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1994

[Reconstructive and restorative surgeries of the large intestine].

Reconstructive-restorative operations in 164 cases of colostomy are analysed. The colostomy was formed for injury to the large intestine in 45.7%, oncoproctological diseases in 35%, complications of diverticulum in 10%, and for other diseases (volvulus of the sigmoid colon, unspecific ulcerous colitis, etc.) in 9.3% of patients. The terms of the operations were chosen individually: from 2.5-4 months after injury to 10-14 months after an oncological operation. The extraperitoneal method was applied in 93 and the intraperitoneal method in 71 operations. Mortality was 2.9%.

Colostomy↗
PubMed2002

[Colonic pouch: indications and technique].

Early functional outcome after low anterior resection with total mesorectal excision (TME) and colo-anal anastomosis for colorectal carcinoma can be improved by the restoration of the colonic reservoir. This can be achieved by the construction of a colonic J-pouch. The technique is safe and has been refined during the last years. A decrease in stool frequency, urgency, and incontinence rates during the first two postoperative years with an improved quality of life has been observed. Alternative methods with similar functional results are provided by the ileocecal reservoir, the transverse coloplasty pouch or the side-to-end anastomosis. Colonic J-pouch reconstruction should be considered as an superior alternative to straight coloanal anastomosis in patients undergoing anterior resection.

Colonic Pouches↗
PubMed1991

Inverted U-pouch construction for restoration of function in patients with failed straight ileoanal pull-throughs.

Patients who have undergone straight ileoanal pull-through operations without a reservoir in adult life frequently have unsatisfactory results. Operative correction of this problem has been difficult. We propose a new operation that preserves the ileoanal anastomosis, constructs a reservoir, and has resulted in good restoration of bowel function in three patients. The operative procedure consists of division of the ileum 30 cm above the dentate line. The distal ileum is then folded over itself so that the point of division reaches into the pelvis, between the rectal muscular cuff and pulled-through ileum, to a point just proximal to the dentate line. The two limbs of ileum are connected using a stapler, completing the reservoir construction. The proximal divided ileum is anastomosed, end-to-side, to the pouch. A protective ileostomy that can be closed in three months is constructed.

Adult↗
PubMed1996

[Restorative proctectomy, reconstruction of continuity with or without colon J pouch].

Of 63 patients undergoing deep anterior resection of the rectum, 39 patients received a straight colo-anal anastomosis (CAA), 24 additionally had a colon-j-pouch (CPA) constructed. Local septic complications occurred in 12.5% of patients after pouch-anal anastomosis compared to 20.5% after colo-anal anastomosis: stool frequency, after pouch-anal anastomosis was 3.3 per 24 h compared to 5.2 per 24 h after straight anastomosis within the first year after ileostomy closure (p = 0.053); continence was slightly better in the pouch group (n.s.); and anal manometry showed a significant postoperative decrease only in resting pressure after straight colo-anal anastomosis (p < 0.001). Pouch construction should be considered after deep rectal resection, as it seems to improve functional outcome and has fewer local septic complications than straight anastomosis.

Fecal Incontinence↗
PubMedDate not supplied

A novel operative technique on proximal gastrectomy reconstructed by interposition of a jejunal J pouch with preservation of the vagal nerve and lower esophageal sphincter.

BACKGROUND/AIMS: This article describes the surgical techniques and postoperative status for proximal gastrectomy reconstructed by interposition of a jejunal J pouch with preservation of the vagal nerve and lower esophageal sphincter. METHODOLOGY: We have performed a new technique for reducing postgastrectomy sequelae such as reflux esophagitis, early dumping syndrome, and microgastria in early gastric cancer located in the proximal third of the stomach. The technique consists of proximal gastrectomy with preservation of the hepatic, pyloric, celiac branch of the vagal nerve, and abdominal esophagus (lower esophageal sphincter), and reconstruction by interposition of a jejunal J pouch. To reserve pyloric function, pyloroplasty can be omitted by preservation of the pyloric branch from the vagal nerve. To restore loss of reservoir function, the reconstruction is performed with an interposed jejunal J pouch. Sacrifice of the mesenteric arcades is kept to a minimum to preserve the autonomic nerve and blood flow in the mesentery. RESULTS: All of the patients who underwent this operation were able to eat an adequate amount of food at 6 months after surgery and they were satisfied with their postoperative status. And that, we have not experienced postgastrectomy disorders such the dumping syndrome and reflux esophagitis. CONCLUSIONS: Therefore, this method is useful for preventing the postoperative disorders in patients with early gastric cancer located in the proximal third of the stomach.

Adult↗
PubMed1997

Surgical therapy for Crohn's disease of the colon and rectum.

Crohn's disease remains incurable by either medical or surgical treatment. Both physician and surgeon must work together with the common objective of restoring health by eliminating or alleviating the complications of Crohn's disease. From the surgeon's viewpoint, operation is performed for complications of the disease or for failure of medical management. Although aggressive surgical excision of affected bowel rids the patient of disease for a period of time, the beneficial effects of operation have to be considered in the context that disease recurrence is always a possibility and that reoperation for such complications may be necessary. The aim of the surgeon is to deal with the current problem as simply as possible and to maintain a long-term, strategic view of the disease process with the understanding that what is done today may affect the patient for life.

Anastomosis, Surgical↗
PubMed2003

[Restorative surgery after combined and extensive radical operations on pelvic organs].

The rates of lower bowel cancer morbidity have risen from 10.1 to 13.5%, while those of urinary bladder--from 7.4 to 8.9%--per 100,000 of population in Omsk Region for the past 6 months. The shares of tumors stage III-IV were 64.3 and 46.1%, respectively. Combined surgery in the organs of the small pelvis was carried out in 275. Since 1997, 32 patients have had the lower part of the bowel and/or urinary bladder removed and an isolated ileocecal angle formed turning towards the small pelvis, as a method of choice for surgical rehabilitation. No early postoperative complications have been reported. At a later stage, 7 patients suffered pyelonephritis and one--stricture of ureteroenteric anastomosis. Our modified procedure of cystoplasty offers optimal means for social rehabilitation of the patient and prevention of reflux-pyelonephritis as well as cutting down the risk of immediate postoperative complications development.

Anastomosis, Surgical↗
PubMed1997

[Restorative proctectomy. A comparison of direct colo-anal and colon-pouch-anal anastomoses for reconstructing continuity].

Thirty-nine of 63 patients undergoing deep anterior rectal resection received a straight coloanal anastomosis (CAA); the remaining 24 patients additionally had a colon-j-pouch (CPA) constructed. After pouch-anal anastomosis, local septic complications occurred in 12.5% of patients compared to 20.5% after coloanal anastomosis. Stool frequency after pouch-anal anastomosis was 3.3 per 24 h compared to 5.2 per 24 h after straight anastomosis within the first year after ileostomy closure (P = 0.053). Continence was slightly better in the pouch group (n.s.), and anal manometry showed a significant postoperative decrease only in resting pressure after straight colonal anastomosis (P < 0.001). This study supports the construction of a colon-j-pouch after deep rectal resection, as the pouch-anal anastomosis has fewer local septic complications and seems to improve functional outcome.

Adult↗
PubMed1997

Ultra-low anterior resection and coloanal pouch reconstruction for carcinoma of the distal rectum.

Facilitated by an enhanced appreciation for pelvic anatomy and physiology along with a better understanding of patterns of rectal cancer spread, great advances have been made in our ability to perform restorative resections for an ever-increasing proportion of mid and distal rectal cancers. Whereas oncologic results following a low anterior resection were the principal concern 20 years ago, recent efforts have focused on improving functional results as well. Aspirations for improved function need to be tempered by the realization that improved sphincter-saving rates must follow improved oncologic results rather than jeopardize them. Some crucial questions are addressed in this paper: What are the variables involved in optimizing the oncologic and functional results of a low anterior resection and a coloanal reconstruction? What are the issues involved in selecting a particular coloanal reconstruction (straight versus pouch, stapled versus handsewn, with or without fecal diversion) for a particular patient? Who is not a good candidate for a coloanal reconstruction?

Anal Canal↗
PubMed1998

Sphincter preservation in rectal cancer. Technical considerations for coloanal anastomosis and J-pouch.

Most patients with midrectal cancer undergo a sphincter-preserving operation using modern bowel stapling techniques. In patients with bulky tumors or unfavorable pelvic anatomy, however, abdominoperineal resection with permanent colostomy may be performed for technical reasons, not based on oncologic clearance needs. In addition, low-lying tumors treated initially with preoperative chemoradiation are often downstaged, increasing the opportunity for restorative procedures. Treatment by total proctectomy and peranal sutured coloanal reconstruction fulfills the need for adequate oncologic clearance and satisfactory bowel function. Sharp pelvic dissection with removal of the entire rectal mesentery, adequate mobilization of the left colon, and precise anastomotic technique are required for optimal results. Creation of a colon J-pouch increases the capacity of the reconstructed rectum and greatly reduces the time required for functional adaptation in the postoperative period. Although irregular evacuation and other minor problems can persist, permanent colostomy is avoided, and patient satisfaction is high. For cancers of the middle and distal rectum, total proctectomy with coloanal reconstruction is an important treatment option that can improve quality of life without compromising cancer treatment.

Abdomen↗
PubMed2000

Dilation of benign strictures following low anterior resection using Savary-Gilliard bougies.

BACKGROUND AND STUDY AIMS: Benign anastomotic strictures occur in up to 22% of patients after colorectal resections. Initially, treatment for these strictures was surgical, but nowadays endoscopic dilation techniques are preferred. This study was conducted to assess the efficacy of dilation using SavaryGilliard bougies. PATIENTS AND METHODS: From 1987 to 1994, 256 consecutive patients underwent low anterior resection (LAR). Twenty-one patients (8.2%) developed a stricture of the colorectal anastomosis. Follow-up data were available for 18 of these patients. The patients were treated using endoscopic Savary dilation, with bougies of increasing diameters (10-19 mm). The mean follow-up period was 19 months (1-60 months). RESULTS: Stricture symptoms presented after a mean period of 7.7 months after LAR. In three of the 18 patients, the stenosis was caused by local recurrence, and these patients were excluded from further evaluation. Normal defecation was restored in 10 of the remaining 15 patients, and symptoms disappeared. In five patients, there was only partial improvement, but only three of them required another type of treatment. Of four patients who received radiotherapy and developed a strictured anastomosis, two had successful dilations. A normal defecation pattern was never regained if more than three dilations were necessary. No complications caused by Savary dilation were observed. CONCLUSIONS: In this study population, Savary dilation appeared to be a safe and effective treatment for benign anastomotic strictures after LAR. All successfully treated patients (ten of 15) required no more than three dilations. Two other patients had partial success. Only three patients required another form of treatment (two endoscopic, one surgical).

Adult↗
PubMed2003

[Continence of anorectal sphincter complex in the early postoperative period after direct colo-anal anastomoses with colo-colic J pouch].

UNLABELLED: According to up-to-date concepts for local spread of a rectal cancer it is possible to perform a radical rectal resection with a restorative anastomosis inspite of the fact that the tumor is located in the middle or the distal third of the rectum. Usually a total resection of the rectum and coloanal anstomosis have to be performed. There are two ways to restore the continuity of the gut: a straight coloanal anstomosis or J pouch anastomosis. 22 patients with rectal cancer localized between 4 and 9 cm from the anal verge, were operated and restorative anastomoses were performed. The first 18 patients were with a straight coloanal anastomosis. In the last 4 cases coloanal anastomoses were done between the anus and colocolic 7 cm J pouch. During the first month there were 6 patients with total and 9 with partial incontinence in the group with straight coloanal anastomosis. Transrectal sonography confirmed contractility of the puborectal muscle and sphinctermanometry showed lower resting tone and squeeze pressure in cases with incotinence. No incontinence was observed in the group with J pouch and the shinctermanometry data were the same as these of healthy controls. CONCLUSION: The rectal ampula has reservoir function and its loss after total resection of the rectum is the reason for frequent bowel movements, urgency and leakage. Reconstruction with a colonic J pouch is associated with better bowel function compared to the straight coloanal anastomosis.

Anal Canal↗
PubMed1994

Total rectal resection and colo-anal anastomosis with colonic reservoir for low rectal cancer.

From March 1990 to December 1992, 47 patients with primary or recurrent low rectal cancer underwent total rectal resection and a coloendoanal anastomosis. Rectal resection was extended downward to the ano-rectal junction. The restorative technique included a colo-endoanal anastomosis between the dentate line and a J-shaped colic reservoir. All lesions were located within 7 cm of the anal verge (within 6 cm in 33 primary cases). Macroscopic and histological radicality was documented in all cases. Pelvic recurrence occurred in six patients and was para-anastomotic in one case. Post-operative morbidity was low. Perfect continence was documented in 36 patients and 72 of the cases had one or two bowel movements a day. All but four patients are alive at a follow-up ranging from 6 to 40 months (median 20 months). This approach is a safe option to conventional total rectal excision with permanent colostomy for lower third rectal carcinoma.

Adenocarcinoma↗
PubMed2004

Colonic pouchography is not routinely required prior to stoma closure.

BACKGROUND: Colonic pouch formation with pouch-anal anastomosis is now regarded as the procedure of choice for restoration of intestinal continuity following anterior resection for low rectal cancers. The aim of this study was to review the necessity for routine colonic pouchography prior to closure of a diverting loop stoma. METHODS: This was a prospective study of 52 consecutive patients who underwent colonic pouch formation between 1 June 1999 and 31 May 2002, four of whom have subsequently died. Each pouch was assessed clinically and radiologically prior to stoma closure. RESULTS: There were no clinical anastomotic leaks. Forty-six of 48 surviving patients have had a colonic pouchogram and in no case was either a pouch or pouch-anal anastomotic defect identified. To date 40 patients have undergone stoma closure without an anastomosis-related complication. CONCLUSION: Following successful colonic pouch formation, routine study of the pouch by contrast radiology does not add to clinical assessment. As a consequence radiological imaging is unnecessary and can be omitted.

Adenocarcinoma↗