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At least 757 records · Page 42Linked to original sources
PubMed2000

Obstructed defecation after undiverted ileoanal pouch reconstruction for ulcerative colitis: pharmacologic approach. Report of a case.

PURPOSE: Obstructed defecation after ileal pouch construction has been reported only after closure of the diverting loop ileostomy, and biofeedback was an effective treatment modality. METHOD: This is a case report of a patient with immediate obstructed defecation after ileal pouch-anal anastomosis without a covering loop ileostomy and its successful pharmacologic management. RESULTS: A 38-year-old female underwent restorative proctectomy and stapled ileal J-pouch-anal anastomosis without a covering loop ileostomy. On the seventh postoperative day, her pouch catheter (in lieu of a covering loop ileostomy) was removed and she failed to evacuate. After ruling out any technical complications, diltiazem was commenced with successful spontaneous pouch emptying. Obstructed defecation reoccurred after cessation of diltiazem one week later, but the symptoms resolved once the diltiazem was recommenced. CONCLUSIONS: Obstructed defecation has been reported in patients after pelvic pouch reconstruction. However, in all those patients a diverting loop ileostomy had been raised and their obstructive symptoms were only apparent after closure of the ileostomy and when the pouch had healed. The concern regarding our patient was the complete outlet obstruction so soon after surgery, with undue strain on the anastomosis and the potential risk of disruption. Our only two options were either to create a diverting loop ileostomy or to try a fast-acting pharmacologic agent (diltiazem) to treat the presumed levator spasm. The latter option spared the patient a further operation.

Administration, Oral↗
PubMed1994

[Acute inflammation of ileal reservoir after restorative ileoanal anastomosis].

Ileo-anal anastomosis (IAA) is a suitable surgical treatment for selected patients with ulcerative colitis or familial adenomatous polyposis. Acute inflammation of the ileal reservoir (pouchitis) is the most frequent late complication and is characterized by endoscopic and histological changes of acute inflammation similar to ulcerative colitis with abdominal and sometimes systemic symptoms. Between May 1984 and April 1993, 160 patients (103 male and 57 female) aged between 7 and 64 years (mean age 32.6) underwent IAA; twenty of these for familial adenomatous polyposis, 138 for ulcerative colitis and 2 for indeterminate colitis. After a mean follow-up of 41.8 months (range 1-108), 138 patients (86.3%) were symptoms free and twenty-two (16 male and 6 female-13.7%) who underwent IAA for ulcerative colitis, had pouchitis. Clinical, biochemical, endoscopic and histologic findings suggest pouchitis as a chronic recurrent disease similar to inflammatory bowel disease. In conclusion, the etiopathology of this new entity is unknown. Bacterial overgrowth is one of the most popular hypothesis, but the onset of the acute inflammation observed by us only in patients with previous ulcerative colitis and in some cases during the period of protective ileostomy suggests a multifactorial pathogenesis.

Acute Disease↗
PubMed1994

A comparison of J and W pouches using an isolated ileal reservoir in pigs.

A new model for studying ileal reservoirs was used to compare J and W pouches. Sixteen female piglets were operated on between 62 and 67 days of age (median = 65). An approximately 50 cm vascularized segment of terminal ileum was isolated from the faecal stream and intestinal continuity restored. The distal 40 cm of the isolated loop was opened along its antimesenteric border and the pouch constructed (J = 8, W = 8). The remaining proximal length of ileum was brought out through the abdominal wall as a mucous fistula. One piglet in the W pouch group died post-operatively and in another, spontaneous closure of the mucous fistula prevented access to the W pouch for testing leaving six W and eight J pouches for comparison. Compliance was tested at 4 weeks by measuring intrapouch pressure during continuous distension by water. The volumes instilled at pressures of 20, 40, 60 and 80 cm of water were compared using the Mann-Whitney U-Test. Volumes varied widely at all pressures within both study groups although W pouches tended to be of larger volume for any given pouch pressure (P = NS). The failure of this study to demonstrate more clearly a difference between J and W pouches may be due to the small numbers involved but the wide range of volumes seen raises doubts about the usefulness of this pouch model.

Anastomosis, Surgical↗
PubMed2000

Colonic J pouch reconstruction of the radiation-damaged neorectum.

BACKGROUND: Postoperative radiotherapy after restorative resection for rectal carcinoma can cause fibrosis, stricture and proctitis. There are few accounts in the literature of the surgical approach to the radiation-damaged neorectum. METHODS: Reported are four patients who underwent resection of the radiation-damaged neorectum with colonic J pouch reconstruction between September 1996 and July 1997. The operative and postoperative course is described. Parameters of bowel function were assessed by standardized interview 6 months after ileostomy reversal. Ongoing follow up has occurred to the present time. RESULTS: There was no mortality. Complications were splenic injury requiring splenectomy and a pelvic collection requiring percutaneous drainage. At 6 months after ileostomy reversal all patients had ongoing disturbance of bowel function, and two patients described some degree of incontinence. The mean frequency of bowel actions was four per day. Two patients have subsequently undergone further resection and formation of an end stoma. CONCLUSIONS: Resection of the radiation-damaged neorectum with colonic J pouch reconstruction is technically feasible. Functional results in the present series were disappointing and half the patients went on to formation of a permanent stoma.

Adult↗
PubMed1995

Ileal pouch-anal anastomosis function following childbirth. An extended evaluation.

PURPOSE: Women undergoing ileal pouch-anal anastomosis (IPAA) are frequently within reproductive years and eager to bear children. Management issues have been raised regarding the effects of pregnancy and delivery on the pouch, particularly with respect to obstetric care. Our experience is updated to search for delayed sequelae of pregnancy and delivery and to establish whether other factors have an adverse effect on pouch function. These results are also compared with the outcome of pregnancy and delivery in patients with ileostomy or Kock pouch. METHODS: Records of 43 women who had a successful pregnancy and delivery following IPAA were reviewed, including 8 women who had more than 1 pregnancy. RESULTS: Pregnancy was generally well tolerated, with complications being managed nonoperatively. Stool frequency (P < 0.01), incontinence (P < 0.01), and pad usage (P < 0.05; sign rank test) were significantly increased during pregnancy, but prepregnancy function was restored following delivery. Vaginal delivery, multiple births, length of labor, and birth weight had no adverse permanent effect on subsequent pouch function. Longer follow-up after vaginal delivery (mean, 2.4 years) demonstrated no compromise of pouch function. CONCLUSIONS: Incidence of pouch-related complications in patients with IPAA compares favorably with incidence in patients with ileostomy or Kock pouch. Operative rate for complications was 0 percent in IPAA patients compared with 9 percent in patients with ileostomy and 19 percent in patients with Kock pouch. The cesarean section rate was higher in patients with IPAA than in those with ileostomy or Kock pouch, and this may be caused by uncertainty about how to manage delivery in patients with IPAA. Pregnancy and childbirth are well tolerated in women with IPAA, with a lower complication rate and a higher cesarean section rate than women with ileostomy or Kock pouch. Type of delivery should be influenced by obstetric considerations, with vaginal delivery avoided in patients with a noncompliant, rigid perineum.

Adult↗
PubMed2001

Changes in glucocorticoid and mineralocorticoid hormone levels due to compensation for ileostomy losses.

BACKGROUND: The Ileo-Pouch-Anal-Anastomosis (IPAA) is the standard restorative procedure for Ulcerative Colitis and Familial Adenomatous Polyposis (FAP). IPAA may lead to considerable losses of fluids, especially in association with a protective loop ileostomy. AIM: The aim of this study was to investigate adrenal mechanisms in the regulation of volume homeostasis immediately after IPAA and protective ileostomy. METHODS: For that purpose, 20 patients out of our patient population with elective IPAA with ileostomy participated in this study between 1993 and 1997. In all patients, routine laboratory tests and gluco- and minealocorticoid hormone measurements were performed preoperatively and 10 days after operation. RESULTS: These blood analyses indicated functional hyperaldosteronism immediately after IPAA. Significantly elevated levels of Aldosterone (36.4 +/- 25.1 ng/dl) and 18-OH-Corticosterone ( 173 +/- 11.3 ng/dl) were found. Among hormones with glucocorticoid effects, blood levels of Cortisol (10.4 +/- 4.8 microg/dl) were significantly elevated, while 11-Desoxycortiosterone (13.9 +/- 8.4 ng/dl) and Corticosterone (0.8 +/- 0.6 microg/dl) were not significantly elevated. Serum electrolytes remained unchanged. CONCLUSIONS: Our results indicate that hormones with mineralocorticoid effects play a predominant role in the compensation of ileostomy losses after IPAA.

Adaptation, Physiological↗
PubMed2003

Sexual function and continence after ileo pouch anal anastomosis: a comparison between a meta-analysis and a questionnaire survey.

BACKGROUND AND AIMS: Ileo pouch anal anastomosis (IPAA) is the standard restorative procedure for patients with ulcerative colitis and familial adenomatous polyposis, but its pros and cons have not been explored in depth. This study analyzed the long-term complications such as incontinence and sexual dysfunction after IPAA. PATIENTS AND METHODS: Netherlands Society for Crohn's disease and Ulcerative Colitis) A questionnaire on complications, sexual dysfunction, and continence was sent to all 137 members of the Netherlands Society for Crohn's disease and Ulcerative Colitis who had IPAA; the questionnaire was returned by 111. Results of the questionnaire were compared with those of a meta-analysis on pooled incidences of complications after IPAA, as previously performed and reported. RESULTS: Pelvic sepsis was reported by 15.3% of respondents. The reported incidence of sexual dysfunction (19.8%), passive incontinence (23.4%), and soiling (39.3%) was significantly higher than that in the meta-analysis. Nevertheless, 90% of the population was satisfied with the results of the IPAA. CONCLUSION: This study underlines that the operation itself, freeing patients of their disease, provides the major satisfaction and improvement of quality of life, even when patients have pouch-related complications such as sexual dysfunction and some degree of fecal incontinence.

Adolescent↗
PubMed1995

Rediversion after ileal pouch-anal anastomosis. Causes of failures and predictors of subsequent pouch salvage.

PURPOSE: The aim of this study was to understand better the cause and predictability of pouch failure requiring rediversion after ileal pouch-anal anastomosis and to assess the ultimate outcome of patients in a large ileal pouch series who required rediversion. METHODS: Data from 460 patients completing ileal pouch-anal anastomosis at one institution were recorded from both a prospectively accumulated ileal pouch registry and patient medical records. RESULTS: Of 460 patients, 21 (4.6 percent) who underwent ileal pouch-anal anastomosis required rediversion. Five of these patients subsequently had successful restoration of pouch continuity, leaving a permanent failure rate of 16 of 460 patients (3.5 percent). The most common reasons for rediversion were pouch fistula formation (12) and poor functional results (5). Preoperative factors, including age, previous colectomy, and indication for colectomy, did not predict eventual need for rediversion. Patients requiring rediversion had significantly higher rates of postoperative complications (95 vs. 43 percent; P < 0.001). Specifically, this group had a higher rate of postoperative pouch fistula (57 vs. 3.4 percent; P < 0.001). Additionally, a final diagnosis of Crohn's disease significantly predicted the need for rediversion. Permanent pouch failure occurred in 36.8 percent of patients with a final diagnosis of Crohn's disease compared with 1.4 percent of patients with a final diagnosis of ulcerative colitis (P < 0.001). All five salvaged patients had fistula formation in the absence of Crohn's disease. CONCLUSIONS: The overall rate of permanent pouch failure is low. The majority of failures were related to fistula formation associated with Crohn's disease or poor functional results. Pouches complicated by fistulas not associated with Crohn's disease can be salvaged with temporary rediversion.

Adenomatous Polyposis Coli↗
PubMed2006

Restorative proctectomy with colon pouch-anal anastomosis by laparoscopic transanal pull-through: an available option for low rectal cancer?

BACKGROUND: There are sporadic reports, with different verdicts, of restorative proctectomy by laparoscopic transanal pull-through (LTPT) without the use of a minilaparotomy for a part of the procedure. This study aimed to explore the applicability and advantages of LTPT with colon pouch-anal anastomosis for low rectal cancer, and to evaluate the results. METHODS: From January 2002 to July 2003, 10 of 12 patients (6 men and 4 women) undergoing a laparoscopic procedure for low rectal cancer (<6 cm from the anal verge) underwent LTPT. The mean age of these patients was 58 years. The results have been compared with those for 12 similar non-pull-through procedures performed during the same period. RESULTS: There was no operative mortality. An anastomotic leakage and a hemorrhagic gastropathy occurred in the LTPT group. During a mean follow-up period of 18 months (range, 12-26 months), there was no local relapse. Four patients manifested moderate incontinence. No significant differences in functional outcome were observed between the LTPT and control groups. CONCLUSION: The authors' experience supports use of the LTPT procedure with colonic pouch-anal anastomosis for selected lower rectal cancers with indications for a laparoscopic approach as an appropriate and reproducible surgical treatment.

Adult↗
PubMedDate not supplied

Surgical approaches to obtaining optimal bowel function.

Approximately 50% of patients have an unsatisfactory functional result after traditional restorative rectal resection, and an even higher percentage, at least in the early postoperative period, suffers from urgency, frequent bowel movements, and occasional faecal incontinence. The rectal reservoir function is disturbed after restorative surgery. This is related to the size of the rectal remnant, the viscero-elastic properties, and the motility pattern of the neorectal wall, because segments of the remaining colon can only substitute for the rectum to a limited extent. A straight anastomosis is recommended when the rectal remnant (measured from the anal verge) is at least 7 to 8 cm. The side-to-end anastomosis is probably preferable to the end-to-end anastomosis. In contrast, a straight anastomosis at the levator plane cannot be recommended. If straight anastomosis is still considered, the descending colon should be used rather than the sigmoid colon. The colonic pouch was introduced to increase the neorectal volume and eliminate some of the functional disturbance associated with the reduced neorectal volume occurring after a straight colo-anal anastomosis. To obtain optimal functional results soon after surgery, a pouch should be used when the anastomosis is located 3 to 5 cm from the anal verge. The size of the pouch should not be too small. A staple line of 6 to 7 cm is a fair compromise between the low anterior resection syndrome and problems with evacuation. Since the descending colon has a thinner wall and often is healthier than the sigmoid colon, it should be the first choice for the anastomosis.

Anal Canal↗
PubMed1997

Comparison between the colonic J pouch-anal anastomosis and healthy rectum: clinical and physiological function.

BACKGROUND: Colonic pouch anastomosis after restorative rectal excision obviates much of the early dysfunction which is commonly experienced with the traditional straight coloanal anastomosis. A disadvantage with colonic pouch reconstruction, however, appears to be impaired evacuation. METHODS: Distal bowel function was investigated in 30 patients with a colonic J pouch anastomosis at 1 year after surgery and in 39 control subjects. RESULTS: While the degree of urgency and incontinence were similar, the patients with a pouch experienced more difficult evacuation. The maximum volume of the pouch (median 235 ml) and rectum (221 ml) was similar, but the rectum was more compliant (3.5 versus 2.6 ml per cmH2O, P < 0.01). The sensory function in terms of initial sensation of filling, urge to defaecate and maximum distension pressure was impaired in those with pouches. The amplitude of the neorectal and anal canal motility pattern was threefold that of controls. Maximum volume of the pouch was significantly associated with degree of impaired evacuation; the larger the volume the more difficult the evacuation. CONCLUSION: To reduce evacuation difficulty the pouch should not be fashioned too large. No conclusion about optimal pouch size could be drawn. In spite of fundamental physiological differences between a pouch and healthy anorectum, patients with a colonic pouch will usually experience satisfactory clinical bowel function.

Aged↗
PubMedDate not supplied

Functional outcome after coloanal anastomosis with J-colonic pouch for rectal cancer.

This study was designed to determine functional outcomes of restorative resections for carcinoma of the rectum. Between 1992 and 1995, 16 patients (8 male) of median age 75 (range 58-88) years underwent resection and coloanal anastomosis with J-colonic pouch reconstruction for rectal cancer. The distance of the lower border of tumor from the anal verge was 5 cm in 7 patients (43.70-0), 6 to 7 cm in 6 patients (37.0%) and 8 to 10 cm in 3 patients (18.7%). The Dukes staging was A in 4 patients (25%), B in 8 patients (50%) and C in 4 patients (25%). Coloanal anastomosis was performed by hand in 4 patients (25%) or with stapler in 12 patients (75%). Seven patients (43.7%) had diverting stoma. No patient died following surgery. Pelvic sepsis and anastomotic dehiscence that required pouch excision occurred in two patients (12.5%). Fourteen patients were evaluated. The mean follow-up was 15 (range 5-23) months. No patient developed recurrent pelvic tumor. Satisfactory fecal continence was achieved by 85.7% of patients. Stool frequency was 1-2 per day in 12 patients (85.7%). Three patients (21.4%) had minor soiling. Five patients (35.7%) occasionally complained urgency. There was no apparent difference between the patients with manual or stapled coloanal anastomosis. Coloanal anastomosis with J-colonic pouch is associated with an excellent long-term outcome.

Aged↗
PubMed2002

Restorative and nonrestorative surgery for low rectal cancer after high-dose radiation: long-term oncologic and functional results.

PURPOSE: This prospective, nonrandomized study evaluates, with a seven-year median follow-up, the morbidity and the functional and oncologic results of conservative surgery after high-dose radiation for cancer of the lower third of the rectum of patients who would otherwise have undergone abdominoperineal resection. METHODS: Between June 1990 and June 1996, 43 patients with distal rectal adenocarcinoma were treated by preoperative radiotherapy (40 + 20 Gy delivered with three fields) and curative surgery. The mean distance from the anal verge was 50 (range, 25-60) mm, and none of the tumors was fixed (15 percent T2N0, 53 percent T3N0, 32 percent T3N1). RESULTS: Postoperative mortality (2 percent) and morbidity (35 percent) were not increased by high-dose preoperative radiation. Conservative surgery was done in 30 patients (70 percent: 26 coloanal anastomoses and 4 low stapled anastomoses). After conservative surgery, long-term functional results showed 30 percent complete continence and 20 percent serious incontinence. Four patients had local recurrence as first development (13 percent). The seven-year overall survival rate was 53 percent, 62 percent after conservative surgery and 31 percent after abdominoperineal resection. The univariate analysis underscores the tumor response impact on long-term survival (pT<3 = 81 percent; pT3 = 35 percent; P = 0.0008). CONCLUSIONS: These long-term results confirm the feasibility of conservative surgery for low rectal carcinoma after high-dose radiation. A prospective multicentric trial began in France in June 1996 to evaluate the reproducibility of these results.

Adenocarcinoma↗
PubMed1999

Ileoneorectal anastomosis: early clinical results of a restorative procedure for ulcerative colitis and familial adenomatous polyposis without formation of an ileoanal pouch.

OBJECTIVE: To evaluate a new surgical procedure, ileoneorectal anastomosis (INRA), in patients with ulcerative colitis (UC) and familial adenomatous polyposis (FAP). SUMMARY BACKGROUND DATA: Surgical treatment in UC and FAP aims to resect diseased colonic mucosa and restore oroanal continuity. The ileopouch anal anastomosis achieves this but has a 15% to 35% complication rate, a 10% failure rate, and an unpredictable functional outcome. An alternative surgical technique, INRA, has been developed in which the rectal mucosa is replaced by a vascularized ileal mucosa graft. METHODS: Eleven patients underwent an INRA procedure with a temporary diverting ileostomy. Clinical history, repeat endoscopy, histologic examination, and rectal compliance measurements were carried out before and after surgery. RESULTS: The INRA procedure was technically successful in all patients. Endoscopy showed ingrowth of ileal mucosa in the neorectum, with 100% coverage after 6 weeks. No patient had pelvic sepsis, neorectal-anal or -vaginal fistula, autonomic nerve damage, or fecal incontinence. Neorectal function improved with time. The median 24-hour defecation frequency decreased from 15 (range 9 to 25) to 7 (range 4 to 10) at 11 months follow-up, and the median maximum tolerated volume increased to 157 (range 130 to 225) ml. Anal manometry and electrosensitivity were not affected by the surgery. Histologic biopsy samples after 1 year showed a normal small intestinal mucous membrane, without inflammation or fibrosis. CONCLUSION: The combination of a low complication rate and good neorectal function at 1 year is a substantial improvement that justifies extension of the clinical application in patients with UC and FAP.

Adenomatous Polyposis Coli↗
PubMed1996

Pouchitis following pelvic pouch operation for ulcerative colitis. Incidence, cumulative risk, and risk factors.

AIM: This study was undertaken to assess the risk for pouchitis in patients with ulcerative colitis who underwent surgery with colectomy, restorative pelvic pouch, and ileoanal anastomosis and to evaluate possible factors predictive for pouchitis development. PATIENTS AND METHODS: All patients receiving a pelvic pouch because of ulcerative colitis at Huddinge University Hospital between 1980 and 1993 (n = 149; 89 men) were prospectively evaluated for symptoms suggestive of pouchitis. Diagnosis of pouchitis was based on occurrence of certain symptoms in combination with endoscopic findings. Pouchitis was divided into mild and severe, and the time span until the first attack of mild or severe pouchitis was calculated for each patient. RESULTS: Median follow-up time was 54 (5-152) months. The absolute cumulative risk of developing mild pouchitis was 21, 26, and 39 percent at 6, 12, and 48 months, respectively. The corresponding cumulative risk of developing severe pouchitis was 9, 11, and 14 percent, respectively. Risk for both groups together was 51 percent at 48 months. The occurrence of pouchitis, calculated at six-month intervals after closure of the loop ileostomy, was highest (23.1 percent) during the first six months. Incidence during the next six-month period was 11.4 percent and then only 3.1 percent thereafter. Thirty-two patients (21.5 percent) had chronic continuous symptoms requiring long-term metronidazole treatment, and 14 (9.4 percent) of those had chronic severe pouchitis. In two patients, removal of the pouch and permanent ileostomy became necessary. Extracolonic manifestations and early onset of ulcerative colitis were predictive factors for developing pouchitis. Former smoking seemed to be a protective factor. CONCLUSION: The risk for pouchitis was highest during the initial six-month period. Cumulative risk leveled off after two years but was substantial (51 percent) at four years. Less than 10 percent of patients had severe, chronic pouchitis, and only two patients (1.3 percent) had their pouches removed.

Adolescent↗
PubMed2003

Colonic J-pouch vs. coloplasty following resection of distal rectal cancer: early results of a prospective, randomized, pilot study.

PURPOSE: In terms of functional outcome, there is evidence of the superiority of the colonic J-pouch over a straight coloanal anastomosis. Even though the colonic J-pouch was created to restore a neorectal reservoir, manometric data show that the volume of a short colonic J-pouch does not differ from a straight coloanal anastomosis. We speculate that the advantage of the colonic J-pouch is not in creating a larger neorectal reservoir, but rather related to decreased motility. Maurer and Z'graggen recently described a new colonic pouch design, performing a "transverse coloplasty" pouch. The purpose of this pilot study was to compare the feasibility and functional outcome of the 5-cm colonic J-pouch vs. the coloplasty pouch. METHODS: From February 2000 to June 2001, we randomized 40 consecutive patients with distal rectal cancer (<12 cm from the anal verge) into the J-pouch or coloplasty group. A low rectal resection and coloanal anastomosis was performed in all patients. Functional data were collected by a standardized questionnaire and anorectal manometry, preoperatively and six months postoperatively. Primary end points of the study were potentially differences of both groups regarding technical feasibility, stool frequency, and anorectal manometry. RESULTS: The construction of a coloplasty pouch was feasible in all cases of the coloplasty group, but not in 5 of 20 (25 percent) patients of the J-pouch group, because of colonic adipose tissue. Six months after operation or stoma closure, respectively, stool frequency was 2.75 +/- 1 per day in the J-pouch group and 2 +/- 2 per day in the coloplasty group. There was no significant difference in resting and squeeze pressure and neorectal volume between both groups, but an increased neorectal sensitivity in the coloplasty group. CONCLUSION: We found similar functional results in the coloplasty group compared to the J-pouch group. The neorectal sensitivity was increased in the coloplasty group. Therefore, the colonic coloplasty seems to be an attractive pouch design because of its feasibility, simplicity, and effectiveness.

Adult↗
PubMed2003

Transverse coloplasty pouch and colonic J-pouch for rectal cancer--a comparative study.

OBJECTIVES: The introduction of the colonic J-pouch has markedly improved the functional outcome of restorative rectal cancer surgery. However colonic J-pouch surgery can be problematic and may present some late evacuatory problems. To overcome these limitations a novel pouch has been proposed: the transverse coloplasty pouch. The purpose of our study was to compare the functional outcomes of these two different types of pouches--the transverse coloplasty pouch (TCP) and the colonic J-pouch (CJP)--during the first 12 months postoperatively. PATIENTS AND METHODS: A prospective randomized trial was conducted in which a total of 30 patients with mid and low rectal cancer were submitted either to a transverse coloplasty pouch or a colonic J-pouch. Clinical defaecatory function was assessed and anorectal physiological assessment was carried out, pre-operatively and at 3, 6 and 12 months postoperatively, by means of a standard clinical questionnaire and by anorectal manometry. RESULTS: No statistically significant differences were found between the two groups regarding bowel function. The postoperative frequency of daily bowel movements was lower in the TCP group in all the phases of the study (3.9 vs. 4.1 at 3 months; 3.1 vs. 3.4 at 6 months; 2.1 vs. 2.8 at 12 months), the same occurring with fragmentation (33% vs. 40% at 3 months; 26.6%vs. 33.3% at 6 months; 7.1%vs. 14.3% at 12 months). Less urgency was also seen in the TCP group during the first 6 months (20%vs. 26.7%), with identical values at 12 months (14.3% vs. 14.3%). No significant differences were also found concerning incontinence grading and scoring, with TCP patients having less nocturnal leaks. At one year two CJP patients (14.3%) needed the use of enemas to evacuate the pouch and provoke defaecation, a problem never seen in TCP patients. The anorectal manometry data was similar in both types of pouches. The local complication rates were also identical in the two groups (20%); more anastomotic leaks were seen in TCP patients (13.2% vs. 6.6%), without reaching a statistical significance. CONCLUSION: The transverse coloplasty pouch has similar functional results but fewer evacuation problems than the J-Pouch, making it a safe and reliable alternative to the colonic J-pouch.

Adult↗
PubMed2004

Ileo-neorectal anastomosis: medium- and long-term follow-up of 37 patients.

BACKGROUND: Ileo-neorectal anastomosis (INRA), an alternative restorative procedure, was developed to reduce the pouch-related complication rate with an (at least) equal functional result. METHODS: For this surgical outcome, data of all INRA patients, including bowel function and complications, were prospectively recorded. The reservoir capacity was determined repeatedly by physiologic tests. The anal sphincter complex was assessed by manometry and ultrasound examination. Evaluation of the neorectal mucosa was performed by endoscopy. RESULTS: An INRA procedure was carried out in 39/53 selected patients (47 ulcerative colitis and 6 familial adenomatous polyposis). Fourteen UC cases were converted to ileal pouch anal anastomosis or proctectomy only, because of impossibility to completely remove the rectal mucosa or short of length of the rectal stump. The median operation time for INRA was 323 min (range 240-518), with 1,400 ml blood loss (400-4,500). The reservoirs were permanently defunctioned in 2 patients--one because of reclassification into Crohn's disease, and one with pouchitis refractory to medical treatment. In 18 out of 37 cases, web-like stenoses occurred at the mucosa-anal level, which were treated by single (9) or repeated (5) dilatation or surgical stenoplasty (2). No pouch-related complications like pelvic sepsis, fistula or sexual dysfunction occurred. Thirteen patients had episodes of 'pouchitis', successfully treated with antibiotics, and 7 other cases, with functioning reservoirs, also had proximal 'non-specific' (i.e. no histological criteria of Crohn's disease found) small bowel inflammation. The median bowel frequency decreased from 15x/24 h initially to 7x/24 h at 2 years. Continence was perfect in 24/37 cases. Twelve out of 37 cases had occasional nocturnal soiling and passive nocturnal fecal incontinence was reported by 2/37 patients. The neorectal compliance volume recovered from 12.5 ml kPa after subtotal colectomy and 11 ml/kPa at 6 months after INRA to a neorectal compliance of 24 ml/kPa at 2 years' follow-up (p < 0.002; Wilcoxon signed rank test). CONCLUSION: The INRA procedure shows a low complication rate and reasonable functional results, there was however a considerable conversion rate in these first 53 cases and a high incidence of reclassification to CD.

Clinical Competence↗