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PubMed1998

Long-term functional evaluation of straight coloanal anastomosis and colonic J-pouch: is the functional superiority of colonic J-pouch sustained?

AIM: This study was designed to analyze the functional and clinical outcomes of straight coloanal anastomosis compared with colonic J-pouch performed after low anterior resection. MATERIALS AND METHODS: Between September 1989 and June 1996, all patients who underwent low anterior resection with anastomosis less than 4 cm from the dentate line were classified into two groups based on the restoration of intestinal continuity: "straight" coloanal anastomosis (n = 39) or colonic J-pouch (n = 44). Both groups were assessed according to the level of anastomosis, anastomotic complications (stricture, leak, pelvic abscess), age, and gender. For comparison of functional outcome, daily bowel movements, tenesmus, urgency, incontinence score (range, 0-20), and anorectal manometric findings were evaluated preoperatively and at six months, and one and two years after surgery. RESULTS: There were no significant differences between the groups relative to age: (coloanal anastomosis, 66.3 +/- 10.1 (range, 46-86), vs. colonic J-pouch, 64.9 +/- 13.2 (range, 39-88) years); gender (females): (coloanal anastomosis, 46.2 percent vs. colonic J-pouch; 38.6 percent); diagnosis: (rectal carcinoma: coloanal anastomosis, 84.6 percent, vs. colonic J-pouch, 77.3 percent); preoperative incontinence score (coloanal anastomosis, 1.5 +/- 4.6, vs. colonic J-pouch, 1.1 +/- 4); bowel movements: (coloanal anastomosis, 2.1 +/- 2.3, vs. colonic J-pouch, 2.1 +/- 1.9/day); level of anastomosis: (coloanal anastomosis, 1.8 +/- 1.3, vs. colonic J-pouch, 1.5 +/- 1.3 cm from the dentate line); history of perioperative radiation therapy: (coloanal anastomosis, 15.4 percent, vs. colonic J-pouch, 20.5 percent); or manometric findings. There was also no significant difference in postoperative mortality: (coloanal anastomosis, 5.1 percent, vs. colonic J-pouch, 2.3 percent); or anastomotic complications: (coloanal anastomosis, 7/39 (17.9 percent), vs. colonic J-pouch, 2/44 (4.5 percent) P = 0.08); strictures: (10.3 vs. 0 percent); leaks: (5.1 vs. 2.3 percent); bleeding: (2.6 vs. 0 percent); rectovaginal fistula: (0 vs. 2.3 percent). Also, in the colonic J-pouch group, two patients developed pouchitis, and one patient experienced difficult evacuation one year after surgery. There was a statistically significant better function judged by less frequent bowel movements (4 +/- 2 vs. 2.4 +/- 1.3/day; P < 0.005) and urgency (36.7 vs. 7.7 percent; P < 0.05), incontinence score (2.2 +/- 3.7 vs. 0.8 +/- 1.6; P < 0.05) up to one year after surgery. At two years, the coloanal anastomosis group did not show statistical improvement in functional results compared with one year postoperatively. Rectal compliance in manometric findings was significantly increased in the coloanal anastomosis group at one year after surgery (12.4 +/- 12.6 vs. 4.2 +/- 1.5 ml/mmHg; P < 0.05). However, these differences were less profound after two years. CONCLUSION: The functional superiority of the colonic J-pouch was greatest at one year after surgery. By two years, adaptation of the "straight" coloanal anastomosis yielded similar functional results. However, the almost fourfold reduction in anastomotic complications in the colonic J-pouch group reveals a second potential advantage of this technique.

Aged↗
PubMedDate not supplied

Long-term prospective assessment of functional results after proctectomy with coloanal anastomosis.

The objective of this study was to prospectively assess the long-term functional results after restorative proctectomy with coloanal anastomosis for rectal cancer. Thirty consecutive patients (18 males; mean age 59.6 +/- 9.8 years, range 40 to 75 years) underwent proctectomy with coloanal anastomosis for rectal cancer between January 1990 and March 1997. Cancers were located between 5 and 12 cm from the anal verge. Differences existed in the administration of adjuvant therapy and in the kind of anastomotic reconstruction. An 8 cm colonic J-pouch was fashioned in 11 patients. The coloanal anastomosis was protected by a diverting loop ileostomy in 22 patients. All patients were evaluated using a prospective patient-completed protocol to record daily bowel activity over a 1-week period at 3, 6, and 12 months, and yearly thereafter. Mean follow-up extends to 55.5 +/- 27 months (range 7 to 117 months). There were no perioperative deaths. Four patients (13.3%) developed a clinically evident anastomotic dehiscence. Overall, stool frequency decreased from 4.4 +/- 2.5 bowel movements per day at 3 months to 3.0 +/- 2.8 bowel movements per day at 5 years. Patients with a J-pouch had a lower stool frequency in comparison to patients with an end-to-end coloanal anastomosis during the entire study period (from 3.2 +/- 2.2 vs. 3.9 +/- 2.7 bowel movements per day at 6 months to 2.8 +/- 1.9 vs. 3.4 +/- 4.0 bowel movements per day at 5 years; no statistical significance). The percentage of continent patients increased from 50% at 6 months to 75% at 5 years; the percentage of patients with incontinence for solid stool and with frequent incontinence (&dollar;7 episodes per week) decreased from 35.7% at 6 months to 12.5% at 5 years. The influence of the type of anastomosis, dehiscence, protective stoma, J-pouch, radiation therapy, and gender was evaluated with univariate analysis. Although there was no statistically significant correlation between any of these variables and the development of incontinence, when incontinence occurred, a history of anastomotic dehiscence increased the number of episodes of incontinence per week and the percentage of episodes of incontinence for solid stools at 6 months, 2 years, and 5 years (P < 0.05 and P < 0.001, respectively); the use of preoperative radiation therapy increased the number of episodes of incontinence per week at 6 months, 1 year, 2 years, and 5 years (P < 0.01) and the percentage of episodes of incontinence for solid stools at 3 and 6 months and 1 and 2 years (P < 0.04); and the presence of a J-pouch increased the number of episodes of incontinence per week at 1 and 2 years (P < 0.03 and 0.005, respectively) and the percentage of episodes of incontinence for solid stools at 2, 3, and 4 years (P < 0.05). These data suggest that the functional results after proctectomy with coloanal anastomosis improve at least over the course of the first 5 postoperative years. Furthermore, when incontinence develops, its severity is made worse by the occurrence of an anastomotic dehiscence, the use of preoperative radiation therapy, and the presence of a J-pouch.

Adult↗
PubMed2000

Ileoanal pouch operation: long-term outcome with or without diverting ileostomy.

HYPOTHESIS: Avoiding a diverting ileostomy does not influence the long-term overall morbidity and functional outcome of patients after ileoanal pouch operation (IAP). DESIGN: All patients undergoing IAP were prospectively entered into a database, and those undergoing operation from October 1, 1989, through January 31, 1996, were contacted by mail questionnaire. SETTING: Tertiary referral center. PATIENTS: One hundred thirty unselected sequential patients. INTERVENTIONS: The IAP was completed by a stapled method without diverting ileostomy, provided the patient agreed, and there were no other complicating factors. MAIN OUTCOME MEASURES: Need for reoperation, fecal leakage, pouch frequency, ability to defer evacuation, pouchitis, and overall quality of life. RESULTS: Of 102 patients (78.5%) who initially underwent IAP without diverting ileostomy, 10 (9.8%) developed an anastomotic leak and required a diverting ileostomy. Additional surgery was required in 12 (9.2%) of the 130 patients for bowel obstruction and in 3 (2.3%) for pouch excision. Two patients died of unrelated causes, leaving 125 functioning pouches (96.2%). Questionnaires were completed in 111 (88.8%) of the 125; 75 patients (67.6%) reported perfect continence for gas and stool, 10 patients (9.0%), regular nighttime leakage, and 24 patients (21.6%), occasional fecal leakage. Pouch evacuation frequency (+/-SD) per 24 hours was 7.8+/-2.4 (range, 4-12), and 95.5% of patients could defer pouch evacuation. Of the 111 patients, 42.3% reported pouchitis, with 7.2% receiving long-term antibiotic therapy. Of the patients, 74.8% reported total satisfaction, and 84.7% regarded themselves as being in perfect health. CONCLUSION: Long-term outcome after IAP remains favorable with or without diverting ileostomy.

Adenomatous Polyposis Coli↗
PubMed2002

Similar functional results and complications after ileal pouch-anal anastomosis in patients with indeterminate vs ulcerative colitis.

HYPOTHESIS: Patients who undergo ileal pouch-anal anastomosis (IPAA) for indeterminate colitis (IC) have a pouch complication and pouch loss rate only slightly higher than that associated with ulcerative colitis (UC). The functional outcome in patients with IC is no different from that in patients with UC. DESIGN: Retrospective review of prospectively gathered data comparing complication rates and outcomes of patients with IC vs UC who have undergone IPAA at a single institution during 19 years. SETTING: University teaching hospital. PATIENTS: Between July 1, 1982, and July 1, 2001, 723 patients underwent IPAA, 644 for colonic inflammatory bowel disease. A further breakdown of the latter group revealed 79 patients (12.3%) with IC and 565 (87.7%) with UC. These 2 patient populations were compared with regard to postoperative complications, pouch loss, and functional outcome. MAIN OUTCOME MEASURES: Patients with IC and UC were compared with regard to pouch complications, such as J-pouch leak, fistula, cuff abscess, stricture, redo IPAA, Crohn diagnosis, and pouch loss. They were also compared with regard to 24-hour stool frequency and nighttime incontinence at 1, 3, 6, and 9 months after surgery. RESULTS: Approximately 98% of patients had 1 year of follow-up and 89% had long-term follow-up (mean, 78.5 months). Patients with IC were compared with those with UC with regard to pouch complications, such as cuff abscess (1.3% vs 1.6%), J-pouch leak (5.1% vs 2.3%), intra-abdominal abscess (0% vs 1.1%), stricture (7.6% vs 4.8%), and fistula (2.5% vs 1.6%). These 2 groups were also compared with regard to small bowel obstruction (6.3% vs 5.5%), pouchitis (34.2% vs 25.0%), eventual diagnosis of Crohn disease (1.3% vs 0.7%), redo IPAA (1.3% vs 0.9%), and eventual pouch loss (2.5% vs 1.2%). An evaluation of functional results revealed no significant differences between the 2 groups with regard to 24-hour stool frequency or nighttime incontinence. The pathologists classified patients with IC into 3 groups: IC but favor UC (group 1), IC but favor Crohn (group 2), and IC (group 3). Most of the postoperative complications occurred in group 1 patients, but the only pouch loss occurred in those in group 2. CONCLUSIONS: The incidences of pouch complications after IPAA were slightly higher in the IC group compared with the UC group, but the differences were not statistically significant. Functional results were the same in both groups. Pouch loss was high in group 2 patients, but was otherwise not significantly higher in the IC group overall (P =.36). Most patients with IC can undergo IPAA and expect an outcome equivalent to that of patients with UC.

Adult↗
PubMed1992

Ileal pouch-anal anastomosis. Patterns of failure.

During the period from 1980 through 1990, our institution constructed 253 ileoanal reservoirs in 253 patients, of whom 25 (9.9%) experienced pouch failure. A poor functional result was the most common cause of pouch failure (seven [28%] of 25 patients). Unsuspected Crohn's disease became manifest in 13 (5%) of the 253 patients, resulting in pouch loss due to perianal sepsis or pouch fistulas in six patients (24% of 25 failures), and resulted in a significantly increased risk of pouch failure compared with that of the non-Crohn's population. Pouchitis occurred in 78 patients (31%) and accounted for four (16%) of 25 failures, but patients with pouchitis were not at higher risk for pouch failure than were patients who did not have pouchitis (failure rates of 6.4% vs 10.4%, respectively; not significant). Significant pelvic sepsis in the absence of Crohn's disease developed in 13 patients, five (38%) of whom lost their pouches. Poor functional results, pelvic sepsis, and unsuspected Crohn's disease were the major causes of pouch failure, while pouchitis was not.

Age Factors↗
PubMed1993

Long-term results of the ileoanal pouch procedure.

Many surgeons consider the ileoanal pouch procedure to be the procedure of choice for patients who require surgery for ulcerative colitis and familial adenomatous polyposis. To determine long-term results, 460 patients (mean +/- SD age, 31 +/- 9 years) who underwent the ileoanal pouch procedure from 1980 through 1991 were prospectively observed by computerized registry. The leading indication for operation was ulcerative colitis (n = 382; 83%). A J-shaped reservoir was created in 434 patients (94%). More than 5 years after ileostomy closure, the mean number of bowel movements was 5.8 +/- 2.2, and 13% of patients had leakage. Most patients (94%) were satisfied with their results. Sixteen patients (3.5%) required recreation of a permanent stoma for pouch failure. Complications (major and minor) occurred in 266 patients (58%) and included obstruction (n = 94; 20%), pouch fistula (n = 26; 6%), anastomotic stricture (n = 40; 9%), anastomosis separation (n = 14; 3%), and pouchitis (n = 83; 18%). Modifications in technique and increased operative experience have significantly decreased the incidence of obstruction (P = .05) and pouch-related complications (P = .004). Despite complications, long-term results are acceptable, and patient satisfaction remains high.

Adult↗
PubMed1994

Does aggressive medical therapy for acute ulcerative colitis result in a higher incidence of staged colectomy?

BACKGROUND: Colectomy with ileal pouch-anal anastomosis is the operation of choice in patients with medically refractory ulcerative colitis. However, aggressive or prolonged medical treatment may result in the patient's needing an urgent operation in which a staged subtotal colectomy is necessary. OBJECTIVE: Our hypothesis is that the incidence of patients requiring a staged approach has increased, along with an increase in hospital stay and total hospital costs. DESIGN: We examined the medical records of 250 consecutive patients with ulcerative colitis who underwent ileal pouch-anal anastomosis between 1984 and 1993. RESULTS: Simultaneous colectomy and ileal pouch-anal anastomosis were performed in 196 patients (78%), while 54 patients (21.6%) required staged subtotal (78%) or partial colectomy (22%). Indications for initial colectomy included failure of medical therapy (42 patients [77.8%]), undifferentiated colitis (five patients [9.3%]), and perforation (six patients [11.1%]). An increase in the incidence of patients requiring staged colectomy during this period was observed (P < .05). Staged procedures led to a prolonged hospital course at a significantly greater total cost. CONCLUSION: We conclude that aggressive medical therapy of acute ulcerative colitis has increased the incidence of urgent staged colectomy with a resulting increase in morbidity, hospital stay, and cost and a less-optimal functional result.

Acute Disease↗
PubMed1994

Outcome of ileorectal anastomosis in an inflammatory bowel disease surgery experience of three decades.

OBJECTIVE: To reevaluate the role of ileorectal anastomosis (IRA) following total colectomy for inflammatory bowel disease in relation to the recent popularity of ileoanal reservoir anastomosis. DESIGN: In a retrospective analysis of 255 patients who underwent colectomy for inflammatory bowel disease, we found that 144 patients had IRAs: 68 for ulcerative colitis and 76 for Crohn's disease. The follow-up ranged from 6 months to 30 years (mean, 22 years). SETTING: A community teaching hospital. Patient compliance for close surveillance was sine qua non in selection. PARTICIPANTS: Patients with ulcerative colitis or Crohn's disease who were selected for IRA if the anal sphincter apparatus was not severely compromised by perineal suppurative disease, if the conventional medical therapies had failed, if the rectum was relatively distensible, and if primary anastomosis was seen to be free of severe inflammatory disease. INTERVENTIONS: Primary IRA was performed in 74 patients in whom the rectum was relatively healthy; in 63 patients, temporary end ileostomy with a mucus fistula was performed. The rectal stump was treated with topical steroids, and a secondary anastomosis was performed. OUTCOME: The quality of life, rate of subsequent rectal excision, and development of carcinoma in the rectum were assessed to determine the validity of and appropriate recommendation for this procedure. RESULTS: In a follow-up of 1 to 33 years, 129 patients had functioning IRAs. Four patients with functioning IRAs died of unrelated causes. Eight proctectomies (11.7%) were performed in patients with ulcerative colitis, seven (9.2%) in patients with intractable Crohn's disease, and two (1.4%) in patients with cancer. CONCLUSIONS: An IRA following total colectomy for patients with ulcerative colitis or Crohn's disease is an acceptable alternative when the sphincter mechanism is intact and the rectum is distensible. Close surveillance is necessary.

Adolescent↗
PubMed1996

Long-term results after colectomy and ileoanal pull-through procedure in children.

OBJECTIVE: To review the clinical experience with colectomy and ileoanal pull-through procedure in children from 1 hospital. DESIGN: Since 1977, 116 children 18 years of age or younger underwent colectomy and ileoanal pull-through procedure at University of California-Los Angeles Medical Center. Ninety-four children had ulcerative colitis, 17 had familial polyposis coli, and 5 had Hirschsprung disease. Sixty-two children had a lateral pouch, 47 a J-pouch, and 7 a straight pull-through. A diverting ileostomy was used for 4 months for all patients except 9 with polyposis coli and 2 with Hirschsprung disease. During the same period, an additional 414 patients older than 18 years underwent the ileoanal pull-through procedure. RESULTS: Forty-eight children (41%) developed complications; the most common was pouchitis, which occurred in 18 patients with ulcerative colitis. Forty-two children underwent reoperation; 38 had ulcerative colitis. There were no deaths. Six children (5.2%) (3 with Crohn disease) required a permanent ileostomy. Six straight pull-throughs were converted to J-pouches because of stool frequency; 19 patients with lateral pouches underwent pouch reconstruction or spout resection because of stasis. With a mean follow-up of 7.1 years, 107 children (92.2%) were progressing well. CONCLUSIONS: Ulcerative colitis is a more severe disease in children. The ileoanal pull-through procedure is the preferred operation for children with ulcerative colitis, polyposis coli, and selected patients with Hirschsprung disease. The J-pouch is preferred because of simplicity of construction and scarcity of complications.

Adenomatous Polyposis Coli↗
PubMed1996

Altered expression of TGF alpha and TGF beta 1 in the mucosa of the functioning pelvic ileal pouch.

The mucosa of the functioning pelvic ileal pouch undergoes loss of villous height and an increase in crypt cell proliferation as an adaptive response to its new luminal environment. These changes can occur in the absence of inflammation and could be mediated by growth factors such as transforming growth factors alpha and beta 1 (TGF alpha and TGF beta 1). Expression of TGF alpha and TGF beta 1 messenger RNA (mRNA) and protein was determined by in situ hybridization and immunohistochemistry in sections of terminal ileum taken at the time of pouch formation and of subsequent pouch biopsies from 14 patients (total of 90 specimens). Crypt cell proliferation was assessed using the monoclonal antibody MIB-1. As ileal pouch mucosa underwent loss of villous height and crypt hyperplasia, epithelial expression of TGF alpha mRNA and protein decreased. In contrast, TGF beta 1 mRNA and protein were abundant in both normal and flat mucosa. Epithelial expression of TGF beta 1 protein was maximal in flat, inflamed biopsies. These results suggest that although altered expression of TGF alpha and TGF beta 1 mRNA and protein may play some part in the regulation of the adaptive response in ileal pouch mucosa, TGF alpha does not have a direct, positive role in the regulation of crypt cell proliferation.

Adult↗
PubMed1998

Anastomotic integrity and function: role of the colonic J-pouch.

Since the colonic J-pouch with a colo-anal anastomosis was first introduced in 1986, many reports have shown the superiority of this design as compared to a "straight" colo-anal anastomosis. These advantages have been demonstrated in retrospective, prospective, and prospectively randomized reports. Furthermore, these attributes are realized for at least 12 and possibly more than 24 months after surgery.

Anal Canal↗
PubMed1991

Pelvic pouches.

Explore the source record for details and available documents.

Anastomosis, Surgical↗
PubMed1991

Function after anoabdominal rectal resection and colonic J pouch--anal anastomosis.

Twenty-eight patients undergoing anoabdominal resection of the rectum with construction of a colonic J reservoir and eight patients without a reservoir were studied 2 years after surgery. Frequency of defaecation and daytime soiling were inversely correlated with the maximum tolerable volume of the colonic J pouch. The distensibility and threshold volume of those with a pouch were significantly greater than in those without a pouch 6 months or more after stoma closure. Anal resting pressure, squeeze pressure, anal canal length and a positive inhibitory reflex were similar in both groups. Anal resting pressure, squeeze pressure and pouch distensibility correlated with frequency of defaecation in the stable phase. Pouch construction may improve the patient's quality of life in the adaptation phase.

Adult↗
PubMed1992

Influence of dietary calcium supplements on ileoanal pouch function and cytokinetics.

A double-blind cross-over study was undertaken in 16 patients after panproctocolectomy and ileoanal pouch reconstruction to compare supplementary calcium (1.5 g/day) with placebo over 2 months with a 2-week washout period. Stool frequency was recorded and the effects on pouch mucosal crypt cellular proliferation were determined using an in vitro stathmokinetic technique which measures the crypt cell production rate (CCPR) and an immunohistochemical method using the Ki67 monoclonal antibody for proliferating nuclei. The median (interquartile range) diurnal stool frequency was reduced by calcium (4 (3-5) per day) compared with values obtained before treatment (7 (5-10) per day, P less than 0.002) and with placebo (7 (6-9) per day, P = 0.002). Similarly, calcium reduced nocturnal stool frequency (1 (0-1) per night) compared with pretreatment and placebo (both 2 (1-3) per night, P less than 0.05) values. Calcium reduced the mean(s.e.m.) CCPR to 1.88(0.41) cells per crypt per hour compared with pretreatment (3.63(0.53), P = 0.01) and placebo (3.24(0.43), P = 0.002) values. Median (interquartile range) Ki67 activity was also reduced by calcium (13.2 (9.7-16.7) per cent), compared with values obtained before treatment (27.3 (14.3-30.2) per cent, P = 0.001) and with placebo (26.0 (17.2-32.0) per cent, P = 0.001). Stool frequency was significantly correlated with the CCPR (diurnal: r = 0.37; nocturnal: r = 0.31, both P less than 0.05). Nine patients used antidiarrhoeal medication while receiving placebo compared with four patients receiving calcium (P = 0.032). This study has shown that supplementary oral calcium significantly reduced stool frequency in patients with pouches, a reduction that was associated with reduced cell proliferation. The mechanisms for this effect are not known.

Administration, Oral↗
PubMed1992

Estimation of small bowel transit time following colectomy and ileal reservoir construction.

A study was carried out to evaluate the breath hydrogen test as a method of estimating small bowel transit in patients with an ileal pouch and to determine whether gut transit time influenced functional outcome. Twelve patients with an ileal reservoir and ten control subjects ingested a test meal of 400 ml chicken soup, 20 g lactulose and 50 ml dilute barium solution. Concurrent breath hydrogen testing and radiological screening was carried out until the head of the test meal reached the ileal pouch or caecum. At the time that the test meal arrived in the pouch, faecal anaerobic bacterial counts were obtained. Pouch compliance, functional capacity and anal sphincter pressures were also measured. While there was an excellent correlation between radiological and breath hydrogen measures of orocaecal transit time in controls (P less than 0.001), no such relationship was found for oropouch transit. Four of the 12 patients with a pouch produced no hydrogen after test meal ingestion, while in two other such patients breath hydrogen peaks occurred when the head of the meal was in the jejunum. The magnitude of the breath hydrogen rise in patients with an ileal pouch correlated well with faecal anaerobic bacterial counts (P less than 0.01). The median (95 per cent confidence interval) radiological small bowel transit time was more rapid in patients with a pouch than in control subjects: 28 (23-33) versus 72 (46-86) min (P less than 0.01). Increased 24-h frequency of defaecation was associated with more rapid small bowel transit after ileal reservoir construction (P less than 0.01) but correlated with neither pouch capacity nor compliance. These data show that small bowel transit time may be a determinant of ileal pouch function but that breath hydrogen estimation of gut transit time in patients with an ileal reservoir is unreliable.

Breath Tests↗
PubMed1993

Function of ileal J pouch-anal anastomosis in patients with familial adenomatous polyposis.

Pouch function after proctocolectomy and ileal J pouch-anal anastomosis was assessed at 1 and 5 years in 41 patients with familial adenomatous polyposis. The mean(s.d.) stool frequency per 24 h decreased from 4.4(1.7) to 3.9(1.8) (P < 0.05), the mean(s.d.) nocturnal stool frequency fell from 0.6(1.0) to 0.3(0.6) (P < 0.05), and the number of patients having nocturnal bowel movements decreased from 16 to seven (P < 0.05). At 5 years, only one patient still followed a strict diet (versus ten at 1 year, P < 0.05) and only two needed antidiarrhoeal medication (versus ten at 1 year, P < 0.05). There were no episodes of pouchitis or late reservoir-related complications. The function of ileal pouch-anal anastomosis improves over time in patients with familial adenomatous polyposis.

Adenomatous Polyposis Coli↗