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PubMed1995

Intraoperative reasons for abandoning ileal pouch-anal anastomosis procedures.

PURPOSE: Ileal pouch-anal anastomosis (IPAA) has become the operation of choice for most patients with chronic ulcerative colitis and familial adenomatous polyposis. However, because of technical or disease factors at the time of pouch construction, IPAA must sometimes be abandoned. A retrospective review was conducted to find reasons for IPAA failure or abandonment. METHODS: Since 1981, 103 patients have had to have an IPAA procedure at the George Washington University Medical Center in Washington, DC. All charts were reviewed and data retrospectively collected. RESULTS: Six of 103 patients (six percent) were unable to have IPAA constructed. Five patients ultimately received a standard end ileostomy, and one had an ileorectal anastomosis. The reasons for abandoning the IPAA procedure were an ischemic pouch, failure to reach the anus, poorly controlled presacral hemorrhage, desmoid of the mesentery, and finding incurable colon carcinoma. CONCLUSIONS: Information regarding the risk of failure or abandonment during the IPAA procedure should be discussed with the patient during preoperative counseling and must be included as an element of informed consent.

Adenomatous Polyposis Coli↗
PubMed1995

Social and sexual function following ileal pouch-anal anastomosis.

PURPOSE: Patients who undergo surgery for ulcerative colitis are usually young and active. When surgery becomes necessary, their future social and sexual function is of major concern. This study was performed to be able to give more detailed information of what is to be expected. METHODS: Forty-nine consecutive patients (26 men and 23 women) who underwent ileal J-pouch-anal anastomosis for ulcerative colitis between November 1983 and September 1986 in the authors' institution were personally interviewed regarding details of their preoperative and postoperative social and sexual functions. RESULTS: Eighty-eight percent had reduced capacity to work preoperatively compared with 6 percent postoperatively. Thirty-one percent resumed work in the period with diverting ileostomy. Leisure time activities were reduced in 47 percent preoperatively, whereas 6 percent had limitations postoperatively. In 35 percent of women, frequency of intercourse was increased postoperatively, and none reported a decreased frequency. None of the women who were able to achieve orgasm preoperatively reported a postoperative disturbance of this ability, and 16 percent experienced an increased quality of orgasm. Postoperatively none reported dyspareunia, vaginal discharge, or changes in their menstrual cycle. Frequency of intercourse and ability to achieve orgasm remained unchanged for the majority of men; however, one developed erectile dysfunction, and one complained of retrograde ejaculation. Sexual activity in men was less affected by the presence of an ileostomy, and 69 percent had intercourse in the period with ileostomy compared with 30 percent of women. None of the patients complained of anal pain, soiling, or fecal leakage during intercourse, but one women reported some discomfort from the pouch during intercourse. None of the patients wanted to return to a life with an ileostomy. CONCLUSION: The social and sexual function, quality of life, after ileal J-pouch anastomosis is improved when compared with the period with ulcerative colitis and the time with diverting ileostomy. In men, however, a frequency of sexual dysfunction similar to what is seen after proctectomy for benign diseases should be underlined.

Adolescent↗
PubMed1995

Pull-through procedures performed months to years after permanent proctectomy.

PURPOSE: Patients who have undergone proctectomy without concomitant rectal reconstruction or coloanal anastomosis were not normally considered candidates for re-establishment of anal continuity until a case report published in 1985. With the addition of nine patients, reported herein is a series of ten patients who have undergone delayed pull-through procedures months to years after permanent proctectomy. PATIENTS: Ten patients (including the single case reported in 1985) have undergone delayed pull-through procedures up to 24 years after permanent proctectomy and ostomy formation. Delayed ileal pouch-anal anastomoses were performed in nine patients, and delayed coloanal anastomosis was performed in one patient. There were four males and six females, each of whom had evidence of external sphincter contraction on physical examination. Average age was 33 (range, 24-51) years at the time of reconstruction. Average duration of follow-up is 32 (range, 1-96) months. RESULTS: One patient is awaiting ileostomy closure. Five of nine patients use constipating agents. Two patients are constipated and use enemas to aid in evacuation. None are wearing protective undergarments. One patient had his ileostomy reconstructed eight years after delayed pull-through for uncontrollable diarrhea associated with chemotherapy for multiple myeloma and recently died. Postoperative complications included wound infection (3), enterocutaneous anastomotic stricture requiring anoplasty (2), small bowel obstruction (1), pneumonia (1), presacral abscess (1), and pouchitis (1). CONCLUSIONS: Delayed pull-through procedures performed months to years after permanent proctectomy can be performed in selected patients, with results comparable to rectal reconstruction done at the time of proctectomy.

Adult↗
PubMed1997

Stapled colonic J-pouch-anal anastomosis without a diverting colostomy for rectal carcinoma.

PURPOSE: Colonic J-pouch reconstruction is designed to improve functional outcome of coloanal anastomosis. Most surgeons use a diverting colostomy to avoid severe pelvic sepsis caused by anastomotic breakdown. METHODS: We report the outcome of 30 consecutive patients with colonic J-pouch-anal anastomosis without a diverting colostomy performed between November 1992 and October 1993. All patients had carcinoma of the lower two-thirds of the rectum. Patients were seen every three months. Functional results were compared with those of 21 rectal cancer patients with straight coloanal anastomosis who underwent surgery in the same period and 20 normal patients. RESULTS: There were two anastomotic leakages and one postoperative death. After one year, patients with pouch anastomosis had significantly less frequency of defecation and rectal urgency compared with those with straight anastomosis (P < 0.01); 48 percent of patients with straight anastomosis had more than five bowel movements per day, whereas all patients with pouch anastomosis had five or less bowel movements per day. Manometric studies showed maximum tolerable volume was significantly higher in patients with pouch anastomosis (81 vs. 152 ml; P < 0.01). CONCLUSIONS: Stapled colonic J-pouch-anal anastomosis without a diverting colostomy is a reliable procedure that provides good, long-term functional results.

Adult↗
PubMed1997

Ileoanal pouch in the active duty population: effect on military career.

UNLABELLED: Patients undergoing proctocolectomy with an ileal pouch-anal anastomosis (IPAA) are reported to have an improvement in lifestyle and are able to return to their previous occupation. We questioned whether this was also true of active duty military personnel who require this operation. The rigors of military service are unlike that of most civilian occupations. Soldiers must maintain a physical fitness regimen and remain eligible to deploy overseas. We reviewed our experience with IPAA to determine whether our active duty patients could return to full duty. METHODS: The charts of all patients undergoing IPAA since October 1990 were reviewed, and each patient was interviewed by telephone to elicit late complications not noted in their medical records and to inquire about their present bowel function. Patients were classified as active duty or nonactive duty. Active duty patients were queried as to whether they have remained on active duty, have required a permanent profile, have been promoted, or have been deployed overseas. If a military medical evaluation board had determined whether they were fit for duty, the findings of the board were reviewed. RESULTS: Thirty-four patients underwent an IPAA; 15 were active duty. Mean follow-up was 24 months. Indication for IPAA was ulcerative colitis in 76 percent of patients and familial adenomatous polyposis in 24 percent. J-Pouch was created in 88 percent of patients. Mean bowel movement frequency was seven per day, and 84 percent could defer a bowel movement for more than one hour. Leakage requiring a pad was reported by three patients (9 percent). Seven of 15 active duty patients (47 percent) remained on active duty, and 3 have been promoted. Of the eight patients who were evaluated by a medical evaluation board and were retired, only four were found unfit because of poor bowel function. Therefore, if it were not for other physical limitations, 11 of 15 (73 percent) active duty patients could have continued to serve. CONCLUSIONS: Barring other disqualifying illnesses, active duty soldiers can anticipate continuation of their military career following IPAA. Active duty soldiers, if motivated, can excel and maintain their status in the military.

Adolescent↗
PubMed1997

Surgical treatment and role of dynamic defecography after ileal pouch-anal anastomosis: technical solutions to a difficult problem.

PURPOSE: Patients with an ileal pouch-anal anastomosis may develop impaired evacuation of the pouch. A new surgical approach and the role of dynamic defecography in such patients are highlighted. METHODS: Five patients with ileal pouch-anal anastomosis were assessed clinically and with dynamic defecography before and after reoperation. RESULTS: In one patient an extensive approach with complete pouch mobilization, stenoplasty of a pouch outlet stenosis, shortening of the rectal remnant, and renewed pouch-anal anastomosis were needed; in three patients, a long and angulated efferent limb was shortened by transabdominal techniques (stenoplasty or a newly developed technique with a linear stapler), and in one patient a pouch inlet stenosis was corrected. In all patients, impaired emptying was cured; in all patients, obstructive abdominal pain improved considerably. CONCLUSIONS: Dynamic defecography is indispensable for tailoring surgical treatment. Effective transabdominal shortening of the efferent limb can be performed with the aid of a linear stapler.

Adolescent↗
PubMed1996

Use of a suture holder facilitates transanal anastomosis.

We report here that use of a suture holder facilitates transanal anastomosis in cases of total proctocolectomy or low rectal anastomosis. Feasible control of multiple interrupted suturing and unhampered visibility of the entire process are made possible with this approach.

Anal Canal↗
PubMed1996

Long-term causes of death following ileal pouch-anal anastomosis.

PURPOSE: The aim of this study was to identify the overall long-term causes of death in a large series of patients who were undergoing proctocolectomy with ileal pouch-anal anastomosis (IPAA). METHODS: Records of patients who underwent proctocolectomy with IPAA at the Mayo Clinic affiliated hospitals between January 1981 and October 1994 were reviewed to determine overall mortality, cause, and timing of death. RESULTS: A total of 1,603 patients underwent proctocolectomy with IPAA reconstruction (1,407 for chronic ulcerative colitis (CUC), 187 for familial polyposis (FAP), and 9 for other diagnoses). Thirty-two patients have died, with an overall mortality rate of 2 percent. Mean age at time of death was 40 (23-60) years. There was no significant difference in overall mortality between patients with CUC and patients with FAP. Three deaths occurred postoperatively (0.2 percent) because of pulmonary embolism, perforated gastric ulcer, and subarachnoid hemorrhage. Late deaths occurred in 29 patients (1.8 percent), 10 months to 10.4 years after the operation. The most common cause of late death was cancer, including colon and rectal carcinoma (10 patients), hematologic malignancies (4 patients), cholangiocarcinoma (3 patients), and germ-cell carcinoma (1 patient). Four patients died from unrelated sepsis, two died following myocardial infarction, two patients died from complications of subsequent orthopedic surgery, and one patient died of cirrhosis. Two additional patients committed suicide. No late deaths were directly attributable to the IPAA procedure. CONCLUSIONS: Proctocolectomy with IPAA is a safe procedure. Operative mortality is low, and late deaths are related to carcinogenic and extracolonic manifestations of underlying or unrelated coexisting diseases and events.

Adenomatous Polyposis Coli↗
PubMed1997

Per anum intersphincteric rectal dissection with direct coloanal anastomosis for lower rectal cancer: the ultimate sphincter-preserving operation.

PURPOSE: The most important goal of sphincter-preserving operations for rectal cancer is to secure a distal surgical margin of safety and the anal sphincter. However, it is not always easy to transect the rectum and to secure a distal surgical margin of safety through the abdominal approach for tumors situated extremely low in the rectum. The aim of this study was to describe and to evaluate a new technique of per anum intersphincteric rectal dissection and coloanal anastomosis. METHODS: The rectum, including the entire width of the internal anal sphincter, is transected circumferentially via the anal route to secure the surgical margin of safety under direct vision and is mobilized proximally as far as possible through the intersphincteric plane. Per anum coloanal anastomosis is performed following transabdominal resection of the rectum. RESULTS: This technique has been used in 12 patients. There have been no instances of short-term or long-term anastomotic complications. CONCLUSIONS: This technique is safe when anastomosis must be performed at the dentate line. It is the best sphincter-preserving operation for lower rectal cancer and does not result in serious postoperative anal dysfunction.

Anal Canal↗
PubMed1997

Advances in rectal cancer surgery in Japan.

A review of advancement of rectal cancer surgery in Japan is presented. The standard operation for rectal cancer was altered in the 1960s from abdominoperineal resection to the pull-through technique and the handsewn anterior resection in the 1970s, and it became the stapled anterior resection in the 1980s. Today, more than 75 percent of rectal cancers are treated with sphincter-preserving anterior resections, and the remaining 20 percent by abdominoperineal resections. Colonic J-pouch is used with anastomoses involving very low anterior rectal resection for cancers. In the late 1970s, a method of dissecting extended pelvic nodes was adopted to decrease local recurrence. However, extended dissection has been applied to only T3 and T4 cancers of the lower rectum because of postoperative dysfunction of pelvic organs. This was caused by injury to the pelvic nerve plexus, thus lowering the quality of life of the patients. Since the middle of the 1980s, the autonomic nerve-preserving operation attracted surgeons' attention because it prevented these dysfunctions from occurring as a result of the treatment of cancer in the upper rectum and for T1 or T2 cancers in the lower rectum. In this article, recent advances in rectal cancer surgery in Japan are reviewed.

Colorectal Surgery↗
PubMedDate not supplied

Results of pouch surgery after ileo-anal anastomosis: the implications of pouchitis.

The ileal pouch-anal operation is the procedure of choice for those suitable patients requiring surgery for chronic ulcerative colitis or familial adenomatous polyposis. The functional results are generally good but pouchitis remains a significant and poorly understood complication. This review encompasses factors relating to pouchitis, e.g., bacteriological, functional and histological changes, with emphasis on its biology and treatment, and the long-term implications.

Anal Canal↗
PubMedDate not supplied

Long-term functional results and quality of life after ileal pouch-anal anastomosis and cholecystectomy.

Among 971 patients with chronic ulcerative colitis who underwent ileal-pouch anal anastomosis during an 8-year period from January, 1982 to December 1989, 30 patients were randomly selected from each year (total = 240 patients) for an assessment of their long-term functional results and quality of life as of 1990. Patients undergoing cholecystectomy during each of the same years served as "controls" (20 patients/year, total = 160 patients). All 400 patients completed a written questionnaire that measured bowel habits, overall quality of life, general health, and performance in sports/recreation, travel, sex life, family relationship, occupational work, social activities, and household activities. Ileo-anal patients had more frequent stools (median, 6 stools/day) and more fecal spotting (68% of patients had episodes) than cholecystectomy patients (median, 1 stool/day, 13% had episodes, p < 0.05). In spite of the altered bowel habits, 90% of ileo-anal patients had an excellent overall quality of life, 76% enjoyed good health, and 91% had good performance scores in the areas examined. In fact, quality of life and performance were similar among ileo-anal patients and cholecystectomy patients. Moreover, quality of life and bowel habits remained steady in both groups of patients during the 8-year follow-up. In conclusion, functional results were satisfactory and quality of life was excellent after ileal pouch-anal anastomosis; neither deteriorated as patients aged over an 8-year period after operation.

Adult↗
PubMed1997

Prospective, randomized study comparing clinical results between small and large colonic J-pouch following coloanal anastomosis.

PURPOSE: Improved functional results can be obtained by construction of a colonic J-pouch after coloanal anastomosis. Variability in pouch size following coloanal anastomosis is prevalent in current literature. In this study, the authors compare clinical bowel function after complete rectal excision with coloanal anastomosis for patients with rectal carcinoma using either a small 6-cm or a large 10-cm colonic J-pouch anastomosis. The clinical outcome is assessed both at short-term and long-term follow-up. METHODS: Fifty-nine consecutive patients with rectal cancers 4 to 8 cm from the anal verge were recruited into the study. Patients were randomized intraoperatively to either a 6-cm J-pouch group or a 10-cm J-pouch group. Clinical assessments were performed prospectively at 3, 6, 12, and 24 months postoperatively, following colostomy closure. Clinical parameters such as frequency, urgency, continence, and laxative and enema use were assessed and compared between the two groups. RESULTS: There was no statistical differences in the mean defecation frequency, urgency, and fecal continence between the two groups at 3, 6, 12, and 24 months. In the first year, laxative and enema use between the two groups was negligible; however at two years, 30 percent of patients with a large reservoir compared with 10 percent of patients in the small-pouch group required laxative and/or enema for constipation and evacuation of bowels. CONCLUSION: Similar clinical results can be expected from patients with either small or large reservoirs at one year. However, with long-term follow-up, patients with a large reservoir are more likely to require medication for constipation and evacuation. To avoid these inconveniences a small reservoir is advocated for patients undergoing coloanal anastomosis.

Adenocarcinoma↗
PubMed1994

Optimization of sphincter function after the ileoanal reservoir procedure. A prospective, randomized trial.

PURPOSE: Impairment of sphincter function in patients who undergo ileoanal reservoir is usually most severe immediately after ileostomy closure. Therefore, a prospective, randomized trial was undertaken to assess the potential value of preileostomy closure sphincter-strengthening exercises to improve early functional outcome. METHODS: Patients were randomized either to a control group (Group 1) or to undergo a five-week pelvic floor exercise program (Group 2). An incontinence score from 0 to 20 was used to clinically assess the functional results. Anorectal manometric assessment included: high-pressure zone length, mean resting pressure, highest resting pressure, mean squeezing pressure, and highest squeezing pressure. The paired t-test was used to compare the functional results preoperatively and at the time of ileostomy closure. This time corresponded to the conclusion of the exercise program or the equivalent time period for the control group. RESULTS: Twenty-six patients who underwent double-stapled ileoanal reservoir between July 1991 and June 1992 were studied. They included 16 males and 10 females with a mean age of 38 (range, 17-69) years. When both evaluations were compared, the mean incontinence score decreased from 0.2 to 2.8 (delta = 2.6) in Group 1 and from 0.2 to 2.0 (delta = 1.8) in Group 2 (P = 0.07). None of the changes between the preoperative and postoperative clinical and physiologic evaluations were statistically significant (P > 0.05). CONCLUSION: Sphincter-strengthening exercises before ileostomy closure did not minimize the transient impairment of functional results.

Adolescent↗
PubMed1994

Double-stapled vs. handsewn ileal pouch-anal anastomosis in patients with chronic ulcerative colitis.

UNLABELLED: Proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the treatment of choice for most patients with chronic ulcerative colitis. Whether or not a double-stapled technique, which should preserve the anal transition zone and avoid prolonged and dilation, facilitates superior fecal continence compared with conventional mucosal resection and handsewn anastomosis is unknown. PURPOSE: The aim of this study was to compare functional results after double-stapled and handsewn IPAA. METHODS: Twenty-seven consecutive patients (13 females, 14 males; mean age, 37 years) who had proctocolectomy and double-stapled IPAA (J) for chronic ulcerative colitis were identified. Each was matched by sex, age, and surgeon to a control who had undergone a conventional handsewn anastomosis. Functional results at six months after ileostomy closure were compared. RESULTS: Median stool frequency in each group was seven. The prevalence of pouchitis was 22 percent in both groups. One pouch failure occurred in each group. The percentage of patients from the double-stapled group with daytime spotting was similar to that of the handsewn group (18 percent vs. 26 percent, P > 0.5). Nighttime soiling rates were similar as well (41 percent vs. 48 percent, P > 0.5). CONCLUSIONS: Double-stapled IPAA appears to convey no early functional advantage over handsewn IPAA for chronic ulcerative colitis.

Adolescent↗
PubMed1996

Comparison of handsewn with stapled loop ileostomy closures.

PURPOSE: The aim of this study was to determine if a stapled side-to-side closure of an ileostomy results in decreased length of hospital stay compared with a handsewn closure. METHODS: From March 1993 to August 1994, patients who had previously undergone total proctocolectomy with pelvic pouch formation and loop ileostomy were studied. At the time of ileostomy closure, patients were randomized to have their stoma closed by a handsewn technique or stapled closure. Data were prospectively gathered. RESULTS: During 17 months, 61 consecutive patients (38 male, 23 female) with a mean age of 37.8 (range, 16-69) years had their ileostomy closed and were entered into this study. There were 31 patients in the stapled group and 30 in the handsewn group. Mean operative time was 55 (range, 32-97) minutes in the stapled group and 67 (range, 42-128) minutes in the handsewn group (P = 0.01 Wilcoxon's test). Average length of stay was three (range, 2-5) days in the stapled group and 2.5 (range, 1-19) days in the handsewn group. One patient from the stapled group and two patients from the handsewn group were readmitted because of small-bowel obstruction. One patient from the stapled group underwent additional surgery for a leaking enterotomy with no defect in staple closure. Two patients from the handsewn group underwent additional surgery for small-bowel obstruction. There was no significant difference in day of first stool or day of solid diet for the two groups. CONCLUSION: Handsewn and stapled closures of loop ileostomy are not significantly different with respect to day of first stool, day until solid diet, or discharge day. Complications were similar in the two groups. Stapled closure is significantly quicker than handsewn closure.

Adolescent↗
PubMed1996

Role of peptide YY and enteroglucagon after low anterior resection. Comparison between straight and colonic J-pouch anastomosis.

PURPOSE: It has been shown in several studies that a colonic J-pouch obviates much of the early dysfunction after a low anterior resection in terms of urgent and frequent bowel movements. In search for specific mediators of the postoperative functional adaptation, two gut peptides, peptide YY and enteroglucagon, were studied METHODS: Plasma and "neorectal" mucosal levels of both peptides were measured in 12 patients with a straight coloanal anastomosis and in 11 patients with a colonic J-pouch anastomosis. Patients were part of a randomized trial comparing straight and colonic pouch anastomosis. Fasting plasma samples of both peptides were collected intraoperatively, after one week, before loop ileostomy closure, and at 1, 3, and 12 months after loop ileostomy closure. RESULTS: There was no difference between the straight and the pouch groups in plasma concentrations of either peptide at any time period postoperatively. The only longitudinal hormonal changes were transient increases in mucosal peptide YY content at one-month follow-up and in mucosal enteroglucagon content before loop ileostomy closure. CONCLUSION: Peptide YY and enteroglucagon responses in these patients appear not to be major factors for improved outcome after formation of a colonic pouch in low anterior resection.

Adaptation, Physiological↗
PubMed1994

Mucosal concentrations of interleukin-1 beta, interleukin-6, interleukin-8, and tumor necrosis factor-alpha in pelvic ileal pouches.

Concentrations of interleukin-1 beta (IL-1 beta), interleukin-6 (IL-6), interleukin-8 (IL-8), and tumor necrosis factor-alpha (TNF-alpha) were determined by solid-phase ELISA in tissue homogenates of mucosal biopsy specimens obtained from pelvic ileal pouches in 13 patients with pouchitis (reservoir ileitis) and 17 with pouches without pouchitis. Normal ileal mucosa was used as a control. IL-1 beta was detected in all tissue homogenates from patients with pouchitis compared with only 29% from pouches without pouchitis and none from controls. IL-6 and IL-8 were present in all pouchitis specimens, in 70% of the specimens from nonpouchitis and only 30% of specimens from controls. TNF-alpha was undetectable in all specimens examined. The concentrations of IL-1 beta, IL-6, and IL-8 were significantly greater (P < 0.001) in biopsy specimens from pouchitis compared to those from pouches without pouchitis or normal ileal mucosa and in patients with pouchitis tissue levels of IL-1 beta significantly correlated with IL-6 (P < 0.05) and IL-8 (P < 0.01). Furthermore IL-1 and IL-8 levels were significantly higher in tissue specimens from nonpouchitis pouches than in those from normal ileal mucosa (P < 0.02). These results suggest that an enhanced cellular immunity operates in vivo at the mucosal level in pouchitis as in the case of ulcerative colitis.

Adult↗