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PubMed1999

Misconceptions about the colonic J-pouch: what the accumulating data show.

INTRODUCTION: Since 1986 when the colonic J-pouch-anal anastomosis was first described, it has gained increasing acceptance as the operation of choice for low rectal cancer surgery. However, there still exist several misconceptions about its use, namely anastomotic complications, alterations in anorectal physiology, and functional outcome. METHODS: All relevant articles derived from MEDLINE databases from 1986 to the present were reviewed. Emphasis was placed on reviewing the features that are claimed to make the colonic J-pouch-anal anastomosis superior to a straight anastomosis. RESULTS AND CONCLUSIONS: The colonic J-pouch has a role in ultra-low rectal cancer surgery, with an apparent reduction in the incidence of anastomotic leaks and reduced bowel frequency. Continence is unchanged and defecatory difficulties can be reduced by constructing a small pouch (< or =5 cm).

Humans↗
PubMed2000

Audit of single-stage proctocolectomy for Crohn's disease: postoperative complications and recurrence.

PURPOSE: This study was undertaken to review our overall experience of single-stage proctocolectomy for Crohn's disease. METHODS: One hundred three patients who underwent single-stage proctocolectomy for Crohn's disease between 1958 and 1997 were reviewed. Factors affecting the incidence of recurrence were examined using a multivariate analysis. RESULTS: Principal indications for proctocolectomy were chronic colitis (49 percent), acute colitis (37 percent), and anorectal disease (14 percent). The commonest postoperative complication was delayed perineal wound healing (n = 36; 35 percent), followed by intra-abdominal sepsis (17 percent) and stomal complications (15 percent). In 23 patients the perineal wound healed between three and six months after proctocolectomy, whereas in 13 patients the wound remained unhealed for more than six months. There were two hospital deaths (2 percent) caused by sepsis. The 5-year, 10-year, and 15-year cumulative reoperation rates for small-bowel recurrence were 13, 17, and 25 percent, respectively, after a median follow-up of 18.6 years. From a multivariate analysis, factors affecting reoperation rate for recurrence were gender (male; hazard ratio 2.4 vs. female; P = 0.03) and age at operation (< or =30 years; hazard ratio 2.6 vs. >30 years; P = 0.04). The following factors did not affect the reoperation rate: duration of symptoms, smoking habits, associated perforating disease, coexisting small-bowel disease, postoperative complications, and medical treatment. CONCLUSIONS: Proctocolectomy for Crohn's disease is associated with a high incidence of complications, particularly delayed perineal wound healing. Proctocolectomy carries a low recurrence rate in the long term. However, young male patients are at high risk of recurrence.

Adolescent↗
PubMed1998

Management of desmoid tumors in patients after ileal pouch-anal anastomosis for familial adenomatous polyposis.

PURPOSE: The aim of this study was to review the management of desmoid tumors in patients who have undergone ileal pouch-anal anastomosis for familial adenomatous polyposis and their outcome. METHODS: A retrospective review of case notes was undertaken in a series of 196 patients with familial adenomatous polyposis who had had an ileal pouch-anal anastomosis. Eleven patients were identified in whom desmoid tumor had developed (4 male; median age, 30 (range, 16-43) years). RESULTS: Desmoid tumors developed in the abdominal wall alone in 4 of 11 patients. Three enlarging tumors were resected with no subsequent recurrence. No patient received adjuvant treatment and pouch function remained stable at a median follow-up of eight years. Mesenteric desmoid tumors developed in seven patients; the pouch has been excised in two because of ischemia; two other patients have had defunctioning stomas created because of slow progression of their desmoid tumors. One patient had a single-lumen pouch excised and a new S-pouch inserted, with no subsequent recurrence of the desmoid tumor, and in two patients the mesenteric desmoid tumor has remained unchanged. All of these patients received long-term Clinoril (sulindac, Merck & Co., Inc., West Point, PA). Although there has been no significant deterioration in pouch function in patients in whom the pouch remains in situ, the pouch function was significantly worse compared with a control group of patients after ileal pouch-anal anastomosis for familial adenomatous polyposis in whom desmoid tumors did not develop. CONCLUSION: Desmoid tumors developed in 5.6 percent of 196 patients after ileal pouch-anal anastomosis for familial adenomatous polyposis. No patient with abdominal-wall desmoid tumor had a recurrence after local excision. By contrast, mesenteric desmoid tumors eventually resulted in pouch failure in four of seven affected patients.

Abdominal Muscles↗
PubMed1999

Colonic pouch vs. side-to-end anastomosis in low anterior resection.

PURPOSE: Colonic pouches have gained increasing popularity in reconstruction after low anterior resection. In this prospective, randomized trial colonic pouch reconstruction is compared with side-to-end anastomosis for functional outcome. METHODS: From October 1995 to October 1996, 29 patients had colonic pouch and 30 patients had side-to-end anastomosis reconstruction after low anterior resection. Patients were matched for age, gender, and tumor stage and localization. All patients underwent functional evaluation preoperatively and at three and six months postoperatively. RESULTS: There was no difference in preoperative anorectal function. The operating time was higher in the colonic pouch group (167 vs. 149 minutes). Twenty-three patients (79.3 percent) with colonic pouch had a protective stoma compared with 21 patients (70 percent) with side-to-end anastomosis. Postoperative complications were 10.3 and 13.3 percent, respectively. There was no difference in manometric pressure of the anus, in anorectal angle, and in continence status after three and six months. Stool frequency was higher in the side-to-end anastomosis group, with 2.2 vs. 5.4 per day at three months and 2.3 vs. 3.1 per day at six months. Constipation was noted in two patients with colonic pouch (7 percent) and none in the side-to-end anastomosis group at three months and two vs. none at six months. Maximum tolerated volume and threshold volume was higher in the colonic pouch group at three and at six months. CONCLUSION: Both forms of reconstruction have similar satisfactory long-term functional results. The major advantage of colonic pouch was seen in the immediate postoperative phase.

Adult↗
PubMed1999

Functional outcome of conversion of ileorectal anastomosis to ileal pouch-anal anastomosis in patients with familial adenomatous polyposis and ulcerative colitis.

PURPOSE: The aim of this study was to review the functional outcome in 20 patients with familial adenomatous polyposis and ulcerative colitis who were converted from ileorectal anastomosis to ileal pouch-anal anastomosis. METHODS: From 1985 to 1997, 12 patients with familial adenomatous polyposis (5 males; mean age, 39.1 years) and 8 patients with ulcerative colitis (5 males; mean age, 36.7 years) underwent conversion from ileorectal anastomosis to ileal pouch-anal anastomosis. Clinical and operative data were analyzed retrospectively. Functional results were obtained by telephone interview in 16 patients (94 percent) after pouch construction. Four patients were not interviewed (2 were deceased, 1 was lost to follow-up, and 1 was not reachable). RESULTS: Indications for conversion were uncontrollable rectal polyps (10 patients) and colonic cancer found in the pathology specimen after ileorectal anastomosis in patients with familial adenomatous polyposis (2 patients), intractable proctitis (5 patients), colonic cancer found in the pathology specimen of patients with ulcerative colitis after ileorectal anastomosis (2 patients), and rectal dysplasia (1 patients). Mean follow-up time was 5 (range, 1-11) years. Ileal pouch-anal anastomosis was handsewn in 14 patients, and the remaining cases were double-stapled in 4 patients with ulcerative colitis. No intraoperative difficulties were reported in 13 cases; technical problems were related to adhesions (3 cases), difficult rectal dissection (2 cases), and stapler-related difficulties (2 cases). Postoperative complications after ileal pouch-anal anastomosis included small-bowel obstruction (4 patients) and ileal pouch-anal anastomosis leak (1 patient). Patients with ileorectal anastomosis vs. those with ileal pouch-anal anastomosis had a better functional outcome with regard to nighttime continence (14 (88 percent) vs. 6 (38 percent) patients) and average bowel movements (<6/day; 12 (75 percent) vs. 4 (25 percent) patients). Complete daytime continence, 15 (94 percent) vs. 10 (62 percent) patients, was similar in the two groups. Physical and emotional well-being were similarly rated as very good to excellent. CONCLUSIONS: In patients with familial adenomatous polyposis and ulcerative colitis with ileorectal anastomosis, conversion to ileal pouch-anal anastomosis may be required. In view of the risk of rectal cancer or intractable proctitis, patients seem to accept the conversion in spite of poorer bowel function.

Adenomatous Polyposis Coli↗
PubMed2000

Lymphoma arising in an S-pouch after total proctocolectomy for ulcerative colitis: report of a case.

The gastrointestinal tract is the most common extranodal site of primary non-Hodgkin's lymphoma. We present a case of a 50-year-old male with primary B cell lymphoma arising in an S-pouch eight years after a total proctocolectomy for ulcerative colitis. After chemoradiotherapy the patient remained asymptomatic, with an intact S-pouch. Pouch conservation is feasible in patients with primary lymphoma of the pouch, using chemoradiotherapy and close follow-up examinations.

Colitis, Ulcerative↗
PubMed2000

Pseudomembranous enteritis after proctocolectomy: report of a case.

Intestinal pseudomembrane formation, sometimes a manifestation of antibiotic-associated diarrheal illnesses, is typically limited to the colon but rarely may affect the small bowel. A 56-year-old female taking antibiotics, who had undergone proctocolectomy for idiopathic inflammatory bowel disease, presented with septic shock and hypotension. A partial small-bowel resection revealed extensive mucosal pseudomembranes, which were cultured positive for Clostridium difficile. Intestinal drainage contents from an ileostomy were enzyme immunoassay positive for C. difficile toxin A. Gross and histopathologic features of the small-bowel resection specimen were similar to those characteristic of pseudomembranous colitis. The patient was treated successfully with metronidazole. These findings suggest a reservoir for C. difficile also exists in the small intestine and that conditions for enhanced mucosal susceptibility to C. difficile overgrowth may occur in the small-bowel environment of antibiotic-treated patients after colectomy. Pseudomembranous enteritis should be a consideration in those patients who present with purulent ostomy drainage, abdominal pain, fever, leukocytosis, or symptoms of septic shock.

Abdominal Pain↗
PubMed2000

Laparoscopic colectomy compares favorably with colectomy by laparotomy for reduction of postoperative ileus.

PURPOSE: The aim of this study was to compare the length of postoperative ileus in patients undergoing colectomy by either laparotomy or laparoscopy. METHODS: A total of 166 patients were studied. These patients were divided into two groups: Group 1, in which colectomy was done laparoscopically, and Group 2, consisting of patients undergoing laparotomy. Both groups contained 83 patients who were matched for disease severity, indications for surgery, and procedure. Indications for surgery included sigmoid diverticulitis in 12 (14 percent) patients, polyps in 22 (27 percent), Crohn's disease in 21 (25 percent), colorectal cancer in 11 (13 percent), stoma reversal in 8 (10 percent), rectal prolapse in 3 (4 percent), and other indications in 6 (7 percent) in each group. Operations were colectomy with anastomosis (42 ileocolic, 26 colorectal, 6 colocolic, 4 ileorectal, and 2 ileal J pouch) or without anastomosis (3 abdominoperineal resections) performed by the same surgeons during the same time period January 1993 to October 1996). The nasogastric tube was removed from all patients immediately after surgery in both groups. All patients received a clear liquid diet on the first postoperative day, followed by a regular diet as tolerated. The nasogastric tube was reinserted if two or more episodes of emesis of more than 200 ml occurred in the absence of bowel movement. Patients were discharged from the hospital when tolerating a regular diet without evidence of ileus. Statistical analysis was performed using unpaired t-test and Fisher's exact probability test. RESULTS: The male-to-female ratio was 38 to 45 in both groups. A total of 10 (12 percent) and 23 (28 percent) patients in Group 1 and Group 2 had emesis (P = 0.02), and the rate of nasogastric tube reinsertion was 5 (6 percent) and 13 (16 percent), respectively (P > 0.05). There were significant differences between Groups 1 and 2 relative to the lengths of ileus (3.5 +/- 1.3 vs. 5.4 +/- 1.7 days, respectively; P < 0.001), hospitalization (6.6 +/- 3.3 vs. 8.1 +/- 2.5 days, respectively; P < 0.002), and operative time (170 +/- 60 vs. 114 +/- 46 minutes, respectively; P < 0.001). The morbidity rate was 16 (19.2 percent) and 18 (21.6 percent) in the laparoscopy and laparotomy groups, respectively. CONCLUSIONS: Although early oral intake is safe and can be tolerated by 84 percent of patients after colectomy by laparotomy, laparoscopic colectomy reduced the lengths of both postoperative ileus and hospitalization.

Anastomosis, Surgical↗
PubMed2000

Development of invasive adenocarcinoma in a long-standing diverted ileal J-pouch for ulcerative colitis: report of a case.

We report a case of a 50-year-old male with ulcerative colitis who developed well-differentiated adenocarcinoma in the ileal J-pouch, which had been defunctioning for 18 years. The extension of the carcinoma in the pouch suggested that it had recently appeared in the pouch. Monitoring by endoscopic examination and biopsy or pouch excision seems to be an appropriate action if a pouch is out of the fecal stream.

Adenocarcinoma↗
PubMed2000

Familial adenomatous polyposis: results after ileal pouch-anal anastomosis in teenagers.

PURPOSE: Virtually all untreated patients with familial adenomatous polyposis develop colorectal carcinoma. Thus, prophylactic colectomy is indicated. Detractors of ileal pouch-anal anastomosis prefer ileorectal anastomosis for teenagers because of the potential negative impact of ileal pouch-anal anastomosis on quality of life. The aim of this study was to assess the effects on quality of life of ileal pouch-anal anastomosis in teenagers with familial adenomatous polyposis. METHODS: Between 1981 and 1998, 48 teenagers underwent ileal pouch-anal anastomosis for familial adenomatous polyposis. One patient had proctectomy and ileal pouch-anal anastomosis after previous ileorectal anastomosis. A temporary diverting loop ileostomy was established in 42 patients (87.5 percent). One patient had colonic carcinoma diagnosed preoperatively. Two other patients were found to have unsuspected rectal cancer at surgery. Mean follow-up (+/- standard deviation) in 43 patients was 80.5 +/- 42 months. RESULTS: There was no immediate postoperative mortality. Postoperative complications included pelvic sepsis (3 patients; 1 requiring reoperation) and bleeding (1 patient; no surgery required). One patient died of metastatic colonic carcinoma. Ten patients required reoperation, seven had bowel obstruction, one had portal hypertension, and two required an ileostomy. The mean (+/- standard deviation) daytime and nighttime stool frequency was 4 +/- 1.5 and 1 +/- 1, respectively. One patient reported daytime and nighttime incontinence, and two patients reported nighttime incontinence only. No patient experienced impotence or retrograde ejaculation. Social, sexual, sport, housework, recreation, family, travel, and work activities were improved or unchanged in 82.5, 87, 80, 90, 80, 92.5, 77.5, and 89 percent of patients, respectively. Three male patients fathered children, and three female patients had a total of six children after normal pregnancies and deliveries. CONCLUSION: The impact of ileal pouch-anal anastomosis on quality of life was favorable in the majority of teenagers. The risk of rectal cancer should be the major consideration before proposing an operation to teenagers with familial adenomatous polyposis.

Adenomatous Polyposis Coli↗
PubMed2000

Proposed association between ileoanal j-pouch perforation and rapid consumption of a high-calorie, high-fiber meal: report of two cases.

PURPOSE: We report two cases of ileoanal J-pouch rupture after rapid consumption of high-fiber, high-calorie meals. METHOD: We review the food intake, presentation, laboratory and radiographic data, and course of two patients who developed ileoanal J-pouch perforation after rapid consumption of meals rich in fiber or calories or both. The potential association between food consumption and rupture is explored. RESULTS: The authors propose that the rapid ingestion of a high-fiber, high-calorie meal may lead to an acute intraluminal pressure elevation or a closed-loop obstruction. These effects may be the basis for an association between food ingestion patterns and perforation at the distal transection site in an ileoanal J-pouch. CONCLUSION: The authors hypothesize that the rapid ingestion of a high-fiber, high-calorie meal may be associated with J-pouch perforation. Further investigative efforts are needed to confirm this association and to evaluate whether a causal relationship is present. If causality is established, physicians may develop a higher index of suspicion for pouch rupture in patients who present with abdominal disturbances after the rapid ingestion of a high-fiber, high-calorie meal.

Adult↗
PubMed2000

Does technique of anastomosis play any role in developing late perianal abscess or fistula?

PURPOSE: This study examines the risk factors for developing perianal abscess or fistula formation after ileal pouch-anal anastomosis procedure for chronic ulcerative colitis or familial adenomatous polyposis. METHODS: A total of 1,457 patients with J-pouch, 1,304 (89.5 percent) with chronic ulcerative colitis and 153 (10.5 percent) with familial adenomatous polyposis who had a two-stage procedure without any evidence of previous perianal disease were included in the study. The effect of pouch-to-anal anastomosis type on perianal abscess or fistula formation was evaluated. RESULTS: A total of 108 patients (7.4 percent) had a perianal abscess or fistula after the ileal pouch-anal anastomosis procedure after at least one year of follow-up. No statistically significant difference was identified in fistula formation regarding the age and gender of the patients (P > 0.05), nor did the risk of fistula formation differ significantly between the patients with handsewn vs. stapled anastomoses (P > 0.05). However, patients with a diagnosis of chronic ulcerative colitis, compared with patients with familial adenomatous polyposis, had a statistically higher risk of developing abscess or fistula (P = 0.012). CONCLUSION: The most important risk factor in developing perianal sepsis in long-term patients with ileal pouch-anal anastomosis is the initial disease type. After excluding patients without Crohn's disease, the risk of developing an abscess or fistula was found to be significantly greater in patients with chronic ulcerative colitis compared with patients with familial adenomatous polyposis, and this risk is independent of anastomotic technique.

Abscess↗
PubMed2000

Ambulatory manometry in patients with colonic J-pouch and straight coloanal anastomoses: randomized, controlled trial.

PURPOSE: Bowel function after ultralow anterior resection may be improved by a colonic J-pouch. The aim of this study was to compare the bowel function and ambulatory manometry in patients randomly assigned to straight coloanal anastomosis or colonic J-pouch. METHODS: Forty-seven consecutive patients underwent ultralow anterior resection for adenocarcinoma. The colonic J-pouch was constructed with 6-cm limbs. A bowel function questionnaire was administered at one year after surgery. Ambulatory manometry was performed before and at one year after surgery. RESULTS: Values are expressed below as mean and (standard error of the mean). Patients with colonic J-pouch were found to have less frequent stools (4.6 (0.3) vs. 7.1 (0.9) stools/day; P < 0.05) and stool clustering (35 vs. 63.2 percent; P < 0.05) and were less unlikely to soil when passing flatus (85 vs. 35.3 percent; P < 0.05). The ambulatory anorectal pressure gradient was better preserved in the colonic J-pouch group (30.3 (3.7) vs. 18 (2.6) mmHg; P < 0.05). Stool frequency was predicted by the mean rectal pressures (t = 3.368; P = 0.003). However, higher mean rectal pressures were tolerated by the colonic J-pouch for each daily bowel movement (6.7 (0.6) vs. 4.4 (0.5) mmHg/stool; P = 0.008). Anal sampling episodes and slow wave activity were impaired postoperatively in both groups. The minimal anal pressures were lower in patients unable pass flatus without soiling (12.4 (5.3) vs. 26 (2.3) mmHg; P = 0.004). Large contraction waves were not seen, and this may be related to the absence of severe defecation problems with 6-cm colonic J-pouches. CONCLUSIONS: A colonic J-pouch resulted in better bowel function and more favorable ambulatory manometric findings at one year of follow-up.

Adenocarcinoma↗
PubMed2000

Does better functional result equate with better quality of life? Implications for surgical treatment in familial adenomatous polyposis.

PURPOSE: The main impetus for a patient with familial adenomatous polyposis to choose colectomy with ileorectal anastomosis over ileal pouch-anal anastomosis is the better functional result. However, does better functional result necessarily translate into better overall quality of life? Previous studies of other diseases have demonstrated no such correlation. This study was performed to determine whether any relationship exists between functional result and quality of life in patients with familial adenomatous polyposis after ileorectal anastomosis and ileal pouch-anal anastomosis. METHODS: All patients with familial adenomatous polyposis who underwent colectomy with ileorectal anastomosis or proctocolectomy with ileal pouch-anal anastomosis from 1980 to 1998 were studied. Functional data were obtained by questionnaire. Health-related quality of life was assessed by two validated instruments, the SF-36 Physical and Mental Health Summary Scales and the SF-36 Health Survey, which measure physical and mental functioning and eight separate health-quality dimensions, including health perception, physical and social functioning, physical and emotional role limitations, mental health, bodily pain, and energy or fatigue. RESULTS: Data were obtained in 44 of 68 patients, 14 with ileorectal anastomosis and 30 with ileal pouch-anal anastomosis. No differences were demonstrated between the two groups for patient age, mean follow-up time, and mean patient age at operation. Functional results were worse for the ileal pouch-anal anastomosis group vs. the ileorectal anastomosis group in number of bowel movements per day (7.5 vs. 5.2; P < 0.05), leakage (43 vs. 0 percent; P < 0.01), pad usage (17 vs. 0 percent; P < 0.01), perianal skin problems (33 vs. 7 percent; P < 0.01), food avoidance (80 vs. 43 percent; P < 0.01), and inability to distinguish gas (37 vs. 7 percent; P < 0.01). Results of the health-related quality-of-life surveys, however, demonstrated no difference between the ileal pouch-anal anastomosis and ileorectal anastomosis groups. The Physical and Mental summary scales for the ileal pouch-anal anastomosis and ileorectal anastomosis groups were not significantly different (Physical Health Scale, 50.3 vs. 50.9; Mental Health Scale, 51.7 vs. 49.6), and none of the eight dimensions of the SF-36 health survey demonstrated statistical differences between the ileal pouch-anal anastomosis and ileorectal anastomosis groups. CONCLUSION: Better functional results were not equated with better quality of life in this pilot study. Although patients with the ileorectal anastomosis have better functional results than those with ileal pouch-anal anastomosis, the measured health-related quality of life as determined by a validated generic health-related quality-of-life instrument is the same for both groups. These results suggest that all patients with familial adenomatous polyposis might be optimally treated with an ileal pouch-anal anastomosis. More importantly, this study suggests that health-related quality of life should play a greater role in the evaluation of care and treatment in colon rectal surgery.

Adenomatous Polyposis Coli↗
PubMed1999

Enlargement of colonic pouch after proctectomy and coloanal anastomosis: potential cause for evacuation difficulty.

PURPOSE: Although the functional outcome after low anterior resection for rectal cancer using colonic J-pouch reconstruction is superior to that using conventional straight reconstruction, the one drawback of colonic J-pouch reconstruction is difficulty with evacuation. Recently it has been suggested that construction of a larger colonic J-pouch causes the evacuation difficulty. The purpose of this study was to elucidate the cause of evacuation difficulty with colonic J-pouch reconstruction. METHODS: We compared pouchography of 26 patients with 10-cm colonic J-pouch reconstructions (10-J group) and 27 patients with 5-cm colonic J-pouch reconstructions (5-J group) at three months, one year, and two years after surgery. Functional assessments were performed one year postoperatively. Clinical function was evaluated using a questionnaire. Evacuation function was evaluated by the balloon expulsion and saline evacuation tests. RESULTS: The greatest width of the pouch in the 10-J group in the anteroposterior view was significantly greater than that in the 5-J group at all three measurement times (3 months, 4.9 vs. 4 cm; P = 0.0011; 1 year, 9 vs. 5.6 cm; P < 0.0001; 2 years, 9.2 vs. 5.8 cm; P < 0.0001). The value in the 10-J group at one year after surgery was 1.9 times that at three postoperative months; in the 5-J group this ratio was 1.4. There was a significant difference between these ratios (P < 0.0001). No significant difference existed between the values at two years and one year after surgery in either the 10-J or the 5-J group. An evacuation difficulty was significantly more common in the 10-J group than the 5-J group. Evacuation function in the 10-J group was significantly inferior to that in the 5-J group. CONCLUSIONS: The evacuation difficulty observed in patients with larger colonic J-pouch reconstructions is associated with excessive distention of the pouch occurring within one year of surgery.

Adult↗