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PubMed1992

Technique for nipple valve fixation to prevent valve slippage in continent ileostomy.

There have been several developments in the evolutionary process associated with continent ileostomy. Despite a progressive decline of the early and late complications associated with this procedure, nipple valve slippage remains a common complication. A technique that provides additional stability to the nipple valve is described here. This procedure involves stapled anchorage of the nipple valve to the anterior pouch wall.

Follow-Up Studies↗
PubMed1992

Quality of life after total proctocolectomy and ileal J-pouch-anal anastomosis.

We investigated the daily life and opinions of patients after total proctocolectomy and ileal J-pouch-anal anastomosis. Eighty patients answered a questionnaire, completed Cattell's anxiety scale, and recorded bowel function for one month. Both colitis and polyposis patients defecated five times daily, had 1.6 episodes of nocturnal motions weekly, and soiled twice weekly. However, colitis patients were more satisfied with their bowel function and surgical outcome than were polyposis patients. This difference had a close relationship to the personality factors of ego strength and frustration. All patients with either disease who defecated less than three times daily, had no nocturnal motions, and had no soiling showed normal ego strength and frustration and were completely satisfied with their bowel status and operation. In contrast, patients defecating more than seven times daily or more than once per week nocturnally and soiling more than four times weekly had high frustration and were dissatisfied. Thus, satisfaction with surgery correlated not only with the objective outcome but also with personality and lifestyle.

Adenomatous Polyposis Coli↗
PubMed1992

Retained mucosa after double-stapled ileal reservoir and ileoanal anastomosis.

A study was undertaken to assess the incidence of inflammation and dysplasia in retained mucosa after double-stapled ileoanal reservoir (IAR) for mucosal ulcerative colitis (MUC). Between September 1988 and February 1992, 56 patients with MUC underwent an IAR. Forty-five patients had a double-stapled IAR (DS-IAR), seven patients had a transanal pursestring stapled IAR (PS-IAR), and four patients had a PS-IAR with mucosectomy. Distal donuts obtained from the stapled IAR were submitted for pathologic review in 55 patients. Nine patients had only small bowel, connective tissue, and/or muscle noted on review. Mucosa was qualified as squamous epithelium (SE), transitional epithelium (TE), or columnar epithelium (CE). All samples were examined for evidence of inflammation and dysplasia. Four patients had SE only, one patient had TE, and 18 had CE. In addition, three patients had SE and CE, seven patients had SE and TE, two patients had CE and TE, and nine patients had all three types. The distance from the dentate line to the anastomosis ranged from 0 to 2.5 cm (mean, 1 cm). In 19 patients (35 percent), the distal donut revealed MUC. Of these 19 patients, six had persistent MUC (43 percent) at the time of subsequent biopsy. An additional four patients had MUC evident on follow-up biopsy but not on distal donuts; two of these four patients had no mucosa in their distal donuts. Only one of the patients with evidence of MUC on donuts and/or biopsy experienced any symptoms referable to active MUC (1.8 percent). None of the specimens examined had any evidence of dysplasia. In 31 patients, no MUC was present in the initial donuts or follow-up biopsies. Although the double-stapled technique appears safe, periodic monitoring is suggested.

Adolescent↗
PubMed1992

Outcome of ileorectal anastomosis for Crohn's colitis.

One hundred thirty-one patients underwent ileorectal anastomosis (IRA) for Crohn's colitis. Preoperatively, 84 patients (63 percent) were found to have mild or moderate proctitis and 47 (37 percent) had rectal sparing. Sixty-eight (52 percent) had associated small bowel disease, and 20 (15 percent) had perianal disease. Sixty-five IRAs were performed at the time of subtotal colectomy, while 56 were done after previous surgery. Anastomotic leaks occurred in four patients. There were no operative deaths. Thirteen patients (10 percent) with protecting stomas never underwent closure. Among the remaining 118 patients with functioning IRAs, 30 (23 percent) required later proctectomy and 16 (13 percent) required proximal diversion, with the mean period with a functioning IRA in these 46 patients being 4.1 years (range, 6.2 months-12.7 years). An additional 13 patients required preanastomotic resection and neo-IRA, and 11 required proximal small bowel resection. The mean duration of function of all 118 IRAs was 9.2 years. At the time of review, after a mean follow-up of 9.5 years, 72 patients (61 percent) retained a functioning IRA, with 44 being free of disease, while 28 were being treated with steroids or antidiarrheal medication. The mean stool frequency was 4.7 per day. In patients with Crohn's colitis, IRA should be considered as an alternative to proctocolectomy if the rectum is not severely diseased and sphincter function is not compromised.

Adolescent↗
PubMed1992

Steroid complications in patients with ulcerative colitis.

Physicians treating patients with ulcerative colitis are confronted with the difficult task of deciding whether medical or surgical treatment is best for their patients. There are no definitive criteria to indicate when medical therapy should be exchanged for definitive surgery. Even in patients who respond well to glucocorticoid treatment, the side effects of these drugs may necessitate surgery. We reviewed the steroid complications of our operative cases retrospectively. Although ulcerative colitis was usually in remission, severe steroid complications were no longer tolerable and definitive surgery was required. We also reviewed the literature regarding the adverse effects of steroid. Because of advances in sphincter-preserving surgery, re-evaluation of the treatment of ulcerative colitis is necessary. Although conservative treatment remains the first choice, tolerance of irreversible side effects (especially in children) no longer seems to be justified. In such patients, early definitive surgery may offer more than it appears to sacrifice.

Adult↗
PubMed1998

Incidence and subsequent impact of pelvic abscess after ileal pouch-anal anastomosis for chronic ulcerative colitis.

PURPOSE: This study was designed to measure the impact of pelvic abscess on eventual pouch failure and functional outcome after ileal pouch-anal anastomosis in patients with chronic ulcerative colitis. PATIENTS AND METHODS: The outcome of 1,508 patients who underwent ileal pouch-anal anastomosis for chronic ulcerative colitis at the Mayo Clinic was determined from a central patient registry, data were collected prospectively. RESULTS: Seventy-three patients developed a pelvic abscess as a complication of ileal pouch-anal anastomosis. Pouch failure occurred in 19 (26 percent). Forty-eight patients (55 percent) required transabdominal salvage surgery, 6 (8 percent) underwent local surgery, and the remaining 27 (37 percent) were treated nonsurgically. Wound infection was more common in patients who experienced pelvic abscess. The majority of pouch failures secondary to pelvic abscess formation occurred within two years of ileal pouch-anal anastomosis. Daytime incontinence, the use of a protective pad, and the need for constipating or bulking medication were significantly more common among patients who had an abscess but kept their reservoir. Ability to perform work and domestic activities and to undertake recreational activities were significantly more restricted among these patients. CONCLUSIONS: Pouch failure occurs in one-fourth of patients who retain their pouch despite pelvic abscess after ileal pouch-anal anasto mosis. Among patients who retain their pouch despite postoperative pelvic abscess, functional outcome and quality of life are significantly poorer than in patients in whom no sepsis occurred.

Abscess↗
PubMed1997

Development of invasive adenocarcinoma in a long-standing Kock continent ileostomy: report of a case.

The first case of adenocarcinoma developing in a continent ileostomy is reported. A healthy, 39-year-old man with a continent ileostomy for 17 years developed subacute obstructive symptoms and was found on endoscopy to have a large adenocarcinoma involving the intussusception valve. At operation, he was found to have a large tumor originating in the valve, extending through the reservoir, and involving the afferent ileal limb. A number of metastatic lymph nodes were identified in the mesentery of the small bowel. He underwent excision of the pouch and formation of an end ileostomy. He is currently undergoing adjuvant chemotherapy. Biochemical and morphologic changes in the ileal pouch, both in the pelvis and the continent ileostomy, are discussed. The implications of this apparent de novo cancer arising in an ileal pouch are discussed.

Adenocarcinoma↗
PubMed1995

Fecal bile acids, short-chain fatty acids, and bacteria after ileal pouch-anal anastomosis do not differ in patients with pouchitis.

Construction of an ileal reservoir changes the fecal bacterial flora and the fecal composition of bile acids and short-chain fatty acids. We examined the relationships between pouch inflammation (pouchitis) and pouch content, as assessed by analysis of fecal bacteria, bile acids, and short chain fatty acids. Four groups were studied: ileal pouch-anal anastomosis (IPAA) for ulcerative colitis with pouchitis (N = 10), IPAA without pouchitis (N =5), IPAA for familial adenomatous polyposis without pouchitis (N = 5); and Brooke ileostomy for ulcerative colitis, which served as controls (N = 5). Pouchitis was defined as > or = 7 points on an 18-point pouchitis disease activity index. Aerobic and anaerobic bacteria were quantitatively cultured. Total aqueous-phase bile acids were measured by thin-layer chromatography and an enzymatic 3 alpha-OH hydroxysteroid dehydrogenase method. Fecal short chain fatty acids were measured by gas liquid chromatography. All patients with an IPAA had higher ratios of anaerobes/aerobes and concentrations of anaerobic gram-negative rods than did patients with an ileostomy. There were no other differences between patient groups with respect to bacteria, aqueous-phase total bile acids, or fecal short-chain fatty acids. Fecal concentrations of bacteria, bile acids, and short-chain fatty acids were similar in patients with and without pouchitis, indicating that these factors can not be the sole cause of pouchitis.

Adenomatous Polyposis Coli↗
PubMed1997

Functional results after "high" coloanal anastomosis and "low" coloanal anastomosis with a colonic J-pouch for rectal carcinoma.

The aim of this study was to determine the postoperative function of neorectoanal components using two different types of very low coloanal reconstruction. The two groups of patients assessed were 22 who underwent abdominal rectal resection and stapled "high" coloanal anastomosis without a pouch, being the HCAA-P group; and 34 who underwent anoabdominal rectal resection and "low" coloanal anastomosis with a colonic J-pouch, being the LCAA + P group. Manometric examination was performed 1, 3, 6, and 12 months postoperatively, and the patients were also assessed by a questionnaire. The LCAA + P group had remarkably less daily stool frequency and urgency, but there were no significant differences in the other functional parameters. Maximum resting pressure (MRP) was significantly less, while threshold volume (TV) and maximum tolerable volume (MTV) were greater in the LCAA + P group than in the HCAA-P group. The colonic J-pouch compensated for decreased MRP. Thus, when HCAA-P is performed, 3.0 cm of residual rectum with internal anal sphincter may be required, and construction of the pelvic pouch is desirable in low coloanal anastomosis.

Adult↗
PubMed1997

Influence of ileal pouch capacity and anal sphincteric function on the clinical outcome after ileal pouch-anal anastomosis.

This study was designed to determine the influence of ileal pouch capacity and anal sphincteric function on the clinical outcome after ileal pouch-anal anastomosis. A total of 24 patients who had undergone ileal pouch-anal anastomosis (J pouch) for ulcerative colitis were studied. The 24-hour stool frequency was found to be inversely correlated with the sensitivity threshold volume (STV), maximal tolerance volume (MTV), and distensibility, but was independent of the maximal resting pressure and maximal squeeze pressure. Patients experiencing nocturnal fecal incontinence had maximal resting pressures that were significantly lower than those of nocturnally continent patients. Among the patients with fecal incontinence, those with frequent soiling had lower resting pressures, STV, and distensibility than the patients with intermittent spotting. In addition, the STV in patients needing nocturnal evacuation were lower than those of patients who did not evacuate after falling asleep. The conclusions are as follows. Both stool frequency and the need for nocturnal pouch evacuation correlated directly with pouch volume. Anal incontinence was more common in patients with low internal sphincteric function. In addition, frequent and gross nocturnal incontinent patients demonstrate a worse function in both the anal sphincter and reservoir than those with intermittent spotting.

Adolescent↗
PubMed1999

Detection of a rectocele-like prolapse in the colonic J-pouch using pouchography: cause or effect of evacuation difficulties?

The functional outcome after a low anterior resection for rectal cancer is improved by a colonic J-pouch reconstruction. One functional problem with J-pouches is difficulty in evacuation, which is more common with large reconstructions. Since rectoceles are common findings on defecography in patients with evacuation difficulties, we proposed that a rectocele-like prolapse may be thus found in patients with large J-pouches. Pouchography was used to identify a rectocele-like prolapse (RP) in 26 patients with a 10-cm J-pouch (10-J group) and 27 patients with a 5-cm J-pouch (5-J group). Pouchography was performed at 3 months, 1 year, and 2 years after surgery. Functional assessments were performed 1 year postoperatively. Clinical function was evaluated using a questionnaire. The evacuation function was evaluated by the balloon expulsion and saline evacuation test. No patients had an RP at 3 months or 1 year after surgery. An RP was significantly more common in the 10-J group than in the 5-J group at 2 years after surgery (P = 0.0374). An evacuation difficulty was significantly more common in the 10-J group than in the 5-J group. The evacuation function in the 10-J group was also significantly inferior to that in the 5-J group. An RP appearing 2 years after surgery is more common in patients with evacuation difficulties and large colonic J-pouch reconstructions.

Aged↗
PubMed1998

Development of an ulcer in the side-to-side anastomosis of a jejunal pouch after proximal gastrectomy reconstructed by jejunal interposition: report of a case.

We present herein the first reported case of a deep ulceration developing in the pouch of a jejunal side-to-side anastomosis following the interposition of a jejunal U-shaped pouch (jejunal pouch), performed as reconstruction. A 47-year-old woman underwent a proximal gastrectomy and interposition of a jejunal pouch for early gastric cancer, 4 months after which she began to develop a fever. Esophagogastroscopy revealed a deep ulceration in the side-to-side anastomosis of the jejunal pouch. Her serum gastrin level was much higher than the normal range, and 24-h monitoring of the intraremnant stomach pH revealed that it was below 7.0 at night. A peptic ulcer was thought to be one of the causes of the pouchitis. Due to the drug-resistant ulceration and fever, a reoperation was performed, in which the jejunal pouch and remnant stomach were removed and Roux-en-Y reconstruction was done. There were no postoperative complications, and the fever resolved after surgery. Reconstruction of the jejunal pouch after proximal gastrectomy is recommended from the standpoint of quality of life (QOL); however, further studies on the size of the remnant stomach and the length of the interposed jejunal pouch are necessary.

Duodenal Ulcer↗
PubMed1999

Functional results of colonic J-pouch anastomosis for rectal cancer.

The purpose of this study was to clarify the functional outcomes of colonic J-pouch anastomosis (J-LAR) for lower rectal cancer in comparison with those of traditional straight anastomosis (S-LAR). A questionnaire regarding anorectal function was conducted 1 year after operation on patients who underwent J-LAR (n = 15) and S-LAR (n = 30). The clinical functions were assessed by an incontinence scoring system. The physiologic function was assessed by anorectal manometry and the balloon expulsion test. No patients demonstrated a diverting stoma. The bowel frequency (range) 1 year after operation was 4.8 (3-6) in the S-LAR group and significantly decreased to 1.8 (1-3) in the J-LAR group (P < 0.05). Complete evacuation was 50.2% (40%-60%) in the S-LAR group and significantly increased to 80.6% (60%-90%) in the J-LAR group (P < 0.05). Neorectal compliance was 2.2 (1.4-2.9) ml/mmHg in the S-LAR group and significantly increased to 3.1 (1.3-3.5) ml/mmHg in the J-LAR group (P < 0.01). No significant difference was observed between the two groups regarding the maximum resting or maximum voluntary squeezing pressure. In conclusion, our findings suggested colonic pouch anastomosis performed after a low anterior resection to support the compliance of the (neo)rectum to be an important factor for retaining a satisfactory bowel frequency.

Adult↗
PubMed1999

Diffuse schwannoma involving the entire large bowel with huge extramural development: report of a case.

Schwannoma of the large bowel is a rare clinical entity, which has reportedly been recognized to arise from one place with a submucosal tumor morphology. We present herein the unique case of a 25-year-old woman who suffered from a schwannoma diffusely involving the entire large intestine. The patient complained of abdominal distension and imaging studies revealed a giant tumor occupying the whole abdomen, but no confirmed preoperative diagnosis could be made. A laparotomy proved the huge tumor detected preoperatively to be the markedly wall-thickened entire large bowel itself due to the diffuse extramural development of a neoplasm, but no other organs were involved. Biopsy specimens from the tumor were histologically diagnosed as benign schwannoma. However, because of the possibility of malignancy, we later performed a total proctocolectomy followed by an ileal J-pouch-anal canal anastomosis. The final pathological diagnosis was also that of a benign schwannoma originating from the large intestine. The patient remains well without recurrence 15 months after surgery. To the best of our knowledge, no such case of a schwannoma in the entire large bowel has yet been reported in the literature, and the pathogenesis of its occurrence remains unknown.

Adult↗
PubMed1996

Anatomic basis of mesenteric elongation for ileo-anal anastomosis with J-shaped reservoir: comparison of two techniques of vascular section.

Total proctocolectomy followed by ileo-anal anastomosis with a reservoir is the operation of choice for the treatment of familial adenomatous polyposis and of certain forms of hemorrhagic proctocolitis. Vascular section is sometimes necessary to enable the extremity of the reservoir to reach the anal sphincter without traction. The aim of this study was to compare the gain in length obtained by two different techniques of vascular section and to assess in terms of the vascular anatomy of the last small intestinal loop which technique best preserved the vascularisation of the reservoir as a whole. Twenty-two fresh cadavers had an ileal J-shaped reservoir of 18 cm fashioned from the last loop of small intestinal loop after section of the root of the mesentery. The gains in length so obtained were measured after section of the ileocolic a. at its origin (group A) or section between the two vascular arches of the last small intestinal loop (group B); the superior mesenteric vessels were then injected with colored resin. The gain in length obtained by these two methods was identical (2.3 +/- 1.1 cm for group A as against 2.18 +/- 0.9 cm for group B), but only if the section of the ileocolic a. was accompanied by section of the mesenteric peritoneum up to the vascular arch formed by the anastomosis between the terminal branch of the superior mesenteric a. and the ileocolic a. The constancy of this anastomosis always allowed section of the ileocolic a. while preserving good vascular distribution to the entirety of the reservoir. Section between the two arches was difficult when the distance separating them was small.

Anal Canal↗
PubMed1996

[Manually assisted laparoscopic surgery--realistic evolution of the minimally invasive therapy concept? Initial experiences with the "Endohand"].

The essential limitations of laparoscopic procedures--lack of palpation, problematic retrieval of specimen and anastomosis, etc.--are abolished by the hand of the surgeon, which is inserted into the peritoneal cavity through a mini-laparotomy. While holding the pneumoperitoneum, the hand acts as an intelligent instrument performing surgical exploration, exposition of the field of operation, blunt dissection or intracorporal knot-tying. The mini-laparotomy is used to insert conventional instruments and suture material, as well as for specimen retrieval and anastomosis. Our preliminary experience (3x splenectomy, 2x sigmoid colectomy, 1x anterior resection of rectum, 1x proctocolectomy with J-pouch) shows that even extensive laparoscopic operations are accomplished much more simply. The time spent for such procedures is markedly reduced.

Adult↗
PubMed1998

[Ulcerative colitis--late functional results of ileoanal pouch anastomosis].

Stool frequency after ileal pouch-anal anastomosis (IPAA) is about 5/day after adaptation during the first year. It depends on stool volume and pouch capacity, not on the design of the pouch. In most cases evacuation is spontaneous and as complete as in healthy rectum. 67% of patients are perfectly continent, while 19% have to wear pads due to intermittent leakage. Complete incontinence is reported in 0-4% of the patients. Preservation of the anal transitional zone by the double-stapling technique does not improve functional results when compared to endoanal mucosectomy or intersphincteric resection. Impairment of continence is caused by damage of the internal sphincter with consecutive decrease of the pouch-anal pressure gradient. Despite altered reflex activity, stool discrimination is preserved in most patients. The loss of colonic water and electrolyte absorption is compensated by decreased renal excretion. Alterations in bile acid metabolism are lower after IPAA than after ileostomy. Bacterial overgrowth may lead to deterioration of the functional results.

Anastomosis, Surgical↗
PubMed2001

A comparison between open versus laparoscopic assisted colonic pouches for rectal cancer.

The aim of this prospective study was to compare the surgical outcomes in patients undergoing laparoscopic assisted vs. open ultralow anterior resection (ULAR) with the creation of a colonic pouch-anal anastomosis. Patients undergoing ULAR with creation of a colonic pouch and who either had conventional open (CO) or laparoscopic assisted (LA) surgery in colorectal cancer were studied and compared. There were 33 patients, 22 in CO group and 11 in LA group. The groups were comparable for age, sex, tumour and anastomotic heights from anal verge, stage of disease, length of specimen removed and duration of surgery. Incisions were significantly shorter in the LA group (median, 9 cm vs. 16 cm, p = 0.01). Less parenteral analgesia was required in the LA group (2 days vs. 3 days, p = 0.05), but there were no significant differences in the time to passage of flatus, commencement of oral fluids or solid foods and length of hospital stay. There was no difference in morbidity or mortality. With regards to patients with Dukes A to C disease only, at a median of 12 months of follow-up, there was no patient with local or port site recurrence in the LA group. In the CO group, there was one local recurrence and two with distal metastases. In conclusion, laparoscopic assisted ULAR with colonic J pouch anal anastomosis is feasible, easy to perform and safe. It s advantages include significantly shorter incision and lower analgesic requirements postoperatively. Return of bowel function and length of hospital stay, however, are comparable to those of conventional open surgery.

Aged↗