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PubMed2004

[The transverse coloplasty pouch after low anterior resection: early postoperative results].

INTRODUCTION: A colon J pouch (CJP) still represents the standard rectal reservoir after low anterior resection. Though the CJP shows favourable early functional results, pouch evacuation problems tend to occur in the long term. The transverse coloplasty pouch (TCP), developed by our group allows comparable early functional results while avoiding evacuation problems. We report our experience with the TCP at the University Hospital of Heidelberg, Germany, and examine the risk of anastomotic leaks with this technique. METHODS: Between 1 October 2001 and 31 May 2003, 201 patients with rectal tumours underwent resection. Eighty-two patients with formation of TCP were enrolled in the study. RESULTS: During the creation of the TCP, no technical problems occurred, and the overall morbidity was 28%, including anastomotic leaks in seven patients (8.5%) and bleeding in two. The reoperation rate was 8.5%. An association between postoperative morbidity and preoperative radiation therapy could not be established. The hospital mortality rate was 3.6%. CONCLUSIONS: The use of TCP is a safe procedure which has gained worldwide acceptance in a short time, representing a technically straightforward procedure. Independently of patient size, habitus, and bulkiness of the colon, a TCP can always be performed after low rectal resection.

Adult↗
PubMed1999

[The physiology of intestinal pouches].

To summarize, J-shaped and W-shaped ileal pouches serve as adequate neorectal reservoirs after proctocolectomy. These pouches anastomosed directly to the anal canal are as distensible and capacious and as readily evacuated as the rectum in health. However, the use of S- or H-shaped ileal pouches, which have efferent limbs positioned between the pouch and the anal canal, sometimes leads to outflow obstruction and incomplete evacuation. There is little doubt that neorectums made of ileum can allow patients to have entirely "normal" patterns of fecal continence. Nonetheless, with pouch distension, large-amplitude, propulsive pouch contractions occur. These large pressure waves bring on the urge to defecate. They stress the anal sphincters more acutely than either the infrequent, small-amplitude, nonpropulsive contractions or clustered contractions of the healthy rectum. Nonetheless, patients learn to recognize the different signals heralding the impending need for evacuation from the ileal pouch and deal with them. Jejunal pouches, because of their greater distensibility and larger capacity, and the greater frequency of interdigestive migrating myoelectric complexes (MMCs) occurring in them, hold the promise of being a better rectal substitute than ileal pouches. They are more difficult to construct, however. Colonic pouches, when anastomosed to the anal canal after rectal resection, also act as adequate fecal reservoirs. Their main drawback is the inability of some patients to empty them. Small (5 cm) colonic pouches seem to empty better than larger (10-15 cm) ones. Jejunal pouches and colonic segments used as gastric substitutes after gastrectomy provide a better reservoir for ingested food than straight jejunal segments. The main drawback of the pouches is their inability to triturate the solid content of a meal and to regulate the rate of its emptying into the small intestine. Liquids and solids likely empty from these pouches at the same rate, in contrast to the slower emptying rate of solids from the healthy stomach. This likely leads to maldigestion of solids, perhaps contributing to the weight loss often found after gastrectomy.

Colorectal Neoplasms↗
PubMed1999

[Ileoanal pouch as rectal substitute].

The ileoanal pouch procedure (IAPP) was the most remarkable breakthrough in the surgical therapy of ulcerative colitis (UC) and familial adenomatous polyposis (FAP) in the last 20 years. The underlying disease is under control, the function preserved and the quality of life markedly improved. Alternative procedures (terminal ileostomy, ileorectal anastomosis) are only indicated in special cases. In the last 16 years we have operated on 662 patients (n = 493 UC; n = 169 FAP) with an ileoanal J-pouch, short rectal cuff, complete mucosectomy and hand-sewn anastomosis. Normally there is a good function for UC and FAP patients after IAPP. Surgical experience, technical modifications concerning the pouch design and the pouch-anal anastomosis, and a differentiated indication lead to a further improvement of these complex procedures with consecutive reduction of complications. Specific complications concerned mainly the pouch-anal anastomosis (fistulas, abscesses, consecutive stenosis) and inflammation of the pouch mucosa (pouchitis). A multivariate analysis showed, that increasing experience of the specialized center is a significant factor reducing inflammatory problems at the anastomosis. The cumulative incidence of pouchitis was 29%. In general there is no problem in successful treatment. But patients with chronic pouchitis are a problematic group (6.2%). Chronic pouchitis is difficult to treat. It is likely that there exists an inflammation dysplasia carcinoma sequence for the ileal pouch mucosa, analogous to the colorectum. Recently we diagnosed the first case of a real ileum pouch carcinoma with associated epithelial dysplasias following chronic pouchitis. Therefore patients with chronic pouchitis must be followed up by endoscopy and random biopsies in a surveillance program. Patients with UC and FAP can gain the life quality of healthy controls, if postoperative complications can be avoided or treated successfully. For the further development of the procedure and the individual long-term success a qualified follow-up and therapy of complications is essential. Both can be carried out only by a specialized center.

Adenomatous Polyposis Coli↗
PubMed1999

[The continent ileostomy. Current indications, techniques and results].

Over a period of 12 years, 73 patients received a continent ileostomy. 19 Kock pouches were primarily constructed due to contraindications against the ileoanal pouch, 30 ileostomies were converted due to psychological rejection of the incontinent stoma and 9 ileoanal pouches for dysfunction. 15 Kock pouches had to be corrected for nipple valve complications. Perioperative complications (14/73) were related to the Kock pouch in only one third of cases. Surgical late complications of the nipple valve function decreased with technical modifications from 41.1% to 20.0% and then to 4.8%. They could always be dealt with surgically. Pouchitis was observed in 26.8% of cases of ulcerative colitis (11/41), and in 6/15 patients with Crohn's disease (40.0%) complicated ileal recurrences developed. The definitive rate of success over the time was 98.1% in ulcerative colitis and familial adenomatous polyposis (53/54) and 63.2% in other conditions (12/19). Continent ileostomy has become universal and safe method for conversion of any previous operation.

Adenomatous Polyposis Coli↗
PubMed2001

[Colo-anal anastomosis: improvement of early function outcome by reconstruction with the colonic pouch].

INTRODUCTION: Early functional outcome after ultra-low anterior resection with coloanal anastomosis (CAA) may be improved by construction of a colonic pouch. The aim of this prospective observational study was to compare results of colonic pouch-anal anastomosis (CPAA) with conventional CAA including the learning curve. METHODS: From February 1996 through May 1998, 45 consecutive patients underwent CAA or CPAA following radical rectal resection for cancer. The technique of resection was identical in both groups, and all patients received a diverting stoma. The colonic pouch was constructed using linear staplers. Three and 12 months following stoma closure subjective continence and bowel habits were assessed; anal manometry was performed at 3 months. RESULTS: 20 patients with CPAA (9 F, 11 M, age 62 +/- 9 years) were compared to 25 CAA patients (11 f, 14 m, age 64 +/- 10 years). There was no mortality, and morbidity was comparable between groups. Three months following stoma closure, in the CPAA group bowel frequency was significantly diminished (1.4 vs 5.8; P < 0.0001), fewer patients had liquid motions (0/20 vs 12/25 patients; P < 0.0001), and more were continent (20/20 vs 4/25; P < 0.001) and able to defer defaecation (20/20 vs 2/25; P < 0.0001). Functional anal canal length was significantly shorter in CPAA patients (2.9 vs 3.5 cm; P < 0.008). Although at 12 months follow-up continence had improved in patients with CAA, bowel frequency (2.5 vs 1.3; P < 0.002), and number of patients with liquid motions (10/25 vs 0/20; P < 0.007) and passive incontinence (12/25 vs 0/20; P < 0.0001) were still significantly higher than the CPAA group. CONCLUSION: Even including the learning curve, CPAA may yield superior functional results at 3 months and 1 year compared to conventional CAA without increasing morbidity.

Adult↗
PubMed2005

[Metastasis of prostate carcinoma to the lamina submucosa of the distal rectum in ulcerative colitis 2 years after transrectal prostate biopsy and radical prostatovesiculectomy].

Transrectal ultrasound-guided prostate biopsy is the standard technique to detect prostate cancer histologically. Based on a few case reports, it is known that prostate biopsy can cause a seeding of tumor cells. We report the case of a 64-year-old man who 2 years after radical prostatectomy for prostate cancer underwent proctocolectomy because of ulcerative pancolitis. In the lamina submucosa of the distal rectum a micrometastasis of the prostate cancer was found. A possible reason for this metastasis is an implantation of prostate cancer cells due to the transrectal biopsy of the prostate.

Adenocarcinoma↗
PubMed2001

Colonic J-pouch function at six months versus straight coloanal anastomosis at two years: randomized controlled trial.

The colonic J-pouch (pouch group) functions better than the straight coloanal anastomosis (straight group) immediately after ultra-low anterior resection, but there are few studies with long-term follow-up. This randomized controlled study compared functional outcome, anal manometry, and rectal barostat assessment of these two groups over a 2-year period. Forty-two consecutive patients were recruited, of which 19 of the straight group [17 men with a mean age of 62.1 +/- 2.3 (SEM) year] and 16 of the pouch group (11 men with a mean age of 61.3 +/- 3.2 year) completed the study. Four died from metastases and two emigrated; there was no surgical morbidity or local recurrence. At 6 months the Pouch patients had significantly less frequent stools (32.9 +/- 2.8 vs. 49 +/- 1.4/week; p < 0.05) and less soiling at passing flatus (38% vs. 73.7%; p < 0.05). At 2 years both groups had improved with no longer any differences in stool frequency (7.3 +/- 0.4 vs. 8 +/- 0.2/week) and soiling at passing flatus (38% vs. 53%). Defecation problems remained minimal in both groups. Anal squeeze pressures were significantly impaired in both groups up to 2 years (p < 0.05). The rectal maximum tolerable volume and compliance were not different between groups. Rectal sensory testing on the barostat phasic program showed impairment at 6 months and recovery at 2 years, suggesting that postoperative recovery of residual afferent sympathetic nerves may play a role in functional recovery. In conclusion, stool frequency and incontinence were less in the Pouch patients at 6 months; but after adaptation at 2 years the straight group patients yielded similar results. Nonetheless, this functional advantage can be given to patients with minimal added effort or complications by using the colonic J-pouch.

Adenocarcinoma↗
PubMed2001

Operative technique on nearly total gastrectomy reconstructed by interposition of a jejunal J pouch with preservation of vagal nerve, lower esophageal sphincter, and pyloric sphincter for early gastric cancer.

Nearly total gastrectomy preserving the vagal nerve, the lower esophageal sphincter (LES), and the pyloric sphincter was developed as a function-preserving surgical technique to improve postgastrectomy disorders. In this paper, application criteria and technique are outlined, and postoperative quality of life was clinically investigated. Ten subjects who underwent this surgical operation (group A: 7 male and 3 female subjects at age 48 to 68 years with a mean age of 58.3 years) were interviewed to inquire about reflux esophagitis, dumping syndrome, and microgastria. Group A was compared with 20 cases of conventional total gastrectomy with D2 lymphadenectomy, excision of the lower esophageal sphincter (LES), total vagotomy, and single jejunal interposition (group B: 16 male and 4 female subjects at age 48 to 72 years with a mean age of 63.9 years). Included were cases with early cancer (M or SM1 of N0) localizing at the middle third and lower stomach, which was not applicable to endoscopic excision of gastric mucosa or partial gastric excision in M cancer, 2 cm or farther from the margin of the cancer to the esophagogastric mucosa cephalad junction and 3.5 cm or farther from the margin of the cancer to the pyloric caudad sphincter; in SM1 cancer, 4 cm or farther from the oral-side margin of the cancer to esophagogastric mucosa junction and 5.5 cm or farther from the anal-side margin of the cancer to the pyloric sphincter. In excision with lymph nodes, hepatic and celiac branches bifurcating from anterior and posterior trunks of the vagal nerve were preserved. To preserve LES, the esophagus was severed at the His angle at right angle to the longitudinal axis of the esophagus. The antrum was severed at 1.5 cm from the pyloric sphincter, preserving the arteria supraduodenalis. An alternative gaster was created as a 15-cm jejunal pouch with a 5-cm jejunal conduit for orthodromic peristaltic movement, using an automatic suture instrument to complete side-to-side anastomosis of folded jejunum with 1- to 1.5-cm long upper end of the pouch not anastomosed. The abdominal esophagus was mechanically anastomosed with a jejunal J pouch, and anastomosis of the pyloric antrum with a jejunal conduit was manually completed by stratum anastomosis. In group A, food ingestion per time could be taken the same as that of a healthy person, with no reflux esophagitis and dumping syndrome being noticed. Reflux esophagitis developed more significantly in group B than in group A (p < 0.05). In food ingestion per time, group B was significantly delayed compared with group A (p < 0.05). The present results suggested that the surgical technique proposed is a function-preserving gastric surgery appropriate to prevent postgastrectomy disorder of subjects.

Aged↗
PubMed2002

Quality of life after gastrectomy: Longmire's reconstruction alone compared with additional pouch reconstruction.

The optimal reconstruction protocol after total gastrectomy is still a matter of debate. Pouch reconstructions are developed to create a larger reservoir for food, to provide a barrier against intestinoesophageal reflux, and to lengthen the food transit time. Preservation of the duodenal passage should result in better physiologic regulation of the ingested food. Controlled randomized clinical studies must be conducted to assess the quality of life after gastrectomy and various types of reconstruction. In the present trial, which compared Longmire's reconstruction without a pouch and Longmire's reconstruction with a pouch of varying sizes, we evaluated the quality of life for 41 patients during the first postoperative year. The quality of life was examined by an EORTC questionnaire and an organ-specific module. There were no statistically proven benefits for pouch reconstruction in comparison with Longmire's reconstruction alone. Some benefits are shown for the large pouch but it was only a trend. This is especially so with regard to diarrhea and food consumption. A definitive answer to the question about the value of a pouch reconstruction after gastrectomy has not yet been attained. It is possible that there will be significant differences between reconstruction groups during the long-term follow-up.

Adult↗
PubMed2005

Surgical treatment of chronic amebic colitis.

There are limited data concerning the surgical management of chronic amebic colitis (CAC) in the literature. We present our experience with 10 patients with CAC treated surgically. Patients' records were retrospectively analyzed for age, sex, duration of clinical manifestations, colonoscopic findings, the type of surgical operation, and the postoperative course. Total proctocolectomy and J-pouch construction was performed in two patients who had CAC with severe rectal involvement. Total colectomy and the Hartmann procedure was performed in eight patients with mild to moderate rectal involvement. This treatment was successful in preserving the rectum in four of the eight. Our results suggest that rectal preservation can be a reliable treatment option in patients with CAC who have mild to moderate rectal involvement. Total proctocolectomy and ileoanal anastomosis with pouch construction should be the treatment of choice for patients with CAC who have severe rectal involvement.

Adult↗
PubMed2000

Risk factors and true incidence of pouchitis in patients after ileal pouch-anal anastomoses.

Total colectomy, mucosal proctectomy, and ileal J pouch-anal anastomosis (IPAA) has become the procedure of choice for patients with ulcerative colitis and familial adenomatous polyposis. The purpose of this study was to determine the short- and long-term outcomes of patients undergoing IPAA by a single surgeon, correlating intraoperative technical aspects with outcomes, and to characterize better the clinical syndrome of pouchitis. A retrospective review was performed of 114 consecutive patients who underwent IPAA by a single surgeon between December 1987 and August 1996. Clinical follow-up and operative notes were reviewed, and patient questionnaires were obtained for all patients. The mean follow-up was 3 years (range 0.5-8.0 years). The average age of the patients was 39 years (range 16-72 years). There were 64 males and 50 females. Indications for operation were ulcerative colitis (n = 101) and familial polyposis coli (n = 13). Long-term morbidity occurred in 41% of patients (small bowel obstruction 10%, anastomotic stricture 9%). Pouch excision was required in only three patients. Stool frequency (mean +/- SE) was 6.1 +/- 0.2 and did not change with duration of follow-up. Only 7% of patients reported fecal soilage. The incidence of pouchitis was 59% (n = 67), with 4.2 +/- 0.3 episodes of pouchitis per patient. Using multivariate analysis, the factors significantly associated with the incidence of pouchitis were gender (p = 0.008) and duration of follow-up (p = 0. 02). A total of 37 of 50 women (74%) but only 30 of 64 men (47%) developed pouchitis. The incidence of pouchitis increased with the duration of follow-up. The incidences of pouchitis in patients followed for 6 months, 1 year, and 3 years were 25%, 37%, and 50%, respectively. Of patients followed more than 6 years, the incidence of pouchitis was 94% (15/16). There was not a significant correlation between anastomotic tension or the extent of arterial dissection of the ileal mesentery required to achieve IPAA and the incidence of pouchitis. The best antibiotics for pouchitis were metronidazole (54% of patients) and ciprofloxacin (37%). Eleven patients have required nearly continuous antibiotics. Patient satisfaction with the outcome is high, with a mean satisfaction of 8. 4 (0, dissatisfied; 10, extremely satisfied). This review demonstrates a high incidence of pouchitis in patients after IPAA, which is due to the more liberal definition of the syndrome and the complete follow-up achieved in this report compared to previous series. This study also is unique in identifying the significantly higher incidence of pouchitis in women, although the overall satisfaction with the clinical outcome in patients undergoing IPAA remains high.

Adenomatous Polyposis Coli↗
PubMed1998

Quality of life of patients with inflammatory bowel disease after surgery.

Quality of life is an important outcome measure following surgery for ulcerative colitis. Quality of life incorporates not only the physical or functional outcome; it also considers the emotional and social well-being of patients. Quality of life may be measured using disease-specific or generic quality of life measures or by utility measurement. Although the pelvic pouch procedure is preferred by most patients, there are data to suggest that the quality of life is excellent irrespective of the procedure, possibly because physical well-being is improved and is the main determinant of outcome. Those who have a pelvic pouch may be less restricted in some activities. Compared to medically treated patients, quality of life is usually superior in surgical patients, although it varies depending on the activity of the disease and the surgical outcome. Despite more publications on this topic in recent years, there is a need for further studies comparing quality of life in patients receiving medical and surgical treatment as well as assessing outcome following the various surgical procedures.

Humans↗
PubMed2003

Anatomical basis for the interposition of a gastric pouch between the ileum and the anus after total proctocolectomy.

After a total proctocolectomy, ileoanal continuity is achieved by an ileal pouch-anal anastomosis. This anastomosis is not possible when the ileum cannot reach the anus. To avoid definitive ileostomy in this circumstance, we devised a gastric pouch, taken from the left half of the vertical portion of the stomach, vascularized by the right gastroepiploic pedicle, then interposed it between the ileum and the anus. The aim of this anatomical study on seven cadavers was to estimate the capacity of this gastric pouch to reach the anus. The distance between the caudal edge of the pubic symphysis and the apex of the pouch was measured. It is accepted that an ileal pouch always reaches the anus without tension if it comes down 6 cm below the caudal edge of the pubic symphysis. The apex of the gastric pouch reached a mean of 13.3 cm (range 10-18 cm) below the caudal edge of the pubic symphysis. This technique was then performed on four patients. The apex of the gastric pouch reached a mean of 12.5 cm (range 10-14 cm) below the caudal edge of the pubic symphysis and always reached the anus. These findings emphasize that a gastric pouch interposed between the ileum and the anus after a total proctocolectomy has an excellent capacity to reach the anus without tension.

Anal Canal↗
PubMed2005

Arthritis accompanying ileal pouchitis or undifferentiated HLA B27-related spondyloarthropathy?

The case of an HLA B27(+) patient who developed inflammatory arthritis accompanying ileal pouchitis, following total proctocolectomy for familial adenomatous polyposis is presented for the first time in the literature. Based on its clinical presentation and serology, it can be classified either as arthritis accompanying ileal pouchitis, or as an undifferentiated spondyloarthropathy.

Adult↗
PubMed1999

Urodynamic analysis of voiding dysfunction in orthotopic ileal neobladder.

We examined the urodynamics, particularly voiding dysfunction, in patients with a neobladder. Free uroflowmetry, pressure-flow study, and voiding cystourethrography were performed in 22 patients (mean age 65 years) at a mean of 21 months after ileal neobladder substitution. The results of free uroflowmetry were used to divide patients into two groups: the good voiders and the poor. Daytime continence was achieved in all patients, while 10 (45%) had nighttime continence. To void 250 ml urine the good voiders strained 2 +/- 1.5 times, and the poor voiders 6 +/- 5 times. The neobladder neck was at the most caudal portion of the reservoir in good voiders, and there was wide funneling. In the group with poor emptying ability, the outlet was not located at the most dependent position. The principal factors for ensuring good voiding function in neobladder patients are the ability to perform effective straining and the location of the neobladder neck.

Adult↗
PubMed1999

Incidence of urolithiasis in cystectomy patients after intestinal conduit or continent urinary diversion.

The purpose of this study was to determine the incidence of nephrolithiasis in radical cystectomy patients treated with either intestinal conduit or continent urinary diversion. The charts from 94 patients who had undergone radical cystectomy with urinary diversion at our institution from 1988 to 1998 were reviewed retrospectively for this study. Charts and radiographs from all patients were examined for renal function and evidence or urinary tract calculi. Two groups were compared: group I patients had undergone diversion with an intestinal conduit, and group II patients had received a continent diversion (primarily involving an Indiana pouch). Conduit diversions were typically done with a freely refluxing anastomosis (Bricker), whereas continent diversions were done with a nonrefluxing ureteral-intestinal anastomosis. Group I consisted of 54 patients who had undergone ileal conduit (50) or colon conduit (4) diversion with a mean follow-up of 2.5 years (range 0.6-7.0 years). Group II consisted of 40 patients who had undergone continent diversion (33 Indiana pouches, 7 orthotopic diversions) with a mean follow-up of 3.1 years (range 0.5-10.5 years). Laboratory studies of serum blood urea nitrogen, creatinine, and CO(2) were similar between the two groups. Six patients in group I developed urolithiasis, all in the upper tract. Stones developed at a mean of 3.1 years after urinary diversion. Three patients required operative intervention, whereas the others were managed expectantly. One patient in group II had an upper tract stone at the time of presentation for his bladder cancer, but no patient developed new upper tract stones during the present study period. Two patients in group II developed pouch calculi at a mean of 5 years after diversion; both required surgical intervention. In our study the risk for upper tract urolithiasis seemed higher in the intestinal conduit group (group I), with 11% of the patients developing stones. In the continent diversion group, no patient developed upper tract stones, although two patients (5%) developed pouch stones. Refluxing urine may contribute to an increased risk for stone formation after urinary diversion, whereas pouch stasis may contribute to stone formation in the continent diversion group.

Aged↗