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PubMed2000

Liver involvement in patients operated for ulcerative colitis, with special reference to the association of cholangitis with colorectal dysplasia and carcinoma.

This study classified liver changes found in patients undergoing proctocolectomy for ulcerative colitis and examined whether patients with cholangitis have an increased risk of colorectal dysplasia and carcinoma. The patients were 152 who underwent liver biopsy during surgery for ulcerative colitis. Prior surveillance colonoscopy specimens and operative liver and proctocolectomy specimens were examined histologically. Patients with dysplasia or carcinoma in colorectal specimens were pair-matched to patients without such neoplasia. Sixteen (10.5%) patients had histological features consistent with small-duct primary sclerosing cholangitis on liver biopsy, five of them showing normal liver function values. Of the 152 patients 4 were found to have colon carcinoma (2.6%) and another 4 low-grade dysplasia (2.6%) either upon colonoscopy or in colectomy specimens. The median duration of the colitis in the 8 patients with colorectal neoplasia was 12 years (range 2-29) and in the other 142 patients 4 years (0.1-33; P=0.007). The prevalence of primary sclerosing cholangitis (PSC) or cholangitis was 50% in cases with colorectal neoplasia and 13% in pair-matched controls without colorectal neoplasia. In this selected group of patients operated on for ulcerative colitis the prevalence of histological cholangitis was thus higher than that of PSC in previous epidemiological studies. In addition, the prevalence of PSC or cholangitis was much higher in cases with colorectal neoplasia than in pair-matched controls without colorectal neoplasia. Our results support the view that cholangitis constitutes an additional risk factor underlying colorectal dysplasia or carcinoma.

Adolescent↗
PubMed1997

Causes of failure and life expectancy of the ileoanal pouch.

180 ileoanal pouches constructed over 10 years and followed for at least 2 years (154 for Inflammatory Bowel Disease (IBD) and 26 for Familial Adenomatous Polyposis (FAP)) were reviewed. 23 pouches have been excised to date, 8 remain defunctioned (pouch failure FAP 7.7%, IBD 18.8%). The reasons for excision were: ischemia (n = 6), pelvic sepsis (n = 5), severe stenosis (n = 3), underlying Crohn's disease (n = 3), poor function (n = 5) and fistula (n = 1). The reasons for defunction were: Crohn's disease (n = 1), pelvic sepsis (n = 5) and ileoanal stenosis (n = 2). The projected overall pouch survival rate (Life table analysis) at 5 years was 81% (confidence interval 74-87%). Beyond 7 years, the figures to calculate survival became unreliable (small numbers). There was a significant association between pouch failure and pelvic sepsis (Fisher's exact test P < 0.0001) and between failure and fistula formation (P < 0.02). Multiple regression analysis showed pelvic sepsis and recurrent pouchitis to be independent factors of pouch failure. Pouch failure can occur many years after initial operation. Long-term follow up is recommended.

Adenomatous Polyposis Coli↗
PubMed1997

Post-operative faecal continence in patients with ulcerative colitis after ileo-anal anastomosis with preservation of the transitional zone: a report from a low-incidence region.

The aim of this prospective study was to analyse post-operative faecal continence by carrying out a manometric and clinical follow-up on ten patients previously suffering from ulcerative colitis, who underwent total proctocolectomy and double-stapled ileo-anal anastomosis with preservation of the transitional zone. An annual histological analysis of the transitional zone was performed post-operatively. A 13% reduction in the length of the high-pressure zone of the anal canal (P = 0.04) was observed without any significant change in the resting anal pressure or the maximal squeeze pressures. Fifty percent of the patients showed histological signs of inflammation, without any clinical manifestations. The median number of bowel movements was 4 per day and 1 per night, and only 1 patient had occasional nocturnal soiling (less than once a week). On being questioned, 9 patients replied that they rated their continence as good or very good and 1 patient, as reasonable. These findings show that ileo-anal anastomosis, without mucosal resection preserves the normal resting anal pressure and anal function despite the reduction in the length of the high pressure zone it involves.

Adult↗
PubMed1998

Terminal ileal transposition procedure in ileoanal anastomosis following proctocolectomy.

We introduced a terminal ileal transposition procedure (TITP) in ileal pouch-anal anastomosis, in which a 50 to 70 cm isolated ileal segment 20 to 40 cm from the ileocecal valve was interposed between the terminal ileum and the anus. Twelve patients underwent this procedure in two or three-staged operations. Mean stool frequency per 24 hours was 4.4 +/- 1.7, and stool consistency was formed and soft in all patients at the mean of 13 months after TITP. We observed neither surgical technique-related complications nor metabolic disorders, except for iron deficiency anemia, during and after the operations. The serum level of vitamin B12 significantly increased after the operation in eight patients (P < 0.05). TITP has advantages such as preventing the terminal ileum from metabolic dysfunction due to pouchitis, avoiding sacrifice of the terminal ileum in the two-staged operation, and obviating the need for reconstruction of ileostomy in the three-staged operation. It may also promote intestinal absorption and reduce late metabolic complications.

Adolescent↗
PubMed1999

Manometric analysis of anal sphincter damage after ileal pouch-anal anastomosis.

A constant reduction in anal sphincter pressure follows an ileoanal pouch procedure for ulcerative colitis and familiar adenomatous polyposis. We analyzed whether this reduction is more likely due to neurogenic damage or to direct sphincter trauma. Three-dimensional vector volume manometry was performed in 75 patients prior to the ileoanal pouch procedure and 3 months thereafter. Resting pressure was significantly reduced from 83.5 +/- 24.4 to 58.1 +/- 18.0 mmHg and squeezing pressure from 204.7 +/- 63.3 to 173.4 +/- 50.6 mmHg. Moreover, significant vector volume reductions were recorded postoperatively, and the asymmetry index increased significantly (resting: 11.5 +/- 4.1% to 18.4 +/- 7.4%; squeezing: 9.6 +/- 3.1 to 13.0 +/- 6.7%). Functional anal sphincter length at the high-pressure zone remained unchanged. Thus, there was no local damage to proximal or distal anal sphincter segments, which suggests that the postoperative impairment of sphincter function is secondary to neurogenic rather than morphological damage.

Adenomatous Polyposis Coli↗
PubMed1999

Gains and losses with stapling and omission of loop ileostomy in pelvic pouch surgery: a matched control study.

After 10 years experience of pelvic pouch surgery with handsewn pouch and ileoanal anastomosis, mucosectomy, and covering loop ileostomy, the surgical technique was altered. Twenty patients were operated on with staple technique in pouch and ileoanal anastomosis but without mucosal proctectomy and loop ileostomy. This study group was compared with a matched control group of patients from our previous series with respect to duration of surgery, blood loss, hospital stay, complications, and functional outcome after 2 months, 12 months, and 60 months. It was found that staple technique significantly reduced the duration of surgery and the need of blood transfusions. Length of hospital stay after pouch surgery did not differ between the two groups, but omitting loop ileostomy reduced total hospital stay by about 2 weeks. Ileoanal anastomotic insufficiency occurred in two patients in the study group. Treatment by establishment of a defunctioning loop ileostomy, local saline perfusion, and administration of antibiotics was successful; the anastomosis healed within 2 weeks, and the longterm functional outcome did not differ from the average. Increased temperature persisted postoperatively in seven patients in the study group. Transient peroneal paresis occurred in three patients in the control group. Only in the control group was there stenosis in the ileoanal anastomosis requiring dilatation and fibrosis at the levator plane demanding emptying by a catheter. Concerning functional outcome, nighttime continence was significantly better in the study group than in the control group. The evacuation rate per 24 h was significantly higher in the study group after 2 and 12 months but not after 60 months. The outcome concerning other functional parameters such as urgency to evacuate, capacity to discriminate between gas and stool, deferral time, and perianal symptoms, did not differ significantly. Staple technique without mucosal proctectomy and loop ileostomy thus results in shorter duration of surgery and shorter hospital stay. In patients with increased risk of insufficiency of the anastomosis, however, covering loop ileostomy may be justified because of the risk for more serious consequences if anastomotic leakage occurs.

Adolescent↗
PubMed1999

Diagnostics and surgical treatment strategy for rectal cavernous hemangiomas based on three case examples.

A 20-year-old man with a congenital vascular malformation extending from the anal canal into the distal sigmoid had had recurrent perianal blood loss as a neonate. A hemangioma was diagnosed for the first time in 1978. The patient received regular and frequent gastroenterological treatment until admission. Decisive for the indication for surgery was the patient's need for blood infusions and shorter bleeding intervals in June 1998. Surgical therapy consisted of deep anterior rectosigmoid resection with coloanal pouch anastomosis. In a second case of a 27-year-old woman a sigmoid hemangioma was diagnosed in conjunction with emergency sigmoid resectioning. Because of recurrent hemorrhages a coloanal pouch was also established here in a second step. The third case involved a 19-year-old woman with a 12-year history of repeated perianal hemorrhages. After sigmoid discontinuity resection we carried out proctectomy with descendostoma creation due to renewed severe intractable perianal bleeding. The histological examination revealed a rectal hemangioma that had caused the repeated perianal hemorrhages. Surgical reconstruction was then achieved by coloanal pouch anastomosis. In view of the good functional and perioperative results, current surgical therapy should aim at preserving continuity and continence by coloanal pouch anastomosis.

Adult↗
PubMed2000

Comparison of anastomotic microcirculation in coloanal J-pouches versus straight and side-to-end coloanal reconstruction: an experimental study in the pig.

Several studies have shown a lower rate of anastomotic leakages in patients with coloanal J-pouch reconstruction than in those with straight coloanal anastomosis following anterior resection of the rectum. This study investigated whether this difference is due to a better anastomotic microcirculation. Thirty-two healthy, adult Göttinger mini-pigs underwent anterior rectal resection. They were subsequently randomized to following four groups (eight pigs per group): straight end-to-end, side-to-end, small pouch (4 cm), and large pouch (8 cm) coloanal anastomosis. Bowel perfusion was measured before and after vessel ligature at predefined locations using laser Doppler flowmetry. After completion of the anastomosis microcirculation was investigated 1 cm above, below, and directly at the anastomotic site. Following vessel ligature there was a 25% drop in blood flow. After completion of the anastomosis there was a further decrease of 25% in the distal segment, while no changes were observed above the anastomosis. There were no statistical differences either before or after completion of the anastomosis between the various groups. It is concluded that anastomotic blood flow does not depend on the type of coloanal reconstruction in healthy pigs.

Anastomosis, Surgical↗
PubMed2001

Does loperamide affect motor activity after proctocolectomy and ileal pouch-anal anastomosis? An experimental study in dogs.

This study investigated the effect of loperamide on the motor function of small intestine and J-pouch. Proctocolectomy and ileal pouch-anal anastomosis were performed in four dogs. Motility was recorded by serosal electrodes and strain gauge transducers. The intestinal transit time was determined radiologically. Multiple measurements were performed before and during chronic administration of loperamide. This treatment led to a significant decrease in median stool frequency from 11 (10-13) to 9 stools/day (8-12) and a tendential increase in intestinal transit time from 60 (50-105) to 70 min (60-90). This was not accompanied by significant changes in fasted or postprandial motility. There were no significant differences in the characteristics of the migrating myoelectric complex or in the fed pattern, either in the small intestine or in the pouch. Loperamide thus does not significantly affect intestinal motility after ileal pouch-anal anastomosis. The reduction in stool frequency seems to be due to antisecretory effects in the first line.

Animals↗
PubMed2003

Pouch reconstruction in the pelvis.

ILEAL POUCH RECONSTRUCTION: Proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the procedure of choice in mucosal ulcerative colitis (MUC) and familial adenomatous polyposis (FAP). Because the disease is cured by surgical resection, functional results, pouch survival prognosis, and disease or dysplasia control are the major determinants of success. There is controversy as to whether the IPAA should be handsewn with mucosectomy or stapled, preserving the mucosa of the anal transitional zone. Crohn's disease is a contraindication for IPAA, but long-term outcome after IPAA is similar to that for MUC in patients with indeterminate colitis who do not develop Crohn's disease. As development of dysplasia and cancer in the ileal pouch have been reported, a standardized surveillance program is mandatory in cases of MUC, FAP, and chronic pouchitis. COLONIC POUCH RECONSTRUCTION: Construction of a colonic pouch is a widely accepted technique to improve functional outcome after low or intersphincteric resection for rectal cancer. Several randomized studies comparing colo-pouch-anal anastomosis (CPA) with straight coloanal anastomosis (CAA) have found the pouch functionally superior. Most controlled studies cover only 1-year follow-up, but randomized studies with 2-year follow-up show similar functional results of CPA and CAA. Evacuation difficulty as initially observed was related to pouch size, and the results with smaller pouches (5-6 cm) are more favorable, showing adequate reservoir function without compromising neorectal evacuation. The transverse coloplasty pouch may offer several advantages to J-pouch reconstruction. Current series question whether the neorectal reservoir is the physiological key of the pouch, but rather the decreased motility. The major advantage reported with colonic pouch reconstruction is the lower incidence of anastomotic complications.

Adenomatous Polyposis Coli↗
PubMed1997

[Long-term outcome of continence function after ileo-anal pouch reconstruction].

An important aim of proctocolectomy with ileal pouch-anal anastomosis (IPAA) is to maintain anal continence. Anal sphincter disruption during IPAA is felt to play an important role in loss of continence, which is described in up to 30% of the treated patients in the early postoperative period. Although sphincter function recovers gradually after surgery, some patients stay incontinent. In our investigation of possible parameters involved in preservation of continence after this operative procedure, we focused on changes in anal manometry. We compared these findings with the functional results obtained by questioning the patients and physical examination. Anal manometry was performed with a low-compliance hydraulic perfusion system. All patients underwent a J-pouch procedure with a short rectal cuff for ileoanal reconstruction. We examined 25 patients, 13 underwent operation for the treatment of ulcerative colitis, 12 because of adenomatous polyposis. In the colitis and polyposis group, 28% of the patients reported events of soiling. Three patients (12%) were incontinent. The remaining 15 patients were completely continent. The median time after operation was 58 months, ranging from 12 to 96 months. Comparing the results of anal manometry with standard values of ten age- and gender-matched healthy volunteers, it was found that there was a significant increase in the threshold of balloon awareness and urge to defecate. These sensations were sometimes elicited by pouch contractions. Median pouch-compliance was also clearly elevated in comparison to rectal compliance (P < 0.005). Inhibitory reflexes during balloon inflation could not be evoked in any of the patients. Comparing continent with incontinent patients there were significant differences in balloon awareness, urge to defecate, and stool frequency (P < 0.01, P < 0.01 and P < 0.001, respectively). But in contrast to other publications, we could not find significant differences in anal sphincter length, resting and squeezing, anal canal pressure. Pouch compliance was lowered in incontinent patients and negatively correlated with stool frequency (P < 0.001, r = -0.82). In conclusion, our study indicates that anal sphincter resting pressure alone is not a crucial factor in continence preservation in the long-term after total proctocolectomy and IPAA. Poor pouch-compliance and concomitant higher stool frequencies seem to be related to incontinence in this patient group.

Adenomatous Polyposis Coli↗
PubMed2001

Comparison of colonic J-pouch reconstruction and straight coloanal anastomosis after intersphincteric rectal resection.

The tendency towards sphincter-preserving resection for distal rectal cancers has led to the technique of straight coloanal anastomosis (CAA) and colonic J-pouch anal anastomosis (CPA) after low anterior resection. The aim of the present study was to compare complication rate, anorectal physiology and functional results after both types of reconstruction after ultra-low intersphincteric resection. A total of 31 patients who had undergone CPA were followed up prospectively using anorectal manometry and a standardised questionnaire and were compared with 63 patients who had undergone CAA and were followed up in the same way. The complication rate after CPA did not differ significantly from that after CAA. One year postoperatively, the median stool frequency and urgency were reduced after CPA (1.7+/-2.2/day; 7% vs. 2.4+/-3.6/day; 14%; P<0.05). Three months after colostomy/ileostomy closure, the maximum tolerable volume, threshold volume and compliance were decreased after CAA when compared with CPA (55+/-12, 34+/-12, and 3.9+/-0.3 ml/mmHg vs. 85+/-21, 53+/-11 and 6.2 ml/mmHg, respectively; P<0.05). Anal manometry revealed no significant differences in the anal resting and squeeze pressure. One year postoperatively, continence also did not differ significantly between CPA and CAA. Colonic J-pouch reconstruction seems to be superior to the straight coloanal anastomosis, especially during the first postoperative year. In view of the often poor prognosis of the patients, it is the reconstruction of choice after ultra-low resections of the rectum.

Anal Canal↗
PubMed1998

Adenocarcinoma in an ileal pouch after prior proctocolectomy for carcinoma in a patient with ulcerative pancolitis.

We report the first known case of pouch carcinoma in a 35-year-old female patient following proctocolectomy for adenocarcinoma in ulcerative pancolitis with backwash ileitis. Pouch cancer was diagnosed 2 years after the pelvic pouch procedure, illustrating that there might be a risk of pouch cancer in such patients. Adenocarcinoma arising in an ileoanal reservoir is rare. Two other cases have been reported: both patients concerned were believed to have developed cancer in small areas of residual remaining rectal mucosa.

Adenocarcinoma↗
PubMed2001

Laparoscopic-assisted total mesorectal excision and colonic J pouch reconstruction in the treatment of rectal cancer.

BACKGROUND: Total mesorectal excision (TME) and colonic J pouch reconstruction has been widely practiced for mid- or low-rectal cancer. However, the laparoscopic version of TME has never been described. METHODS: Five patients suffering from newly diagnosed mid- to low-rectal cancer were seen between March and July 1999. These five patients were selected for laparoscopic TME and colonic J pouch reconstruction because preoperative investigations revealed resectable tumor without extrarectal disease. RESULTS: There were three men and two women with a mean age of 61 years. The average body weight was 69 kg (range, 57-80). None of the patients had had previous abdominal operations. In all five patients, the tumor was located within 9 cm from anal verge. The average size of the main incision was 5 cm. All patients had a covering ileostomy at the end of the procedure. The mean operating time was 208 min; average blood loss was 158 ml; and mean hospital stay was 10.6 days. Three patients had Dukes' B disease and two had Dukes' C disease. The resection margins (proximal, circumferential, and distal) were all clear. There were no deaths or major complications. Two patients suffered from transient urinary retention. After ileostomy closure, the median frequency of bowel motion was twice per day at 6-month follow-up. Neither incontinence nor nocturnal soiling was reported. CONCLUSION: To the best of our knowledge, this is the first published series of such an operation. With good patient selection, laparoscopic-assisted TME and colonic J pouch-anal anastomosis is safe and feasible.

Aged↗
PubMed2003

Hand-assisted laparoscopic colorectal surgery using GelPort.

BACKGROUND: An easily usable hand access device will optimize success in hand-assisted laparoscopic surgery (HALS). The authors describe their initial series of HALS colorectal resections using GelPort to evaluate their current technique and results with this new device. METHODS: A retrospective study investigated 33 HALS colorectal procedures including total colectomy ( n = 16) and low anterior resection ( n = 10). All operative data, including intraoperative GelPort performance, were prospectively recorded and retrospectively analyzed. RESULTS: In this study, 3 (9.1%) of 33 HALS procedures were converted to open surgery, and 4 (13.3%) of 30 HALS procedures required minimal enlargement of incisions to facilitate extracorporeal procedures. The operative time was 263 +/- 85 min, and the blood loss was 282 +/- 148 ml. There were no device malfunctions. Three major complications (9.1%) and 7 minor wound infections (21%) were noted postoperatively. The mean hospital stay was 7.9 +/- 3.8 days. CONCLUSION: When performed with GelPort, HALS is safely and reliably applicable for various colorectal procedures.

Adult↗
PubMed2004

Laparoscopic total colectomy: hand-assisted vs standard technique.

BACKGROUND: Although hand-assisted laparoscopic surgery (HALS) has been proposed as an alternative to laparoscopically assisted surgery (LAP), little is known about its role in total colectomy. The objectives of the study were to compare the outcomes in patients undergoing total colectomy via either HALS or LAP and to determine what benefits HALS might have in extensive colorectal procedures. METHODS: We reviewed the data for 23 patients who underwent total proctocolectomy (TPC) or total abdominal colectomy (TAC) using either a HALS or LAP technique. RESULTS: There were 12 HALS (five TPC, seven TAC) and 11 LAP (seven TPC, four TAC) for ulcerative colitis (n = 17), familial polyposis (n = 5), and colonic inertia (n = 1). One LAP was converted (9.1%). The operative time was shorter for HALS than for LAP (210 vs 273 min; p = 0.03). Blood loss and incision length were similar. Postoperative recovery and morbidity rates were comparable. CONCLUSION: HALS reduces the operative time but patient morbidity rates and recovery are similar to LAP. HALS may be preferable for extensive colorectal procedures such as TPC and TAC.

Adolescent↗
PubMed2003

Laparoscopic vs open resection for the treatment of diverticular disease.

INTRODUCTION: The aim of this study was to evaluate whether laparoscopic colon resection (LCR) offers any advantages over open colon resection (OCR) in the treatment of diverticular disease. METHODS: Between 1992 and 2002, 95 patients underwent LCR and 80 patients underwent OCR for the treatment of diverticular disease. Demographics, details of operative procedure, outcome, and pathology were compared. RESULTS: Patients in both groups were matched for age, sex, body mass index, history of previous abdominal operations, comorbidities, location of the disease, and presence of complications. LCR resulted in significantly less estimated blood loss and postoperative complications, shorter time to first bowel movement, and shorter length of stay than the OCR. There was no difference in operative time, intraoperative complications, mortality rates between groups. CONCLUSIONS: LCR is a safe and effective approach for the treatment of patients with diverticular disease. It results in less estimated blood loss, shorter time to first bowel movement, less postoperative complications, and shorter length of hospital stay.

Aged↗