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PubMed2001

Comparison of ileoanal pouch and rectal function measured by barostat.

The aim of this study was to compare pouch and rectal sensory and motor characteristics and to assess the influence of a meal on pouch tone and motility. Fifteen patients with an ileoanal J-pouch, with adequate pouch function and 12 healthy controls were studied. Visceral compliance was assessed using an electronic barostat by a pressure distension procedure, during which also sensitivity was scored by visual analog scales (VAS). The response to a meal was assessed during set pressure. Pouch and rectal compliance were not significantly different (9.3+/-0.7 vs 10.6+/-1.1 ml/mm Hg). VAS score for urge at 28 mm Hg was reduced in patients: 2.4+/-0.5 cm vs 4.7+/-0.9 cm in controls (P < 0.05). The postprandial decrease in intra-bag volume was more pronounced in patients (44+/-11%) than in controls (9+/-6%, P < 0.01). Postprandial phasic contractions were also more pronounced in patients. In conclusion, compliance is not significantly different between ileoanal pouch and rectum; differences in sensitivity reach significance only at high pressure. Significant differences were especially observed in the postprandial state with an increase in tone and frequency of phasic contractions in pouch patients.

Adult↗
PubMed1997

Azoreductase and nitroreductase activity of bacteria in feces from patients with an ileal reservoir.

Azoreductase and nitroreductase activities of bacteria in feces of five patients with ileal reservoirs were evaluated, both at the onset of symptoms of pouchitis and following recovery after treatment with drugs. All stool samples tested had bacteria with azoreductase and nitroreductase activities. Azoreductase and nitroreductase activities were higher after recovery than during attacks of pouchitis. During reestablishment of the normal microflora in the ileal reservoirs after pouchitis, the anaerobic bacteria increased and the aerobic bacteria decreased.

Bacteria↗
PubMed1998

Preoperative perfusion of bypassed ileum does not improve postoperative function.

This study evaluated whether twice daily isotonic perfusion of the bypassed ileum for six weeks would enhance its motor activity and its absorption of fluids, electrolytes, and vitamin B12. The study also determined if patients undergoing perfusion had improved bowel function and decreased hospital stay after ileostomy closure. Following proctocolectomy, ileal pouch-anal canal anastomosis, and diverting loop ileostomy, six patients self-infused an isotonic solution (sucrose and sodium chloride) into the bypassed ileum twice daily, while seven patients did not (controls). Two months following proctocolectomy, and just prior to ileostomy closure, a manometric catheter assembly was placed into the unused distal ileum via the stoma and the distal ileum perfused with an isotonic sodium chloride solution for 3 hr during fasting and 3 hr after a meal. Absorption was measured, single and clustered pressure waves were identified, and a motility index was calculated. Water absorption, motility index, and cluster parameters did not improve in perfused patients compared to controls during fasting or after a meal, nor did perfused patients have improved vitamin B12 absorption. The perfused patients also did no better clinically following ileostomy takedown; the onset of bowel movements, their frequency, time to tolerate a diet, and hospital stay were similar to controls. We conclude that six weeks of twice daily isotonic perfusion did not improve motor activity or water, electrolyte, and vitamin B12 absorption in the bypassed distal ileum after proctocolectomy, ileal pouch-anal canal anastomosis, and loop ileostomy. The perfusion also did not improve bowel function after ileostomy takedown.

Chronic Disease↗
PubMed1998

Plasma and mucosal fatty acid pattern in colectomized ulcerative colitis patients.

Patients with inflammatory bowel disease (IBD) have increased plasma n3 polyunsaturated fatty acids (PUFAs), which in ulcerative colitis (UC) patients persists six months after colectomy, suggesting a primary abnormality in fatty acid (FA) metabolism in IBD. This finding needed to be confirmed in a larger series of UC long-term colectomized patients. We aimed to assess the plasma FA pattern in UC colectomized patients with either Brooke's ileostomy (UC-BI) or ileal pouch anal anastomosis (UC-IPAA) and the mucosal FA pattern in the ileal reservoir of the UC-IPAA patients. Plasma FAs were assessed in 63 UC colectomized patients (31 with BI and 32 with IPAA) and 30 controls. In 26 UC-IPAA (8 with pouchitis and 18 without pouchitis) and in 13 healthy controls gut mucosal FAs were also investigated. FAs were detected by capillary column gas-liquid chromatography. Increased levels of saturated fatty acids (SFAs) and decreased percentages of monounsaturated fatty acids (MUFAs) were observed in both groups of patients. There were no changes in plasma n3 and n6 PUFAs. The mucosal FA pattern of the ileal reservoir consisted of increased long-chain PUFAs, specially n6 PUFA, and a decrease of their essential precursors. High percentages of SFAs and low percentages of MUFAs were also seen. The plasma FA profile previously described in IBD is not observed long-term after colectomy in UC, suggesting that it is related with the presence of inflamed intestine. High concentrations of SFAs and decreased percentages of MUFAs might represent early events in disturbed FA metabolism in IBD. The changes in FAs of the ileal reservoir, which closely resemble those found in human and experimental IBD, probably represent a common pattern of intestinal inflammation.

Adult↗
PubMed1999

Morphological and immunohistochemical changes in intestinal mucosa and PYY release following total colectomy with ileal pouch-anal anastomosis in dogs.

Other studies have shown that both morphological and functional adaptation occur in the ileal mucosa after total colectomy and may be mediated by humoral factors. To elucidate the participation of peptide YY (PYY) in intestinal adaptation after total proctocolectomy with ileal pouch-anal anastomosis (IPAA), changes in the number of PYY-containing cells and in histological appearance in the intestinal mucosa, especially in the mucosa of ileal pouch, were investigated in dogs. We further examined changes in postprandial PYY release in relation to those in PYY-containing cells. Ten adult beagle dogs underwent IPAA. Before and 2, 6, and 12 months after surgery, a test meal was given, and blood samples were taken from a foreleg vein at intervals for 3 hr for measurements of plasma PYY concentration by radioimmunoassay. Before and one year after surgery, morphological studies of the intestinal mucosa were performed using parameters such as villous height (VH), mucosal thickness (MT), and villous index (VI). Immunohistochemical studies of PYY were also done in the intestinal mucosa. Both fasting and postprandial plasma PYY levels were reduced to half of the preoperative levels at two months after surgery. Thereafter, postprandial levels approached preoperative concentrations, while fasting levels remained unchanged. VH, MT, and VI were significantly smaller in the ileal pouch than in the ileal end of the controls. The MT of the ileal pouch was similar to that of the colon. PYY-containing cells in the mucosa of the ileal pouch were distributed more densely than those in the ileal end, similar to those in the colon of the controls. It was concluded that after IPAA, the pouch mucosa gradually changed to resemble the colonic mucosa not only in histological appearance but also in the population of PYY-containing cells. It is therefore considered that colonic transformation of the ileal-pouch mucosa is closely related to the increase in the number of PYY-containing cells and the steady recovery of postprandial PYY secretion.

Animals↗
PubMed2004

Ileal pouch-anal anastomosis, conventional ileostomy and ileorectal anastomosis modify cholesterol metabolism.

Proctocolectomy modifies the enterohepatic circulation and activity of bacterial enzymes depending on the structure of the stoma and function of the terminal ileum. We evaluated in our comparative study effects of different colectomy constructions on cholesterol metabolism. Levels of lipoprotein cholesterol and triglycerides, noncholesterol sterols, and squalene in serum, fecal fat, and bile acids, cholesterol absorption efficiency, and cholesterol metabolism by sterol balance technique were analyzed in human subjects with ileal pouch-anal anastomosis (n = 34), conventional ileostomy (n = 8), ileorectostomy (n = 6), and controls (n = 29). Malabsorption of bile acids, but not of fat, and low serum levels of total and low-density lipoprotein cholesterol, but high levels of high-density lipoprotein cholesterol and increased cholesterol synthesis were evident in the colectomy groups. In contrast to the ileorectostomy group, expressing high absorption and biliary secretion of cholesterol, a low cholesterol absorption percentage accompanied by elevated serum proportions of cholesterol precursor sterols and phytosterols characterized the ileal pouch-anal anastomosis and conventional ileostomy groups. After colectomy, fecal excretion of secondary bile acids was low, whereas relative proportions of identifiable bile acids remained the same in each study group. Low serum levels of total and low-density lipoprotein cholesterol of colectomized subjects may decrease the risk of premature atherosclerosis. The favorable serum lipid profile was due to enhanced fecal loss of cholesterol as bile acids despite abnormally high cholesterol synthesis. Ileal dysfunction probably diminished cholesterol absorption in subjects with ileal pouch-anal anastomosis and conventional ileostomy, with no explanation for those with ileorectostomy with no clinical gastrointestinal dysfunction. Relative synthesis of identifiable primary bile acids remained unchanged postoperatively, but formation of secondary bile acids was weak due to scarce bacterial flora.

Anal Canal↗
PubMed2003

[Surgical strategies in patients with inflammatory bowel disease].

Crohn's disease and ulcerative colitis are specific inflammatory bowel diseases. Quality of life can be considerably limited. It does not depend on the form of therapy that Crohn's disease is highly recurrent, whereas colitis ulcerosa is curable by proctocolectomy. For both forms of disease surgery is an important option. It has to be included early in the therapy concept and not as last choice. Quality of life in patients with Crohn's disease can be raised significantly by surgery. Meticulous selection of the patients are essential to the policy of surgery as well as a regular aftercare. Best profit for those patients are treatment with an interdisciplinary team, consisting of gastroenterologists, nutrition advisers, psychologists, surgeons and radiologists.

Acute Disease↗
PubMed2001

Ileoanal pouch function is related to postprandial pouch tone.

BACKGROUND: Functional impairments are frequently observed in patients with an ileoanal pouch. Meal ingestion increases pouch tone and motility. Little is known, however, about the influence of meal-stimulated pouch characteristics on pouch function. The aim was to characterize basal and postprandial pouch motor and sensory characteristics in relation to clinical pouch function in patients with an ileoanal pouch. METHODS: Nineteen patients with an ileoanal pouch, without faecal incontinence but with either a high stool frequency (n = 8) or an adequate stool frequency (n = 11), underwent pressure distension of the pouch, by which pouch compliance and sensitivity characteristics were assessed using an electronic barostat. A set pressure procedure was performed to assess the influence of a meal on pouch tone and motility. RESULTS: Mean(s.d.) compliance was 10(6) and 11(4) ml/mmHg in the groups with poor and adequate pouch function respectively (P not significant). Mean(s.d.) visual analogue scale scores (0-10 cm) for urge at the highest pressure of 28 mmHg were 2.3(1.0) versus 2.3(2.4) cm respectively (P not significant); those for pain were 0.8(1.0) versus 0.5(0.7) (P not significant). Postprandially mean(s.d.) pouch volume decreased by 70(24) per cent in the group with poor pouch function and 29(25) per cent in the group with adequate pouch function (P < 0.01). The frequency and amplitude of phasic pouch contractions increased significantly postprandially, but no differences in motility characteristics were observed between the two groups. CONCLUSION: In patients with uniform pouch design and follow-up after pouch construction, pouch compliance and sensitivity were no different between patients with normal and high stool frequency; however, postprandial pouch tone was increased significantly in patients with a high stool frequency.

Adenomatous Polyposis Coli↗
PubMed2001

Function of a colonic J pouch continues to improve with time.

BACKGROUND: J pouch-anal anastomosis is thought to give superior functional results to straight coloanal anastomosis after rectal resection. Follow-up studies have suggested that this improvement is not maintained and that evacuatory difficulties may increase. METHODS: Some 119 consecutive patients had a coloanal anastomosis after resection for rectal carcinoma over 113 months, 62 with a J pouch and 57 with a straight coloanal anastomosis. Functional results were determined by patient questionnaire. The two groups were compared for the first and second 5-year intervals of study. RESULTS: Patients who had a J pouch had significantly better median Kirwan continence scores for the duration of the study and 5-9 years after surgery: 1 versus 2 (P = 0.05) and 1 versus 2 (P < 0.01), respectively. Some 5-9 years after surgery the median number of nocturnal bowel movements was significantly lower in patients who had a J pouch than in those with a straight coloanal anastomosis (0 versus 1; P = 0.02). Similarly, significantly better results were seen with regard to evacuation difficulties and urgency of defaecation. CONCLUSION: The function of the J pouch was superior to that of the straight coloanal anastomosis and appeared to improve with time.

Adenocarcinoma↗
PubMed2002

Outcome after septic complications in J pouch procedures.

BACKGROUND: Despite the wide range of surgical approaches for pouch salvage, septic complications are among the main causes of pouch failure. METHODS: This study analysed the mode and outcome of various therapeutic approaches for pouch salvage and the impact of time of diagnosis, localization and form of septic complications on the risk of pouch failure in 131 patients with septic complications of a total of 706 patients undergoing a J pouch procedure. RESULTS: Septic complications consisted of 76.3 per cent fistulas, 15.3 per cent anastomotic breakdowns and 8.4 per cent pelvic abscesses. A total of 107 patients (81.7 per cent) with septic complications required a mean of 2.2 surgical procedures. The frequency of permanent defunctioning and excision of the pouch in the 131 patients with septic complications was 23.7 and 6.1 per cent respectively. The estimated cumulative 3-, 5- and 10-year rate of pouch failure in patients with septic complications was 19.6, 31.1 and 39.2 per cent respectively. The risk of pouch failure was significantly affected by the site of origin of septic complications (P = 0.02). The 5-year pouch failure rate increased in a subgroup of patients with septic complications at the pouch-anal anastomosis when the anal sphincter was involved (50.1 versus 29.2 per cent; P = 0.18). CONCLUSION: Pouch failure as a result of septic complications may occur several years after ileal pouch-anal anastomosis. For prevention of pouch failure, surgery for septic complications is required in a high percentage of patients and repeated attempts are justified. Follow-up studies are required for further analysis of pouch failure.

Abscess↗
PubMed2002

Fate of the rectum in patients undergoing total colectomy for Crohn's disease.

BACKGROUND: This study aimed to analyse disease recurrence and fate of the rectum in patients who had a total colectomy for Crohn's disease. METHODS: One hundred and forty-four patients who had a total colectomy for Crohn's colitis were reviewed retrospectively. Ileorectal anastomosis (IRA) was performed in 118 patients, while 26 never had an IRA after colectomy because of severe anorectal lesions. Factors associated with recurrence and rectal preservation failure were studied. RESULTS: The probability of clinical recurrence after IRA was 58 and 83 per cent at 5 and 10 years respectively. The probability of rectal preservation at 5 and 10 years was 70 and 63 per cent after colectomy, and 86 and 86 per cent after IRA, respectively. Patients with extraintestinal manifestation had a higher risk of recurrence and of rectal preservation failure. Previous ileal involvement was associated with a higher rate of ileal recurrence after IRA. After IRA, prophylactic treatment with 5-aminosalicylic acid was associated with a lower rate of recurrence and of failure to preserve the rectum. CONCLUSION: Overall, 63 per cent of patients had a functioning IRA 10 years after total colectomy. Absence of extraintestinal manifestation and prophylactic treatment with 5-aminosalicylates after IRA were the main factors associated with long-term rectal preservation.

Adolescent↗
PubMed2002

In vitro determination of active bile acid absorption in small biopsy specimens obtained endoscopically or surgically from the human intestine.

BACKGROUND: In the construction of a Kock reservoir for continent urinary diversion, 70 cm of the distal ileum are used. Impaired absorption of bile acids in these patients might cause diarrhoea. Data on the absorption of bile acids in different parts of the human intestine are limited. METHODS: Biopsies were taken during endoscopy from the duodenum, the terminal ileum or the right colon, and during surgery 10, 50, 100 and 150 cm proximally to the ileo-caecal valve using standard endoscopy biopsy forceps. The biopsy specimens were incubated in vitro with radio-labelled taurocholic acid at 37 degrees C for 22 or 45 min The radioactivity was determined using the liquid scintillation technique. RESULTS: A linear increase in the uptake was observed, with increased concentrations of taurocholic acid between 100 and 500 microm in all specimens tested, that represented passive uptake or unspecific binding. The active uptake could be calculated from the intercept of the line representing passive uptake with the ordinate. The active uptake in the terminal ileum was 3-4 times greater than 100 cm proximal to the valve. CONCLUSIONS: The active absorption of bile acids in humans can be determined in small biopsy specimens taken using standard biopsy forceps during endoscopy or surgery. This method is suitable for clinical studies of bile acid absorption. Active uptake of bile acids not only takes place in the very distal part of the ileum but also to a considerable degree 100 cm proximally to the ileo-colonic valve. This should be taken into account when selecting the ileal segment for continent urinary diversion.

Adult↗
PubMed2003

Infliximab in refractory pouchitis complicated by fistulae following ileo-anal pouch for ulcerative colitis.

AIM: To determine the efficacy of infliximab in the treatment of chronic refractory pouchitis complicated by fistulae following ileal pouch-anal anastomosis for ulcerative colitis. METHODS: This open study included seven patients (four females, three males) with chronic refractory pouchitis complicated by fistulae. Pouchitis was diagnosed by clinical, endoscopic and histological criteria. The sites of the fistulae were as follows: pouch-bladder in one, vaginal in three, perianal in two, and both vaginal and perianal in one. Extra-intestinal manifestations (erythema nodosum, arthralgia) were present in four patients. Crohn's disease was carefully excluded in all patients after re-evaluation of the history, re-examination of the original proctocolectomy specimen and examination of the proximal small bowel. All patients had been treated with antibiotics and three with steroids. Patients received infliximab, 5 mg/kg, at 0, 2 and 6 weeks. Azathioprine (2.5 mg/kg) was also started for all patients as bridge therapy. Clinical response was classified as complete, partial or no response. Fistulae closure was classified as complete (cessation of fistulae drainage and total closure of all fistulae), partial (a reduction in the number, size, drainage or discomfort associated with fistulae) or no closure. The pouchitis disease activity index and quality of life were also used as outcome measures. RESULTS: Clinically, all patients improved. At the 10-week follow-up, six of the seven patients had a complete clinical response, and five had complete fistulae closure. At the 10-week follow-up, the median pouchitis disease activity index decreased from 12 (baseline) (range, 10-15) to 5 (range, 3-8); the median quality of life decreased from 37 points (range, 33-40) to 14 (range, 9-18). Erythema nodosum and arthralgia showed complete remission soon after the first infusion of infliximab. CONCLUSIONS: These preliminary results indicate that infliximab may be recommended for the treatment of refractory pouchitis complicated by fistulae following ileal pouch-anal anastomosis for ulcerative colitis.

Adult↗
PubMed1998

Reconstruction after total gastrectomy by the interposition of a double jejunal pouch using a double stapling technique.

BACKGROUND: After total gastrectomy, sustaining good nutrition is extremely important for maintaining quality of life. A technique of neogastric pouch formation based on current physiological reconstructive principles is presented. METHODS: The use of a modified interpositioned double jejunal pouch following total gastrectomy in 18 patients with cancer was reviewed. This technique results in a complete pouch and uses a double stapling technique with site-specific anastomosis between the oesophagus and pouch, in which a Hisoid angle is created. RESULTS: There were no anastomotic leaks and pouch blood flow was within normal expected limits. Mean oesophageal pH above 7.0 for one 24-h period was 7.7 per cent. Emptying half-time was 67.8 min. After 2 years mean body-weight was 98.3 per cent of expected, mean food volume was 94.0 per cent of expected and mean meal frequency was 3.0 per day. CONCLUSION: This form of gastric reconstruction is an acceptable procedure which improves the quality of life in patients undergoing total gastrectomy.

Adult↗
PubMed1998

J ileal pouch-anal anastomosis for chronic ulcerative colitis: complications and long-term outcome in 1310 patients.

AIM: The purpose of the study was to determine the risk of postoperative complications and the functional outcome after a hand-sewn ileal pouch-anal anastomosis (IPAA) for ulcerative colitis using a single J-shaped pouch design. METHODS: Preoperative function, operative morbidity and long-term functional outcome were assessed prospectively in 1310 patients who underwent IPAA between 1981 and 1994 for ulcerative colitis. RESULTS: Three patients died after operation. Postoperative pelvic sepsis rates decreased from 7 per cent in 1981-1985 to 3 per cent in 1991-1994 (P = 0.02). After mean follow-up of 6.5 (range 2-15) years, the mean number of stools was 5 per day and 1 per night. Frequent daytime and nighttime incontinence occurred in 7 and 12 per cent of patients respectively, and did not change over a 10-year period. The cumulative probability of suffering at least one episode of 'clinical' pouchitis was 18 and 48 per cent at 1 and 10 years and the cumulative probability of pouch failure at 1 and 10 years was 2 and 9 per cent respectively. CONCLUSION: These results indicate that increased experience decreases the risk of pouch-related complications and that with time the functional results remain stable, but the failure rate increases.

Adolescent↗