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At least 19 recordsLinked to original sources
PubMed1992

The role of the defunctioning ileostomy in restorative proctocolectomy.

Restorative proctocolectomy is now the treatment of choice for most patients with ulcerative colitis and familial polyposis coli. Temporary defunctioning ileostomy has been advocated during the period of anastomotic healing to prevent pelvic sepsis. However, the ileostomy itself may be a source of significant complications. To examine ileostomy function we reviewed thirty five patients (mean age 34.5 +/- 1.95 years) who underwent restorative proctocolectomy. Thirty four patients had a defunctioning ileostomy established at the time of pouch anal anastomosis. Closure of the ileostomy has been carried out in 33 patients (mean closure time 3.1 +/- 0.29 months). One patient underwent early pouch excision. Thirteen of the 35 patients developed post-operative complications (37%), two directly related to the defunctioning ileostomy. Both occurred following closure of the stoma and required laparotomy. Serious complications associated with defunctioning ileostomy as demonstrated in this study are uncommon (8.5%). Given the potentially disastrous consequences of a pouch-anal anastomotic leak we feel that the relatively low morbidity associated with a defunctioning ileostomy justifies its continued routine usage in the operation of restorative proctocolectomy.

Adenomatous Polyposis Coli↗
PubMed1991

Clinical and functional outcome after restorative proctocolectomy.

Restorative proctocolectomy and ileal pouch-anal anastomosis (IPAA) has been carried out on 88 patients since 1982. Three different pouch designs (J, S and W) were used. Ten pouches had to be removed. Detailed analysis was performed on 61 patients (J = 23, S = 15, W = 23) whose pouches had been functioning for at least 6 months. There was no significant difference in surgical complications before or after ileostomy closure between pouch designs but the hospital stay was greater after construction of an S pouch (P less than 0.05). There were no significant differences in stool frequency, degree of continence or urgency between the three types. Twelve patients with J pouches required antidiarrhoeal medication compared with only one with S and five with W pouches. Only seven patients with S pouches could defaecate spontaneously compared with 22 with W pouches and all patients with J pouches (P less than 0.001). Twenty-five of 29 patients who had preservation of the anal transition zone had perfect continence compared with 23 of 32 with a mucosal proctectomy (P = n.s.). Pouchitis occurred in 13 patients, all of whom had ulcerative colitis. In a subgroup of 23 patients, pouch evacuation was assessed scintigraphically. There was no difference in pouch capacity or total volume evacuated, but spontaneous evacuation was better in J and W pouches compared with S pouches.

Adult↗
PubMed1994

Transanal mucosectomy. Ileal pouch advancement for anorectal dysplasia or inflammation after restorative proctocolectomy.

PURPOSE: Restorative proctocolectomy has gained increasing popularity in the surgical treatment of ulcerative colitis. However, symptomatic proctitis in an excessively long anorectal stump or high-grade dysplasia within the retained anorectal mucosa can pose challenging problems. A corrective operation for these problems is described. METHODS: A sphincter-preserving perineal approach to mobilize the pouch was described. It allows excision of the inflamed or dysplastic-retained anorectal mucosa, followed by pouch advancement and a neoileoanal anastomosis. RESULTS: The technique was successfully performed in two patients, one with symptomatic "proctitis" and another with high-grade dysplasia in the anorectal mucosa after a previously stapled ileoanal (distal rectal) anastomosis. CONCLUSIONS: This report illustrates the relative ease and safety of delayed mucosectomy via a perineal approach, provided that the initially stapled anastomosis is within 3 cm to 4 cm of the dentate line. This technique also obviates the need for complex abdominopelvic surgery after previous restorative proctocolectomy.

Adult↗
PubMed1995

Clinical and physiological evaluation of anorectal eversion during restorative proctocolectomy.

Fifty patients had a restorative proctocolectomy with stapled end-to-end ileoanal anastomosis by the eversion technique. Median (interquartile range) maximum resting anal pressure was 90 (73-116) cmH2O before restorative proctocolectomy and 71 (51-88) cmH2O 1 year after surgery (P < 0.001). Median maximum squeeze pressure was 141 (110-185) cmH2O before surgery and 146 (118-186) cmH2O 1 year after surgery (P not significant). Median thresholds for sensation in the lower third of the anal canal before and 1 year after surgery were 5.3 and 7.1 mA, respectively (P = 0.006). One year after restorative proctocolectomy, all patients were continent, although two experienced leakage of mucus requiring a pad. Forty-two patients (84 per cent) could discriminate between faeces and flatus. Eversion of the anorectum during restorative proctocolectomy impairs the motor and sensory functions of the anal sphincter. Most patients achieved satisfactory anal continence, however, despite these physiological changes.

Adolescent↗
PubMedDate not supplied

Early results with restorative proctocolectomy.

The first 25 restorative proctocolectomies (RP) performed by one surgeon since 1986 are reviewed. Ulcerative colitis (23) and idiopathic megarectum (2) were the indications for surgery. The initial seven patients had a submucosal proctectomy and transanal hand sewn pouch-anal anastomosis. Eighteen patients had a totally stapled RP. One patient with malignancy died from factors unrelated to surgery. Complications developed in eight patients after pouch-anal anastomosis and in four patients after ileostomy closure. There was one pouch failure due to pelvic sepsis. No pelvic sepsis has occurred following a stapled ileal pouch-anal anastomosis with defunctioning ileostomy. After a mean follow up period of 20.5 months all patients are continent (mean stool frequency = 4/day and 0.5/night). Soiling occurred in three patients who had a transanal hand sewn pouch-anal anastomosis. All patients in the stapled group have satisfactory control. Restorative proctocolectomy produces satisfactory operative and functional results which have improved as our experience has increased.

Adolescent↗
PubMed1995

Restorative proctocolectomy without diverting ileostomy.

PURPOSE: Restorative proctocolectomy (RPC) by abdominal colectomy and ileal pouch-anal anastomosis (IPAA) in the setting of chronic ulcerative colitis (CUC) and familial adenomatous polyposis (FAP) has gained widespread popularity among surgeons and patients. Traditionally, temporary loop ileostomy has been established proximal to the ileal pouch in an effort to mitigate the effects of any suture line complications that may occur. This study compares functional results and complications encountered after RPC with mucosectomy with and without temporary ileostomy. METHODS: One hundred forty-three consecutive patients with either CUC or FAP underwent RPC including mucosectomy and ileal "J" reservoir. Proximal loop ileostomy was performed in 69 patients, and ileostomy was omitted in 74. Ileostomy was omitted if the patient was taking no immunosuppressives and less than 20 mg of prednisone daily in the month preceding surgery, the anastomosis was absolutely tension-free, and blood supply to the pouch was excellent. RESULTS: There were no perioperative deaths. There were two instances of pelvic abscess, one in the diverted group and one in the nondiverted group. Occurrence of IPAA suture line dehiscence was not significantly different between the two groups (ileostomy, 4/69 (6 percent), vs. no ileostomy, 6/74 (8 percent); P > 0.05). Comparison of 129 patients with colitis with and without diversion also failed to demonstrate a significant difference with regard to IPAA suture line dehiscence (ileostomy, 4/69 (6 percent) vs. 4/60 (7 percent); P > 0.05). Frequency of bowel movements and continence were the same in both groups and were comparable with results obtained without mucosectomy. Mean hospital stay at time of RPC for the nondiverted group was significantly longer (12 days vs. 10 days; P = 0.0004). Significantly fewer patients without an ileostomy were hospitalized for partial intestinal obstruction (ileostomy, 13/69 (19 percent), vs. no ileostomy, 3/74 (4 percent); P = 0.02), and significantly fewer required enterolysis (ileostomy, 7/69 (10 percent), vs. no ileostomy, 1/74 (1 percent); P = 0.04). On average, patients without an ileostomy spent significantly fewer total days in the hospital (17 vs. 24; P = 0.002). CONCLUSION: Restorative proctocolectomy with mucosectomy and without ileostomy is the procedure of choice for selected patients with FAP and CUC. Septic complications and functional results are similar to those seen in patients managed with a stoma. Anastomotic leakage, when it occurs, can be safely managed in most cases without surgery. RPC without ileostomy results in significantly fewer episodes of intestinal obstruction, fewer instances of re-exploration, and fewer total days in the hospital.

Abscess↗
PubMed1992

Restorative proctocolectomy in patients after previous intestinal or anal surgery.

Restorative proctocolectomy is now established as the procedure of choice in many patients with ulcerative colitis or familial polyposis coli as well as in some patients with multiple colorectal tumors, ischemia, trauma, or congenital abnormalities. Some patients, however, may have had previous pelvic, abdominal, or perineal surgery, which might be considered a contraindication to restorative proctocolectomy. In a consecutive series of 73 private patients undergoing restorative proctocolectomy under one surgeon, we have reviewed in detail 13 who had had previous "significant" abdominal, pelvic, or anal surgery. Eight patients had previously had surgery for fistula-in-ano or fissure-in-ano, two had had an anal sphincter repair, and three had undergone possibly compromising abdominal or pelvic surgery prior to restorative proctocolectomy. Twelve of the 13 made an uncomplicated recovery from restorative proctocolectomy, although one has since died from carcinomatosis. One patient died after closure of an ileostomy from a combination of enterocutaneous fistula, infection, bleeding, and a perforated duodenal ulcer. One patient developed sepsis, necessitating removal of the pouch, and is classified as a failure. Two of the remaining 11 have had minor long-term functional problems with nocturnal fecal incontinence, and one patient needs to catheterize the pouch to evacuate, but all three patients prefer a pouch to an ileostomy. Restorative proctocolectomy can be performed successfully even after previous pelvic, abdominal, or anal surgery with an acceptable complication rate when compared with pouch surgery in the uncompromised patient.

Anal Canal↗
PubMedDate not supplied

[Technical aspects of neorectum: restorative proctocolectomy].

In the last decade, restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) is considered as the procedure of choice in the surgical management of most patients with familial adenomatous polyposis and chronic ulcerative colitis. Beyond the attraction of this operation, which permit to completely remove disease-bearing mucosa, spare the anal sphincter, and avoid a permanent ileostomy, it remains a difficult procedure with not negligible complication rate. Correct operative technique is required: to the purpose, main technical aspects of IPAA are analysed.

Adenomatous Polyposis Coli↗
PubMed1992

One-stage restorative proctocolectomy without temporary defunctioning ileostomy.

A temporary ileostomy has been employed routinely by most medical centers to defunction the ileal reservoir after restorative proctocolectomy. The aim of this study was to compare the clinical outcome in patients who underwent restorative proctocolectomy with and without the use of a temporary, defunctioning ileostomy. A consecutive series of 58 patients was studied. Each patient underwent restorative proctocolectomy with quadruplicated ileal reservoir and stapled pouch-anal anastomosis, without mucosectomy; 28 had a temporary, defunctioning ileostomy and 30 did not. The decision for or against an ileostomy was taken at the end of the operation. The two groups of patients were similar in age and sex distribution. There was no postoperative mortality. There were no significant differences in the incidence of pelvic sepsis, anastomotic stricture, and intestinal obstruction in patients without an ileostomy compared with patients with an ileostomy. The total length of stay in hospital after the operation was significantly reduced in the group of patients without an ileostomy (P less than 0.01). The avoidance of a temporary ileostomy did not lead to an increase in postoperative complications and was associated with a shorter length of stay in hospital after restorative proctocolectomy.

Adult↗
PubMed1989

Anal canal mucosa in restorative proctocolectomy for ulcerative colitis.

In an attempt to improve continence after restorative proctocolectomy, ileal reservoir-anal anastomosis at the level of the anorectal junction has been advocated. This procedure preserves the entire mucosa of the anal canal. The histological appearances of the anal mucosa have been examined in 16 consecutive patients undergoing restorative proctocolectomy for ulcerative colitis. In 14 patients there was chronic inflammation characteristic of ulcerative colitis. Four patients had moderate dysplasia and in one of these patients an unsuspected adenocarcinoma of the anal canal extending down to the level of the dentate line was present. We believe that the anal mucosa should always be removed down to the level of the dentate line in restorative proctocolectomy for ulcerative colitis.

Anal Canal↗
PubMed1992

Temporary loop ileostomy following restorative proctocolectomy.

A retrospective study compared the outcome of restorative proctocolectomy in patients who had a covering ileostomy (n = 53) with those who had no proximal stoma (n = 32). Those who had a loop ileostomy had a higher incidence of anastomotic leakage (21 per cent), pelvic abscess (32 per cent) and postoperative fistula (28 per cent) than those with no covering ileostomy (6, 12 and 12 per cent respectively). Intestinal obstruction occurred in 23 per cent of those with an ileostomy, compared with 6 per cent in those who had no stoma. The functional outcome was identical.

Abscess↗
PubMed1988

Restorative proctocolectomy for ulcerative colitis.

The results of 36 restorative proctocolectomies (with 2-loop reservoir) for ulcerative colitis (UC) performed in a three-year period were surveyed. These patients represented 69% of all those undergoing definitive surgery for UC at the same time at our department. There was no operative mortality. Both early (44.4%) and late complications (45.2%) were quite common, but they were mostly minor and only two were permanent failures (5.6%) requiring construction of conventional ileostomy. Anastomotic retraction and sinus formation (25%), as revealed by pouch x-ray, were the most frequent early complications, occurring in a lesser degree (19.4%) also after stoma closure. Pouchitis was also a common (20%) late complication, but usually resolved promptly with metronidazole treatment. The functional results in the 23 patients evaluated were satisfactory, with a mean defaecation frequency of 5.4 per 24 hour and a minor soiling frequency of 36%. None of the patients had to wear a pad. The over-all results are compatible to those from other centres and suggest that acceptable anal function follows restorative proctocolectomy in most suitable cases with UC. The role of adequate surgical experience and consideration of contraindications must, however, be emphasised, and the surgeon must be ready to handle many minor and even major complications.

Adolescent↗
PubMed1995

[Restorative proctocolectomy. A morphological-functional study by computed tomography with coronal scans].

Restorative proctocolectomy with ileal pouch has become the surgical treatment of choice for patients with ulcerative colitis and familial polyposis of the colon. Defecography is the radiologic technique commonly used to obtain detailed information on function and morphology of the ileal pouch, but it fails to depict the pelvis. Computed Tomography (CT), with coronal images only was used to examine 10 patients with ulcerative colitis, submitted to restorative proctocolectomy. Coronal CT, yielding a panoramic view of the pelvis, represent an effective alternative technique to defecography. In fact, the two techniques provide comparable information relative to the ileal pouch; coronal CT also depicts the possible thickening of pouch walls and of pelvic fat tissue. Coronal CT also depicts the continence of ileo-anal and ileo-ileal anastomoses and the functional changes of the perineal muscles at rest and during squeezing. Coronal CT images allow easy and clear detection of such major postoperative complications as pelvic inflammation and fistulae (less frequently stenosis or dehiscences of the anastomosis).

Adult↗
PubMed1991

Comparison of morbidity and function after colectomy with ileorectal anastomosis or restorative proctocolectomy for familial adenomatous polyposis.

Restorative proctocolectomy with an ileal reservoir (RPC) should prevent colorectal cancer in patients with familial adenomatous polyposis. Until this is confirmed its role compared with total colectomy and ileorectal anastomosis (IRA) will depend on the relative morbidity and postoperative bowel function after the two procedures. This was analysed in 99 patients (37 RPC, 62 IRA) operated on between 1977 and 1989. Morbidity was greater after RPC with subsequent ileostomy closure (median hospital stay, 24 versus 11 days; complications, 60 versus 21 per cent; reoperation, 29 versus 3 per cent; return to normal activity; 31 versus 14 weeks). There was little difference in bowel function; after IRA median frequency was 3/24 h and urgency (unable to wait 15 min) occurred in 50 per cent, compared with 4.5/24h and 17 per cent after RPC. Night evacuation occurred in 10 and 43 per cent respectively. IRA was performed in younger patients (median 19 versus 31 years) who had fewer bowel motions before operation (2 versus 5/24 h). The greater morbidity of RPC suggests that it should be restricted to patients at higher risk of developing later rectal cancer, including those unavailable for follow-up and those with large or confluent rectal polyps or with curable colon cancer at the initial colectomy.

Adenomatous Polyposis Coli↗
PubMed1991

[Restorative proctocolectomy].

Indications and procedures of restorative proctocolectomy in the surgical treatment of ulcerative colitis and familial polyposis are reported. Surgical procedure and some technical innovations are discussed.

Adenomatous Polyposis Coli↗
PubMed1995

Surgery for the teenager with familial adenomatous polyposis: ileo-rectal anastomosis or restorative proctocolectomy?

Increasing numbers of polyposis registries have led to more young patients being diagnosed with familial adenomatous polyposis (FAP). To provide guidelines for selecting the appropriate surgical procedure in teenagers (10-19 years), we compared the results of colectomy and ileo-rectal anastomosis (IRA, n = 17 patients) to the results of restorative proctocolectomy and ileal pouch-anal anastomosis (IPAA, n = 7 patients). Charts were reviewed to obtain data on the operative technique, blood loss and transfusions, hospital stay (including the time for ileostomy closure), and early (within 30 days of surgery) and late complications. Functional results (bowel movements per 24 h, use of antidiarrheal drugs, seepage, and fecal incontinence) and quality of life were evaluated prospectively with a questionnaire and physical examination. The median follow-up time was 49 months (range, 6 to 95 months) after IRA, and 36 months after IPAA (range, 4 to 87 months). Although restorative proctocolectomy and IPAA, is a longer (5.75 vs 3.1 hours), more bloody (500 vs 300 mL blood loss), and more complex operation with a longer hospital stay (12 vs 7 days) than IRA (P = 0.008, P = 0.006, P = 0.02, respectively), no significant difference (P > 0.05) was found between groups concerning the complication rate or quality of life. For teenagers with FAP and rectal carpeting, large rectal adenomas, curable cancer in the upper two-thirds of the rectum, or who are unavailable for follow-up, we recommend a restorative proctocolectomy and IPAA. For the other patients, the decision whether to perform IRA or restorative proctocolectomy with IPAA depends on the patient's desire and the surgeon's skill.

Adenomatous Polyposis Coli↗
PubMed1992

Restorative proctocolectomy--the pouch operation: good or bad?

Restorative proctocolectomy is now the procedure of choice for patients requiring surgery for ulcerative colitis and some for familial adenomatosis. The indications for operation are being refined, and technically the procedure has been simplified. Although it avoids ileostomy, it does not restore normality. Stool frequency, continence problems, and pouchitis can all spoil a good result. In spite of these shortcomings, it represents a major advance.

Adenomatous Polyposis Coli↗
PubMed1995

Preservation of complete anal sphincteric proprioception in restorative proctocolectomy: the inhibitory reflex and fine control of continence need not be impaired.

This study evaluates whether reflux function of the anal sphincter remains unchanged after restorative proctocolectomy, provided that the sphincter remaining is kept intact, without mucosal stripping or endo-anal anastomosis. Paired tests of anorectal function were performed before, and a median of 6 (range 2-12) months after restorative proctocolectomy with stapled, end to end pouch-anal anastomosis. Beforehand, distension of the rectum with 50 ml of air produced a median (interquartile range) increase in pressure within the rectum of 22 (15-29) cm H2O and reflex inhibition of the anal sphincter from a pressure of 76 (62-106) cm H2O to a pressure of 34 (15-52) cm H2O. After the procedure, distension of the ileal pouch with 50 ml of air produced an increase in pressure within the pouch of only 5 (4-8) cm H2O (p < 0.001 compared with beforehand) and reflex inhibition of the anal sphincter from a pressure of 62 (25-79) cm H2O to 37 (17-68) cm H2O. Maximal reflex inhibition of the upper third if the anal sphincter to a pressure of 26 (15-48) cm H2O was observed when pressure within the pouch increased by 16 (11-22) cm H2O. After restorative proctocolectomy, all patients were continent (two experienced minor nocturnal leakage of mucus) and 25 could discriminate between flatus and faeces. Thus, reflux function was preserved in response to changes in pressure, ensuring that the subtler aspects of anal continence were preserved.

Adolescent↗