- Email: [email protected]
The ileoanal reservoir
The lleoanal Reservoir Steven D. Wexner, MD, FortLauderdale,Florida, W. Douglas Wong, MD, David A. Rothenberger, MD, Stanley M. Goldberg, MD, Minneapolis,Minnesota
One hundred nine men and 71 women with a mean age of 31 years had construction of 164 S, 2 J, and 14 other ileoanal reservoirs. Postoperative gastrointestinal complications included small bowel obstruction in 11 percent and liens, hemorrhage, and sepsis in 6 percent, 5 percent, and 11 percent, respectively. T h e r e was a 13 percent incidence of miscellaneous postoperative complications. Pouch perianal fistulas developed in 5 percent of patients, and pouch vaginal and other pouch fistulas developed in an additional 4 percent. During long-term follow-up, small bowel obstruction developed in 27 percent of patients, and enterolysis or enterectomy was required in 15 percent of patients. One hundred fourteen patients who were followed for a mean length of 5 years after ileostomy closure (range 16 to 8 8 months) were evaluated for functional outcome. Function improved with time in 63 percent of patients and remained stable in another 33 percent; only 4 percent had long-term deterioration. Ninety-five percent of patients would again choose an ileoanal reservoir over a permanent ileostomy. This long-term assessment shows that although the ileoanal reservoir is a viable option in the management of mucosal ulcerative colitis, it should not be recommended to every patient.
he ileoanal reservoir is now in its 12th year of clinical use [1]. The procedure can be technically demandT ing, and a steep learning curve has been documented [2]. Despite many reports of excellent functional results, some investigators have found the procedure to be fraught with complications [3-7]. Good functional results which are acceptable to the patient must be balanced against potentially unacceptable complications. Towards this end, we reviewed our first 180 consecutive ileoanal reservoir procedures and addressed both of these issues. MATERIAL AND M E T H O D S Between November 1980 and April 1988, 180 patients underwent total abdominal colectomy, rectal muFrom the DepartmentOfColorectalSurgery,ClevelandClinicFlorida, Fort Lauderdale,Floridaand the Divisionof ColonandRectalSurgery, Universityof MinnesotaSchoolof Medicine,Minneapolis,Minnesota. Requests for reprints should be addressed to Steven D. Wexner, MD, 3000WestCypressCreekRoad, Fort Lauderdale,Florida33309. Presentedat the 30th Annual Meetingof the Societyof Surgeryof the AlimentaryTract, Washington,D.C., May 16-17, 1989. 178
cosectomy, ileal reservoir construction, and ileoanal anastomosis at the University of Minnesota affiliated hospitals. Since 1978, a computerized data registry has been in place at the University of Minnesota Division of Colon and Rectal Surgery. Sixty categories of technical and demographic data were prospectively entered on each of the 180 patients who had an ileoanal reservoir constructed; all calculations were based on the number of patients rather than the number of operative procedures. One hundred fifty-nine of these patients also underwent iliostomy closure, and these data were also prospectively evaluated. One hundred nine men and 71 women with a mean age of 31 years (range 13 to 60 years) had construction of 164 three-limbed (S) ileoanal reservoirs, 2 twolimbed (J) ileoanal reservoirs, and 14 ileoanal reservoirs of other design. Indications for surgery were mucosal ulcerative colitis (169 patients; 94 percent) and familial adenomatous polyposis (11 patients; 6 percent). One hundred sixty ileoanal reservoir procedures were performed electively (89 percent), 18 were performed on an urgent basis (10 percent), and 2 were performed emergently (1 percent). The technique for ileoanal reservoir construction has been described in previous publications [8-11]. The office records and hospital charts of all 180 patients were analyzed. One hundred seventy-eight medical records were complete; thus although prospective data retrieval was complete in 100 percent of the cases, retrospective chart review was complete in only 99 percent. In addition, the prospective computerized registry and medical records relating to the ileostomy closures were reviewed. Prior to the end of April 1980, 159 of these 180 patients also had their ileostomies closed, and 6 patients never had ileostomies constructed (one-stage ileoanal reservoir procedure). Twenty-two patients (12 percent) underwent an abdominal colectomy followed by an ileoanal reservoir construction with ileostomy creation and then closure of ileostomy (three-stage procedure). Thus, 180 patients underwent a total of 333 surgical procedures, not including morbidity-related procedures. Complications that arose in the postoperative period and those that occurred during the long-term follow-up were both included in this study. Postoperative complications included those which occurred within 30 days of either the ileoanal reservoir construction or ileostomy closure. Complications directly related to the ileoanal reservoir and those related to other organ systems were both included in the analysis. Long-term complications, however, were limited to ileoanal reservoir-related problems. Associated conditions such as dehydration ensuing from pouchitis were included. Prolonged ileus was defined as the need to reinsert a nasogastric tube or to withhold oral intake for more than 7 days after surgery without radiographic proof of obstruction or the subsequent need for laparotomy. Longterm complications were reviewed in an identical manner to early complications.
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TABLE
TABLE II
I
Postoperative Gastrointestinal Complications ( n = 1 7 8 ) Patients Complication
n
%
Operations n %
Small bowel obstruction Prolonged ileus Intestinalbleeding* Wound infection Intraabdominal sepsis Parastomal sepsis Perianastomotic sepsis Pancreatitis Cholecystitis Laparotomy t
20 11 9 7 7 3 2 3 1 2
11 6 5 4 4 2 1 2 <1 1
5 0 6 0 2 1 0 1 1 2
3 0 3 0 1 1 0 <1 <1 1
9 Includes bleeding from ileoanal reservoir anastomotic and suture lines (6), peptic ulcer (1), ileostomy closure (1), and unknown site (1). t No pathology.
Other Postoperative Complications ( n = 1 7 8 ) Patients Complication
n
%
Hypertransaminaserhia *
2 1 5 3 3 2 2 1 2 1 1 1 1
1 <1 3 2 2 1 1 <1 1 <1 <1 <1 <1
Hepatitis Pneumothorax ~ Pneumonia Urinary retention P!eural effusion Deep venous thrombosis Nephrolithiasis Adrenal insufficiency Brachial palsy Peroneal neuropathy
Epididymitis Parotitis
* Asymptomatic increases. t From insertion of central venous parenteral nutrition catheters.
Functional results were limited to an appraisal of long-term function. Only the 129 patients who underwent ileoanal reservoir construction and re-establishment of intestinal continuity between November 1980 and December 1986 were included in the functional assessment. All of these 129 patients were sent questionnaires concerning their ileoanal reservoir function and their quality of life. Questions addressed frequency of evacuation, continence; diet and medications, social and sexual activity, pregnancy, and overall patient satisfaction. Patients who did not return their questionnnaires within 4 weeks and those about whom additional data or clarification of an; swers were required were contacted by telephone. One of us (SDW) reviewed all questionnaires and queried all patients on the telephone; this author had not participated in the surgery or the pre-or postoperative management of any of these patients. Office records and hospital charts were specifically not utilized in order to minimize bias and maximize the validity of the data. One hundred fourteen patients (88 percent) were available for complete long-term evaluation. The mean length of follow-up was 5 years, ranging from 16 to 88 months after ileostomy closure. Seventy-four men and 40 women with a mean age of 31 years (range 13 to 60 years) were assessed. The indications for and timing of surgery in the functional group of 114 patients were similar to that for the entire group of 180 patients. One hundred five patients had a S ileoanal reservoir, I had a J ileoanal reservoir, and 8 had other types of ileoanal reservoirs created. Incontinence was defined as the leakage of liquid or solid stool in quantities sufficient to merit a trip to the toilet or change of undergarments. Spotting was defined as the leakage of flatus or of a small quantity of liquid, enough to warrant the use of a pad but not a change of undergarments or the use of a toilet. All functional parameters were defined in terms of always, usually, sometimes, rarely, and never occurring. RESULTS There was no postoperative mortality. Morbidity and complications were divided into early postoperative and
late or long-term. Postoperative gastrointestinal complications represented a large number of the problems seen (Table I). Twenty patients had a small bowel obstruction (11 percent), which required surgery in 5 patients (3 percent). An additional 11 patients (6 percent) had a prolonged ileus. Nine patients (5 percent) had some degree of hemorrhage from the gastrointestinal tract manifested by melena, hematochezia, hematemesis, or decreasing hemoglobin. In all nine patients, confirmation of the source of hemorrhage was confirmed either clinically, endoscopically, or surgically. Four patients required laparotomy for hemorrhage: one for peptic ulcer disease, one for bleeding from the site of ileostomy closure and two for bleeding from the reservoir itself. Two additional patients required transanal suture and ligation of reservoir sutureline hemorrhage. Sepsis was a major cause of postoperative morbidity. There were seven wound infections (4 percent), seven cases of intraabdominal sepsis (4 percent), three parastomal abscesses (2 percent), and two ileoanal perianastomotic abscesses (1 percent). Surgery was required for two pelvic abscesses and for one ileocutaneous fistula. In addition to the relatively more prevalent complications of obstruction, bleeding, and sepsis, a variety of other postoperative complications were noted. These included both gastrointestinal and nongastrointestinal problems (Table II): The two most frequent long-term complications were pouchitis and small bowel obstruction; each was noted in 49 patients (27 percent). Twentyfive of these 49 patients required exploratory laparotomy (14 percent); 20 patients underwent enterolysis only (11 percent) and 5 had enterectomies with anastomoses (3 percent). Forty-nine patients were treated for pouchitis (27 percent); approximately half of these patients had only a single episode which responded to oral hydration and metronidazole. Eleven patients required hospitalization due to pouchitis-associated dehydration (6 percent), and 5 patients (3 percent) who normally achieved spontaneous ileoanal reservoir evacuation found catheterization
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necessary during bouts of poUchitis. Two ileoanal reservoirs were ultimately excised for intractable pouchitis, Delayed sepsis seen more than 30 days after either ileoanal reservoir construction or ileostomy closure was not uncommon. Seven patients (4 percent) had periileoanal anastomotic cuff abscesses, all of which required local drainage. Five patients developed pelvic abscesses and one patient each developed a parastomal and perianal abscess, all of which required surgical or antibiotic therapy. Fistulas from the ileoanal reservoir to the perianal area developed in nine patients (5 percent) and fistulas from the reservoir or anastomotic line developed to other sites in an additional seven patients (4 percent). This latter group included fistulas to the paracoccygeal area, buttocks, and vagina, five of which ultimately were discovered due to initially misdiagnosed Crohn's disease. All five of these patients (12 percent) required per-anal dilatation of anastomotic strictures or anal stenoses. These problems were probably related to either local sepsis or ischemia. Virtually all patients developed at least some degree of transient perineal and perianal excoriation. In most cases this responded to local perianal hygiene, dietary changes, and the use of antidiarrheal agents. Seven patients required reestablishment of an ileostomy, one of which was permanent. Indications included pelvic sepsis, poor ileoanal reservoir function, and a mesenteric desmoid; the latter required creation of a permanent end-stoma. Two patients had pouch revision for poor function, and 14 patients (8 percent) ultimately underwent ileoanal reservoir excision. Indications for excision were functional failure in five patients, Crohn's disease in five, intractable pouchitis in two, and severe postoperative hemorrhage and pelvic sepsis in one each. Failures occurred early and seemed related to postoperative complications. Five of the 15 ileoanal reservoir failures occurred within the first year (33 percent of failures), 5 within the second year (33 percent of failures), 2 during the third year (13 percent of failures), and only 1 during each of the next 3 years (7 percent per year). If one excludes the failed ileoanal reservoirs, the complication rates are much lower in the remaining group of permanent ileoanal reservoirs. Four of the 7 patients with intraabdominal sepsis; 4 of the 20 patients with small bowel obstructions-and 4 of the 9 patients with intestinal bleeding ultimately had failure of their ileoanal reserVoirs. Thus the overall rate of postoperative exploratory laparotomy was 67 percent in those 15 patients who required eventual reservoir exclusion or excision and 9 percent in the entire group of 178 patients (16 of 178 patients) but only 4 percent in those patients with a long-term successful outcome (6 of 163 patients). Likewise, if the rates of small bowel obstruction, intestinal bleeding, and sepsis requiring laparotomy were analyzed, in the successful cases the rate decreased to 0.6 percent, 1.2 percent, and 0 percent, respectively. Ninety-tw0 percent of patients achieved spontaneous ileoanal reservoir evacuation; subsequent to a decrease in limb size from 4 to 5 cm to 2 to 3 cm, no patient required ileoanal reservoir catheter intubation. The mean number 180
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of evacuations is 5.4 4- 2.5 during the day (range 1 to 12, median 5) and 1.5 4- 1 at night (range 0 to 6, median 1). Seventy-nine percent of patients have six or fewer daytime bowel actions and 84 percent empty twice or less at night. Three percent of patients always or usually have incontinence of stool dUring the day and 8 percent find this true at night; however, no patient with daytime incontinence was operated on since 1983, and 91 percent of those who reported nocturnal incontinence also underwent ileoanal reservoir construction prior to 1983. Daytime minor spotting occurs at least some of the time in 39 percent of patients and at night in 57 percent. Sixty-two percent of patients usually wear a protective pad during the day and 68 percent do this at night. However, the majority of patients who use a protective pad do so to bolster self-confidence rather than out of necessity. Prior to ileoanal reservoir construction, 86 percent of patients were sexually active. Fifty percent reported no change in activity level, 23 percent had increased activity, 25 percent had minor decreases, and 2 percent had severely limited or absent sexual activities. In no instance did either the patient or the physician attribute decreased activity to the ileoanal reservoir. There were no cases of impotence and only one case of undocumented retrograde ejaculation. Three patients became pregnant and had successful cesarean section deliveries. Ninety percent of patients were employed or in school prior to ileoanal reservoir construction, and 87 percent continued to do so after surgery. Ninety-eight percent of patients believed that the ileoanal reservoir in no way limited their daily activities. Importantly, 63 percent of patients felt that their functional results continued to improve over many years, often even after a plateau had been reached. These data are all shown in Table III. COMMENTS Many centers have reported excellent functional resuits with the ileoanal reservoir procedure [6,12-16]. We analyzed our entire group of patients both prospectively and retrospectively to assess functional outcome and morbidity. It has been suggested by some investigators that function improves over time [2,4]. This conclusion prompted us to limit our long-term functional analysis to a minimum of 18 months after ileostomy closure. Thus, while 180 patients were eligible for prospective and retrospective assessment regarding morbidity, only 129 patients were eligible for long-term functional analysis. The most common complications after ileoanal reservoir remain small bowel obstruction and pouchitis [6,17]. Yves et al [17] reported 626 patients who underwent the ileoanal reservoir procedure for either mucosal ulcerative colitis or familial adenomatous polyposis [17]. Seventeen percent of the patients in that series developed small bowel obstruction, half of whom required laparotomy. In the series of 163 patients reported by Fleshman and coworkers [13], 34 patients (19 percent) developed small bowel obstructions, almost half of whom required laparotomy. Nicholls and associates [18] reported a 13 percent incidence of small bowd obstruction necessitating laparotomy and Schoetz and colleagues [7] reported a 24
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percent incidence of small bowel obstruction and an 11 percent incidence of laparotomy for obstruction. In the present study, we divided all complications into those occurring in the immediate postoperative period and those which occurred subsequent to that time. In the postoperative period 20 patients developed small bowel obstructions, 5 of whom required laparotomy. In the long-term evaluation, an additional 49 patients (27 percent) developed obstructions of whom 25 patients required laparotomy. Thus 17 percent of the overall group of evaluated ileoanal reservoir patients had a laparotomy at some time during the follow-up period. Although our rate of small bowel obstruction is slightly higher than that cited in other series, our length of follow-up is also longer, ranging from 16 to 88 months. The most serious complication is probably pelvic or perianal suppuration, as this often antedates poor function and may indicate a misdiagnosed case of Crohn's disease. Schoetz and colleagues [19] reported a rate of pelvic sepsis of 3.6 percent (6 of 165 patients). In over 80 percent of these cases (five of six patients) antibiotics alone were successful in obtaining resolution of the suppuration without surgery. In addition, five patients had ileoanal reservoir fistulae, three of which were pouchvaginal. All five patients required re-establishment of a diverting ileostomy and two were actually cases of Crohn's disease. Scott and colleagues [20] reported a 6 percent rate of pelvic sepsis (30 of 500 patients) and made several important points. First, the incidence of significant sepsis decreased from 11 percent with the first 100 procedures to 4 percent of the last 100 performed. This represents a learning curve which has been observed in other practices as well [8,11,13,14]. Second, patients who had a previous colectomy and Brooke ileostomy had higher rates of sepsis than patients in whom colectomy and ileoanal reservoir construction were performed during the same laparotomy. Third, approximately half of those patients who required laparotomy to treat the sepsis ultimately required pouch excision. By contrast, no reservoir was excised from patients who did not require laparotomy but responded to antibiotic therapy or local surgical or percutaneous drainage alone. These data correlate well with the previously reported finding by our group that functional results improve with time because those patients with complications lose their reservoirs during the first two postoperative years, often because of poor function [6]. However, this should not detract from the fact that the majority of patients who retain their ileoanal reservoirs continue to experience functional improvement even up to several years after surgery. Poor function can be correlated to previous colectomy, as has been documented by Zenilman and associates [21]. Our overall rate of abdominal, perianal, pelvic, and parastomal sepsis was 7 percent in the postoperative period. An additional 7 percent developed delayed suppuration. The majority of these incidences of sepsis occurred during the first 3 years of ileoanal reservoir constructions, and many, as discussed, represented patients who ultimately lost their reservoirs because of Crohn's disease
TABLE IIl Summary of Functional Outcome (n = 114)* Frequency of evacuation Daytime Mean Median Nighttime Mean Median Always or usually continent Solids, liquids: Daytime Nighttime Gas: Daytime Nighttime Wear a pad Daytime Nighttime Changes In diet Antldlarrheal medication No limitations In dally activity No sexual limitations Continued functional improvement
5.4 5 1.5 1
97 92 88 71 62 68 32 30 98 98 63
9 Values expressed as percentages unless otherwise Indicated.
(five patients) or poor function (five patients). These results compare favorably with those reported in other major centers worldwide [22]. Pouch-vaginal fistulas represent a relatively common problem that is rather recalcitrant to most forms of therapy. A recent multicenter study reported the incidence to be 7 percent (27 fistulas in 306 female patients) [23]. This type of fistula should alert the physician to the possibility of Crohn's disease and should prompt an aggressive evaluation in that direction. Initial treatment is aimed at treatment of local suppuration and re-establishment of proximal ileal diversion. The next step is an attempt at local treatment with either an endoanal sliding flap or an overlapping sphincteroplasty [23]. Gracilis muscle interposition and reservoir reconstruction remain second-line treatments, and ultimate ilcoanal reservoir failure and excision can be expected in approximately 18 percent of cases. Pouchitis was one of the two most common long-term complications reported. Pemborton and co-workers [2] place the incidence at 14 percent with a relatively short follow-up (mean 2.3 years). Other investigators report rates of pouchitis which vary from I0 percent to 29 percent [7,8,13,15,24]. We found that the incidence of pouchitis increased with the length of follow-up as shown in Figure I. Therefore, it is not surprising that our patients experienced a slightly higher rate of pouchitis than that reported in some of the above-cited references. It has been suggested that evacuation frequency decreases most within the first 6 months after surgery [22]. Becker and Raymond [15] reported this improvement continuing for at least 12 months. They reported a mean daily stool frequency which decreased from 7.5 at i month to 5.4 at I year postoperatively. Schoctz and colleagues [7] reported 7 daily evacuations during the first 3 postoperative months and 5.1 subsequent to that time.
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Pouchitis Rate (%) 5O
30 20 10 0
|
|
|
1981 1982 1983 1884 1985 1888
47
31
32
26
33
9
Figure 1. The incidence of pouchltls relative to the length of follow-up. The overall Incidence Is 27 percent.
Pemberton and associates [2] reported that although stool frequency did not change with the length of followup (mean 2.3 years), the incidence of nocturnal incontinence and spotting significantly decreased over the first 3 years, from 30 percent to 13 percent. Although most functional improvement may occur during the first 3 to 6 postoperative months, our patients' responses show that continued improvements in both frequency of bowel action and degree of continence occur for at least 2 years. Much of the incontinence may be attributable to a sharp learning curve of this technically exacting procedure. All of the patients in this series who experienced daytime incontinence and 89 percent of those who experienced nocturnal incontinence underwent ileeanal reservoir construction between 1981 and 1983. A previous report from this group also showed a trend towards a decrease in minor leakage and spotting, although this did not achieve statistical significance [6]. Nasmyth and co-workers [25] showed that patients with good ileoanal reservoir function could postpone dalecation as shown by an increase in squeeze pressures over those with poor function. In addition, patients with "perfect" anal continence after the ileoanal reservoir procedure had higher resting anal canal pressures than the imperfect continence group. Those investigators demonstrated that resting anal canal pressure (high pressurezone pressures) was significantly lower (by 50 percent) in patients after ilr reservoir construction than in control subjects (median 50 cm water versus 97 cm water). Patients with minor leakage had significantly lower resting pressures than patients who were continent. Similarly, those who could not defer evacuation had significantly lower maximal squeeze pressuress than those who could defer evacuation. Martin and associates [26] reported improved func182
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tional results in 69 patients in whom the anal transitional mucosa was preserved and the mucosectomy was performed from a transabdominal rather than transanal approach. This technique obviates the sphincter stretch necessary for transanal mucosectomy and anastomosis, thereby avoiding decreased postoperative resting pressures. Bartolo and colleagues [27] prospectively studied 12 patients in whom the ileoanal reservoir was performed. In six patients, the anal mucosa was removed proximal to the anal valves, and in the other six it was removed proximal to the top of the anal columns. Preservation of the anal transitional zone was associated with normal sensation postoperatively as assessed by electrosensitivity and temperature sensitivity. However, the technique of transanal mucosectomy was utilized in all 12 patients, and, as expected, marked decreases in both resting pressures and maximum voluntary contraction pressures were documented. Keighley [28] compared 12 patients who underwent endoanal mucosal stripping with I 0 patients who underwent the transabdominal technique of mucosectomy. Incidences of complications between the methods of mucosal excision were comparable, except for the cuff abscesses which were seen exclusively after the transanal technique. Functional results were similar, although the incidence of soiling requiring a perianal pad was 50 percent after the transanal stripping and only 10 percent after the transabdominal method. This is probably attributable to the decrease in resting anal canal pressures seen in the transanal group that was not seen in the transabdominal group. These changes were, respectively, 87 cm and 82 cm water preoperatively and 60 cm and 81 cm water postoperatively. In addition, maximum squeeze pressures also changed from 180 cm to 166 cm water in the transanal group and from 171 cm to 168 cm water in the transabdominal group. Keighley [28] noted that the median duration of anal retraction was 72 minutes in the transanal group. Liljeqvist and co-authors [29] reported a similar improvement in results with preserving the transitional zone and decreasing the duration of anal stretch. In this later series, normal continence improved from 65 percent to 92 percent with the newer technique. Thus, based on these data, it seems desirable to preserve the transitional zone to optimize anal canal sensation and to eliminate sphincter stretch to maintain normal postoperative resting and squeeze pressures to improve continence. The stapling techniques described by Heald and Allen [30] and others [31,32] achieves both of these goals. A stapled J-type reservoir is created from a single apical enterotomy. The enterotomy is then used for purse-string application, and the circular stapling device is used to effect an end-to-side ileoanal anastomosis without mucosectomy or sphincter stretch. Clinical trials are under way. In conclusion, our study achieved several goals. First, we reconfirmed previous reports regarding acceptable function. Second, we ascertained that although complications are prevalent after such an extensive and technically demanding procedure, they occur with an acceptable incidence. Third, it may be possible to predict ultimate failure based upon early postoperative ileoanal reservoir-
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related complications. Our data suggest that early postoperative laparotomy augurs poorly for ultimate success. In addition, sepsis, in the form of either abscesses or fistulas, is also associated with high rates of ultimate ileoanal reservoir failure. Moreover, the development of fistulas from the ileoanal reservoir to the perineum, vagina, paracoocygeal area, or buttocks suggest that Crohn's disease rather than mucosal ulcerative colitis was the colonic pathology. Crohn's disease represented the single most common reason for ultimate ileoanal reservoir excision. Fourth, we believe that further improvements can be achieved through newer surgical techniques. More clinical study along this avenue is required. At present, the ileoanal reservoir is not a panacea. Although it is a viable and useful alternative to proctectomy or to ileorectal anastomosis in the treatment of both mucosal ulcerative colitis and familial adenomatous polyposis, it is not perfect. There is no way at present to preoperatively predict which patients will have good clinical outcomes. Although many research protocols are underway using anorectal manometry, rectal and reservoir compliance, scintigraphy, and a variety of other analytic techniques, no studies have proven uniformly reliable as predictors. At the present time, technical refinements seem to be the best methods of ensuring good postoperative outcomes. Although the ileoanal reservoir has celebrated its 12th anniversary, the "perfect pouch" is still under development.
REFERENCES 1. Parks AG, Nicholls RJ. Proctocolectomy without ileostomy for ulcerative colitis. Br Med J 1978; 2: 85-8. 2. Pemberton JH, Kelly KA, Beart RW, Dozois RR, Wolff BG, Ilstrup DM. Ileal-pouch anal anastomosis for chronic ulcerative colitis. Ann Surg 1987; 206: 504-13. 3. Nicholls J, Pescatori M, Motson RW, Pezim ME. Restorative proctocolectomy with a three-loop ileal reservoir for ulcerative colitis and familial polyposis. Ann Surg 1984; 199: 383-8. 4. McHugh SM, Diamant NE, McLe~xiR, Cohen Z. S-pouches vs. J-pouches: A comparison of functional outcomes. Dis Colon Rectum 1987; 30: 671-7. 5. Pezim ME, Nicholls ILl. Quality of life after restorative proctocolectomy with palvic ileoanal reservoir. Br J Surg 1985; 72: 31-3. 6. Wexner SD, Jensen L, Rothenberger DA, Wong WD, Goldberg SM. Long-term functional analysis of the ileoanal reservoir. Dis Colon Rectum 1989; 32: 275-81. 7. Schoctz D J, Coller JA, Veidenheimer MC. Ileoanal reservoir for ulcerative colitis and familial polyposis. Arch Surg 1986; 121: 4049. 8. Wong WD, Rothenberger DA, Goldborg SM. Ileoanal pouch procedures. Curt Probl Surg 1985; 22: 1-78. 9. Rolfsmeyer F_S,Rothenberger DA, Goldberg SM. Ileoanal pullthrough. In: Kodner IJ, Fry RD, Roe JP, eds. Colon, rectal and anal surgery. St. Louis: CV Mosby, 1985: 312-28. 10. Rothenberger DA, Wong WD, Buls JG, Goldberg SM, The S ileal pouch-anal anastomosis. In: Dozois RR, eel. Alternatives to conventional ileostomy. Chicago: Year Book Medical Publishers, 1985: 345-62. 11. Rotheaberger DA, Vermeulen FD, Christenson CE, et al. Restorative proctocolectomy with ileal reservoir and ileoanal anastomosis. Am J Surg 1983; 143: 82-8. 12. Pezim ME, Nicholls RJ. Quality of life after restorative proctocolectomy with pelvic ileal reservoir. Br J Surg 1985; 72:31-3. 13. Fieshman JW, Cohen Z, McLeod RS, Stern H, Blair J. The
ileal reservoir and ileoanal anastomosis procedure. Factors effecting technical and functional outcome. Dis Colon Rectum 1988; 31: 10-6. 14. Vasilevsky CA, Rothenberger DA, Goldberg SM. The S ileal pouch-anal anastomosis. World J Surg 1987; 11: 742-50. 15. Becker JM, Raymond JL. Ileal pouch-anal anastomosis. Ann Surg 1986; 204: 375-83. 16. Dozois RR. Restorative proctocolectomy and ileal reservoir. Mayo Clin Proc 1986; 61: 283-6. 17. Yves F, Dozois RR, Kelly KA, et al. Small intestinal obstruction complicating ileal pouch-anal anastomosis. Ann Surg 1989; 209: 46-50. 18. Nicholis R J, Lubowski DZ. Restorative proctocolectomy: the four loop (w) reservoir. Br J Surg 1987; 74: 564-6. 19. Schoetz D J, Coller JA, Veidenheimer MC. Can the pouch be saved? Dis Colon Rectum 1988; 31: 671-5. 20. Scott NA, Dozois RR, Beart RW, Pemberton JH, Wolff BG, Ilstrup DM. Postoperative intraabdominal and pelvic sepsis complieating ileal pouch-like anastomosis. Int J Colorect Dis 1988; 3:14952. 21. Zenilman ME, Becker JM, Dunnegan DL. Effect of staged colectomy on functional outcome after ileoanal anastomosis. Presented at the 21st annual meeting of the Missouri Chapter of the American College of Surgeons, Lake Ozark, M e , June 10-12, 1988. 22. Dozois RR, Goldberg SM, Rothonberger DA, et al. Restorative proctocole,ctomy with ileal reservoir (Symposium). Int J Colorect Dis 1986; I: 2-19. 23. Wexner SD, Rotbenberger DA, Belliveau P, et al. Pouchvaginal fistulae: incidence, etiology, and management. Dis Colon Rectum 1989; 32: 460-5. 24. Fonkalsrud EW. Update on clinical experience with different surgical techniques of the endorectal pull-through operation for colitis and polyposis. Surg Gynecol Obstet 1987; 165: 309-16. 25. Nasmyth DG, Johnston D, Godwin PGR, Dixon MF, Smith A, Williams NS. Factors influencing bowel function after ileal pouchanal anastomosis. Br J Surg 1986; 73: 469-73. 26. Martin LW, Sayers H J, Alexander F, Fischer JE, Torres MA. Anal continence following the Soave procedure. Ann Surg 1986; 203: 525-30. 27. Bartolo DCC, Miller R, Mortenson NJMcC. Does presentation of the anal transitional zone influence sensation after ileoanal anastomosis for ulcerative colitis? Presented at the 87th annual meeting of the American Society of Colon and Rectal Surgeons, Anaheim, CA, June 12-17, 1988. 28. Keighley MRB. Abdominal mucosectomy reduces the incidence of soiling and sphincter damage after restorative proctocolectomy and J-pouch. Dis Colon Rectum 1987; 30: 386-90. 29. Liljeqvist L, Lindquist K, Ljungdahl I. Alterations in ileoanal pouch technique, 1980 to 1987. Complications and functional outcome. Dis Colon Restum 1988; 31: 929-38. 30. Heald R J, Allen DR. Stapled ileoanal anastomosis: a technique to avoid mucosal proctemomy in the ileal pouch operation. Br J Surg 1986; 73: 571-2. 31. Ramos R, Bode WE. A simple technique for construction of a J-pouch. Dis Colon Rectum 1988; 31: 87-9. 32. Soper N J, Kestenberg A, Becker JM. Experimental rival Jpouch construction. A comparison of three techniques. Dis Colon Rectum 1988; 31: 186-9.
DISCUSSION H. Sugerman (Richmond, VA): It is my understanding that you are now using the stapled supra-levator procedure as recommended by the British surgeons. I was curious as to why you have switched. What are the early results? We have done several of these, and it appears to be an exciting new technique. But since you have probably had
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more experience than we have had, I would like to know the effect of this procedure compared with the data you presented today. Theodore R. Sehrock (San Francisco, CA): The paper is particularly interesting because your group is one of the few that continues to favor the S pouch, at least until recently. I am curious about your use of a 2-cm outlet spout. Was that true originally, or did you shorten it in response to problems with outlet obstruction? What percentage of your patients with a 2-cm spout require the use of a catheter, at least occasionally? In view of your experience with fistulas attributed to Crohn's disease, what do you recommend for patients with indeterminate colitis? E. Christopher Ellison (Columbus, OH): You presented 159 of 178 patients that had their ileostomy closed. What happened to the additional 19 patients that did not have the ilcostomy closed? Second, you made an interesting observation in that the patients that had initial postoperative complications were patients who subsequently had pouch failure. Do you recommend a delay in closure of the temporary ileostomy in patients with early postoperative complications? Zane Cohen (Toronto, Ontario, Canada): Was there any correlation between pouchitis and stenosis? Are there any other factors you have identified which are related to these high complication rates, such as the use of highdose steroids in the preoperative period or a two-stage versus a three-stage operation? Bruce G. Wolff (Rochester, MN): Dr. Wexner, you have certainly put the complication rate in perspective for this procedure. You mentioned six or eight patients in your series who did not have a temporary diverting ileostomy. I would like to know how those patients fared, and if they had a high rate of subsequent pouch failure. Russell G. Postier (Oklahoma City, OK): I would like to focus for a second on the patients with Crohn's disease. W e have done about 60 of these procedures and have had to take 2 down because of Crohn's disease. In retrospect,these patients clinicallyand pathologicaUy had clear-cut ulcerativecolitis,and there is now a suggestion that pouchitisor something akin to itcreatesa picture very consistentwith Crohn's disease.W e are currently following three patientswho we would have identified previouslyas having Crohn's diseasein the pouch and who have responded well to Flagyl;we now believethose patients have pouchitis.In retrospect,were your patients with Crohn's diseasejustmisdiagnosed, or are we seeing a new syndrome that mimicks Crohn's? Josef E Fischer (Cincinnati, OH): I have one comment and severalquestions.W e also use the S pouch but with a shorter spout, about a centimeter. I agree that a strictureis probably one of the worst
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aspects of pouchitis that cannot be controlled. Our incidence is somewhat less than yours. It is about 6 percent at the present time, but we have been unable to determine any relationship between surgical techniques and subsequent stricture. We do not use staples, so it is not stapling. Do you have any ideas as to what technical details are associated with stricture? Our impression is that the evolution of bowel obstruction to closed-loop obstruction in this group of patients is much faster than in the general population. I have thought that maybe it is because these patients don't have an omentum and they don't have colon to restrain the volvulus. Is this your impression as well? We tend to be very aggressive in taking these patients to the operating room when they develop bowel obstruction. Merril T. Dayton (Salt Lake City, UT): Perhaps the incidence of pouchitis is much higher in ulcerative colitis than in patients who have this operation for Gardner's syndrome and familial polyposis. Would you comment7 Are there patients with ulcerative colitis on whom you would not operate because of body habitus or age? Theodore E. Eisenstat (Plainfield, NY): We have also seen that this operation is not without complications. Our experience has been that longer rectal cuffs are associated with better continence but also with more complications related to abscess formation. How do you deal with these complications? Are you using preoperative manometry to try to predict postoperative function? Steven D. Wexner (closing): Dr. Sugerman, the stapled supra-levator reservoir is the procedure towards which we are evolving based on data originally presented by Keighley [28, Br J Surg 1989; 76."961-4] and subsequently by Bartolo and others [27]. The transanal mucosectomy is eliminated, and the anastomosis is effected to the top of the anal columns. The anastomosis can be stapled or handsewn. My preference is for a double-stapled technique [ Wexner SD, Jagelman DG. The double-
stapled ileal reservoir and ileoanal anastomosis (film). Woodbury, CT: Cin~ Med, 1989]. This top-of-the-columns anastomosis achieves several goals. First, in not performing sphincter stretch, postoperative resting pressures are not decreased; this helps prevent postoperative incontinence. Second, by not performing a mucosectomy there is no nidus for subsequent cuff abscess or for pouch-vaginal fistula. One leaves about a centimeter of tissue that potentially could turn into a carcinoma or develop colitis. However, we perform fourquadrant biopsies in all of these patients at the time of ileostomy closure and on each subsequent office visit; we are finding only transitional mucosa immediately distal to the anastomosis. Ours is a side-to-end anastomosis without a spout and with a short anal canal. To date, the procedure has been performed with complete pre- and postoperative evaluation in 13 patients, none of whom has leakage during the day or at night. There has been no pelvic sepsis. Regarding Dr. Eisenstat's question about the length
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of the cuff, these patients have very good control, even with the shortened anal canal; this is seen both manometrically and clinically. We assess all patients with manometry preoperatively and before and after ileostomy closure. To answer Dr. Schrock's question, with the 2-cm efferent spout, no patients required catheterization, and that is the reason that it was shortened from the original 4- to 5-cm length. Two of the pouches that were revised underwent revision because of long obstructive efferent limbs. Regarding fistulas in Crohn's disease, the Mayo Clinic had a study about indeterminate colitis with a larger experience than ours [Dis Colon Rectum 1989; 32: 653-8]. They found that it is safe to perform an ileoanal reservoir procedure in indeterminate colitis. Based on our data, I would agree with them. Dr. Ellison, the other 19 patients had ileostomy closure subsequent to our data retrieval. They all had undergone pouch construction in the few months immediately prior to the study. Dr. Wolff, we had six patients in whom no ileostomy was created, and none of those patients did well. They all had postoperative septic complications. Therefore, we do not perform the one-stage procedure in colitis or polyposis. If the patient does have initial complications, should ileostomy closure be delayed? I don't have concrete data on that. Dr. Fischer, I think that bowel obstruction occurs
because the bowel is flied at three points with a shortened mesentery. It is tethered at the duodenojejunal flexure, in the pelvis and at the ileostomy site. I think this configuration tends to lend itself to an obstruction. In the case of obstruction, I would actually close the ileostomy earlier. Regarding septic complications, I would delay closure to try to let things return to normal in the pelvis. Most of the patients who had pelvic sepsis ended up with poor function. They have a pouch which is not as compliant as most others. Is stenosis correlated with pouchitis? I am not sure; we do have a slightly higher stenosis rate than others at 12 percent. I think the stenosis has more to do with the efferent limb as the most distant point of the blood supply. Regardless of technique, that is the area most likely to be compromised, resulting in an ischemic stricture. Dr. Dayton, pouchitis was higher in our series, and was seen more often in, though not exclusively in, ulcerative colitis as compared with familial adenomatous polyposis. I can't think of specific reasons not to offer this procedure to a patient with ulcerative colitis. I think one has to exercise a modicum of discretion. If the patient is very elderly and has poor manometric pressures, I would perhaps shy away from it. Patient body habitus is not a contraindication to surgery, especially with a J type pouch stapled to the top of the columns as I have described previously.
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One hundred nine men and 71 women with a mean age of 31 years had construction of 164 S, 2 J, and 14 other ileoanal reservoirs. Postoperative gastrointestinal complications included small bowel obstruction in 11 percent and liens, hemorrhage, and sepsis in 6 percent, 5 percent, and 11 percent, respectively. T h e r e was a 13 percent incidence of miscellaneous postoperative complications. Pouch perianal fistulas developed in 5 percent of patients, and pouch vaginal and other pouch fistulas developed in an additional 4 percent. During long-term follow-up, small bowel obstruction developed in 27 percent of patients, and enterolysis or enterectomy was required in 15 percent of patients. One hundred fourteen patients who were followed for a mean length of 5 years after ileostomy closure (range 16 to 8 8 months) were evaluated for functional outcome. Function improved with time in 63 percent of patients and remained stable in another 33 percent; only 4 percent had long-term deterioration. Ninety-five percent of patients would again choose an ileoanal reservoir over a permanent ileostomy. This long-term assessment shows that although the ileoanal reservoir is a viable option in the management of mucosal ulcerative colitis, it should not be recommended to every patient.
he ileoanal reservoir is now in its 12th year of clinical use [1]. The procedure can be technically demandT ing, and a steep learning curve has been documented [2]. Despite many reports of excellent functional results, some investigators have found the procedure to be fraught with complications [3-7]. Good functional results which are acceptable to the patient must be balanced against potentially unacceptable complications. Towards this end, we reviewed our first 180 consecutive ileoanal reservoir procedures and addressed both of these issues. MATERIAL AND M E T H O D S Between November 1980 and April 1988, 180 patients underwent total abdominal colectomy, rectal muFrom the DepartmentOfColorectalSurgery,ClevelandClinicFlorida, Fort Lauderdale,Floridaand the Divisionof ColonandRectalSurgery, Universityof MinnesotaSchoolof Medicine,Minneapolis,Minnesota. Requests for reprints should be addressed to Steven D. Wexner, MD, 3000WestCypressCreekRoad, Fort Lauderdale,Florida33309. Presentedat the 30th Annual Meetingof the Societyof Surgeryof the AlimentaryTract, Washington,D.C., May 16-17, 1989. 178
cosectomy, ileal reservoir construction, and ileoanal anastomosis at the University of Minnesota affiliated hospitals. Since 1978, a computerized data registry has been in place at the University of Minnesota Division of Colon and Rectal Surgery. Sixty categories of technical and demographic data were prospectively entered on each of the 180 patients who had an ileoanal reservoir constructed; all calculations were based on the number of patients rather than the number of operative procedures. One hundred fifty-nine of these patients also underwent iliostomy closure, and these data were also prospectively evaluated. One hundred nine men and 71 women with a mean age of 31 years (range 13 to 60 years) had construction of 164 three-limbed (S) ileoanal reservoirs, 2 twolimbed (J) ileoanal reservoirs, and 14 ileoanal reservoirs of other design. Indications for surgery were mucosal ulcerative colitis (169 patients; 94 percent) and familial adenomatous polyposis (11 patients; 6 percent). One hundred sixty ileoanal reservoir procedures were performed electively (89 percent), 18 were performed on an urgent basis (10 percent), and 2 were performed emergently (1 percent). The technique for ileoanal reservoir construction has been described in previous publications [8-11]. The office records and hospital charts of all 180 patients were analyzed. One hundred seventy-eight medical records were complete; thus although prospective data retrieval was complete in 100 percent of the cases, retrospective chart review was complete in only 99 percent. In addition, the prospective computerized registry and medical records relating to the ileostomy closures were reviewed. Prior to the end of April 1980, 159 of these 180 patients also had their ileostomies closed, and 6 patients never had ileostomies constructed (one-stage ileoanal reservoir procedure). Twenty-two patients (12 percent) underwent an abdominal colectomy followed by an ileoanal reservoir construction with ileostomy creation and then closure of ileostomy (three-stage procedure). Thus, 180 patients underwent a total of 333 surgical procedures, not including morbidity-related procedures. Complications that arose in the postoperative period and those that occurred during the long-term follow-up were both included in this study. Postoperative complications included those which occurred within 30 days of either the ileoanal reservoir construction or ileostomy closure. Complications directly related to the ileoanal reservoir and those related to other organ systems were both included in the analysis. Long-term complications, however, were limited to ileoanal reservoir-related problems. Associated conditions such as dehydration ensuing from pouchitis were included. Prolonged ileus was defined as the need to reinsert a nasogastric tube or to withhold oral intake for more than 7 days after surgery without radiographic proof of obstruction or the subsequent need for laparotomy. Longterm complications were reviewed in an identical manner to early complications.
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TABLE
TABLE II
I
Postoperative Gastrointestinal Complications ( n = 1 7 8 ) Patients Complication
n
%
Operations n %
Small bowel obstruction Prolonged ileus Intestinalbleeding* Wound infection Intraabdominal sepsis Parastomal sepsis Perianastomotic sepsis Pancreatitis Cholecystitis Laparotomy t
20 11 9 7 7 3 2 3 1 2
11 6 5 4 4 2 1 2 <1 1
5 0 6 0 2 1 0 1 1 2
3 0 3 0 1 1 0 <1 <1 1
9 Includes bleeding from ileoanal reservoir anastomotic and suture lines (6), peptic ulcer (1), ileostomy closure (1), and unknown site (1). t No pathology.
Other Postoperative Complications ( n = 1 7 8 ) Patients Complication
n
%
Hypertransaminaserhia *
2 1 5 3 3 2 2 1 2 1 1 1 1
1 <1 3 2 2 1 1 <1 1 <1 <1 <1 <1
Hepatitis Pneumothorax ~ Pneumonia Urinary retention P!eural effusion Deep venous thrombosis Nephrolithiasis Adrenal insufficiency Brachial palsy Peroneal neuropathy
Epididymitis Parotitis
* Asymptomatic increases. t From insertion of central venous parenteral nutrition catheters.
Functional results were limited to an appraisal of long-term function. Only the 129 patients who underwent ileoanal reservoir construction and re-establishment of intestinal continuity between November 1980 and December 1986 were included in the functional assessment. All of these 129 patients were sent questionnaires concerning their ileoanal reservoir function and their quality of life. Questions addressed frequency of evacuation, continence; diet and medications, social and sexual activity, pregnancy, and overall patient satisfaction. Patients who did not return their questionnnaires within 4 weeks and those about whom additional data or clarification of an; swers were required were contacted by telephone. One of us (SDW) reviewed all questionnaires and queried all patients on the telephone; this author had not participated in the surgery or the pre-or postoperative management of any of these patients. Office records and hospital charts were specifically not utilized in order to minimize bias and maximize the validity of the data. One hundred fourteen patients (88 percent) were available for complete long-term evaluation. The mean length of follow-up was 5 years, ranging from 16 to 88 months after ileostomy closure. Seventy-four men and 40 women with a mean age of 31 years (range 13 to 60 years) were assessed. The indications for and timing of surgery in the functional group of 114 patients were similar to that for the entire group of 180 patients. One hundred five patients had a S ileoanal reservoir, I had a J ileoanal reservoir, and 8 had other types of ileoanal reservoirs created. Incontinence was defined as the leakage of liquid or solid stool in quantities sufficient to merit a trip to the toilet or change of undergarments. Spotting was defined as the leakage of flatus or of a small quantity of liquid, enough to warrant the use of a pad but not a change of undergarments or the use of a toilet. All functional parameters were defined in terms of always, usually, sometimes, rarely, and never occurring. RESULTS There was no postoperative mortality. Morbidity and complications were divided into early postoperative and
late or long-term. Postoperative gastrointestinal complications represented a large number of the problems seen (Table I). Twenty patients had a small bowel obstruction (11 percent), which required surgery in 5 patients (3 percent). An additional 11 patients (6 percent) had a prolonged ileus. Nine patients (5 percent) had some degree of hemorrhage from the gastrointestinal tract manifested by melena, hematochezia, hematemesis, or decreasing hemoglobin. In all nine patients, confirmation of the source of hemorrhage was confirmed either clinically, endoscopically, or surgically. Four patients required laparotomy for hemorrhage: one for peptic ulcer disease, one for bleeding from the site of ileostomy closure and two for bleeding from the reservoir itself. Two additional patients required transanal suture and ligation of reservoir sutureline hemorrhage. Sepsis was a major cause of postoperative morbidity. There were seven wound infections (4 percent), seven cases of intraabdominal sepsis (4 percent), three parastomal abscesses (2 percent), and two ileoanal perianastomotic abscesses (1 percent). Surgery was required for two pelvic abscesses and for one ileocutaneous fistula. In addition to the relatively more prevalent complications of obstruction, bleeding, and sepsis, a variety of other postoperative complications were noted. These included both gastrointestinal and nongastrointestinal problems (Table II): The two most frequent long-term complications were pouchitis and small bowel obstruction; each was noted in 49 patients (27 percent). Twentyfive of these 49 patients required exploratory laparotomy (14 percent); 20 patients underwent enterolysis only (11 percent) and 5 had enterectomies with anastomoses (3 percent). Forty-nine patients were treated for pouchitis (27 percent); approximately half of these patients had only a single episode which responded to oral hydration and metronidazole. Eleven patients required hospitalization due to pouchitis-associated dehydration (6 percent), and 5 patients (3 percent) who normally achieved spontaneous ileoanal reservoir evacuation found catheterization
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necessary during bouts of poUchitis. Two ileoanal reservoirs were ultimately excised for intractable pouchitis, Delayed sepsis seen more than 30 days after either ileoanal reservoir construction or ileostomy closure was not uncommon. Seven patients (4 percent) had periileoanal anastomotic cuff abscesses, all of which required local drainage. Five patients developed pelvic abscesses and one patient each developed a parastomal and perianal abscess, all of which required surgical or antibiotic therapy. Fistulas from the ileoanal reservoir to the perianal area developed in nine patients (5 percent) and fistulas from the reservoir or anastomotic line developed to other sites in an additional seven patients (4 percent). This latter group included fistulas to the paracoccygeal area, buttocks, and vagina, five of which ultimately were discovered due to initially misdiagnosed Crohn's disease. All five of these patients (12 percent) required per-anal dilatation of anastomotic strictures or anal stenoses. These problems were probably related to either local sepsis or ischemia. Virtually all patients developed at least some degree of transient perineal and perianal excoriation. In most cases this responded to local perianal hygiene, dietary changes, and the use of antidiarrheal agents. Seven patients required reestablishment of an ileostomy, one of which was permanent. Indications included pelvic sepsis, poor ileoanal reservoir function, and a mesenteric desmoid; the latter required creation of a permanent end-stoma. Two patients had pouch revision for poor function, and 14 patients (8 percent) ultimately underwent ileoanal reservoir excision. Indications for excision were functional failure in five patients, Crohn's disease in five, intractable pouchitis in two, and severe postoperative hemorrhage and pelvic sepsis in one each. Failures occurred early and seemed related to postoperative complications. Five of the 15 ileoanal reservoir failures occurred within the first year (33 percent of failures), 5 within the second year (33 percent of failures), 2 during the third year (13 percent of failures), and only 1 during each of the next 3 years (7 percent per year). If one excludes the failed ileoanal reservoirs, the complication rates are much lower in the remaining group of permanent ileoanal reservoirs. Four of the 7 patients with intraabdominal sepsis; 4 of the 20 patients with small bowel obstructions-and 4 of the 9 patients with intestinal bleeding ultimately had failure of their ileoanal reserVoirs. Thus the overall rate of postoperative exploratory laparotomy was 67 percent in those 15 patients who required eventual reservoir exclusion or excision and 9 percent in the entire group of 178 patients (16 of 178 patients) but only 4 percent in those patients with a long-term successful outcome (6 of 163 patients). Likewise, if the rates of small bowel obstruction, intestinal bleeding, and sepsis requiring laparotomy were analyzed, in the successful cases the rate decreased to 0.6 percent, 1.2 percent, and 0 percent, respectively. Ninety-tw0 percent of patients achieved spontaneous ileoanal reservoir evacuation; subsequent to a decrease in limb size from 4 to 5 cm to 2 to 3 cm, no patient required ileoanal reservoir catheter intubation. The mean number 180
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of evacuations is 5.4 4- 2.5 during the day (range 1 to 12, median 5) and 1.5 4- 1 at night (range 0 to 6, median 1). Seventy-nine percent of patients have six or fewer daytime bowel actions and 84 percent empty twice or less at night. Three percent of patients always or usually have incontinence of stool dUring the day and 8 percent find this true at night; however, no patient with daytime incontinence was operated on since 1983, and 91 percent of those who reported nocturnal incontinence also underwent ileoanal reservoir construction prior to 1983. Daytime minor spotting occurs at least some of the time in 39 percent of patients and at night in 57 percent. Sixty-two percent of patients usually wear a protective pad during the day and 68 percent do this at night. However, the majority of patients who use a protective pad do so to bolster self-confidence rather than out of necessity. Prior to ileoanal reservoir construction, 86 percent of patients were sexually active. Fifty percent reported no change in activity level, 23 percent had increased activity, 25 percent had minor decreases, and 2 percent had severely limited or absent sexual activities. In no instance did either the patient or the physician attribute decreased activity to the ileoanal reservoir. There were no cases of impotence and only one case of undocumented retrograde ejaculation. Three patients became pregnant and had successful cesarean section deliveries. Ninety percent of patients were employed or in school prior to ileoanal reservoir construction, and 87 percent continued to do so after surgery. Ninety-eight percent of patients believed that the ileoanal reservoir in no way limited their daily activities. Importantly, 63 percent of patients felt that their functional results continued to improve over many years, often even after a plateau had been reached. These data are all shown in Table III. COMMENTS Many centers have reported excellent functional resuits with the ileoanal reservoir procedure [6,12-16]. We analyzed our entire group of patients both prospectively and retrospectively to assess functional outcome and morbidity. It has been suggested by some investigators that function improves over time [2,4]. This conclusion prompted us to limit our long-term functional analysis to a minimum of 18 months after ileostomy closure. Thus, while 180 patients were eligible for prospective and retrospective assessment regarding morbidity, only 129 patients were eligible for long-term functional analysis. The most common complications after ileoanal reservoir remain small bowel obstruction and pouchitis [6,17]. Yves et al [17] reported 626 patients who underwent the ileoanal reservoir procedure for either mucosal ulcerative colitis or familial adenomatous polyposis [17]. Seventeen percent of the patients in that series developed small bowel obstruction, half of whom required laparotomy. In the series of 163 patients reported by Fleshman and coworkers [13], 34 patients (19 percent) developed small bowel obstructions, almost half of whom required laparotomy. Nicholls and associates [18] reported a 13 percent incidence of small bowd obstruction necessitating laparotomy and Schoetz and colleagues [7] reported a 24
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percent incidence of small bowel obstruction and an 11 percent incidence of laparotomy for obstruction. In the present study, we divided all complications into those occurring in the immediate postoperative period and those which occurred subsequent to that time. In the postoperative period 20 patients developed small bowel obstructions, 5 of whom required laparotomy. In the long-term evaluation, an additional 49 patients (27 percent) developed obstructions of whom 25 patients required laparotomy. Thus 17 percent of the overall group of evaluated ileoanal reservoir patients had a laparotomy at some time during the follow-up period. Although our rate of small bowel obstruction is slightly higher than that cited in other series, our length of follow-up is also longer, ranging from 16 to 88 months. The most serious complication is probably pelvic or perianal suppuration, as this often antedates poor function and may indicate a misdiagnosed case of Crohn's disease. Schoetz and colleagues [19] reported a rate of pelvic sepsis of 3.6 percent (6 of 165 patients). In over 80 percent of these cases (five of six patients) antibiotics alone were successful in obtaining resolution of the suppuration without surgery. In addition, five patients had ileoanal reservoir fistulae, three of which were pouchvaginal. All five patients required re-establishment of a diverting ileostomy and two were actually cases of Crohn's disease. Scott and colleagues [20] reported a 6 percent rate of pelvic sepsis (30 of 500 patients) and made several important points. First, the incidence of significant sepsis decreased from 11 percent with the first 100 procedures to 4 percent of the last 100 performed. This represents a learning curve which has been observed in other practices as well [8,11,13,14]. Second, patients who had a previous colectomy and Brooke ileostomy had higher rates of sepsis than patients in whom colectomy and ileoanal reservoir construction were performed during the same laparotomy. Third, approximately half of those patients who required laparotomy to treat the sepsis ultimately required pouch excision. By contrast, no reservoir was excised from patients who did not require laparotomy but responded to antibiotic therapy or local surgical or percutaneous drainage alone. These data correlate well with the previously reported finding by our group that functional results improve with time because those patients with complications lose their reservoirs during the first two postoperative years, often because of poor function [6]. However, this should not detract from the fact that the majority of patients who retain their ileoanal reservoirs continue to experience functional improvement even up to several years after surgery. Poor function can be correlated to previous colectomy, as has been documented by Zenilman and associates [21]. Our overall rate of abdominal, perianal, pelvic, and parastomal sepsis was 7 percent in the postoperative period. An additional 7 percent developed delayed suppuration. The majority of these incidences of sepsis occurred during the first 3 years of ileoanal reservoir constructions, and many, as discussed, represented patients who ultimately lost their reservoirs because of Crohn's disease
TABLE IIl Summary of Functional Outcome (n = 114)* Frequency of evacuation Daytime Mean Median Nighttime Mean Median Always or usually continent Solids, liquids: Daytime Nighttime Gas: Daytime Nighttime Wear a pad Daytime Nighttime Changes In diet Antldlarrheal medication No limitations In dally activity No sexual limitations Continued functional improvement
5.4 5 1.5 1
97 92 88 71 62 68 32 30 98 98 63
9 Values expressed as percentages unless otherwise Indicated.
(five patients) or poor function (five patients). These results compare favorably with those reported in other major centers worldwide [22]. Pouch-vaginal fistulas represent a relatively common problem that is rather recalcitrant to most forms of therapy. A recent multicenter study reported the incidence to be 7 percent (27 fistulas in 306 female patients) [23]. This type of fistula should alert the physician to the possibility of Crohn's disease and should prompt an aggressive evaluation in that direction. Initial treatment is aimed at treatment of local suppuration and re-establishment of proximal ileal diversion. The next step is an attempt at local treatment with either an endoanal sliding flap or an overlapping sphincteroplasty [23]. Gracilis muscle interposition and reservoir reconstruction remain second-line treatments, and ultimate ilcoanal reservoir failure and excision can be expected in approximately 18 percent of cases. Pouchitis was one of the two most common long-term complications reported. Pemborton and co-workers [2] place the incidence at 14 percent with a relatively short follow-up (mean 2.3 years). Other investigators report rates of pouchitis which vary from I0 percent to 29 percent [7,8,13,15,24]. We found that the incidence of pouchitis increased with the length of follow-up as shown in Figure I. Therefore, it is not surprising that our patients experienced a slightly higher rate of pouchitis than that reported in some of the above-cited references. It has been suggested that evacuation frequency decreases most within the first 6 months after surgery [22]. Becker and Raymond [15] reported this improvement continuing for at least 12 months. They reported a mean daily stool frequency which decreased from 7.5 at i month to 5.4 at I year postoperatively. Schoctz and colleagues [7] reported 7 daily evacuations during the first 3 postoperative months and 5.1 subsequent to that time.
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Pouchitis Rate (%) 5O
30 20 10 0
|
|
|
1981 1982 1983 1884 1985 1888
47
31
32
26
33
9
Figure 1. The incidence of pouchltls relative to the length of follow-up. The overall Incidence Is 27 percent.
Pemberton and associates [2] reported that although stool frequency did not change with the length of followup (mean 2.3 years), the incidence of nocturnal incontinence and spotting significantly decreased over the first 3 years, from 30 percent to 13 percent. Although most functional improvement may occur during the first 3 to 6 postoperative months, our patients' responses show that continued improvements in both frequency of bowel action and degree of continence occur for at least 2 years. Much of the incontinence may be attributable to a sharp learning curve of this technically exacting procedure. All of the patients in this series who experienced daytime incontinence and 89 percent of those who experienced nocturnal incontinence underwent ileeanal reservoir construction between 1981 and 1983. A previous report from this group also showed a trend towards a decrease in minor leakage and spotting, although this did not achieve statistical significance [6]. Nasmyth and co-workers [25] showed that patients with good ileoanal reservoir function could postpone dalecation as shown by an increase in squeeze pressures over those with poor function. In addition, patients with "perfect" anal continence after the ileoanal reservoir procedure had higher resting anal canal pressures than the imperfect continence group. Those investigators demonstrated that resting anal canal pressure (high pressurezone pressures) was significantly lower (by 50 percent) in patients after ilr reservoir construction than in control subjects (median 50 cm water versus 97 cm water). Patients with minor leakage had significantly lower resting pressures than patients who were continent. Similarly, those who could not defer evacuation had significantly lower maximal squeeze pressuress than those who could defer evacuation. Martin and associates [26] reported improved func182
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tional results in 69 patients in whom the anal transitional mucosa was preserved and the mucosectomy was performed from a transabdominal rather than transanal approach. This technique obviates the sphincter stretch necessary for transanal mucosectomy and anastomosis, thereby avoiding decreased postoperative resting pressures. Bartolo and colleagues [27] prospectively studied 12 patients in whom the ileoanal reservoir was performed. In six patients, the anal mucosa was removed proximal to the anal valves, and in the other six it was removed proximal to the top of the anal columns. Preservation of the anal transitional zone was associated with normal sensation postoperatively as assessed by electrosensitivity and temperature sensitivity. However, the technique of transanal mucosectomy was utilized in all 12 patients, and, as expected, marked decreases in both resting pressures and maximum voluntary contraction pressures were documented. Keighley [28] compared 12 patients who underwent endoanal mucosal stripping with I 0 patients who underwent the transabdominal technique of mucosectomy. Incidences of complications between the methods of mucosal excision were comparable, except for the cuff abscesses which were seen exclusively after the transanal technique. Functional results were similar, although the incidence of soiling requiring a perianal pad was 50 percent after the transanal stripping and only 10 percent after the transabdominal method. This is probably attributable to the decrease in resting anal canal pressures seen in the transanal group that was not seen in the transabdominal group. These changes were, respectively, 87 cm and 82 cm water preoperatively and 60 cm and 81 cm water postoperatively. In addition, maximum squeeze pressures also changed from 180 cm to 166 cm water in the transanal group and from 171 cm to 168 cm water in the transabdominal group. Keighley [28] noted that the median duration of anal retraction was 72 minutes in the transanal group. Liljeqvist and co-authors [29] reported a similar improvement in results with preserving the transitional zone and decreasing the duration of anal stretch. In this later series, normal continence improved from 65 percent to 92 percent with the newer technique. Thus, based on these data, it seems desirable to preserve the transitional zone to optimize anal canal sensation and to eliminate sphincter stretch to maintain normal postoperative resting and squeeze pressures to improve continence. The stapling techniques described by Heald and Allen [30] and others [31,32] achieves both of these goals. A stapled J-type reservoir is created from a single apical enterotomy. The enterotomy is then used for purse-string application, and the circular stapling device is used to effect an end-to-side ileoanal anastomosis without mucosectomy or sphincter stretch. Clinical trials are under way. In conclusion, our study achieved several goals. First, we reconfirmed previous reports regarding acceptable function. Second, we ascertained that although complications are prevalent after such an extensive and technically demanding procedure, they occur with an acceptable incidence. Third, it may be possible to predict ultimate failure based upon early postoperative ileoanal reservoir-
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related complications. Our data suggest that early postoperative laparotomy augurs poorly for ultimate success. In addition, sepsis, in the form of either abscesses or fistulas, is also associated with high rates of ultimate ileoanal reservoir failure. Moreover, the development of fistulas from the ileoanal reservoir to the perineum, vagina, paracoocygeal area, or buttocks suggest that Crohn's disease rather than mucosal ulcerative colitis was the colonic pathology. Crohn's disease represented the single most common reason for ultimate ileoanal reservoir excision. Fourth, we believe that further improvements can be achieved through newer surgical techniques. More clinical study along this avenue is required. At present, the ileoanal reservoir is not a panacea. Although it is a viable and useful alternative to proctectomy or to ileorectal anastomosis in the treatment of both mucosal ulcerative colitis and familial adenomatous polyposis, it is not perfect. There is no way at present to preoperatively predict which patients will have good clinical outcomes. Although many research protocols are underway using anorectal manometry, rectal and reservoir compliance, scintigraphy, and a variety of other analytic techniques, no studies have proven uniformly reliable as predictors. At the present time, technical refinements seem to be the best methods of ensuring good postoperative outcomes. Although the ileoanal reservoir has celebrated its 12th anniversary, the "perfect pouch" is still under development.
REFERENCES 1. Parks AG, Nicholls RJ. Proctocolectomy without ileostomy for ulcerative colitis. Br Med J 1978; 2: 85-8. 2. Pemberton JH, Kelly KA, Beart RW, Dozois RR, Wolff BG, Ilstrup DM. Ileal-pouch anal anastomosis for chronic ulcerative colitis. Ann Surg 1987; 206: 504-13. 3. Nicholls J, Pescatori M, Motson RW, Pezim ME. Restorative proctocolectomy with a three-loop ileal reservoir for ulcerative colitis and familial polyposis. Ann Surg 1984; 199: 383-8. 4. McHugh SM, Diamant NE, McLe~xiR, Cohen Z. S-pouches vs. J-pouches: A comparison of functional outcomes. Dis Colon Rectum 1987; 30: 671-7. 5. Pezim ME, Nicholls ILl. Quality of life after restorative proctocolectomy with palvic ileoanal reservoir. Br J Surg 1985; 72: 31-3. 6. Wexner SD, Jensen L, Rothenberger DA, Wong WD, Goldberg SM. Long-term functional analysis of the ileoanal reservoir. Dis Colon Rectum 1989; 32: 275-81. 7. Schoctz D J, Coller JA, Veidenheimer MC. Ileoanal reservoir for ulcerative colitis and familial polyposis. Arch Surg 1986; 121: 4049. 8. Wong WD, Rothenberger DA, Goldborg SM. Ileoanal pouch procedures. Curt Probl Surg 1985; 22: 1-78. 9. Rolfsmeyer F_S,Rothenberger DA, Goldberg SM. Ileoanal pullthrough. In: Kodner IJ, Fry RD, Roe JP, eds. Colon, rectal and anal surgery. St. Louis: CV Mosby, 1985: 312-28. 10. Rothenberger DA, Wong WD, Buls JG, Goldberg SM, The S ileal pouch-anal anastomosis. In: Dozois RR, eel. Alternatives to conventional ileostomy. Chicago: Year Book Medical Publishers, 1985: 345-62. 11. Rotheaberger DA, Vermeulen FD, Christenson CE, et al. Restorative proctocolectomy with ileal reservoir and ileoanal anastomosis. Am J Surg 1983; 143: 82-8. 12. Pezim ME, Nicholls RJ. Quality of life after restorative proctocolectomy with pelvic ileal reservoir. Br J Surg 1985; 72:31-3. 13. Fieshman JW, Cohen Z, McLeod RS, Stern H, Blair J. The
ileal reservoir and ileoanal anastomosis procedure. Factors effecting technical and functional outcome. Dis Colon Rectum 1988; 31: 10-6. 14. Vasilevsky CA, Rothenberger DA, Goldberg SM. The S ileal pouch-anal anastomosis. World J Surg 1987; 11: 742-50. 15. Becker JM, Raymond JL. Ileal pouch-anal anastomosis. Ann Surg 1986; 204: 375-83. 16. Dozois RR. Restorative proctocolectomy and ileal reservoir. Mayo Clin Proc 1986; 61: 283-6. 17. Yves F, Dozois RR, Kelly KA, et al. Small intestinal obstruction complicating ileal pouch-anal anastomosis. Ann Surg 1989; 209: 46-50. 18. Nicholis R J, Lubowski DZ. Restorative proctocolectomy: the four loop (w) reservoir. Br J Surg 1987; 74: 564-6. 19. Schoetz D J, Coller JA, Veidenheimer MC. Can the pouch be saved? Dis Colon Rectum 1988; 31: 671-5. 20. Scott NA, Dozois RR, Beart RW, Pemberton JH, Wolff BG, Ilstrup DM. Postoperative intraabdominal and pelvic sepsis complieating ileal pouch-like anastomosis. Int J Colorect Dis 1988; 3:14952. 21. Zenilman ME, Becker JM, Dunnegan DL. Effect of staged colectomy on functional outcome after ileoanal anastomosis. Presented at the 21st annual meeting of the Missouri Chapter of the American College of Surgeons, Lake Ozark, M e , June 10-12, 1988. 22. Dozois RR, Goldberg SM, Rothonberger DA, et al. Restorative proctocole,ctomy with ileal reservoir (Symposium). Int J Colorect Dis 1986; I: 2-19. 23. Wexner SD, Rotbenberger DA, Belliveau P, et al. Pouchvaginal fistulae: incidence, etiology, and management. Dis Colon Rectum 1989; 32: 460-5. 24. Fonkalsrud EW. Update on clinical experience with different surgical techniques of the endorectal pull-through operation for colitis and polyposis. Surg Gynecol Obstet 1987; 165: 309-16. 25. Nasmyth DG, Johnston D, Godwin PGR, Dixon MF, Smith A, Williams NS. Factors influencing bowel function after ileal pouchanal anastomosis. Br J Surg 1986; 73: 469-73. 26. Martin LW, Sayers H J, Alexander F, Fischer JE, Torres MA. Anal continence following the Soave procedure. Ann Surg 1986; 203: 525-30. 27. Bartolo DCC, Miller R, Mortenson NJMcC. Does presentation of the anal transitional zone influence sensation after ileoanal anastomosis for ulcerative colitis? Presented at the 87th annual meeting of the American Society of Colon and Rectal Surgeons, Anaheim, CA, June 12-17, 1988. 28. Keighley MRB. Abdominal mucosectomy reduces the incidence of soiling and sphincter damage after restorative proctocolectomy and J-pouch. Dis Colon Rectum 1987; 30: 386-90. 29. Liljeqvist L, Lindquist K, Ljungdahl I. Alterations in ileoanal pouch technique, 1980 to 1987. Complications and functional outcome. Dis Colon Restum 1988; 31: 929-38. 30. Heald R J, Allen DR. Stapled ileoanal anastomosis: a technique to avoid mucosal proctemomy in the ileal pouch operation. Br J Surg 1986; 73: 571-2. 31. Ramos R, Bode WE. A simple technique for construction of a J-pouch. Dis Colon Rectum 1988; 31: 87-9. 32. Soper N J, Kestenberg A, Becker JM. Experimental rival Jpouch construction. A comparison of three techniques. Dis Colon Rectum 1988; 31: 186-9.
DISCUSSION H. Sugerman (Richmond, VA): It is my understanding that you are now using the stapled supra-levator procedure as recommended by the British surgeons. I was curious as to why you have switched. What are the early results? We have done several of these, and it appears to be an exciting new technique. But since you have probably had
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more experience than we have had, I would like to know the effect of this procedure compared with the data you presented today. Theodore R. Sehrock (San Francisco, CA): The paper is particularly interesting because your group is one of the few that continues to favor the S pouch, at least until recently. I am curious about your use of a 2-cm outlet spout. Was that true originally, or did you shorten it in response to problems with outlet obstruction? What percentage of your patients with a 2-cm spout require the use of a catheter, at least occasionally? In view of your experience with fistulas attributed to Crohn's disease, what do you recommend for patients with indeterminate colitis? E. Christopher Ellison (Columbus, OH): You presented 159 of 178 patients that had their ileostomy closed. What happened to the additional 19 patients that did not have the ilcostomy closed? Second, you made an interesting observation in that the patients that had initial postoperative complications were patients who subsequently had pouch failure. Do you recommend a delay in closure of the temporary ileostomy in patients with early postoperative complications? Zane Cohen (Toronto, Ontario, Canada): Was there any correlation between pouchitis and stenosis? Are there any other factors you have identified which are related to these high complication rates, such as the use of highdose steroids in the preoperative period or a two-stage versus a three-stage operation? Bruce G. Wolff (Rochester, MN): Dr. Wexner, you have certainly put the complication rate in perspective for this procedure. You mentioned six or eight patients in your series who did not have a temporary diverting ileostomy. I would like to know how those patients fared, and if they had a high rate of subsequent pouch failure. Russell G. Postier (Oklahoma City, OK): I would like to focus for a second on the patients with Crohn's disease. W e have done about 60 of these procedures and have had to take 2 down because of Crohn's disease. In retrospect,these patients clinicallyand pathologicaUy had clear-cut ulcerativecolitis,and there is now a suggestion that pouchitisor something akin to itcreatesa picture very consistentwith Crohn's disease.W e are currently following three patientswho we would have identified previouslyas having Crohn's diseasein the pouch and who have responded well to Flagyl;we now believethose patients have pouchitis.In retrospect,were your patients with Crohn's diseasejustmisdiagnosed, or are we seeing a new syndrome that mimicks Crohn's? Josef E Fischer (Cincinnati, OH): I have one comment and severalquestions.W e also use the S pouch but with a shorter spout, about a centimeter. I agree that a strictureis probably one of the worst
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aspects of pouchitis that cannot be controlled. Our incidence is somewhat less than yours. It is about 6 percent at the present time, but we have been unable to determine any relationship between surgical techniques and subsequent stricture. We do not use staples, so it is not stapling. Do you have any ideas as to what technical details are associated with stricture? Our impression is that the evolution of bowel obstruction to closed-loop obstruction in this group of patients is much faster than in the general population. I have thought that maybe it is because these patients don't have an omentum and they don't have colon to restrain the volvulus. Is this your impression as well? We tend to be very aggressive in taking these patients to the operating room when they develop bowel obstruction. Merril T. Dayton (Salt Lake City, UT): Perhaps the incidence of pouchitis is much higher in ulcerative colitis than in patients who have this operation for Gardner's syndrome and familial polyposis. Would you comment7 Are there patients with ulcerative colitis on whom you would not operate because of body habitus or age? Theodore E. Eisenstat (Plainfield, NY): We have also seen that this operation is not without complications. Our experience has been that longer rectal cuffs are associated with better continence but also with more complications related to abscess formation. How do you deal with these complications? Are you using preoperative manometry to try to predict postoperative function? Steven D. Wexner (closing): Dr. Sugerman, the stapled supra-levator reservoir is the procedure towards which we are evolving based on data originally presented by Keighley [28, Br J Surg 1989; 76."961-4] and subsequently by Bartolo and others [27]. The transanal mucosectomy is eliminated, and the anastomosis is effected to the top of the anal columns. The anastomosis can be stapled or handsewn. My preference is for a double-stapled technique [ Wexner SD, Jagelman DG. The double-
stapled ileal reservoir and ileoanal anastomosis (film). Woodbury, CT: Cin~ Med, 1989]. This top-of-the-columns anastomosis achieves several goals. First, in not performing sphincter stretch, postoperative resting pressures are not decreased; this helps prevent postoperative incontinence. Second, by not performing a mucosectomy there is no nidus for subsequent cuff abscess or for pouch-vaginal fistula. One leaves about a centimeter of tissue that potentially could turn into a carcinoma or develop colitis. However, we perform fourquadrant biopsies in all of these patients at the time of ileostomy closure and on each subsequent office visit; we are finding only transitional mucosa immediately distal to the anastomosis. Ours is a side-to-end anastomosis without a spout and with a short anal canal. To date, the procedure has been performed with complete pre- and postoperative evaluation in 13 patients, none of whom has leakage during the day or at night. There has been no pelvic sepsis. Regarding Dr. Eisenstat's question about the length
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of the cuff, these patients have very good control, even with the shortened anal canal; this is seen both manometrically and clinically. We assess all patients with manometry preoperatively and before and after ileostomy closure. To answer Dr. Schrock's question, with the 2-cm efferent spout, no patients required catheterization, and that is the reason that it was shortened from the original 4- to 5-cm length. Two of the pouches that were revised underwent revision because of long obstructive efferent limbs. Regarding fistulas in Crohn's disease, the Mayo Clinic had a study about indeterminate colitis with a larger experience than ours [Dis Colon Rectum 1989; 32: 653-8]. They found that it is safe to perform an ileoanal reservoir procedure in indeterminate colitis. Based on our data, I would agree with them. Dr. Ellison, the other 19 patients had ileostomy closure subsequent to our data retrieval. They all had undergone pouch construction in the few months immediately prior to the study. Dr. Wolff, we had six patients in whom no ileostomy was created, and none of those patients did well. They all had postoperative septic complications. Therefore, we do not perform the one-stage procedure in colitis or polyposis. If the patient does have initial complications, should ileostomy closure be delayed? I don't have concrete data on that. Dr. Fischer, I think that bowel obstruction occurs
because the bowel is flied at three points with a shortened mesentery. It is tethered at the duodenojejunal flexure, in the pelvis and at the ileostomy site. I think this configuration tends to lend itself to an obstruction. In the case of obstruction, I would actually close the ileostomy earlier. Regarding septic complications, I would delay closure to try to let things return to normal in the pelvis. Most of the patients who had pelvic sepsis ended up with poor function. They have a pouch which is not as compliant as most others. Is stenosis correlated with pouchitis? I am not sure; we do have a slightly higher stenosis rate than others at 12 percent. I think the stenosis has more to do with the efferent limb as the most distant point of the blood supply. Regardless of technique, that is the area most likely to be compromised, resulting in an ischemic stricture. Dr. Dayton, pouchitis was higher in our series, and was seen more often in, though not exclusively in, ulcerative colitis as compared with familial adenomatous polyposis. I can't think of specific reasons not to offer this procedure to a patient with ulcerative colitis. I think one has to exercise a modicum of discretion. If the patient is very elderly and has poor manometric pressures, I would perhaps shy away from it. Patient body habitus is not a contraindication to surgery, especially with a J type pouch stapled to the top of the columns as I have described previously.
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